神经内镜经鼻蝶窦垂体瘤手术鞍底重建策略

目的探讨神经内镜下经鼻蝶窦入路垂体瘤手术的鞍底重建策略。方法回顾分析神经内镜经鼻蝶窦垂体瘤手术病例165例,总结鞍底重建修补的手术技术及手术策略。术中依据鞍膈损伤程度,采用分类修补方案:(1)术中鞍膈保护完整,颅底缺损较小,无需鞍底重建,仅用明胶海绵填塞,若颅底缺损较大,伴有鞍膈塌陷,可用自体脂肪填塞,人工硬脑膜修复;(2)术中鞍膈局部小破口,需鞍底重建修补,取预留脂肪填塞,人工硬脑膜修复,带蒂粘膜瓣鞍底贴覆;(3)术中鞍膈大破口,可行Gasket seal技术封闭鞍底,人工硬脑膜修复,带蒂粘膜瓣鞍底贴覆,生物蛋白胶固定,膨胀海绵填塞鼻腔。结果 114例(69.1%)鞍膈保护完整,采用1类修补方法,49例(29.7%)术中鞍膈小破口,采用2类修补方法,2例(1.2%)术中鞍膈大破口,采用3类修补方法。术后短暂性脑脊液鼻漏5例,经保守治疗治愈4例,1例患者再次内镜下经鼻入路行颅底重建得以修复,术后随访6个月~5年,有1例患者脑脊液漏复发,经保守治疗治愈。结论术前评估鞍膈厚度,术中评估脑脊液漏程度,对于手术方案的选择具有较大的指导意义,采用鞍底重建分类修补手术,有助于提高手术疗效,降低术后脑脊液漏并发症。

Strategy of sellar floor reconstruction about neuroendoscopic transnasal sphenoid pituitary adenoma surgery

Objective To explore the strategy of sellar floor reconstruction about neuroendo-scopic transnasal sphenoid pituitary adenoma surgery.Methods The clinical data of 165 patients of neuroendoscopic transnasal sphenoid sinus pituitary tumor surgery were analyzed retrospectively.The sellar floor reconstruction surgical techniques and surgical strategies were summarized.Based on the degree of intraoperative CSF leakage, we adopted classification scheme in sellar floor reconstruction. (1) The integrity of saddle diaphragm was protected,There is no need to sellar floor reconstruction. If large pituitary adenoma with skull defects,sellar reconstruction was necessary.Autologous fat local packing and artificial dura mater repair.( 2 ) Local small leakage with intraoperative saddle diaphragm, there must be sellar floor reconstruction.The reserved fat packing and artificial dura mater repair,the mucosal flap with vascular pedicle lay over sellar floor.( 3 ) Large leakage with intraoperative saddle diaphragm,Gasket seal technology was used to close sellar floor.The mucosal flap with vascular pedicle lay over sellar floor.Fibrin glue application.Results The integrity of the saddle diaphragm was protected in 114 ( 69.1%) cases, which were applied in type 1 repair method.49 cases (29.7%) appeared small break in the saddle diaphragm, these patients were applied in type 2 method.2 (1.2%) occurred large break in saddle diaphragm,the 2 were applied in type 3 method.5 presented transient after operation.4 were cured by conservative treatment.1 patient remained CSF two weeks after conservative treatment.This patient was healed with endoscopictranssphenoidal sellar floor repair surgery.Patients followed up for 6 months to 5 years, 1 patient recurrened with cerebrospinal fluid leakage caused by fell after one year of pituitary tumor surgery. With flat bed rest and lumbar drainage, the patient was healed well.Conclusions Preoperative assessment thickness of saddle diaphragm,intraoperative assessment the extent of CSF,are beneficial to the choice of surgical options.Classification scheme in sellar floor reconstruction helps to improve surgery,reduce postoperative complications of cerebrospinal fluid leakage .