鼻至斜坡区解剖特点及经扩大的鼻入路切除斜坡区肿瘤的可行性与安全性

Extended endoscopic endonasal approach to ventral part of clival region: an anatomic study and clinical application

目的研究扩大的内镜下经鼻至斜坡区手术入路的解剖要点及其位置关系。方法防腐尸头标本10例,显微镜下解剖观察扩大的经鼻至斜坡区手术入路的解剖结构。新鲜尸头标本5例,模拟扩大的内镜经鼻入路斜坡手术。另外,对2例侵犯斜坡区的病例,采用扩大的内镜下经单鼻孔手术入路,结合影像检查资料,观察肿瘤影像解剖结构及切除情况。结果扩大的内镜经鼻至斜坡区中线部位主要标志点由前至后依次为中鼻甲、后鼻孔、咽鼓管咽口、鼻咽部黏膜、双侧蝶窦口、头长肌和颈长肌、咽结节、枕骨大孔前缘中点等结构。手术中斜坡能够磨除的最大范围(分别以两侧颅内翼管和破裂孔为界,各自距中线最短距离):翼管左侧(9.25±0.26)mm,右侧(9.19±0.27)mm;破裂孔左侧(10.64±0.43)mm和右侧(10.75±0.51)mm。内镜下完全模拟手术操作表明,内镜经鼻入路可充分显露颅颈交界区及斜坡的解剖结构,完全达到真实内镜下操作要求。2例肿瘤全切,术中、术后未发现严重手术并发症。结论采用扩大的单纯内镜经鼻入路可更直接到达斜坡区,并可安全切除肿瘤,避免损伤重要的神经血管和脑组织。

Objective To study the key anatomical landmarks and the relationship used in surgical approach from nasal cavity to ventral slope by extended endoscopy. Combined with 2 cases of sellar tumors,the clinical application of the surgical approach in ventral slope was explored. Methods Ten formalin-fixed specimens of head were used to observe the key anatomical landmarks from nasal cavity to ventral slope with anatomical microscope,and established surgical mark. Five fresh specimens of head were used to do along the endoscopic nasal approach. Two cases of tumor invasion slope were used to observe anatomical characteristics of tumor and surgical results by expanded endonasal endoscopic and image data. Results Marking points in the middle line of surgical approach from nasal cavity to ventral slope were as follows： the middle turbinate,choanal,pharyngeal mouth,nasopharynx mucosa,bilateral sphenoid mouth,head length and longus muscle,pharyngeal tubercle,the midpoint of the leading edge of the foramen magnum and so on. To expose the ventral region of middle-lower part of clivus completely,the ranges of stripping the inferior wall of sphenoid sinus and the lower clivus were bounded by pterygoid canal and foramen lacerum,and the distances from the median line were（ 9. 25 ± 0. 26） mm and（ 9. 19 ± 0. 27） mm,respectively. Simulating surgeries under endoscopy proved the facticity was equal to the real operation. The tumor in 2 cases was completely removed without serious complications after postoperative and follow-up period. Conclusions Extended endoscopic nasal approach can directly reach the clivus,remove tumor safely and keep away the important neurovascular structures and avoid traction of brain.