目的 探讨神经内镜下经鼻扩大蝶窦入路手术切除鞍上区肿瘤的可行性和安全性.方法 选用10具灌注固定的正查尸头,模拟经鼻扩大蝶窦入路,内镜下观察鞍上区解剖结构,应用神经导航获取并分析解剖数据.采用神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤12例,并以人工硬脑膜、明胶海绵和生物胶"三明治"式A结构重建颅底.结果 视神经一颈内动脉隐窝是丙镜下经鼻扩大蝶窦入路中恒定且关键的解剖标志.剪开硬脑膜后,可显露视交叉下间隙和上间隙,其中视交叉下间隙可见两侧颈内动脉、两侧垂体上动脉、垂体上部、垂体柄、视神经和视交叉,视交叉上间隙内可见大脑前动脉A1和A2段、前交通动脉以及直回.12例鞍上区肿瘤全切除10例,次全切除2例;随访12例,时间6～62个月,术后出现脑脊液鼻漏1例,再次行内镜下修补术后恢复.结论 神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤是可行和安全的,熟练的内镜技术和可靠的颅底重建是手术成功的关键.%Objective To explore the feasibility and safety of extended endoscopic endonasal transsphenoidal approach for the treatment, of tumors in the suprasellar region. Methods Endoscopic endonasal extended transsphenoidal approach was simulated in 10 cadaveric heads fixed by vascular perfusion. The anatomic structures of the suprasellar region were observed under neuroendoscope and the anatomic distances were measured by neuronavigation system. The tumors in the suprasellar region were resected via extended endoscopic endonasal transsphenoidal approach in 12 patients and then the skull base was reconstructed by sandwich structure consisting of artificial dura mater, biological glue and gelatin sponge. Results The optic nerve-internal carotid artery recess was the constant and key anatomic landmark in the extended endoscopic endonasal transsphenoidal approach. After the dura was opened, suprachiasmatic and subchiasmatic spaces were exposed. The bilateral internal carotid arteries, bilateral superior hypophyseal arteries, upper portion of the pituitary, pituitary stalk, optic nerve and optic chiasm were seen in the subchiasmatic space. The Al and A2 segments of the anterior cerebral artery, the anterior communicating artery and gyrus rectus were visible in the suprachiasmatic space. Ten of 12 patients with tumors in the suprasellar region were totally removed and 2 were subtotally removed. The 12 patients were followed up for 6 to 62 months and cerebrospinal fluid rhinorrhea occurred in 1 patient who underwent endoscopic repair again and recovered. Conclusions The extended endoscopic endonasal transsphenoidal approach is feasible and safe for the treatment of tumors in the suprasellar region. Skilled endoscopic technique and reliable skull base reconstruction are important to ensure success of surgery.
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