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目的研究内镜下扩大经鼻蝶窦入路至鞍区、鞍上区的显露范围,及手术入路中重要的解剖标志与其相互位置关系。结合该入路切除鞍结节脑膜瘤的临床应用体会,探讨内镜在此区域手术中面临的主要问题和解决办法。方法选择10例灌注尸头标本,采用显微镜解剖2例,其中冠状位和矢状位切开各1例;另8例标本模拟经鼻蝶窦入路。在内镜和显微镜下扩展显露鞍前及鞍上区的主要解剖标志,并研究其相互位置关系。对2例女性鞍结节脑膜瘤病人,采用神经导航经鼻蝶窦入路手术,肿瘤切除过程中和切除后分别应用成角内镜观察肿瘤周围结构及切除情况,肿瘤切除后以脂肪、人工硬膜及明胶海绵重建鞍底。结果内镜下在颅前窝向外侧显露的主要限制是两侧的眶内侧壁和视神经管;选择三个平面测量向侧方的显露范围,分别为筛骨鸡冠后缘平面(19.1±2.65)mm,鞍结节前方10mm的蝶骨平台平面(23.2±2.35)mm,两侧视神经管内口平面(13.1±2.18)mm。内镜下可清晰显示双侧视神经、视交叉、垂体柄、前交通动脉复合体等颅内结构。2例鞍结节脑膜瘤病人均达到肿瘤全切除,视力部分改善,术后均出现脑脊液漏,再次经原入路手术修补后痊愈。结论采用单纯内镜或内镜辅助的经鼻蝶窦入路可更直接达到鞍前及鞍上区病变,避免了经过重要的神经血管结构及对脑组织的牵拉。颅底骨质磨除位置和范围以及颅底的修补和重建是采用该入路需要解决的主要问题。
Objective To study the scope of endoscopic exploration of the nasospinal sinus to the saddle area and the suprasellar area and the important anatomical landmarks in the surgical approach. Combined with the clinical application of the approach to remove the tuberculum sellae meningioma clinical experience, to explore the main problems in endoscopic surgery in this region and solutions. Methods Ten cases of cadaveric perfusion were selected and 2 cases were dissected with microscope. Coronal and sagittal incisions were made in 1 case. The other 8 cases were simulated by transnasal sphenoid sinus approach. Under endoscopy and microscopy, the major anatomical landmarks in the anterior and suprasellar regions were revealed and their mutual positional relationships were studied. Two patients with saddle nodular meningioma were treated with neuro navigation through the nasal sphenoid sinus. During the tumor resection and after resection, angioscopic endoscopic observation of the structure and resection of the tumor was performed respectively. After resection of the tumor, Dural and gelatin sponge reconstruction of the saddle. Results The main limitations of the anterior cranial fossa revealed by endoscopy were the lateral orbital medial wall and the optic canal. The lateral extent of the three planes was selected to be the posterior edge of the cage (19.1 ± 2.65) mm, flat plane of sphenoid bone (23.2 ± 2.35) mm in front of saddle nodule 10 mm, and internal plane of optic canal in both sides (13.1 ± 2.18) mm. Endoscopic clearly shows bilateral optic nerve, optic chiasm, pituitary stalk, anterior communicating artery complex and other intracranial structures. 2 cases of saddle nodular meningioma patients achieved complete tumor resection, partial improvement of visual acuity, cerebrospinal fluid leakage occurred after surgery, once again restored by the original surgical repair. Conclusions The transsphenoidal sinus approach with endoscopic or endoscopic assistance can directly reach the lesion in the anterior and posterior region of the saddle, avoiding the important neurovascular structures and pulling of the brain tissue. The location and extent of the skull base bone removal and the repair and reconstruction of the skull base are the main problems to be solved by this approach.