鞍区肿瘤所致解剖结构改变的术中初步观察

目的：观察鞍区肿瘤所致解剖结构改变，探讨相关的手术策略。方法：在连续进行的30例经颅鞍区肿瘤显微手术中观察解剖结构改变，包括13例垂体腺瘤、8例颅咽管瘤、6例鞍结节脑膜瘤、1例星形细胞瘤、1例Rathke囊肿和1例胆质瘤，均进行术中照片并记录，并作相互比较，观察细微解剖在手术中的意义与价值。结果：垂体腺瘤多数经间隙1扩展，常经间隙1、2操作，多需要偏前方的翼点入路或额下入路手术。鞍区的颅咽管瘤多经视交叉后扩展，与垂体柄关系密切，一般需经偏侧方的翼点入路手术，充分利用鞍区的多个间隙仔细分离。而鞍结节脑膜瘤起源偏前．向外侧和后方推压视神经和视交叉，间隙1为主要操作间隙．垂体柄也不容易损伤：胆质瘤呈推挤性生长，而胶质瘤则浸润和破坏周围结构，结构辨认难度大。Rathke囊肿起源于垂体腺内，情况因大小而异。结论：不同类型的鞍区肿瘤由于起源部位及扩展方向不同，对邻近结构的推压移位即不同，手术间隙也发生了不同的变化，使各间隙的利用价值不同，应根据肿瘤显露和切除需要规划出个体化的手术入路与操作间隙。无论采用哪种手术入路，都要按照显露好的原则．细心识别和保护鞍区的所有小动脉，努力保持垂体柄的完整性是所有鞍区手术的共同原则。

A preliminary surgical study on morphologic changes of anatomic structures of saddle area caused by sellar tumors

Objective: To observe morphologic changes of anatomic structures of saddle area caused by sellar tumors and explore corresponding surgical strategies. Methods: Morphological changes of anatomic structures were observed in 30 patients suffering sellar tumors received transcranial microsurgical operations, including 13 cases with pituitary adenoma, 8 craniopharyngioma, 6 tuberculum sellae meningioma ,1 astrocytoma, 1 Rathke' cleft cyst,and 1 epidermoid cyst. Intraoperative photos were taken and compared each other to evaluate the importance and value of microanatomy. Results: Pituitary adenomas mostly expanded from space 1. Space 1 and 2 were often used in these operations via anteriorly shifted pterional approach or subfrontal approach. Craniopharyngiomas expanded from posterior margin of optic chiasm with close relation to pituitary stalk. Several spaces were used in the operation via laterally shifted pterional approach. With more anteriorly origin, tuberculum sellae meningioma brought lateral and posterior oppression to optic nerve and optic chiasm. Space 1 was used in its operation and pituitary stalk was not easy to injury. Epidermoid cyst took on swollen growth and glioma took on invasive growth which made peripheral structures difficult to be identified. Rathke' cleft cyst originated from pituitary tissue and intraoperative conditions were various according to its sizes. Conclusions: For different origin positions, expansion directions of tumors and oppression directions of peripheral structures, operative spaces of sellar region are changed differently and their utilization values are various. According to the demand of exposure and resection for tumors, choice of operative approach and space should be individualized. To make good exposure, identify and preserve all small arteries in sellar region and retain integrity of pituitary stalk is common principle for sellar surgery.