神经内镜下经鼻蝶入路鞍上区域手术的应用解剖

Applied anatomic study on suprasellar region surgery through endoscopic transsphenoidal approach

目的探讨经鼻蝶入路和翼点入路对鞍上区暴露的差异,为内镜下经鼻蝶入路进入鞍上区的手术方法建立解剖学基础。方法在12例成人尸颅标本上,分别模拟经鼻蝶入路和翼点入路,暴露鞍上区,观察视神经、视交叉、垂体柄、颈内动脉及其分支。比较两个入路对于鞍上区重要结构的显露。结果翼点入路下,鞍结节后缘至视交叉前缘距离为5.35±1.38mm,两侧视神经内缘间距10.58±1.46mm,小脑幕游离缘长度6.73±0.84mm,后交通动脉长度16.52±2.98mm,前交通动脉长度2.11±0.35mm。神经内镜下经鼻蝶入路可以暴露视神经、视交叉、垂体柄、颈内动脉、大脑前动脉、大脑中动脉、前交通动脉、后交通动脉等结构,对于颈内动脉分叉以上结构暴露欠佳。结论经鼻蝶入路可以完全暴露第Ⅰ、Ⅱ间隙内的神经血管结构,对于第Ⅲ、Ⅳ间隙内结构显露较差,可以在微侵袭条件下部分代替翼点入路。

Objective To provide an anatomy basis for the suprasellar region surgery through the endoscopic transsphenoidal approach by studying the suprasellar region exposure differences between the transsphenoidal approach and pterional approach.Methods Twelve adult cadaver heads were dissected and the suprasellar region was exposed by imitating extended endoscopic endonasal transsphenoidal approach and microsurgical pterional approach.Observe the optic nerve,chiasma opticum,stalk hypophysial,internal carotid and its branches and compare the differences in the exposure of the major structure in the suprasellar region between these two approaches.Results Through the pterional approach,the distance between the trailing edge of the olivary eminence and the leading edge of the chiasma opticum is 5.35±1.38 mm.The distance between the inner edge of two optic nerve is 10.58±1.46 mm.The length of the free edge of the tentorium is 6.73±0.84 mm.The length of the arteriae communicans posterior is 16.52±2.98 mm and the length of the arteriae communicans anterior is 2.11±0.35 mm.Through endoscopic transsphenoidal approach,the structure,such as optic nerve,chiasma opticum,stalk hypophysial,internal carotid,arteriae cerebri anterior,arteriae cerebri media,arteriae communicans anterior,arteriae communicans posterior,are exposed and the exposure of the components above the internal carotid artery bifurcation is not very good.Conclusion Through the endoscopic transsphenoidal approach,nerve and vascular between Ⅰ and Ⅱ is exposed completely and the exposure of nerve and vascular between Ⅲ and Ⅳ is poor（or not very good）.The endoscopic transsphenoidal approach can partly substitute for the pterional approach under the condition of microinvasion.