圖8.1 (a)。腦下垂體及其關係。腦下垂體的前視圖。腺位於以下視神經交叉和頸內動脈海綿段之間的。正確的視神經已經發展到了公開垂體。上級出現垂體動脈的內側supraclinoid部分頸內動脈內側並傳遞到垂體和視交叉。腦下垂體的B,優越的視圖。在這種情況下,膜片在很大程度上是缺席,所以,蛛網膜下腔擴大,分開的頂部前葉隻有蛛網膜。正確的一半的背sellae被移除暴露後葉,這是隱藏在背。的旅行下垂體動脈內側intracavernous頸後葉。 C and D, superior and inferior surfaces of a gland in which the anterior and posterior lobes form a relatively ovoid structure. The pars tuberalis wraps partially around the stalk. E, the anterior and posterior lobes have been separated. The stalk joins the anterosuperior surface of the posterior lobe and is partially surrounded by the pars tuberalis. F and G, superior and inferior surfaces of another gland. The posterior lobe is multinodular and the right half of the posterior lobe seems larger than the left half. H, inferior surface of another pituitary. The anterior and posterior lobes form separate distinct nodules. The posterior lobe forms a nodule attached to the posterior edge of the anterior lobe. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Diaph., diaphragm; Fiss., fissure; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Lam., lamina; Ophth., ophthalmic; Opticocar., opticocarotid; Orb., orbital; Pit., pituitary; Post., posterior; Rec., recess; Seg., segment; Sphen., sphenoid; Sup., superior; Term., terminalis; Tuber., tuberalis. (Images courtesy of AL Rhoton, Jr.)

圖8.1 (i n)。腦下垂體及其關係。我,薩拉的矢部分擴展通過前部和後部葉和蝶竇。intercavernous頸產生日珥的側壁下麵的蝶竇和前腺。的鞍延伸到了前邊緣intracavernous頸隻有極大地擴張了腫瘤。Intercavernous鼻竇課程前和後緣的隔膜。基部的竇,位於背的後麵,是最大的連接跨中線之間的配對海綿竇的後邊緣。下垂體動脈起源於intercavernous頸動脈的後彎,直接朝後葉內側。J,後上的觀點,另一個腺深深intercavernous頸的外表麵縮進。的舌腺延伸上方外側動脈。 The anterior clinoid has been removed and the nerves in the wall of the cavernous sinus exposed. K, anterior view of another gland. The cavernous sinuses are located on the lateral side of the gland and separate the gland from the intracavernous carotids. The superior hypophyseal arteries arise from the medial side of the supraclinoid carotid and pass to the chiasm and stalk. The anterior intercavernous sinus crosses the anterosuperior margin of the gland, and the inferior intracavernous sinus extends below the gland interconnecting the cavernous sinuses. L, the optic nerves and chiasm have been elevated to expose the pituitary stalk, superior hypophyseal, and ophthalmic arteries. M, another gland and sella viewed from superiorly. The diaphragm partially covers the upper surface of the gland, but the opening in the diaphragm is larger than the pituitary stalk. The posterior lobe (not shown) was entirely hidden below the dorsum sellae. An intercavernous sinus passes across the upper anterior surface of the gland. N, superior view of another gland exposed below a large natural opening in the diaphragm. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Diaph., diaphragm; Fiss., fissure; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Lam., lamina; Ophth., ophthalmic; Opticocar., opticocarotid; Orb., orbital; Pit., pituitary; Post., posterior; Rec., recess; Seg., segment; Sphen., sphenoid; Sup., superior; Term., terminalis; Tuber., tuberalis. (Images courtesy of AL Rhoton, Jr.)

圖8.2 (f)。逐步剝離的鼻腔通路蝶手術指導。矢狀切麵,左邊的中線和鼻中隔。鼻中隔形成在前麵的中隔軟骨,篩骨垂直板上麵,和下麵的犁骨後方。下方壓迫鼻中隔的一部分是由蝶齶骨的動脈的分支機構提供,終端上頜動脈的分支。的上部隔,在篩狀板,是由樹枝篩骨的動脈,這源於眼動脈。隔分裂中線附近的蝶竇。視交叉、光學和眼球運動的神經,第三腦室和垂體上方的腦下垂體。額葉腦回腹直肌的篩狀板上方的嗅神經束。B,矢的蝶竇和腦下垂體。 Prominences overlie the optic canal, internal carotid artery, superior orbital fissure, and maxillary nerve in the wall of the sphenoid sinus. The opticocarotid recess extends laterally between the optic nerve, internal carotid artery, and the prominence passing through the superior orbital fissure, and extends into the optic strut, which separates the optic canal from the superior orbital fissure. The serpiginous prominence overlying the internal carotid artery is located anterior to and below the pituitary gland. C, the lateral wall of the nasal cavity is constituted below by the nasal surface of the maxilla and above by the nasal surface of the ethmoidal sinuses. The inferior concha (turbinate) is an independent bone, that articulates with the nasal surface of the maxilla and the perpendicular plate of the palatal bone. The middle and superior concha are appendages of the ethmoid bone. The lacrimal duct opens below the anterior part of the inferior concha. The inferior, middle, and superior nasal meatus are located below their respective concha. The superior meatus is located between the middle and superior concha. The sphenoethmoidal recess, a narrow cleft located above the superior concha, separates the superior concha from the anterior surface of the sphenoid sinus and is the site of the ostium communicating the sphenoid sinus and nasal cavity. The eustachian tube opens into the nasopharynx in front of Rosenmüller’s fossa. D, the concha has been removed. The maxillary and frontal sinuses drain into the middle meatus. The lacrimal duct opens below the inferior turbinate into the inferior meatus. The ethmoid bullae are rounded prominences overlying the middle ethmoid air cells. The anterior ethmoid air cells drain into the superior meatus. The posterior ethmoid air cells and the sphenoid sinus drain into the sphenoethmoidal recess. E, enlarged view after removal of the nasal mucosa. The olfactory fila pass through the small openings in the cribriform plate to innervate the olfactory mucosa. The sphenopalatine artery, the terminal branch of the maxillary artery, passes through the sphenopalatine foramen in the medial wall of the pterygopalatine fossa and gives rise to the posterior lateral nasal arteries. F, the cribriform plate and medial wall of the ethmoid air cells have been removed. The thin lateral wall of the ethmoidal and sphenoid sinuses forms the medial wall of the orbit. The frontal sinus opens into the anterior part of the middle meatus. A., artery; Ant., anterior; Bas., basilar; Br., branch; Cart., cartilage; Cav., cavernous; Cent., central; Cil., ciliary; CN, cranial nerve; Crib., cribriform; Eth., ethmoid, ethmoidal; Eust., eustachian; Fiss., fissure; Front., frontal; Gang., ganglion; Gr., greater; Gyr., gyrus; Inf., inferior; Infraorb., infraorbital; Lat., lateral; M., muscle; Max., maxillary; Med., medial; Mid., middle; N., nerve; Nasolac., nasolacrimal; Obl., oblique; Olf., olfactory; Ophth., ophthalmic; Opticocar., opticocarotid; Orb., orbital; Pal., palatine; Perp., perpendicular; Pit., pituitary; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., recess, rectus; Ret., retinal; Seg., segment; Sept., septal; Sphen., sphenoid; Sphenoeth., sphenoethmoidal; Sphenopal., sphenopalatine; Sup., superior; Tr., tract; V., vein. (Images courtesy of AL Rhoton, Jr.)

圖8.2 (G-L)。逐步剝離的鼻腔通路蝶手術指導。G,上頜竇的內側牆被移除公開竇屋頂,形成軌道樓。眼眶下的溝和運河,坐落在地上的軌道,形成一個在上頜竇的屋頂。前部和後部篩骨的動脈來自眼動脈和通過前部和後部篩骨的運河到達前窩在篩狀板旁邊的地板上,在那裏他們再次穿透骨頭到達鼻腔的牆壁。運河是維迪安的通道pterygopalatine神經節神經維迪安。副交感神經纖維形成的神經是維迪安從堅硬的大神經和交感神經纖維從深頸叢的堅硬的分支。H,去除空氣篩骨的側壁細胞,形成牆內側的軌道,使periorbita。額竇位於上層前內側牆的一部分。鼻淚管被移除的內側牆暴露的內部管道。 I, enlarged view. The pterygoid process extends downward and forms the posterior wall of the pterygopalatine fossa. The medial pterygoid plate is situated beneath the nasopharyngeal mucosa just in front of the orifice of the eustachian tube. The greater and lesser palatine nerves arise from the pterygopalatine ganglion in the pterygopalatine fossa and are distributed to the palate, tonsil, and lining of the nasal cavity. J, the periorbita has been opened and some of the orbital fat removed to expose the medial and inferior rectus and superior oblique muscles. The annular tendon is the condensation of periorbita from which the rectus muscles arise. It surrounds the optic foramen and medial part of the superior orbital fissure. The lateral wall of the nasal cavity has been opened to expose the terminal part of the maxillary artery in the pterygopalatine fossa. K, the medial rectus muscle has been divided near the globe and reflected posteriorly. In this case, the ophthalmic artery courses below the optic nerve to reach the medial part of the orbit. The branch of the inferior division of the oculomotor nerve to the medial rectus muscle enters the medial side of the muscle. The ophthalmic artery gives rise to the anterior and posterior ethmoidal arteries as it courses near the superior oblique muscle. L, the ophthalmic artery has been retracted posteriorly to show the central retinal artery coursing below the optic nerve. Short ciliary arteries and nerves pass to the globe. A., artery; Ant., anterior; Bas., basilar; Br., branch; Cart., cartilage; Cav., cavernous; Cent., central; Cil., ciliary; CN, cranial nerve; Crib., cribriform; Eth., ethmoid, ethmoidal; Eust., eustachian; Fiss., fissure; Front., frontal; Gang., ganglion; Gr., greater; Gyr., gyrus; Inf., inferior; Infraorb., infraorbital; Lat., lateral; M., muscle; Max., maxillary; Med., medial; Mid., middle; N., nerve; Nasolac., nasolacrimal; Obl., oblique; Olf., olfactory; Ophth., ophthalmic; Opticocar., opticocarotid; Orb., orbital; Pal., palatine; Perp., perpendicular; Pit., pituitary; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., recess, rectus; Ret., retinal; Seg., segment; Sept., septal; Sphen., sphenoid; Sphenoeth., sphenoethmoidal; Sphenopal., sphenopalatine; Sup., superior; Tr., tract; V., vein. (Images courtesy of AL Rhoton, Jr.)

圖8.3 (f)。,前結構軌道頂端和左邊上方的部分上頜骨牙槽突被揭露鼻中隔,形成犁骨後方,篩骨垂直板上麵的,在前麵的中隔軟骨。B,鼻中隔和蝶竇前壁已被移除。這暴露了上級,中間,偽劣半圓屋頂和中線蝶竇內的隔膜。篩骨空氣細胞暴露在牆內側的正確的軌道。下麵的蝶竇內側的一部分,軌道頂點已被打開。C,麵部骨骼的左半部分,包括左半部分上頜骨和軌道,被移除暴露左側鼻中隔,形成篩骨垂直板上麵的和下麵的犁骨。口感前方上頜骨和後方形成的水平板齶骨。D,鼻中隔被移除。下半圓屋頂是一個單獨的骨頭,從上頜突出進入鼻腔。 The middle and superior concha are appendages of the ethmoid bone. The maxillary ostium is located between the perpendicular plate of the palatine bone behind, the ethmoid superiorly, and the medial maxillary wall below. The maxillary and frontal sinus and the anterior ethmoid air cells drain into the middle meatus, and the posterior ethmoid air cells drain into the superior meatus. E, the anterior nasal aperture is formed above by the nasal bones and laterally and below by the maxilla. The anterior part of the osseous nasal septum is formed above by the perpendicular ethmoid plate and below by the vomer. The inferior concha, a separate bone, and the middle concha, an appendage of the ethmoid bone, are visible through the aperture. F, posterior view of the posterior nasal aperture. The floor of the posterior aperture is formed by the horizontal plate of the palatine bone. The lateral margin is formed by the medial plate of the pterygoid process and is joined anteriorly by the perpendicular plate of the palatine bone, which forms the part of the lateral nasal wall between the maxilla and the medial pterygoid plate. Posteriorly, the middle concha is much more prominent than the inferior concha and often must be displaced laterally in the transsphenoidal approach to the sphenoid sinus. The vomer extends from the upper surface of the hard palate to the body of the sphenoid bone and separates the paired nasal cavities at the posterior aperture. Alv., alveolar; Ant., anterior; Aper., aperture; Cart., cartilage; Clin., clinoid; CN, cranial nerve; Crib., cribriform; Eth., ethmoid; Front., frontal; Horiz., horizontal; Inf., inferior; Infratemp., infratemporal; Lat., lateral; M., muscle; Max., maxilla, maxillary; Med., medial; Mid., middle; Palat., palatal, palatine; Perp., perpendicular; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Pyr., pyriform; Sphen., sphenoid; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖8.3 (G-J)。G,中間外耳被移除。這讓篩骨鉤狀的過程。空氣篩漏鬥狀器官,下水道前篩骨的細胞,有時加入額管道,打開上麵向下鉤狀的過程。蝶竇的H,斜前視圖。前壁的左半部分蝶竇被移除。視神經管位於蝶的身體之間,視杆,前床形的過程,前根的較小的蝶翼。蝶門打開,上半圓屋頂上方,進入鼻腔。我,後鼻腔側壁切除外耳。的上部側壁的鼻腔篩骨的空氣形成的細胞。 The lower part of the lateral wall is formed, from anterior to posterior, by maxilla, perpendicular palatal plate, and the pterygoid process and medial pterygoid plate. The palate is formed anteriorly by the palatal plate of the maxilla and posteriorly by the horizontal plate of the palatine bone. J, section through the nasal cavity and both maxillae. The maxillary sinuses form part of the lateral wall of the nasal cavity and drain through the middle meatus into the nasal cavity. The cribriform plate is located above the nasal cavity in the midline. The part of the nasal septum below the cribriform plate is formed by the perpendicular ethmoid plate. The vomer forms the lower and posterior parts of the nasal septum. The wings of the vomer spread laterally along the lower surface of the sphenoid body. The ethmoid air cells are in the upper part of the lateral wall of the nasal cavity. Alv., alveolar; Ant., anterior; Aper., aperture; Cart., cartilage; Clin., clinoid; CN, cranial nerve; Crib., cribriform; Eth., ethmoid; Front., frontal; Horiz., horizontal; Inf., inferior; Infratemp., infratemporal; Lat., lateral; M., muscle; Max., maxilla, maxillary; Med., medial; Mid., middle; Palat., palatal, palatine; Perp., perpendicular; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Pyr., pyriform; Sphen., sphenoid; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖8.4(模擬)。蝶竇和蝶鞍底路線。,這種橫截麵延伸到鼻腔,優越和鼻甲,上頜竇,頂端附近的軌道和篩骨的鼻竇在蝶竇前。顴骨和眼眶下的神經來自上頜神經pterygopalatine窩,位於後上頜牆後麵。上麵的鼻中隔形成篩骨垂直板,下麵的犁骨和軟骨隔在前麵。B,外耳和後篩骨空氣細胞已被移除公開犁骨和蝶竇前壁和蝶門。鼻淚管下降沿鼻腔側壁。C,放大圖。篩骨垂直板連接前蝶的臉,和犁骨向上延伸至加入下蝶牆,在中線。後篩骨空氣細胞位於前外側部分蝶的臉和蝶門的上外側邊緣重疊。 D, the anterior face of the sphenoid has been removed to expose the multiseptated sphenoid sinus and the anterior wall of the sella. The bony prominences over the optic canals are situated in the superolateral margins of the sinus. A., artery; Car., carotid; Cart., cartilage; Cav., cavernous; CN, cranial nerve; Eth., ethmoid; Gang., ganglion; Hyp., hypophyseal; Infraorb., infraorbital; Max., maxillary; Mid., middle; N., nerve; Nasolac., nasolacrimal; Ophth., ophthalmic; Perp., perpendicular; Pet., petrous; Pit., pituitary; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Seg., segment; Sept., septal; Sphen., sphenoid; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖8.4(情況)。蝶竇和蝶鞍底路線。E,薩拉的前壁和側壁的蝶竇已被移除暴露的岩石的和海綿段頸動脈和腦下垂體。上頜竇後壁的被移除公開上頜神經和動脈和pterygopalatine神經節pterygopalatine窩。F,正確的軌道和pterygopalatine窩的放大圖。上頜神經引起眼眶下的顴骨神經和交流rami pterygopalatine神經節。上頜動脈的分支課程通過pterygopalatine窩。pterygopalatine窩的後壁是由翼狀的過程。G,放大圖。上頜動脈的分支穿透的鼻腔側壁沿蝶的臉。 The maxillary nerve sends communicating rami to the sphenopalatine ganglion. The vidian nerve enters the posterior aspect of the sphenopalatine ganglion. The pituitary gland is surrounded by the cavernous sinuses laterally and an anterior intercavernous sinus above. H, the optic nerves have been elevated to show the suprasellar area and the relationships between the orbital apex, optic canals, nasal cavity, pterygopalatine fossa, and the petrous and intracavernous segments of the internal carotid artery. The superior hypophyseal arteries pass to the lower margin of the optic chiasm and the pituitary stalk. A., artery; Car., carotid; Cart., cartilage; Cav., cavernous; CN, cranial nerve; Eth., ethmoid; Gang., ganglion; Hyp., hypophyseal; Infraorb., infraorbital; Max., maxillary; Mid., middle; N., nerve; Nasolac., nasolacrimal; Ophth., ophthalmic; Perp., perpendicular; Pet., petrous; Pit., pituitary; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Seg., segment; Sept., septal; Sphen., sphenoid; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖8.5(模擬)。骨性蝶骨的關係。蝶骨每個視圖中列出。優越的觀點。B,前視圖。C,側麵圖。D,劣質的觀點。對。孔;緯度。, lateral; Med., medial; Pal., palato-; Sup., superior; Temp., temporal. (From, Rhoton AL Jr, Hardy DG, Chambers SM: Microsurgical anatomy and dissection of the sphenoid bone, cavernous sinus and sellar region. Surg Neurol 12:63–104, 1979 [21].)

圖8.5(情況)。骨性蝶骨的關係。蝶骨每個視圖中列出。型蝶骨E,因素納入考慮範圍後不難得出。F,骨頭presellar類型蝶竇。G,骨骼sellar類型蝶竇和定義良好的蝶門。H,骨頭與sellar類型與定義糟糕的蝶蝶竇口和麵向斜楔形的septae。對。孔;緯度。, lateral; Med., medial; Pal., palato-; Sup., superior; Temp., temporal. (From, Rhoton AL Jr, Hardy DG, Chambers SM: Microsurgical anatomy and dissection of the sphenoid bone, cavernous sinus and sellar region. Surg Neurol 12:63–104, 1979 [21].)

圖8.6 (f)。優越的sellar地區。之間,薩拉位於海綿竇。隔膜,通常把鞍上水箱,在本例中是缺失的。眼球運動的神經進入海綿竇的屋頂有一個狹窄的水箱周圍神經。眼球運動的三角形,三角形的硬腦膜的動眼神經進入海綿竇的硬腦膜屋頂,前部和後部鞍突之間的定位過程和岩石的頂端。海綿竇的屋頂前鞍突下向前延伸的過程。B,硬腦膜覆蓋前鞍突過程和視神經管被移除。硬腦膜的外層海綿竇的側壁被移除揭露薄側竇壁內層的側麵氏洞穴。鐮狀韌帶,硬腦膜的褶皺上麵延伸視覺神經近端神經進入視神經管,從前鞍突延伸到結節。 C, the inner layer of the lateral sinus wall has been removed to expose the nerves coursing in the wall of the cavernous sinus and middle fossa. The oculomotor nerve enters the narrow oculomotor cistern in the sinus roof and passes forward along the lower margin of the anterior clinoid process. D, enlarged view. A probe has been passed between the optic nerve and the falciform ligament. The dissector can be seen through the dura proximal to the osseous optic canal. The anterior clinoid is located lateral to the optic nerve and internal carotid artery and above the oculomotor nerve. E, the dura covering the dorsum sellae, basilar sinus, and posterior clinoid process has been removed. The oculomotor nerve passes forward lateral to the posterior clinoid and below the anterior clinoid. An abnormal bony projection extends laterally from the right posterior clinoid below the oculomotor nerve toward the petrous apex. The basilar sinus crosses the back of the dorsum and upper clivus and communicates widely with the posterior edge of the paired cavernous sinuses. The abducens nerve passes through the lower margin of the basilar sinus. An anterior intercavernous passes along the anterior margin of the sella. F, the posterior part of the cavernous sinus has been cleared to expose the abducens passing through Dorello’s canal, which is roofed by the petrosphenoid ligament. A., artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Cist., cistern; Clin., clinoid;CN, cranial nerve; Falc., falciform; Gr., greater; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Lig., ligament; Men. Hyp., meningohypophyseal; N., nerve; Oculom., oculomotor; Pet., petrous; Petroling., petrolingual; Petrosphen., petrosphenoid; Pit., pituitary; Post., posterior; Seg., segment; Tent., tentorial; Tuberc., tuberculum. (Images courtesy of AL Rhoton, Jr.)

圖8.6 (G-J)。優越的sellar地區。G,前床形的過程已經被暴露的鞍突段頸內動脈上、下定義的硬腦膜的戒指。上環是由硬腦膜上表麵的擴展內側前鞍突。較低的硬鋁環是由硬腦膜,延伸內側的下緣前鞍突和分離從動眼神經下鞍突緣。薩拉的H,後上的視圖。背部和後鞍突被揭露垂體後葉,這是隱藏在背。下麵的外展神經暴露petrosphenoid韌帶。三叉神經已經反映暴露petrolingual韌帶,延伸上麵隻頸內動脈近端動脈進入海綿竇。我,petrolingual和petrosphenoid韌帶的放大圖。 The inferior hypophyseal artery passes to the capsule of the posterior lobe. The greater petrosal nerve courses medially and is joined by the deep petrosal branch of the periarterial carotid plexus to form the vidian nerve. J, enlarged view. The carotid artery protrudes medially to deform the lateral surface of the anterior lobe of the pituitary gland. A tongue of anterior lobe extends laterally above the intercavernous carotid. A., artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Cist., cistern; Clin., clinoid;CN, cranial nerve; Falc., falciform; Gr., greater; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Lig., ligament; Men. Hyp., meningohypophyseal; N., nerve; Oculom., oculomotor; Pet., petrous; Petroling., petrolingual; Petrosphen., petrosphenoid; Pit., pituitary; Post., posterior; Seg., segment; Tent., tentorial; Tuberc., tuberculum. (Images courtesy of AL Rhoton, Jr.)

圖8.7。模擬,劣質的sellar地區及周邊顱基地。,地板的右半邊的蝶竇被移除公開sellar地板和蝶竇的部分在平麵和結節。標本的左側,咽鼓管,翼狀的過程,和上頜竇的後部分保留。在右邊,內側部分的咽鼓管和翼狀的過程已被移除。這暴露了下頜神經退出卵圓孔未閉和上頜神經退出孔rotundum向前,眼眶下的神經。pterygopalatine神經節位於上頜竇背後的pterygopalatine窩側壁的鼻腔。正確的翼狀的過程已經被揭露運河,維迪安的神經維迪安前往pterygopalatine神經節。下麵的骨頭堅硬的頸動脈被刪除了,動脈變成向上進入海綿竇的後部分。B,犁骨的一部分,篩骨垂直板,和蝶竇的地板已被移除暴露海綿竇,intracavernous頸動脈和腦下垂體。 The floor of the optic canals have been removed to expose the ophthalmic arteries coursing below the optic nerves. The cavernous sinus surrounds the intracavernous carotid. An anterior intercavernous sinus crosses the anterior margin of the gland. Some of the upper clivus has been removed to expose the basilar sinus, which sits on the back of the dorsum and is the largest connection between the cavernous sinuses. C, the venous spaces around the pituitary gland have been cleared to expose the petrous and intracavernous carotid segments. D, enlarged view of the pituitary gland, intracavernous carotid, and the optic nerves and ophthalmic arteries. The inferior hypophyseal arteries pass to the posterior lobe. The superior hypophyseal arteries arise in the chiasmatic cistern and pass medially to reach the stalk and chiasm. A., artery; Ant., anterior; Bas., basilar; Cap., capitus; Cav., cavernous; CN, cranial nerve; Eth., ethmoid; Eust., eustachian; Hyp., hypophyseal; Inf., inferior; Infraorb., infraorbital; Long., longus; M., muscle; Max., maxillary; N., nerve; Ophth., ophthalmic; Perp., perpendicular; Pet., petrous; Post., posterior; Proc., process; Pteryg., pterygoid; Rec., rectus; Seg., segment; Sphen., sphenoid; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖8.8。鼻蝶竇通路。逐步解剖顯示的結構形式的橫向極限蝶竇和蝶鞍底路線。一個,矢狀切麵中線。鼻中隔,蝶竇入路的指導,形成由篩骨垂直板上麵,在前麵的鼻中隔軟骨,犁骨和下麵。犁骨製定下蝶的身體的一部分,和垂直板一端前臉。蝶竇位於蝶骨的主體。B,矢狀切麵一直延伸到中線的權利。鼻外耳和口咽鼓管側緣的曝光。C,中、下鼻甲的一部分被移除。 The ostia of the maxillary and frontal sinuses opens into the middle meatus located below the middle turbinate. The nasolacrimal duct opens below the lower turbinate into the inferior meatus. Rosenmüller’s fossa is located behind the eustachian tube. D, the mucosa in the lateral margin of the nasal cavity and the posterior part of the inferior and middle turbinates have been removed to expose the pterygoid process and the posterior maxillary wall, which form the posterior and anterior boundaries of the pterygopalatine fossa, respectively. The eustachian tube opens into the nasopharynx at the posterior edge of the pterygoid process. The terminal branches of the maxillary artery pass through the pterygopalatine fossa, located between the posterior maxillary wall and the pterygoid process, to enter the posterosuperior part of the nasal cavity at the anteroinferior margin of the sphenoid sinus. The medial wall of the pterygopalatine fossa is formed by the perpendicular plate of the palatine bone. E, the medial wall of the maxillary sinus has been opened to expose the infraorbital nerve, which arises in the pterygopalatine fossa and passes forward in the sinus roof. The maxillary nerve passes through the foramen rotundum to enter the pterygopalatine, where it gives rise to the infraorbital, zygomatic, and greater palatine nerves, plus communicating rami to the pterygopalatine ganglion. F, enlarged view. The bone and dura covering the optic canal in the superolateral part of the sphenoid sinus has been opened to expose the optic nerve and ophthalmic artery in the optic canal. The junction of the petrous and cavernous carotid limits the exposure below the level of the sella. Terminal branches of the maxillary artery intermingle with the neural structures in the pterygopalatine fossa and exit the fossa to supply the tissues on the sphenoid face. A., artery; Bas., basilar; Car., carotid; Cart., cartilage; CN, cranial nerve; Eth., ethmoid; Eust., eustachian; For., foramen; Gang., ganglion; Gr., greater; Inf., inferior; Infraorb., infraorbital; M., muscle; Max., maxillary; Mid., middle; N., nerve; Nasolac., nasolacrimal; Ophth., ophthalmic; Pal., palatini; Palat., palatine; Perp., perpendicular; Pit., pituitary; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., recess; Sphen., sphenoid; Sphenoeth., sphenoethmoid; Sphenopal., sphenopalatine; Sup., superior; Tens., tensor. (Images courtesy of AL Rhoton, Jr.)

圖8.9。隔在蝶竇。沉重的折線中央圖顯示了飛機上的每個標本的斷麵圖紙,和大型的箭頭表示視圖的方向。平麵上麵,下麵的背和斜坡,薩拉是每個圖在一個中間位置。圖紙上的沉重的黑色線條,顯示的位置septae蝶竇。各種septae分離竇腔,在大小和形狀不同,很少從一邊到另一邊是對稱的。(Renn WH從Rhoton AL Jr:顯微外科解剖學sellar地區。J Neurosurg 43:288 - 298, 1975 [15]。)

圖8.10。日冕的前視圖部分在蝶竇前,通過鼻腔,軌道,篩骨的上頜竇。鼻腔的上部是分開的軌道篩骨的鼻竇。鼻腔的下部是由上頜竇的外側。中間外耳項目從外鼻內側牆交界處的屋頂上頜骨和篩骨的鼻竇。後篩骨空氣細胞位於前外側的蝶竇的一部分。B,左邊中間偽劣鼻半圓屋頂和鼻中隔後部篩骨的鼻竇雙方已被移除暴露後鼻咽壁,前的蝶的身體,和蝶門。後篩骨空氣細胞重疊的側緣蝶門。C、蝶竇前壁的已經開了,蝶隔膜被揭露前sellar牆中線和日珥視神經管和頸動脈的側牆well-pneumatized蝶竇。內側左上頜竇後壁的一部分被移除暴露pterygopalatine窩上頜動脈的分支。 The opticocarotid recesses extend laterally between the prominences over the carotid arteries and optic nerves. D, the pituitary gland, intracavernous carotids, optic nerves, ophthalmic arteries, and cavernous sinuses have been exposed by removing the bone of the sinus wall. The inferolateral trunk passes above and lateral to the abducens nerve. The shortest distance between the paired carotid arteries is usually located just below the tuberculum selle. A capsular artery arises from the intercavernous carotid and passes upward and medially. E, oblique view. The bony prominences overlying the optic canal, superior orbital fissure, intracavernous carotid artery, and the maxillary nerve are exposed in the lateral wall of the sphenoid sinus. The bony depression between the carotid prominence and the optic canal, the opticocarotid recess, extends into the medial end of the optic strut. The broad round prominence below the opticocarotid recess is produced by the structures passing through the superior orbital fissure. F, oblique view. The pituitary gland, intracavernous carotid artery, ophthalmic artery, and optic, ophthalmic, maxillary, oculomotor, and abducens nerves have been exposed. The abducens nerve courses medial to the ophthalmic nerve. A., artery; Brs., branches; Cav., cavernous; CN., cranial nerve; Eth., ethmoid; Fiss., fissure; Inf., inferior; Lat., lateral;M., muscle; Max., maxillary; Med., medial; Mid., middle; Ophth., ophthalmic; Opticocar., opticocarotid; Orb., orbital; Pet., petrous; Pit., pituitary; Post., posterior; Pterygopal., pterygopalatine; Rec., recess, rectus; Seg., segment; Sphen., sphenoid; Sup., superior; Tr., trunk. (Images courtesy of AL Rhoton, Jr.)

圖8.11。逐步解剖研究的關係蝶竇垂體窩,海綿竇,sellar地區。,前視圖為蝶竇粘膜刪除顯示結構的關係,可以公開的蝶竇入路。暴露的結構主要包括楔形的隔膜,前sellar牆,在頸動脈和視神經運河日珥。的結節sellae和平麵sphenoidale前sellar上方的牆上。頸動脈之間的opticocarotid休會橫向延伸和視神經管。B,蝶竇壁的骨頭已經被移除,同時保留硬腦膜。視神經,intracavernous頸動脈,通過硬腦膜和腦下垂體。的前彎intracavernous頸硬腦膜內凸起立即低於光學運河。基部的竇,形成之間的最大連接配對海綿竇,坐落在斜坡和背sellae。 The inferior hypophyseal artery passes to the capsule of the posterior lobe. The optic nerve and ophthalmic artery can be seen through the optic sheath. C, the dura forming the medial and lower walls of the cavernous sinuses has been removed. Intercavernous sinuses connect the paired cavernous sinuses across the midline. The dura in the floor of the optic canals has been opened to expose the ophthalmic arteries and the optic nerves. The basilar sinus sits on the dorsum sellae and clivus and interconnects the posterior end of the paired cavernous sinuses. D, the venous space has been cleared to expose the intracavernous carotid and the anterior and posterior pituitary lobes. The inferior hypophyseal arteries arise from the meningohypophyseal branch of the intracavernous carotid and pass to the capsule of the posterior lobe. Sympathetic nerves ascend on the carotid arteries. The abducens nerve passes through the cavernous sinus on the lateral side of the internal carotid artery and medial to the ophthalmic nerve. E, oblique view of the intracavernous carotid showing the inferior hypophyseal artery passing to the capsule of the posterior lobe. F, the dura has been removed to expose the intradural structures. The anterior cerebral arteries are situated above and the pituitary gland is situated below the optic chiasm. The basilar apex is located behind the gland. The oculomotor nerve passes forward between the posterior cerebral and superior cerebellar arteries. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Comm., communicating; Eth., ethmoid; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; N., nerve; Ophth., ophthalmic; Opticocar., opticocarotid; P.C.A., posterior cerebral artery; Pet., petrosal; Pit., pituitary; Post., posterior; Prom., prominence; Rec., recess; S.C.A., superior cerebellar artery; Seg., segment; Sphen., sphenoid; Symp., sympathetic; Tuberc., tuberculum. (Images courtesy of AL Rhoton, Jr.)

圖8.12。六矢狀部分sellar地區顯示變化intercavernous在硬腦膜靜脈連接。所示的變化包括組合前、後,偽劣intercavernous聯係和頻繁的基底動脈竇後背部。前(低中心)或後(左下)intercavernous連接或兩者(頂部中心)可能會缺席。前intercavernous竇可能擴展在整個的前邊緣腺(左下)。基部的竇可能缺席(右下)。(Renn WH從Rhoton AL Jr:顯微外科解剖學sellar地區。J Neurosurg 43:288 - 298, 1975 [15]。)

圖8.13(模擬)。神經上地區的關係。薩拉的矢部分,腦垂體、蝶竇和第三腦室。第三腦室前部的位於鞍上。列的穹窿下沿著優越和室間孔的前利潤率達到乳頭狀的身體。視交叉和杆上方的鞍。內部腦靜脈在第三腦室的屋頂。B,放大圖。視交叉上休息之間的第三腦室位於板terminalis和交叉。莖的漏鬥狀凹槽延伸到後麵的區域交叉。 The lamina terminalis extends upward and is continuous with the rostrum of the corpus callosum. The thin part of the third ventricular floor between the chiasm and the mamillary bodies is suitable for a third ventriculostomy. The anterior commissure crosses the wall of the third ventricle in front of the columns of the fornix. The massa intermedium crosses the midportion of the third ventricle. C, the anterior part of the hemisphere has been removed to expose the lateral ventricles and suprasellar area. The optic nerve and chiasm are located above the sella. The chiasmatic cistern is located below the optic chiasm and opens upward between the optic nerves to the area in front of the lamina terminalis. The anterior commissure crosses the anterior wall of the third ventricle above the lamina terminalis. The anterior part of the third ventricle is located above the sella. The body of the lateral ventricle is situated above the third ventricle. The columns of the fornix form the superior and anterior margins of the foramen of Monro. The olfactory tracts pass above the optic nerves and the optic tracts pass above the oculomotor nerves. D, the cross section on the right hemisphere has been extended backward to the midportion of the temporal horn and thalamus. This exposes the oculomotor nerve arising on the medial surface of the cerebral peduncle and passing below the floor of the third ventricle and lateral to the sella. The crural cistern is located between the uncus and the cerebral peduncle. The mamillary bodies are positioned in the floor of the third ventricle. The posterior commissure sits above the aqueduct. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Cap., capsule; Car., carotid; Caud., caudate; Cav., cavernous; Cer., cerebral; Chiasm., chiasmatic; Chor., choroidal; Cist., cistern; Clin., clinoid; CN, cranial nerve; Comm., commissure; For., foramen; Gen., geniculate; Infundib., infundibular; Int., intermedia, internal; Lam., lamina; Lat., lateral; Lent., lenticular; Mam., mamillary; M.C.A., middle cerebral artery; Nucl., nucleus; Olf., olfactory; P.C.A., posterior cerebral artery; Ped., peduncle; Pit., pituitary; Post., posterior; Rec., recess; Seg., segment; Suprachiasm., suprachiasmatic; Tent., tentorial; Term., terminalis; Tr., tract; V., vein; Vent., ventricle. (Images courtesy of AL Rhoton, Jr.)

圖8.13(情況)。神經上地區的關係。E,地板的完整的第三腦室已經暴露出閨房雙邊通過移除。乳頭狀體位於前部和中部的結三分之二的地板上。乳頭狀的身體後麵的地板是由上層中腦。前麵的地板上的乳頭狀的身體非常瘦,第三腦室切開術作為一個合適的地點。第三腦室的F,地板被揭露後下麵的眼球運動的神經退出interpeduncular窩第三腦室的地板的一部分。幕的邊緣向下掃在中腦的側緣。上層腦橋之間暴露在視交叉和眼球運動的神經。腳水箱位於鉤和大腦腳之間。 G, anterior oblique view with the arteries preserved. The chiasm forms the upper margin of the chiasmatic cistern, which opens laterally into the carotid cistern surrounding the internal carotid arteries and upward around the optic chiasm to the cistern of the lamina terminalis. The anterior cerebral arteries ascend in front of the lamina terminalis. The anterior commissure crosses in the upper part of the anterior third ventricular wall. The columns of the fornix form the superior and anterior margins of the foramen of Monro. H, anterosuperior view. The upper part of the left thalamus has been removed to expose the optic tract, which extends backward above the oculomotor nerve in the lateral part of the suprasellar area to reach the lateral geniculate body. The chiasm and posterior part of the optic nerves are located directly above the sella. The anterior cerebral arteries pass above the chiasm. The left anterior cerebral artery is hypoplastic. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Cap., capsule; Car., carotid; Caud., caudate; Cav., cavernous; Cer., cerebral; Chiasm., chiasmatic; Chor., choroidal; Cist., cistern; Clin., clinoid; CN, cranial nerve; Comm., commissure; For., foramen; Gen., geniculate; Infundib., infundibular; Int., intermedia, internal; Lam., lamina; Lat., lateral; Lent., lenticular; Mam., mamillary; M.C.A., middle cerebral artery; Nucl., nucleus; Olf., olfactory; P.C.A., posterior cerebral artery; Ped., peduncle; Pit., pituitary; Post., posterior; Rec., recess; Seg., segment; Suprachiasm., suprachiasmatic; Tent., tentorial; Term., terminalis; Tr., tract; V., vein; Vent., ventricle. (Images courtesy of AL Rhoton, Jr.)

圖8.14。矢狀部分(左)和優越的觀點(右)sellar地區顯示視神經交叉,和頸動脈。前綴的交叉位於結節。正常的交叉位於膈膜上麵。的後綴交叉坐落在背之上。一個。動脈;N。,神經。(從,Rhoton Jr:解剖腦下垂體和sellar地區,在塔帕爾K, Kovacs K, Scheithauer BW,勞埃德房車(eds):垂體腫瘤的診斷和管理。 Totowa, Humana Press Inc., 2000 [17].)

圖8.15。血管上地區的關係。,大腦前動脈課程視交叉和薄terminalis前麵。頸動脈海綿竇和退出通過向上的側邊緣上。上級垂體動脈十字交叉的水箱達到的下邊界交叉和垂體。B,蝶鞍部的高級視圖。第三腦室的地板已經暴露的視交叉上休息在前麵渡槽後的水平。大腦前動脈通過交叉。溝通後動脈通過向後的地板下麵第三腦室。底動脈分叉形成大腦後動脈的地板下麵第三腦室。 C, superior view of the suprasellar region. The carotid arteries course along the lateral margin of the chiasmatic cistern. The basilar bifurcation is located above and behind the sella. The posterior communicating arteries travel backward across the dorsum to join the posterior cerebral arteries. The posterior communicating arteries usually course above and medial to the oculomotor nerves. D, the optic chiasm is positioned above the diaphragm and sella. The optic tracts extends backward and laterally above the posterior cerebral arteries and oculomotor nerves toward the lateral geniculate bodies. The basilar bifurcation has been retracted forward to show the perforating arteries entering the midbrain, which can be damaged in the transsphenoidal approach if the posterior wall of the capsule of a pituitary adenoma is opened. E, diagrammatic view of the arteries in the suprasellar area, which can be stretched over the margin of a large tumor with suprasellar extension. All of the components of the circle of Willis and their perforating branches can be stretched over the dome of these tumors. F, superolateral view of the left optic nerve, chiasm, and tract and the floor of the third ventricle. The optic tract extends backward from the optic chiasm, around the upper edge of the cerebral peduncle, and above the posterior cerebral artery. The anterior cerebral arteries pass in front of the lamina terminalis and around the corpus callosum. G, some of the anterior part of the left cerebral peduncle has been removed while preserving the optic tract. The posterior cerebral and terminal part of the posterior communicating artery can be seen through the interval between the floor of the third ventricle and the optic tract. A., artery; A.C.A., anterior cerebral artery; A.Ch.A., anterior choroidal artery; Ant., anterior; B., body; Bas., basal; C.A., carotid artery; Car., carotid; Chor., choroidal; CN, cranial nerve; Comm., communicating; Diaph., diaphragm; Hyp., hypophyseal; Lam., lamina; Mam., mamillary; M.C.A., middle cerebral artery; O.N., optic nerve; P.C.A., posterior cerebral artery; P.Co.A., posterior communicating artery; Ped., peduncle; Perf., perforating; Pit., pituitary; Post., posterior; Rec., recurrent; Sup., superior; Term., terminalis; Tr., tract; V., vein; Vent., ventricle. (Images courtesy of AL Rhoton, Jr.)

圖8.16。關係sellar和上地區。劣質的視圖。頸動脈的supraclinoid部分分為三個部分的起源的基礎上其主要分支:眼科領域延伸到眼動脈的起源溝通後動脈的起源;通信段從溝通後動脈的起源到脈絡膜前動脈的起源;和脈絡膜的環節延伸從原點脈絡膜前動脈的頸動脈的分叉。視神經眼動脈之上。上麵的視神經交叉和視神經束前和腦下垂體後葉。灰結節是前的基底動脈頂端的。大腦後動脈通過在大腦總花梗在眼球運動的神經。 The perforating branches arising from the ophthalmic segment pass to the anterior lobe, optic nerve, and chiasm and to the anterior part of the tuber cinereum. A single perforating branch arises from the communicating segment on each side and passes upward to the optic tract and the floor of the third ventricle. B, the pituitary gland has been reflected backward to show the superior hypophyseal arteries passing from the ophthalmic segments to the infundibulum. The anterior cerebral and the anterior communicating arteries pass above the optic chiasm. C, posterior view. The basilar artery and brainstem have been divided and the floor of the third ventricle elevated to provide this posterior view of the arteries in the suprasellar area. The tuber cinereum and mamillary bodies are exposed between the optic tracts. D, the right half of the dorsum and the right posterior clinoid process have been removed to expose the anterior and posterior lobes of the pituitary gland. The basilar, posterior cerebral, and superior cerebellar arteries have been elevated to expose the pituitary stalk and floor of the third ventricle. The inferior hypophyseal and the tentorial arteries arise from the carotid artery. A., artery; A.C.A., anterior cerebral artery; A.Ch.A., anterior choroidal artery; A.Co.A., anterior communicating artery; Ant., anterior; B.A., basilar artery; C.A., carotid artery; Cer., cerebral; Ch., chiasm, choroidal; Cin., cinereum; Co., communicating; Diaph., diaphragm; Hyp., hypophyseal; Inf., inferior; Infund., infundibulum; Mam., mamillary; M.C.A., middle cerebral artery; O.Ch., optic chiasm; O.N., optic nerve; Op., Ophth., ophthalmic; O.Tr., optic tract; P.C.A., posterior cerebral artery; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial. (From, Gibo H, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg 55:560–574, 1981 [6].)

圖8.17(模擬)。Sublabial transseptal,蝶竇和鼻內的方法。,sublabial方法指導下的嘴唇和平滑肌瘤一邊鼻中隔蝶的臉。插圖顯示了站點gingivobuccal切口,插入的方向下的鏡唇到鼻腔。B, transseptal方法是直接通過一個小切口一側的黏膜與皮膚的結鼻小柱和平滑肌瘤在鼻中隔兩側蝶的臉。C, Rhoton蝶鏡已經插入沿途的鼻內的蝶竇入路直接通過一個鼻孔,鼻中隔貝殼狀結構外側和內側。D,虛線顯示區域後隔分開的蝶竇。榍石。蝶。(圖片由AL Rhoton Jr。)

圖8.17(情況)。Sublabial transseptal,蝶竇和鼻內的方法。E,優越的鼻腔(左)。鏡先進鼻中隔、鼻甲之間的一個鼻孔蝶的臉。粘膜打開蝶左臉的隔膜(黃色箭頭)和粘膜升高,後隔分開蝶的臉(紅色箭頭)(右邊)。窺器葉片已經先進的平滑肌瘤在蝶竇的臉。F,左上角,側視的暴露蝶竇的鼻內的接觸。右下方,一個小骨鑿是用來打開蝶的臉。沒有骨頭的隔膜和骨取自蝶的臉是保留作為支架關閉前sellar牆。G,蝶窺器的變化。 The speculum on the left has blades that are tapered so that the opening at the nostril is greater than the exposure obtained at the sphenoid face. The Rhoton speculum on the right was designed for endonasal transsphenoidal surgery. It has parallel blades that open so that the exposure at the sphenoid face is slightly greater than the opening of the speculum at the anterior nasal aperture. H, the upper right shows the thicker, wider blades on the traditional transsphenoidal speculum. The lower left shows the Rhoton modified endonasal speculum with smaller, thinner blades that open like the parallel blades shown in G. Sphen., sphenoid. (Images courtesy of AL Rhoton, Jr.)

圖8.18。前上的視圖的蝶竇和sellar地區鼻內的路線。的屋頂,地板的鼻腔和內側部分的前窩已被移除sellar地區暴露鼻內的路線。鏡的鼻內的方法是先進的課程調查。先進的在一個鼻孔向上並通過鼻中隔和外耳的蝶的臉。後中間外耳的一部分提供了一個相對障礙暴露蝶的臉在這種情況下,但是可以取代橫向外耳窺器的刀片。著名的外耳,像這樣,可能傾向於轉移窺器對麵,除非是注意中心窺器葉片兩側的中線垂直脊蝶的臉。後篩骨空氣細胞定位前外側蝶臉的一部分。鼻中隔,在這種情況下,是向右傾斜。B,鼻內的鏡已經先進到蝶的臉在該地區蝶門的下麵。 The septum at this level is formed by the perpendicular plate of the ethmoid. The septum below is formed by the vomer. C, enlarged view of the speculum blades at the face of the sphenoid. The mucosa is opened in the area below the sphenoid ostia and elevated in a small area so that the blades can be inserted submucosally. D, opening the speculum separates a small section of the septum from the sphenoid face and displaces the septum to the opposite side. The speculum blades can then be advanced submucosally along the sphenoid face bilaterally. The crest on the sphenoid face formed by the ethmoid perpendicular plate and vomer should be positioned in the midline between the blades of the speculum. A., artery; Cart., cartilage; CN, cranial nerve; Endonas., endonasal; Eth., ethmoid; Mid., middle; Ophth., ophthalmic; Perp., perpendicular; Sept., septal; Sphen., sphenoid. (Images courtesy of AL Rhoton, Jr.)

圖8.19。底路線sellar地區的前視圖。這個斜截麵,沿線的擴展用於蝶手術。橫截麵的斜坡向上和向後的前部下麵的鼻腔蝶竇前和軌道頂端之上。軌道的屋頂已被刪除,留下一些地板和側壁的軌道。軌道下麵的上頜竇接觸地板。外鼻的半圓屋頂擴展內側牆。軌道極點位於外側篩骨的鼻竇。鼻中隔的下部是由犁骨和篩骨垂直板上方形成。B,橫截麵已經向後擴展在蝶竇前。 The nasal septum deviates to the right. The ethmoidal sinuses are located anterior to the lateral part of the sphenoid sinus. The maxillary sinuses are exposed below the floor of the orbits. C, enlarged view. The posterior ethmoid air cells are located in front of the upper lateral part of the sphenoid sinus and overlap the lateral margin of the sphenoid ostia. The middle concha, which block the view of the sphenoid face, must be displaced laterally in the transsphenoidal approach. D, the anterior wall of the sphenoid sinus has been removed to expose the sphenoid septi and sella. The carotid prominences are located forward and lateral to the anterior sellar wall. E, the sphenoid septi and osseous wall of the sphenoid sinus and the dural wall of the cavernous sinus have been removed to expose the cavernous sinuses and the dura lining the sella. The cavernous sinus and intracavernous carotid are exposed lateral to the sella. The lamina terminalis is exposed above the chiasm. F, enlarged view. The dura lining the sella has been removed to expose the pituitary gland, the intracavernous carotid, and the cavernous sinuses. The optic canals are exposed in the superolateral part of the sphenoid sinus. A., artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Eth., ethmoid; Infraorb., infraorbital; Lam., lamina; Max., maxillary; Mid., middle; N., nerve; Perp., perpendicular; Pit., pituitary; Prom., prominence; Seg., segment; Sphen., sphenoid; Term., terminalis. (Images courtesy of AL Rhoton, Jr.)

圖8.20。內窺鏡sellar地區的觀點。內窺鏡蝶竇的觀點。頸動脈日珥是薩拉的前壁外側。前sellar牆已被打開暴露硬腦膜襯裏薩拉的前壁。B,硬腦膜襯裏鞍和覆蓋intracavernous頸動脈海綿竇已被刪除。暴露在腺垂體。C,視圖與30度角內窺鏡。視杆,把視神經管眶上裂,被移除。opticocarotid休會,已打開,延伸到支柱。 The cavernous sinus surrounds the intracavernous carotid. D, the venous material in the cavernous sinus has been cleared to expose the nerves coursing in the walls of the cavernous sinus. The abducens nerve courses on the medial side of the ophthalmic nerve. The maxillary nerve is in the lower margin of the exposure. The inferolateral trunk arises from the cavernous carotid artery and passes between the abducens and ophthalmic nerves. E, enlarged view of the inferior hypophyseal artery passing from the intracavernous carotid to the posterior lobe. F, the tuberculum and planum sphenoidale have been removed to expose the optic nerves and chiasm and the pituitary stalk. In addition, the clivus and the clival dura have been opened to expose the basilar artery and pons below the gland. A., artery; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Dors., dorsal; Hyp., hypophyseal; Inf. Lat., inferolateral; Men., meningeal; Opticocar., opticocarotid; Pet., petrous; Pit., pituitary; Post., posterior; Prom., prominence; Rec., recess; Seg., segment; Sphen., sphenoid; Tr., trunk. (Images courtesy of AL Rhoton, Jr.)

圖8.21。模擬,subfrontal暴露蝶鞍部。插圖顯示了,小右額葉顱骨切開術。額葉已經發展到了曝光正確的視神經和交叉插圖所示。這種方法是最常見的選擇之間的病變位於在視神經交叉的水箱。刪除了硬腦膜上表麵的平麵sphenoidale,視神經管和前床形的過程。在大多數情況下,這種方法被選中時,不需要暴露蝶竇或刪除前床形的過程。B, subfrontal接觸已經被改造成一個transfrontal-transsphenoidal方法sellar地區通過消除蝶竇的屋頂。前sellar牆是通過開放的平麵sphenoidale。垂體上動脈起源於supraclinoid頸動脈和通過垂體。 C, the optic nerve has been displaced laterally to show the origin of the ophthalmic artery. The anterior sellar wall has been removed to expose the anterior surface of the pituitary gland. D, the pituitary gland has been displaced to the left to open the space between the lateral surface of the pituitary gland and the medial surface of the intracavernous carotid. The inferior hypophyseal artery, which arises from the meningohypophyseal trunk of the intracavernous carotid, passes to the capsule of the posterior lobe. A., artery; Ant., anterior; Car., carotid; Clin., clinoid; CN, cranial nerve; Hyp., hypophyseal; Inf., inferior; Ophth., ophthalmic; Pit., pituitary; Sphen., sphenoid; Sup., superior; Temp., temporal. (Images courtesy of AL Rhoton, Jr.)

圖8.22。Subfrontal方法下第三腦室的一部分。一個,左:頭皮切口,右額骨瓣,硬腦膜的切口,自我保留牽開器的位置。右:顱內暴露與額葉收回。視神經、視交叉、視束向上延伸如果腫瘤。正確的嗅覺神經分裂,但左邊一個是完好無損。前大腦前動脈交叉視覺大片溝通和板terminalis。顳葉和頸動脈和大腦中動脈外側視神經交叉。中,不同的subfrontal方法下第三腦室的一部分。B, subchiasmatic方法。 The tumor is exposed between the optic nerves, the optic chiasm, and the tuberculum sellae. A knife incises the tumor capsule. C, opticocarotid approach. This approach is directed through the interval between the optic nerve and the anterior cerebral and carotid arteries. A cup forceps reaches through a hole in the tumor capsule. Perforating arteries cross the interval between the carotid artery and the optic nerve. D, lamina terminalis approach. The lamina terminalis is above the optic chiasm and between the optic tracts. The lamina terminalis has been opened, and a cup forceps reaches between its edges to remove tumor in the anteroinferior part of the third ventricle. E, transfrontal-transsphenoidal approach. A prefixed optic chiasm blocks the subchiasmatic approach to a tumor. The tumor is exposed by removing the posterior part of the planum sphenoidale and the tuberculum sellae to expose the sphenoid sinus. The sinus mucosa is depressed inferiorly and the anterior sellar wall is removed to expose the tumor. A., artery; A.C.A., anterior cerebral artery; A.Co.A., anterior communicating artery; Ant., anterior; C.A., carotid artery; Fr., frontal; Lam., lamina; M.C.A., middle cerebral artery; N., nerve; O.Ch., optic chiasm; Olf., olfactory; O.N., cranial nerve; O.Tr., optic tract; Perf., perforating; Temp., temporal; Ter., terminalis; Tub., tuberculum. (From, Rhoton AL Jr, Yamamoto I, Peace DA: Microsurgery of the third ventricle: Part 2—Operative approaches. Neurosurgery 8:357–373, 1981 [23].)