翼点入路经终板切除鞍区肿瘤的显微外科技术

目的 探索利用终板切开更好地显露肿瘤,争取对颅咽管瘤和巨大垂体瘤、胚胎瘤、脑膜瘤实施全切手术。方法 自1994年至1998年所施行的347例鞍区肿瘤中,有44例需切开终板行肿瘤切除。视交叉前置和侵及三脑室前部的肿瘤是施行终板切开的适应证,此种情况可在术前MR片上获取有益信息。终板切开前,仔细地解剖侧裂池、颈动脉池、视交叉池,分离切断蛛网膜连结是暴露终板的前提条件。沿同侧视束切开终板、注意辨识和保护视交叉及对侧视束是防止术后视力下降、视野缺失的关键。肿瘤的囊内分块切除,联合间隙1、间隙2,牵引剥离肿瘤是既能全切肿瘤,又能防止术后下丘脑、丘脑受损的有效方法。结果终板切开结合间隙1、间隙2切除鞍区肿瘤,全切率达84％(37/44),其中颅咽管瘤全切率为94％(29/31),垂体瘤为89％(8/9)。术后死亡率为14.6％,死因多为癫痫大发作或持续癫痫。结论 终板附近有下丘脑等重要神经结构,此区手术如方法得当不会损伤上述重要结构,并能达到全切肿瘤的目的。

Microsurgical Techniques of Removal of Neoplasms of Sellar Region via Pterional Approach Through Lamina Terminalis

Objective To discuss the techniques and results of opening of the lamina terminalis, which is used for the exposure and total removal of the tumors of the sellar region,such as craniopharyngiomasjarge pituitary adenomas,germ cell tumors and meningiomas through the pterional approach. Methods Forty-four of 347 patients with tumors of the sellar region, who were treated in our department from 1994 to 1998, underwent opening of the lamina terminalis to remove the tumors. Prefixed optic chiasma and the tumors invading into the anterior portion of the third ventricle, which could be known from the preoperative MRI, were the indications of the opening the lamina terminalis. Careful dissection of the sylvian cistern, carotid cistern and chiasmatic cistern and divorce of the arachnoid connection were necessary for the exposure of the lamina terminalis. It was important to make a incision parallel to the ipsilateral optic tract on the lamina terminalis and to distinguish and protect the optic chiasm and the contralateral optic tract in order to prevent the postoperative deficit or even loss of the visual acuity and field. The intratumoral removal, traction and striping of the tumors via the space 1 and space 2 were the effective methods of the total removal and preventing the damage to the hypothalamus or the thalamus. Results Opening of lamina terminalis and/or space 1 and space 2 was used for the removal of the tumors in the sellar region. The rate of total removal of the sellar region tumors was 84% (37/44), and the rates of the total removal of the craniopharyngiomas and pituitary adenomas was 94% (29/31) and 89% (8/9) respectively. The postoperation mortality was 14.6%, resulting from grand mal and persistent epileptic state which appeared frequently in the reoperative patients with recurrent tumors. Conclusions There are the hypothalamus and other important nuclei near the lamina terminalis, but the surgical techniques presented here, by which the tumors in the sellar region can be totally removed, can prevent these important structures from damage.