经鼻内窥镜泪囊鼻腔造口自体组织移植泪道再造术的应用解剖

目的:研究泪道的显微外科应用解剖,为经鼻内窥镜泪囊鼻腔造口自体组织移植泪道再造手术提供解剖学依据。方法:对20个成人尸头的40侧泪道标本进行了手术显微镜下解剖观察和测量。观察泪囊和鼻泪管在鼻腔外侧壁的投影和毗邻关系,测量泪囊窝的长径、前后径、深度。测量泪囊窝内侧壁的厚度,测量骨性鼻泪管上口、中部和下口的口径,并根据椭圆面积公式计算出骨性鼻泪管上口、中部和下口的横截面积。测量泪阜-鼻腔及泪囊的水平距、30°斜距、45°斜距。测量泪阜-鼻泪管上口距离和泪阜-鼻泪管上口连线与鼻底平面的夹角。结果:泪囊窝的长径为(17.85±1.72)mm,泪囊窝的前后径为(6.74±1.28)mm,深度为(3.09±0.78)mm。泪囊窝中1/3部在泪前嵴、泪囊窝骨壁中垂线和泪后嵴的厚度分别为(4.03±0.89)mm,(0.61±0.36)mm,(0.63±0.24)mm,泪前嵴最厚(F检验,P<0.05),泪囊窝骨壁中垂线处和泪后嵴(即:泪囊窝中央和中央偏稍后部)均较薄,两者比较差异具无显著性意义(Q检验,P>0.05)。骨性鼻泪管上口、中部和下口横截面积分别为(29.04±3.40)mm2,(26.19±2.96)mm2,(43.50±5.60)mm2,显示中段最为狭窄(Q检验,P<0.05)。泪阜-鼻腔水平距、30°斜距和45°斜距分别为(17.23±0.70)mm,(14.51±1.72)mm,(17.34±2.38)mm,30°斜距最短,30°斜距和45°斜距比较差异无显著性意义(Q检验,P>0.05)。泪阜到鼻泪管上口距离为(11.86±1.84)mm,泪阜到鼻泪管上口连线与鼻底平面的夹角为49.9°±1.8°(48.0°~54°)。结论:泪阜到鼻腔及泪囊的距离和泪阜-鼻泪管上口连线与鼻底平面的夹角对鼻腔外侧壁造口部位选择、隧道的倾斜角度和自体移植组织长短的确定有指导意义。造骨孔应该从泪囊窝中央或中央稍偏后部起始,然后向前和下方扩大,隧道下斜45°为最佳。全泪道再造所取移植组织的长度应大于21.22mm。

Applied anatomy of endoscopic transnasal lacrimal duct reconstruction with grafting of autogenous tissue

AIM: To study applied microsurgical anatomy of lacrimal duct and to provide detailed knowledge of this region for the surgery of endoscopic transnasal lacrimal duct reconstruction with grafting of autogenous tissue.·METHODS: Forty optic lacrimal duct specimens in 20 fixed human cadaver heads were observed and measured under the operating microscope. The profiles of lacrimal sac and nasolacriamal duct were traced on the lateral wall of the nasal cavity. The diameters and depths of lacrimal fossa, and its thickness of inner wall were detected. The calibers of upper opening, middle part and lower opening of nasolacrimal canal were measured, and the transverse area was calculated according to the ellipse proportion formula. Horizontal distance, 30 oblique distance, 45 oblique distance from lacrimal caruncle to lateral wall of the nasal cavity and lacrimal sac were determined, respectively. The distance from lacrimal caruncle to upper opening of lacrimal canal and its oblique angle were measured. The detailed anatomic relations among these structures were carefully identified.·RESULTS: The length, width and depth of lacrimal fossa were 17.85±1.72mm,6.74±1.28mm,3.09±0.78mm,respectively. At middle one-third, the thickness of the lacrimal fossa wall at anterior lacrimal crest, vertical middle line, posterior lacrimal crest was 4.03±0.89 mm,0.61±0.36 mm,0.63±0.24mm, respectively. Anterior lacrimal crest was the thickest (F test,P<0.05), the part of vertical middle line and posterior lacrimal crest ( i.e. the center and posterior middle part of lacrimal fossa) was thinner, and there was no significant difference between two parts (Q test, P>0.05). The transverse area at upper opening, middle part and lower opening of the nasolacrimal canal were 29.04±3.40mm2,26.19±2.96mm2,43.50±5.60mm2, respectively, showing that middle part was the narrowest (Q test, P<0.05). Horizontal distance, 30ooblique distance, 45ooblique distance from lacrimal caruncle to lateral wall of the nasal cavity were 17.23±0.70mm, 14.51±1.72mm, 17.34±2.38mm, respectively,30ooblique distance was the shortest (F test, P<0.05). Comparing horizontal distance with 45ooblique distance, there was no significant difference (Q test, P>0.05). The distance from lacrimal caruncle to upper opening of lacrimal canal was 11.86 1.84mm (9.58-13.5 mm), its oblique angle was 49.9±1.8(48-54 ).·CONCLUSION: The distance from lacrimal caruncle to lateral wall of the nasal cavity and lacrimal sac are helpful and with guidance significance for deciding the place of making bony hole, tunnel oblique angle and the lengths of of autogenous tissue graft. Making bony hole shall start at middle or posterior middle part and extend to lower and front part, 45 is the best tunnel oblique angle. The length of tissue graft for total lacrimal duct reconstru-ction should be longer than 21.22mm. ·