海绵窦内侧壁的显微解剖与扩大经蝶窦入路治疗侵袭海绵窦的垂体腺瘤（附103例分析）

目的研究海绵窦内侧壁结构的解剖特点，并探讨采用扩大经蝶窦入路治疗侵袭海绵窦垂体腺瘤的方法。方法在10具成人新鲜尸头上模拟扩大经蝶窦手术入路，观察海绵窦内侧壁结构的解剖特点。根据解剖学研究结果，指导临床采用扩大经蝶窦手术入路治疗侵袭海绵窦的垂体腺瘤103例。结果垂体侧方的海绵窦内侧壁薄弱，仅有一层疏松的纤维组织结构。颈内动脉是扩大经蝶窦入路海绵窦内所见的主要结构，可分为5段，有3个主要分支。颈内动脉海绵窦段主要的分支有脑膜垂体干、海绵窦下动脉和被囊动脉。向内侧走行的脑膜垂体干和被囊动脉是经蝶窦入路中较易损伤的血管。手术显微镜下全切除肿瘤62例（60．2％），次全切除38例（36．9％），大部切除3例（2．9％）；无手术死亡；手术并发症包括短暂性脑脊液鼻漏5例，暂时性脑神经功能损伤4例，垂体功能低下3例，颈内动脉损伤2例，永久性尿崩症1例。术后行放射治疗17例，γ刀治疗15例，药物治疗13例。随访3个月～8年，2例出现肿瘤复发而予以γ刀治疗。无再手术病例。结论扩大经蝶窦入路是切除侵袭海绵窦垂体腺瘤理想的入路；了解颈内动脉海绵窦段及其分支在解剖形态上的变化，对于减少术中出血，确保术中安全，具有重要意义。

Microsurgical anatomy of the medial wall of cavernous sinus and removal of pituitary adenoma invading to the cavernous sinus through extended transsphenoidal approach: analysis of 103 cases

Objective To study the anatomical features of the medial wall of the cavernous sinus （CS） and the surgical methods via extended transsphenoidal approach for invasive pituitary adenoma. Methods Simulated extended transsphenoidal approach was used for observing the appearance characteristic of the CS medial wall on ten adult cadaver heads and study the relation of the cavernous internal carotid artery to the pituitary gland under microscope. The surgery was guided by the anatomic results. The clinical data and follow-up results of 103 consecutive patients with pituitary adenoma invasive to the cavernous sinus undergoing surgery via extended transsphenoidal approach was analyzed retrospectively. Results The medial wall ofparapituitary CS has only one layer loose fibrous tissue. The internal carotid artery is a main structure which was seen in the CS via extended transsphenoidal approach, can be divided into 5 segments and has 3 major branches： meningohypophyseal trunk, hypocavernous artery and McCormell capsular artery. The meningohypophyseal trunk and McCormell capsular artery are prone to be damaged in the operation. The clinic data involved 42 males and 61 females. Total tumor removal was achieved in 62 cases （60.2%）, subtotal removal in 38 （36.9%）, and partial removal in 3 （2.9%）. There was no operative mortality. Transient postoperative complications included CSF leakage in 5 cases, partial cranial nerve palsy in 4, and acute panhypopituitarism in 3, carotid artery injury in 2, and permanent diabetes insipidus and panhypopituitarism in 1 each. The follow-up period ranged from 3 months to 8 years. The tumor recurred in two patients and then was treated with Gamma knife. No patient needs re-operation. Conclusion The extended transsphenoidal approach provides an excellent exposure of the tumor invasive to the cavernous sinus. The rate of total tumor removal is high, while the complication is few. Understanding these anatomical and morphological features of the cavernous sinus in this region is mo