完全神经内镜下经Poppen锁孔入路松果体区手术的应用解剖学研究

目的 解剖观察完全神经内镜下经Poppen锁孔入路开颅松果体区手术的相关解剖结构及其特征,并探讨该术式的可行性。方法 选取12具经10%甲醛固定、红蓝乳胶灌注的成人尸头湿标本进行实验观察,其中男7例、女5例,年龄34~71岁。应用随机数字表法将12具标本随机分为内镜组和显微组,每组6具,分别采用完全神经内镜Poppen锁孔入路和显微镜常规Poppen入路进行模拟开颅手术松果体区手术。模拟手术中,利用神经导航对松果体区以及手术间隙进行观察测量：（1）观察2组松果体区重要解剖结构;（2）内镜组术中,于剪开小脑幕前后,分别测量松果体区暴露面积,并采用配对t检验进行比较;（3）内镜组与显微镜组术中,分别测量第1、2、3手术间隙的暴露面积,并采用独立样本t检验进行组间比较;（4）其他重要解剖结构间距的神经内镜测量。结果 （1）2种入路均可观察到双侧基底静脉、小脑中脑裂静脉、大脑内静脉、大脑后动脉、小脑上动脉等重要血管,以及滑车神经、四叠体、胼胝体压部和松果体等重要解剖结构,但显微镜常规Poppen入路的手术通道狭窄、倾斜,视野局限。（2）内镜组模拟手术中,剪开小脑幕前后松果体区显露面积分别为（73.14±3.38）mm²和（127.77±7.90）mm²,剪开后明显大于剪开前,差异有统计学意义（t=28.84,P<0.001）。（3）内镜组和显微镜组模拟手术中,第1、2、3手术间隙的暴露面积分别为（20.93±2.49）mm²、（72.55±4.18）mm²、（208.57±11.79）mm²和（9.12±1.12）mm²、（53.45±3.17）mm²、（175.29±9.98）mm²,内镜组均大于显微镜组,差异均有统计学意义（t=14.92、12.61、7.41,P值均<0.001）。（4）神经内镜测量显示：双侧基底静脉最大距离为（14.41±0.94）mm,双侧小脑中脑裂静脉最大距离为（8.23±0.84）mm,双侧大脑内静脉最大距离为（8.41±0.96）mm,双侧大脑内静脉最小距离（第1间隙最窄长度）为（2.58±0.22）mm,松果体中心点至丘脑枕部中心点距离为（16.83±1.16）mm。结论 完全神经内镜下经Poppen锁孔入路模拟手术中间隙恒定,可安全到达松果体区;与显微镜常规Poppen入路相比,完全神经内镜Poppen锁孔入路的手术操作空间更大,松果体区显露得更充分。

Applied anatomical study of pineal region surgery using the Poppen keyhole approach under complete neuroendoscope

Objective To investigate the anatomical characteristic of the operation of pineal region craniotomy using the Poppen keyhole approach with complete neuroendoscope, and explore its feasibility. Methods Twelve adult head wet specimens, including 7 males and 5 females aged 34-71 years, fixed with 10% formaldehyde and perfused with red and blue latices were used for the experiment wet head specimens from adults, were fixed with 10% formaldehyde and perfused with red and blue milk for the experiments. The 12 specimens were randomly divided into the endoscopic group (six specimens) and microscopic group (six specimens) using random number table method. A simulated craniotomy surgery was performed using the complete neuroendoscopic Poppen keyhole approach in the endoscopic group and the conventional Poppen approach with a microscope in the microscopic group. The pineal region and the surgical space were observed with neuronavigation during the operation. (1)The important anatomical structures of pineal region were observed during the simulated operation in the two groups. (2) In the endoscopic group, the exposed area of the pineal region before and after tentorial incision was measured during the simulated operation and compared through paired t-test. (3)During the simulated operation, the exposed areas of the first, second, and third operation spaces of the two groups were measured. The comparison between the two groups was performed through independent sample t-test. (4) The spacing of other important anatomical structures were measured in endoscopic. Results (1) The important blood vessels such as bilateral basal vein, middle cerebellar fissure vein, internal cerebral vein, posterior cerebral artery, superior cerebellar artery, and other important anatomical structures such as trochlear nerve, quadrigeminal body, splenium of corpus callosum and pineal gland were observed in both approaches. However, the conventional Poppen approach had narrow and oblique surgical access and limited visual field. (2) During the simulated operation in the endoscopic group, the exposed area of the pineal region before and after the tentorium cerebelli cut was (73.14±3.38) and (127.77±7.90) mm², respectively, with a statistically significant difference (t=28.84, P<0.001). (3) Moreover, the exposure areas of the first, second, and third operation spaces were (20.93±2.49), (72.55±4.18), and (208.57±11.79) mm², respectively. Meanwhile, during the simulated operation in the microscopic group, the exposure areas of the first, second, and third operation spaces were (9.12±1.12), (53.45±3.17), and (175.29±9.98) mm², respectively. Significant differences were observed between groups (t=14.92, 12.61, 7.41; all P values<0.001). (4) The maximum distance between the bilateral basal veins was (14.41±0.94) mm, the maximum distance between the bilateral middle cerebellar fissure veins was (8.23±0.84) mm, the maximum distance between the bilateral internal cerebral veins was (8.41±0.96) mm, and the minimum distance between the bilateral internal cerebral veins (the narrowest length of the first gap) was (2.58±0.22) mm. The distance from pineal center to occipital center of thalamus was (16.83±1.16) mm. Conclusion The pineal region can be safely reached by means of the Poppen keyhole approach with complete neuroendoscope, and its three surgical spaces are constant. Compared with the conventional Poppen approach under a microscope, the operation space of the Poppen keyhole approach with complete neuroendoscope is larger and the pineal region is more fully exposed.