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学科主题: 外科学(神外)
题名:
神经内镜下第三脑室肿瘤手术入路解剖研究
作者: 罗雷雷
答辩日期: 2016-05-17
导师: 胡志强
专业: 外科学(神外)
授予单位: 北京大学
授予地点: 北京大学第九临床医学院
学位: 硕士
关键词: 神经内镜 ; 第三脑室 ; 手术入路 ; 解剖
其他题名: Neuroendoscopical anatomy study of surgical approaches to the third ventricle tumor
分类号: R739.41
摘要:

目的  本研究利用新鲜灌注尸头标本模拟临床中行第三脑室手术常用的四种手术入路(经额角侧脑室入路、经胼胝体前部入路、幕下小脑上入路、经枕叶小脑幕入路),神经内镜下观察入路中重要解剖标志及侧脑室、三脑室内重要结构,量化重要解剖部位间距离,探讨各入路特点,为神经内镜下行三脑室手术提供解剖学依据。

方法  在12例新鲜灌注尸头标本上模拟神经内镜下四种手术入路的操作,用Storze 0°角内镜观察经额角-侧脑室入路、经胼胝体前部入路、幕下小脑上入路和枕叶小脑幕入路中的“路标”结构及其与周围组织间位置关系,用精度 0.02mm的游标卡尺测量重要结构间距离。

结果 经额角-侧脑室入路中,脉络丛、丘纹静脉、隔静脉、室间孔为重要的路标结构,脉络丛、丘纹静脉和隔静脉构成“Y”字形,室间孔位于其相交处。室间孔的大小对于该入路的操作至关重要。测得室间孔长径(5.79±0.13)mm,室间孔宽径(3.73±0.17)mm。经室间孔导入神经内镜,在内镜下可清楚的观察到三脑室底解剖结构,从前向后依次是视交叉、漏斗隐窝、灰结节、乳头体、中脑被盖、中脑导水管。测量透明隔前后径(36.57±3.45)mm,透明隔上下径(12.92±1.48)mm,乳头体前缘至漏斗隐窝后缘(5.95±0.95)mm,室间孔至乳头体(14.09±0.85)mm,乳头体前缘至后联合(17.34±0.97)mm。

经冠胼胝体前部入路中,矢点(冠状缝与矢状缝交点)为定位的重要标志,测得眉间距冠矢点距离为(125.56±5.83)mm。冠状缝前2cm,5例标本均无引流静脉,在冠状缝前2cm向下方分离胼胝体,在该处胼胝体厚度为(6.40±0.68)mm。进入侧脑室,可见丘纹静脉、隔静脉、脉络丛和室间孔等重要路标结构,测得室间孔长径(5.79±0.13)mm,室间孔宽径(3.73±0.17)mm。经胼胝体室间孔入路进入第三脑室,测得透明隔前后径(36.57±3.45)mm,透明隔上下径(12.92±1.48)mm,乳头体前缘至漏斗隐窝后缘(5.95±0.95)mm,室间孔至乳头体(14.09±0.85)mm,乳头体前缘至后联合(17.34±0.97)mm。

幕下小脑上入路中,在小脑幕切迹下方,可见Galen静脉、蚓上静脉、枕内静脉等错综复杂的静脉系统。在该区域中,Galen静脉居中,其下部侧边界为小脑幕,外侧和内侧分别可见丘脑后结节和胼胝体压部,下方可见缰三角,再下方为上丘。沿松果体旁置入内镜,在三脑室内可见位于三脑室后上部的脉络丛。通过丘脑间联合,可见穹窿柱、三角隐窝、视交叉、视隐窝上部、终板、漏斗隐窝等结构。测得直窦长度为(52.60±3.79)mm,大脑大静脉长度为(10.92±0.89)mm,大脑内静脉长度为(35.23±0.94)mm,直窦与大脑大静脉夹角(72.79±3.93 )°。

枕叶小脑幕入路中,在松果体区可见大脑内静脉、基底静脉等深静脉系统,胼胝体压部位于深静脉系统上方,同侧大脑内静脉和基底静脉之间的间隙内。松果体位于大脑内静脉下方,松果体外下方可见同侧的上丘,上丘表面有四叠体动脉网覆盖。沿松果体旁置入内镜,可见三脑室内脉络丛、穹窿柱、三角隐窝、视交叉、视隐窝上部、终板、漏斗隐窝等结构。测得直窦长度(52.60±3.79)mm,大脑大静脉长度(10.92±0.89)mm,大脑内静脉长度(35.23±0.94)mm,直窦与大脑大静脉夹角(72.79±3.93)°。

结论  神经内镜为第三脑室手术的理想选择,应根据病变的位置、大小、病理类型等因素综合考虑,选择最佳手术入路。经额角侧脑室入路主要适用于切除位于第三脑室前部病变,尤其当室间孔扩张明显,肿瘤经室间孔突入侧脑室者;经胼胝体前部入路适用于位于第三脑室前上部的病变;幕下小脑上入路适用于切除尺寸较小、没有侧方及幕上侵犯的病变;经枕叶小脑幕入路主要应用于延伸至幕上的病变。

英文摘要:

Objective In this study, we use fresh perfused cadaver heads to simulate four commonly used surgical approaches of treating third ventricle lesions(frontal transcortial approach、anterior transcallosal approach、infratentorial supracerebellar approach、occipital transtentorial approach). We use endoscope to observe the important anatomical landmarks in the approach and the anatomical acteristics of the lateral ventricle and third ventricle, and to quantify the distance between the important landmarks. We explore the acteristics of the different approaches to provide anatomical basis for endoscopical surgery to the third ventricle lesions.

Methods We simulate the neuroendoscopical operations of four surgical approaches in the 12 fresh injected cadaver head specimens, observe the landmarks and the position relationin between each other in frontal transcortial approach、anterior transcallosal approach、infratentorial supracerebellar approach and occipital transtentorial approach. Then we measure the distance between important structures in 0.02mm precision vernier caliper.

< > In the frontal transcortial approach, choroid plexus、vena thalamostriata、septal vein、foramen of Monro are important landmarks, choroid plexus、vena thalamostriata and septal vein constitute the "Y" shape, and the forman of Monro is located at the intersection. The size of forman of Monro is vital to the operation. We measured the length of the foramen of Monro is(5.79±0.13)mm, the wide of foramen of Monro is(3.73±0.17)mm. Introduce the endoscope through the forman of Monro, the third ventricle floor could be clearly observed under the endoscope,  the following structures can be observed front to back: optic chiasma、infundibular recess、tuberculum cinereum、mamillary body、tegmentum mesencephali and aqueduct of sylvius. We measured the antero-posterior diameter of septum pellucidum is(36.57±3.45)mm,the distance from top to bottom of septum pellucidum is(12.92±1.48)mm, the distance from the infundibular recess to anterior part of mamillary body is(5.95±0.95)mm, the distance from foramen of Monro to mamlillary body is(14.09±0.85)mm, the distance from anterior part of mamlillary body to posterior commissure is(17.34±0.97)mm.

In anterior transcallosal approach, the intersection of coronal and sagittal suture is the important symbol for positioning. We measured the distance between glabella and bregma is(125.56±5.83)mm. Before coronal suture 2cm, there is no drainage veins in 5 cases. Separat the corpus callosum down 2cm before coronal suture, and the thickness of corpus callosum under the point 2cm anterior coronal suture was(6.40±0.68)mm. Into the lateral ventricle, the choroid plexus、the vena thalamostriata、the septal vein and the foramen of Monro could be observed. The length of the foramen of Monro is(5.79±0.13)mm, the wide of foramen of Monro is(3.73±0.17)mm. Get into the third ventricle through the foramen of Monro , we measured the antero-posterior diameter of septum pellucidum is(36.57±3.45)mm,the distance from top to bottom of septum pellucidum is(12.92±1.48)mm, the distance from the infundibular recess to anterior part of mamillary body is(5.95±0.95)mm, the distance from foramen of Monro to mamlillary body is(14.09±0.85)mm, the distance from anterior part of mamlillary body to posterior commissure is(17.34±0.97)mm.

    In the Infratentorial supracerebellar approach , there are visible complicated venous system below the tentorium , Galen vein, superior vermian vein, internal occipital vein. The Galen vein centered in the region,  the lower part of the lateral boundary was tentorium of cerebellum, lateral and medial are respectively posterior thalamic nodules and corpus callosum splenium, and below the region is the habenular trigone , below which was the superior colliculus. Insert the endoscope along the side of the pineal, the choroid plexus is located in the upper part of the third ventricle. Through the joint of the thalamus, fornix column , triangular recess, optic chiasm, optic recess of the upper endplate, and infundibular recess are visible. We can measure The length of straight sinus is (52.60±3.79)mm, the length of Galen vein is (10.92±0.89)mm, the length of internal cerebral vein is (35.23±0.94)mm, the included angle between straight sinus and Galen vein is (72.79±3.93)°.

    In occipital transtentorial approach, the deep venous system such as the Galen vein and basal vein can be seen in the pineal region, the splenium of corpus callosum is above the deep vein system, and within the gap between the internal cerebral vein and the basal vein. The pineal is located below the internal cerebral vein, the same side superior colliculus is located at the inferolateral ofthe pineal. The surface of the  superior colliculus is covered by quadrigeminal artery network. Insert the endoscope along the side of the pineal, the choroid plexus、the column of fornix、the triangular recess、the optic chiasma、the  upper part of the optic recess and the infundibular recess could be observed. The length of straight sinus is (52.60±3.79)mm, the length of Galen vein is (10.92±0.89)mm, the length of internal cerebral vein is (35.23±0.94)mm, the included angle between straight sinus and Galen vein is (72.79±3.93)°.

Conclusions  Neuroendoscope is a ideal choice for the third ventricle surgery, we should have a comprehensive consideration base on lesion’s position、size、pathologic type and so on, to make the best choice. The frontal transcortial approach is applied to resect the tumors in the front third ventricle, especially for the tumors that obviously expand through the interventricular foramen into the lateral ventricle and the interventricular foramen. The anterior transcallosal approach is applied for that the tumor is in the upper third ventricle. Infratentorial supracerebellar approach is mainly suitable for resection of small or medium size without invasion of lateral and supratentorial lesions. Occipital lobe of the cerebellum is mainly suitable for resecting of tumors extending to the cerebellum screen.

语种: 中文
相关网址: 查看原文
内容类型: 学位论文
URI标识: http://ir.bjmu.edu.cn/handle/400002259/124804
Appears in Collections:北京大学第九临床医学院_学位论文

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作者单位: 北京大学第九临床医学院

Recommended Citation:
罗雷雷. 神经内镜下第三脑室肿瘤手术入路解剖研究[D]. 北京大学第九临床医学院. 北京大学. 2016.
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