经鼻内镜蝶鞍区手术的立体解剖研究方法

目的 探讨一种立体解剖学方法,研究经鼻内镜蝶鞍区手术中重要解剖结构的空间关系,为经鼻内镜蝶鞍区手术提供立体解剖学参考.方法 ①改进MicronTracker双日视觉导航仪,并检验其测量角度与距离的准确性.②依次暴露10具(20侧)去脑颅底湿标本蝶鞍区重要结构,以S点(同侧鼻棘侧缘点)和M点(上颌线中点)为基准点,鼻底平面和正中矢状面为基准平面,应用MicronTracker双目视觉导航仪测量基准点到各解剖标志连线的俯仰角、方向角和距离,并行统计学处理.③利用3D-max和AutoCAD-2008软件建立蝶鞍区解剖结构的立体模型.结果 ①改进的MicronTracker双目视觉导航仪与游标卡尺及角度转台之间的测量值差异无统计意义(P值均>0.05).②测量得到了蝶窦口、视神经-颈内动脉隐窝、球形鞍底、蝶窦后壁、斜坡中部顶点及外侧顶点等重要结构或标志的定位数据.③应用3D-max 9.0和AutoCAD-2008软件建立蝶鞍区解剖结构的立体模型.结论 应用改进MicronTracker双目视觉导航仪可得到蝶鞍区重要解剖结构定位数据,并在此基础上建立经鼻内镜蝶鞍区手术解剖结构的立体构象.     

Computer-assisted surgical navigation in revision endoscopic sinus surgery

The anatomical variations of surgical landmarks associated with revision endoscopic sinus surgery (ESS) represent a significant challenge even to the most experienced surgeon. Multiple studies have demonstrated higher rates of both minor and major complications associated with revision cases. In the past decade, the availability of multiple computer-assisted surgical navigation systems has resulted in its widespread adoption as a tool in ESS.Computer-aided surgery (CAS) allows for triplanar anatomic localization, which may improve spatial orientation and help avoid trauma to vital structures, namely the orbit and anterior skull base.Theoretically, this would result in a lower rate of complications and a more complete surgical exploration. Future advances in CAS involve real-time computer-assisted surgical navigation using an operating room-based CT, C-arm, or MRI unit.     

Experience with various 3-dimensional navigation systems in head and neck surgery

OBJECTIVE: To evaluate the benefits and difficulties encountered when using various 3-dimensional (3-D) navigation systems in head and neck procedures. DESIGN: Five different navigation systems were used for preoperative planning and intraoperative 3-D navigation in procedures at the paranasal sinuses, the frontal and lateral skull bases, and the petrous bone. INTERVENTION: Intraoperative 3-D localizing systems (position-sensitive mechanical arms, infrared cameras, etc) demand reliable patient fixation on the operating table. We achieved this by developing a noninvasive head holder. Other systems allow patient movements by using magnetic digitizing technology (ARTMA System) and sophisticated programming. RESULT: Having surpassed an initial learning curve, we now achieve an accuracy of 1 to 2 mm regularly. Especially in paranasal and frontal basal surgery, all navigation systems used provide valuable positioning information during surgery. In particular for revision or tumor surgery, decisive benefits resulted from use of these systems: shorter overall operation time; safer manipulation near delicate structures; and reliable identification of the skull base even in patients with bleeding, scarring, or missing anatomical landmarks. CONCLUSIONS: We performed approximately 250 operations with different systems and introduced navigation at the lateral skull base and the petrous bone with mechanical, optic, and magnetic digitizers. In these anatomical areas, navigation was used successfully; the technical challenge is greatest at the lateral skull base, however.     

颅底临床解剖标志与颅底肿瘤手术的安全性

目的 探讨颅底手术的重要解剖标志，保证颅底手术的安全性并彻底根治肿瘤。方法 对我院10年来29例不同颅底手术进行回顾性总结，分析颅底的鸡冠、翼突和颞骨棘、茎突和颈内动脉及其各自的毗邻解剖结构在术前诊断、不同手术进路切除肿瘤时的应用情况。结果 本组初期3例手术中有2例术后颅底有部分肿瘤残留；其余26例颅底手术中，皆在直视下完全切除肿瘤，无手术死亡及严重颅脑并发症。本组29例中，侵犯颅底的恶性肿瘤行不同的颅底手术19例，其3年生存率为72．2％(13／18)，5年生存率为35．7％(5／14)。结论 鸡冠、翼突和颞骨棘、茎突和颈内动脉及其各自的毗邻解剖结构分别是不同的颅底手术重要标志，正确认识这些临床解剖标志是颅底手术安全成功的保证。     

影像导航下鼻内镜手术58例临床分析

OBJECTIVE: To evaluate the availability and our experience of intraoperative image-guidance in endoscopic nasal surgery. METHODS: Fifty-eight cases of endoscopic nasal surgery with intraoperative image-guidance were retrospectively reviewed, including 39 cases of chronic sinusitis with or without nasal polyp; 3 cases of necrotizing maxillary sinusitis; 6 cases of sphenoid sinus cyst; 2 cases of nasopharyngeal angiofibroma; 1 case of cranio-nasal meningioma; 1 case of traumatic cerebrospinal rhinorrhea; 1 case of traumatic optic nerve lesion. All patients were operated on with Brain Lab operation imaging navigation system and nasal endoscope. RESULTS: The preoperative preparatory time would take 10-20 minutes, including coordination, head holder localization, conventional instrument registration. In our cases, the localization accuracy between 3-D image landmarks of navigation system and actual anatomical landmarks was less than 1.5 mm. The optic nerve and other anatomical points could be orientated accurately in intraoperative procedures. No complication occurred. CONCLUSIONS: Nasal endoscope combined with image-guidance systems provides accurate anatomical localization of nasal cavity, sinuses and anterior skull base with enlarged operation field. It is possible for surgeons to observe the surrounding important anatomical structures during endoscopic nasal surgery. It could increase the effectiveness and decrease surgical complications, especially in complicated cases.     

成人侧颅底临床解剖学研究

目的:通过对侧颅底重要解剖标志的观察与测量.为临床侧颅底手术的定位、导航提供解剖学依据.方法:20具40侧10%甲醛浸泡的成人尸头(黄种人)和20例临床手术患者进行侧颅底指引标志的观察与测量.尸头标本按1～40的顺序进行编号;20侧临床手术患者按1～20的顺序进行编号.结果:通过测量得出侧项底相关定位标志的解剖数据:颈静脉孔静脉部、神经部与颅底重要指引标志的距离;迷路三角、迷路后三角及乳突表面三角的面积;侧颅底手术中面神经主动移位的最大距离.结论:耳科与颅底外科的手术几乎均在深埋于颅(颞)骨的狭窄空间内操作,周围布满了重要的血管和神经,术者了解侧颅底重要标志的定位测量数据有利于手术中安全扩大手术视野,有效避免术中损伤重要血管、神经,最大限度地保留面神经功能,最终提高患者的生存质量.     

计算机辅助导航技术在鼻窦及鼻颅底手术中的应用

目的:探讨计算机辅助导航技术在鼻窦及鼻颅底手术中的应用价值。方法:49例患者(复发性鼻窦炎、鼻息肉25例,鼻腔鼻窦肿瘤9例,脑脊液鼻漏7例,脑膜脑膨出2例,先天性后鼻孔闭锁4例,垂体瘤1例,中颅窝底异物1例)均在计算机辅助导航下行鼻内镜手术。结果:计算机辅助导航术前准备时间为5～13min,平均7min,靶点误差≤1.5mm。49例患者均顺利完成手术,无并发症出现。结论:计算机辅助导航系统有助于术者正确判断鼻窦、颅底及相邻的解剖标志,可提高手术的精确性和安全性,减少术中及术后并发症的发生。     

影像导航系统在复杂鼻颅底内镜手术中的应用

目的 评价影像导航系统在复杂鼻颅底内镜手术中的作用。方法 26例中额窦复发性内翻性乳头状瘤2例,鼻腔鼻窦肿瘤侵及颅底5例,垂体腺瘤7例,创伤性视神经病12例,均应用影像导航系统行鼻内镜手术。结果 影像导航术前准备时间(包括配准、头架定位、常规器械注册等) 5～10min, 平均7min。手术区域影像标志与实体解剖标志间的误差≤1. 5mm,手术均顺利完成,术中、术后未出现并发症。结论 导航系统定位准确, 能帮助术者确定术区周围重要解剖结构,可以实时判定肿瘤切除程度, 能够最大限度地切除肿瘤, 减少并发症。尤其在有既往手术史或病变破坏了鼻鼻窦及颅底解剖标志的情况下,导航系统对术者的帮助更大,增强了术者自信心,提高了手术的安全因素,保证了肿瘤切除的彻底性。     

颅底临床解剖标志与颅底肿瘤手术的安全性

目的　探讨颅底手术的重要解剖标志 ,保证颅底手术的安全性并彻底根治肿瘤。方法对我院 10年来 2 9例不同颅底手术进行回顾性总结 ,分析颅底的鸡冠、翼突和颞骨棘、茎突和颈内动脉及其各自的毗邻解剖结构在术前诊断、不同手术进路切除肿瘤时的应用情况。结果　本组初期3例手术中有 2例术后颅底有部分肿瘤残留 ;其余 2 6例颅底手术中 ,皆在直视下完全切除肿瘤 ,无手术死亡及严重颅脑并发症。本组 2 9例中 ,侵犯颅底的恶性肿瘤行不同的颅底手术 19例 ,其 3年生存率为 72 2 % (13/ 18) ,5年生存率为 35 7% (5 / 14 )。结论　鸡冠、翼突和颞骨棘、茎突和颈内动脉及其各自的毗邻解剖结构分别是不同的颅底手术重要标志 ,正确认识这些临床解剖标志是颅底手术安全成功的保证     

Navigation und Robotik an der Otobasis

Computer-aided microscopic surgery of the lateral skull base is a rare intervention in daily practice. It is often a delicate and difficult minimally invasive intervention, since orientation between the petrous bone and the petrous bone apex is often challenging. In the case of aural atresia or tumors the normal anatomical landmarks are often absent, making orientation more difficult. Navigation support, together with imaging techniques such as CT, MR and angiography, enable the surgeon in such cases to perform the operation more accurately and, in some cases, also in a shorter time. However, there are no internationally standardised indications for navigated surgery on the lateral skull base. Miniaturised robotic systems are still in the initial validation phase.     

Vidian canal: analysis and relationship to the internal carotid artery

OBJECTIVES: The purpose of this study is to describe the anatomy and relationships of the vidian canal to known endonasal and skull base landmarks. This will allow the endoscopic skull base surgeon to safely approach the anterior genu of the petrous carotid artery during expanded endonasal approaches to the skull base. STUDY DESIGN: The study is a prospective cohort study. METHODS: Axial, coronal, and sagittal computed tomography scans of the paranasal sinuses and skull base of 44 patients were examined. Individuals with known skull base pathology were excluded. Measurements included the length of the vidian canal, the relationship of the vidian canal to the anterior genu of the petrous carotid artery, and the type of pneumatization of the sphenoid sinus as it pertains to foramen rotundum and the vidian canal. In addition, we will focus on the relationship of the vidian canal to the sphenopalatine foramen and base of the medial pterygoid plate. RESULTS: The degree of pneumatization of the sphenoid sinus is highly variable. The mean length of the vidian canal is 18 mm (10-23 mm). The vidian canal is found entirely within bone in 27% to 30% of scans reviewed. The anterior genu of the petrous internal carotid artery is found superior-medial to the vidian canal in 44 of 44 of the CT scans reviewed. The vidian canal runs medial to lateral in 93% to 98% of patients studied. CONCLUSIONS: As a result of this study the endoscopic skull base surgeon has a number of anatomical landmarks and measurements that may be helpful in safely localizing the anterior genu of the petrous internal carotid artery during expanded endonasal approaches to the skull base.     

Guided surgery in a subtemporal approach in CPA tumors?

BACKGROUND: Computer assisted surgery (CAS) permits the visualization of hidden bony covered structures invisible for the human eye with radiological 3d data sets. The surgeon might be able to orientate anatomically during surgery without having to prepare the according landmarks. This would mean less surgical traumatization and a shorter and smaller operation corridor. METHOD: We determined the use of CAS in a quality assurance analysis with the subtemporal approach in 8 patients with supra-meatal tumors type A of the cerebellopontine angle. Various navigation systems and methods for referencing for the registration of the patients' heads were used. The question was whether it is possible intraoperatively without preparation of known anatomical landmarks to define the borders of an optimal positioned temporary bone cap and to identify the bony covered inner auditory canal and its neuronal structures without orienting neurostimulation. RESULT: It was possible with CAS to assess intraoperatively the borders of a temporary bone cap above the cranially positioned mastoid cell. However, the objective inaccuracy of 2 to 28 mm observed during surgery did not allow a secure identification of the inner auditory canal. CONCLUSIONS: CAS with the subtemporal approach cannot replace the conventional preparation of known anatomical landmarks nor neurostimulation to identify neural structures, due to the expected high inaccuracy with the non-invasive referencing systems that are available today.     

影像导航下鼻内镜手术58例临床分析

目的　探讨影像导航技术在鼻内镜手术中应用的有关问题。方法　回顾性分析 5 8例患者 ,其中慢性鼻窦炎、鼻息肉 39例、孤立性蝶窦炎 6例、坏死性上颌窦炎 3例、蝶窦囊肿 5例、鼻咽纤维血管瘤 2例 ;鼻颅沟通性脑膜瘤、外伤性脑脊液鼻漏、外伤性视神经损伤各 1例。所有病例均采用BrainLab影像导航系统及鼻内镜实施手术。结果　影像导航术前准备时间 (包括配准、头架定位、常规器械注册等 ) 10～ 2 0min ,平均 15min。 5 2例手术区域影像标志与实体解剖标志间的误差≤ 1 5mm ,6例 >3mm。影像导航可准确定位视神经等解剖标志 ,无手术并发症发生。结论　影像导航系统与内镜相驳接 ,不仅可以帮助术者在术中定位鼻腔、鼻窦、颅底的解剖结构 ,并可使手术视野扩展到内镜之外 ,使术者在术野中进行手术操作的同时 ,能顾及到术野周围的重要结构。特别是在复杂的手术中 ,可提高手术的精确性和安全性     

Application of the navigation system in endoscopic surgery of paranasal sinuses and base of the skull

The intraoperative navigation computer system Stealth Station is an effective technique of stereotactic guidance during endoscopic endonasal interventions. Use of navigation allows performance of a radical operation without damaging basic anatomical structures of the base of the skull (vision nerve, cribriform lamina, internal carotid arteries, cavernous sonus, etc.). In rhinosurgery, Stealth Station is indicated in borderline pathology of the paranasal sinuses and base of the skull. Ten cases of patients with combined pathology of the paranasal sinuses and base of the skull, cases of endoscopic endonasal removal of the lesions of the base of the skull and foreign bodies with application of the navigation system are reported.     

Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model

INTRODUCTION: The pterygopalatine fossa (PPF) is a narrow space located between the posterior wall of the antrum and the pterygoid plates. Surgical access to the PPF is difficult because of its protected position and its complex neurovascular anatomy. Endonasal approaches using rod lens endoscopes, however, provide better visualization of this area and are associated with less morbidity than external approaches. Our aim was to develop a simple anatomical model using cadaveric specimens injected with intravascular colored silicone to demonstrate the endoscopic anatomy of the PPF. This model could be used for surgical instruction of the transpterygoid approach. METHODS: We dissected six PPF in three cadaveric specimens prepared with intravascular injection of colored material using two different injection techniques. An endoscopic endonasal approach, including a wide nasoantral window and removal of the posterior antrum wall, provided access to the PPF. RESULTS: We produced our best anatomical model injecting colored silicone via the common carotid artery. We found that, using an endoscopic approach, a retrograde dissection of the sphenopalatine artery helped to identify the internal maxillary artery (IMA) and its branches. Neural structures were identified deeper to the vascular elements. Notable anatomical landmarks for the endoscopic surgeon are the vidian nerve and its canal that leads to the petrous portion of the internal carotid artery (ICA), and the foramen rotundum, and V2 that leads to Meckel's cave in the middle cranial fossa. These two nerves, vidian and V2, are separated by a pyramidal shaped bone and its apex marks the ICA. CONCLUSION: Our anatomical model provides the means to learn the endoscopic anatomy of the PPF and may be used for the simulation of surgical techniques. An endoscopic endonasal approach provides adequate exposure to all anatomical structures within the PPF. These structures may be used as landmarks to identify and control deeper neurovascular structures. The significance is that an anatomical model facilitates learning the surgical anatomy and the acquisition of surgical skills. A dissection superficial to the vascular structures preserves the neural elements. These nerves and their bony foramina, such as the vidian nerve and V2, are critical anatomical landmarks to identify and control the ICA at the skull base.     

电磁导航技术在鼻颅底手术中的应用

摘要：目的探讨电磁导航技术在鼻颅底手术中的临床应用。方法收集 2017 年 8月—2019 年 2月应用电磁导航技术行 15例鼻颅底手术,患者病变范围涉及蝶窦、鞍区、咽旁隙、颈静脉孔区、筛顶、蝶骨平台等解剖区域。术前均完善 CT、MRI 等影像学资料,录入导航系统行三维重建,鼻内镜下进行手术,涉及复杂、重要解剖结构时使用导航系统进行定位。结果15例手术中1例鼻颅底纤维血管瘤术中出血约1 000 ml,余手术出血均可控。15例手术术中均未出现重要结构损伤,术后无严重并发症。15 例患者术后随访3~20个月,1例鼻颅底腺样囊性癌患者术后12个月复查考虑肿瘤复发。结论电磁导航技术应用于鼻颅底手术中,安全、精准,手术并发症少,特别适用于解剖结果变异、修正鼻内镜手术、病变广泛的恶性肿瘤患者。     

颅底筋膜结构的解剖学研究进展

颅底的筋膜结构是颅底区域最为复杂的结构之一,分隔出了众多的筋膜间隙,其有助于术者在传统的开放式入路手术中对自外侧向中线方向的颅底解剖层次的理解。同时,在颅底外科手术中更是起着重要解剖标志的作用。近20年来,颅底外科的技术和理念出现了重大变革,从以往的开放式入路手术发展到如今占据主流的内镜经鼻或经口手术。但颅底筋膜结构的研究依然存在很多争议,其在内镜经鼻或经口手术入路中的应用解剖学认识及其临床应用价值依然处于探索阶段。本文就近20余年来的颅底筋膜结构的解剖学研究进展进行综述。     

A systematic approach to the interpretation of computed tomography scans prior to endoscopic sinus surgery

Computed tomography (CT) provides an excellent map for the sinus surgeon as well as providing information about the extent of disease and the presence of bony destruction. Surgeons need to be aware of the anatomical configuration of the sinuses and the presence of any structural changes such as a dehiscent lamina papyracea, asymmetric skull base, low level of posterior skull base or an Onodi cell, which place the patient at increased risk. Described here is a six-step guide to help the sinus surgeon avoid missing any of the radiologically important features.     

Innovations in neuroimaging of skull base pathology

Recent advances in CT and MR technology have allowed detailed imaging of the skull base with greater diagnostic accuracy. Innovations such as multidetector volumetric CT scanners with 3-D reconstructions provide soft tissue and bony detail with very high resolution for small structures such as the neural foramina. CT angiography can assess vascular structures noninvasively, and CT perfusion can help differentiate between malignant and benign tumors. MR technology has provided high-resolution, rapid volumetric sequences that are useful in skull base imaging. MR angiography and MR venography can also assess vascular structures noninvasively. PET scanning and CT/PET scanning will increasingly become a mainstay of head and neck tumor imaging for initial staging, monitoring response to therapy,and detecting recurrent disease or metastases. Many more diagnostic imaging options are available to the head and neck surgeon today than ever before.     

Klinische Anatomie der Nasennebenhöhlen

Detailed knowledge of the complicated anatomy and topography of the paranasal sinuses is an essential requirement for successful surgery in this region. The topographical relationship to essential neighbouring structures (vessels, nerves and spaces) must be borne in mind. Typical landmarks play a particularly important role, especially for reliable orientation in endoscopic procedures. Therefore, it must be stressed that detailed anatomical knowledge of the complicated nasal and paranasal architecture is very important for the success of nasal and paranasal surgery, as well as for the avoidance of serious complications. However, this knowledge can only be acquired by performing numerous dissections of the nasal and paranasal system [4] once a good theoretical grasp of the various structures, regions and their nomenclature has been gained. Common anatomical variations, which may lead to complicated and hazardous changes in normal anatomy, are also of particular importance and the surgeon must be familiar with these variations.