颞下锁孔入路与传统颞下入路显露范围的解剖学对比研究

目的 探讨颞下锁孔入路与传统颞下入路的显露范围差异．及各入路的适用范围。方法 对8例经10％甲醛溶液固定的成人尸头湿标本，依次模拟颞下锁孔入路、保留颧弓颞下入路和去颧弓颞下入路手术，显微镜下观察各入路的显露范围．再运用神经导航系统测量并比较各入路下重要结构的显露长度。结果 在保留颧弓颞下入路中均可显露床突周围位置较低的结构．但2例标本因颞肌遮挡，显露下丘脑、中脑、大脑后动脉P2段等位置较高的结构困难．其中1例高位基底动脉分叉部及大脑后动脉P1段显露困难。去颧弓颞下入路与颞下锁孔入路中上述所有结构，尤其是位置较高的结构均很容易显露。量化研究显示颞下锁孔入路中小脑幕缘显露长度与传统颞下入路无显著差异；脑干腹侧面显露长度与去颧弓颞下入路无显著差异．但大于保留颧弓颞下入路中的显露长度（P〈0．05）。结论 三种入路均可用于鞍区和岩斜区绝大多数病变手术，但中脑、下丘脑、高位大脑后动脉和基底动脉动脉瘤等手术在保留颧弓颞下入路中可能因显露不良而使手术操作困难。

Comparison study on anatomy and surgical exposure of subtemporal keyhole approach and traditional subtemporal approach

Objective To compare the surgical exposure of subtemporal keyhole approach and traditional subtemporal approach, and explore their applications. Methods Surgeries via subtemporal keyhole approach and traditional subtemporal approach with and without preservation of the zygomatic arch were performed in turn on each head of 8 adult formalin-fixed cadaveric heads. The surgical exposure was observed under microscope. The exposure lengths of important intracranial structures were measured and compared by neuronavigation system. Results Paraclinoid structures in lower position could be exposed via subtemporal approach without zygomatic arch removal in each head. But higher structures, such as hypothalamus structures, mesencephalon and P2 segment of posterior cerebral artery (PCA) in two heads, and high basilar bifurcation and P1 segment of PCA in one of them were difficult to be exposed because of obstruction of view by temporal muscle. All the structures exposed by subtemporal approach without zygomatic arch removal could be observed easily, especially those in higher position. There was no significant difference between the length of the tentorial edge exposed via subtemporal keyhole approach and traditional subtemporal approach. And there was no significant difference between length of the anterior surface of the brain stem exposed via subtemporal keyhole approach and subtemporal approach with zygomatic arch removal. But the length of the anterior surface of the brain stem exposed via subtemporal approach without zygomatic arch removal was shorter than that via subtemporal keyhole approach (P<0.05). Conclusions The three approaches are suitable to most operations for lesions in the sellar and petrosa regions. But the operations for the lesions to the mesencephalon, hypothalamus and high aneurysms located at PCA and basilar artery may be difficult via subtemporal approach without zygomatic arch removal because of difficulty in satisfactory exposure.