- 期刊
蝶鞍、蝶鞍上與蝶鞍旁解剖手術
Dissection of the Sellar, Suprasellar, Parasellar Regions
摘要
內視鏡經蝶竇蝶鞍手術（endoscopic trans-sphenoidal sellar approach）是內視鏡顱底手術（endoscopic skull base surgery）的入門。內視鏡手術具有直接、視野放大以及微創的優點，已成為處理腦下垂體腫瘤（pituitary tumor）的常規。除此之外，拉特克列囊腫（Rathke's cleft cyst）、某些蝶鞍腦膜瘤（meningioma）、蜘蛛網膜囊腫（arachnoid cyst）、轉移性腫瘤（metastatic tumor）以及蝶鞍區有腦脊液滲漏（CSF leak）等，都可以用這種手術方式進行處理。手術時需能清楚辨認手術地標，並以鼻內階段、蝶竇內階段、蝶鞍階段、硬膜內階段依次處理。內視鏡蝶鞍上手術（endoscopic suprasellar approach）乃內視鏡經蝶竇蝶鞍手術的延伸，包含內視鏡經蝶鞍結節（transtuberculum approach）與經蝶骨平台手術（transplanum approach），依解剖位置可分為視交叉上區域（suprachiasmatic region）、視交叉下區域（subchiasmatic region）、鞍後區域（retrosellar region）與腦室區域（ventricular region）。此術法可以用來處理顱咽管瘤（craniopharyngioma）、視交叉後病變（retrochiasmatic lesions）、部分蝶鞍結節與蝶骨平台腦膜瘤（meningioma）、鼻及鼻竇腫瘤具蝶鞍上（suprasellar）侵犯、蝶鞍上蜘蛛網膜囊腫（arachnoid cyst）等等。蝶骨結節腦膜瘤（tuberculum sellae meningioma）或一些因侵犯性黴菌感染（invasive fungal sinusitis）常造成視神經的壓迫，此手術法能夠打開視神經的硬腦膜鞘（dural sheath）並達到最大程度約270度環形的視神經減壓。蝶鞍旁最重要的結構即海綿竇（cavernous sinus）。海綿竇內除靜脈血流之外，還包括內頸動脈以及第三、四、五、六對腦神經（cranial nerve）等構造。海綿竇又依其與海綿竇內頸動脈（cavernous ICA）的關係分成上、後、下、外四個隔間。此處的手術包含處理腦膜瘤、神經瘤、惡性腫瘤或轉移性癌症。手術需考量腫瘤的生物學特性，腫瘤生長型態與質地等。簡言之，本文橫跨顱底手術入門即內視鏡經蝶竇蝶鞍手術（level II）到最困難的海綿竇手術（level V），具備完整解剖學知識，不斷在解剖課程演練，並能跨團隊合作，將經驗與知識實際應用在病人身上，乃是獲得最佳手術結果的不二法門。
關鍵字
endoscopic endonasal skull base surgery ； parasellar ； sellar ； suprasellar ； surgical landmark（內視鏡經鼻顱底手術 ； 蝶鞍旁 ； 蝶鞍 ； 蝶鞍上 ； 手術地標）並列摘要
The endoscopic transsphenoidal sellar approach is the gold standard for endoscopic skull base surgery, particularly for sellar lesions. Direct access to the sellar region, a magnified field of view, and minimal invasiveness serve as advantages of endoscopic surgery, which is widely accepted as standard treatment for most pituitary tumors. The endoscopic approach is useful for management of a wide variety of conditions, including Rathke's cleft cysts, certain sellar meningiomas, arachnoid cysts, metastatic tumors, and cerebrospinal fluid leakage in the vicinity of the sellar area. It is necessary to clearly identify the surgical landmarks intraoperatively and sequentially follow the procedure of the intranasal, intrasphenoidal, sellar, and intradural stage. The endoscopic suprasellar approach is an extension of the endoscopic transsphenoidal approach and includes the transtuberculum and transplanum approaches, depending on the surgical anatomy. Anatomically, the suprasellar compartment can be divided into the suprachiasmatic, subchiasmatic, retrosellar, and ventricular regions in the sagittal plane. This approach can be used to treat craniopharyngiomas, retrochiasmatic lesions, pituitary tumors with suprasellar extension, tuberculum sellae meningiomas, planum sphenoidale meningiomas, sinonasal tumors with suprasellar invasion, and arachnoid cysts with suprasellar and third ventricle invasion, among other such lesions. Tuberculum sellae meningiomas and some invasive fungal infections (for example, invasive fungal sinusitis) often cause optic nerve compression; this surgical approach is useful to open the dural sheath of the optic nerve and attain a maximum of 270° of optic nerve decompression. The cavernous sinus represents the most important parasellar structure and contains the internal carotid artery (ICA), as well as the III, IV, V, and VI cranial nerves. The cavernous sinus is divided into superior, posterior, inferior, and lateral compartments based on its relationship with the cavernous segment of the ICA. Surgical treatment at this location involves resection of meningiomas, neuromas, and malignant tumors and metastatic cancer. Cavernous sinus surgery necessitates careful evaluation to confirm tumor biology, growth pattern, and texture owing to the complex neurovascular anatomy and potential surgical morbidity following operations in this area. In this article, we discuss the surgical anatomy and endoscopic skull base surgery procedures, ranging from conventional endoscopic transsphenoidal sellar surgery (level II) to advanced cavernous sinus surgery (level V). Thorough knowledge of anatomy, hands-on training in cadaver dissection, and effective teamwork are important to gain experience and for successful treatment to achieve favorable surgical outcomes.