模拟内镜下经双鼻孔至Meckel腔的解剖

Endoscopic anatomy of a double nostrils surgical approach to Meckel's cave

目的通过模拟内镜下经双鼻孔至Meckel腔手术入路,对Meckel腔及入路的相关结构进行解剖学研究,为临床内镜下Meckel腔手术提供解剖学及形态学资料。方法对10具(20侧)动静脉灌注乳胶的成人尸头标本,完全模拟经双鼻孔至Meckel腔的手术入路逐层显微解剖,对入路相关解剖标志进行观察、分析、拍摄和测量。结果该入路可分4步,即寻找上颌窦口,进入上颌窦,进入翼腭窝和进入Meckel腔。鼻小柱距上颌窦口的距离为(45.07±2.01)mm,与蝶腭孔的距离为(64.84±3.00)mm,距翼管前孔距离为(71.34±2.99)mm。以鼻小柱至鼻后棘的连线为底边,其与鼻小柱与上颌窦口连线的夹角为(38.81±1.72)。其与鼻小柱与蝶腭孔连线的夹角为(25.92±2.05)°。蝶腭动脉及翼管动脉平均外径分别为(2.21±0.24)mm和(1.07±0.27)mm。翼腭窝区结构复杂,其内上颌动脉及其终支蝶腭动脉和腭降动脉变异较大,沿蝶腭动脉逆行解剖有助于寻找上颌动脉及其分支结构。解剖分离翼腭窝内神经、血管等结构,追踪翼管神经血管束,依据翼管后端正对颈内动脉破裂孔段的特点,解剖分离四方形空间可较直接进入Meckel腔。结论侵犯Meckel腔肿瘤的入路选择应该个体化,应依据肿瘤主体在Meckel腔的位置及范围等决定选1种或联合入路;内镜下经双鼻孔至Meckel腔入路可较直接地暴露Meckel腔的前下内面及翼腭窝区域的解剖结构;手术中重要的解剖标志为蝶腭孔、翼管神经、翼管和上颌神经;翼腭窝中浅部血管结构的解剖有助于深部神经结构的保护,深部神经结构(如翼管神经和上颌神经)和其穿行的骨孔有助于在颅底辨别和控制颈内动脉。

Objective To study the structures relevant to the endoscopic approach to the Meckel＇ s cave via the amphirhinal in order to provide the anatomy and morphology information for the Meckel＇ s cave surgery. Methods By simulating the operative approach to the Meckel＇ s cave via the amphirhinal under the endoscope, the operative approach- relevant anatomic landmarks in 10 cadaveric heads （20 sides） were observed, analyzed, photographied and measured. The cadavers were arterially and venously perfused with colored latex. Results The approach to the Meckel＇ s cave via the amphirhinal was divided into 4 steps： finding ostium of the maxillary sinus, entering the maxillary sinus, entering pterygopalatine fossa（PPF） and entering the Meckel＇ s cave. The distance from the nasal columella to the ostium of the maxillary sinus was （45.07 ± 2.01 ） ram; the distance from the nasal columella to the sphenopalatine foramen was （64. 84 ±3.00） mm;the distance from the nasal columella to the anterior foramen of the pterygoid canal was （71：34 ± 2.99）mm. The angle between the lines from nasal columella to posterior nasal spine and from nasal columella to apertura maxillaries was （38.81 ± 1.72） . The angle between the lines from nasal columella to posterior nasal spine and from nasalcolumella to sphenopalatine foramen was （25.92 ± 2.05 ）°. The diameter of sphenopalatine artery was （2.21 ± 0.24）ram, and the diameter of vidian artery was （ 1.07_± 0. 27） mm. The PPF region was structurally complicated due to the inside maxillary artery and its terminal branch-sphenopalatine artery, and great variation of the descending palatine artery. Tracing the sphenopalatine artery made it easier to localize the maxillary artery and its branches. When the constitutions such as pterygopalatine ganglions, veins were carefully departed, the vidian nerve and vessel bundles were tracked. The vidian ending was characterized to face with the ruptured fractions of the internal carotid artery. Meckel＇ s cave was straightly accessed by anatomically departing the quadrangular space （QS）. Conclusion The selection of the operative approach to Meekel＇ s cave should be individualized. The location and the size of the lesion in Meckel＇ s cave are the major factors in deciding approaches for surgical treatment. The endoscopic approach of double nostrils-Meckel＇ s cave provides direct exposure to the anteromedial compartment of Meekel＇ s cave and PPF. Notable anatomical landmarks for the endoscopic surgeon are the sphenopalatine foramen, the vidian nerve and its canal and maxillarynerve （V2）. A dissection superficial to the vascular structures preserves the neural elements. The nerves, such as the vidian nerve and V2, and their bony foramina are critical anatomical landmarks to identify and control the ICA（ internal carotid artery） at the skull base.