Department of Neurosurgery, College of the First Clinical Medicine, Dalian Medical University, Dalian, China.
Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China.
J Neurosurg Sci. 2024 Jun;68(3):327-337. doi: 10.23736/S0390-5616.21.05455-2. Epub 2021 Sep 21.
The quantitative anatomic analysis of comprehensively endoscopic approaches to the third ventricle is scarce at present. The objective of the study is to quantitatively assess and compare the exposure and microsurgical maneuverability of three absolutely endoscopic keyhole approaches, including interhemispheric transcallosal transchoroidal (TCTC), frontal transforminal transchoroidal (TFTC) and supraorbital subfrontal translamina terminalis (SFTL) approaches.
Anatomical dissections and exposure of the important structures of the third ventricle were performed using six formalin-fixed cadaveric human heads (twelve sides) under endoscope. Tubular retractor system was used in the TFTC approach. Quantitative anatomical relationship between the important landmarks were obtained. Moreover, the exposure and surgical operability of three approaches were evaluated through applying the rating scale and accomplishing the quantitative anatomic analysis, area of surgical freedom and angle of attack.
The mediolateral, anteroposterior (AM: between aqueduct and mammillary body; IM: between infundibular recess and mammillary body) and superoinferior distance of TCTC, TFTC and SFTL approaches were 4.0±1.0, 4.2±0.4, 4.1±1.1 mm; 17.3±1.4, 17.6±0.5, 12.8±3.3 mm (AM); 7.7±0.3, 7.8±0.5 mm, not measured (IM); and 5.6±0.3, 7.8±0.8, 7.8±1.5 mm, respectively. Similar to TFTC, the exposed landmarks of TCTC were almost scored a "4" by three neurosurgeons except the infundibular recess scored a "3" according to the rating scale. During the SFTL approach, apart from the roof, the majority of the landmarks were scored a "4" except for the infundibular recess, which was scored a "3." The mean area of surgical freedom of TCTC (0° endoscope: 220±47; 30°: 247±56 mm) was not significantly different from that of TFTC approach (0° endoscope: 216±49; 30°: 245±53 mm) under same endoscope, P>0.05. Mean angle of attack of TCTC (0° endoscope: 21±4°; 30°: 26±4°) was significantly larger than that of TFTC approach (0° endoscope: 16±3°; 30°: 19±3°), P<0.05.
Purely endoscopic TCTC and TFTC approaches offer brilliant exposure of the anterior, middle and posterior third ventricle. TCTC approach may have better surgical maneuverability than TFTC approach. Despite the long working distance, the whole third ventricle are exposed well except for the roof in the SFTL approach, and surgical manipulation can be accomplished smoothly.
目前，对于全面的内镜下第三脑室入路的定量解剖分析还很少。本研究的目的是定量评估和比较三种绝对内镜锁孔入路，包括额下入路经胼胝体-脉络膜（TCTC）、经额下入路经蝶骨-脉络膜（TFTC）和经眶上锁孔经终板前（SFTL）入路的显露和显微手术可操作性。
在显微镜下使用管状牵开器系统对 6 个福尔马林固定的人体头颅（12 侧）进行第三脑室重要结构的解剖和显露。对重要标志之间的定量解剖关系进行了研究。此外，通过应用评分量表和完成定量解剖分析、手术自由度面积和攻击角度，评估了三种方法的显露和手术可操作性。
TCTC、TFTC 和 SFTL 入路的中外侧距（AM：在导水管和乳头体之间；IM：在漏斗隐窝和乳头体之间）、前后距（17.3±1.4、17.6±0.5、12.8±3.3mm）和上-下距（4.0±1.0、4.2±0.4、4.1±1.1mm）分别为 7.7±0.3、7.8±0.5mm，未测量（IM）；5.6±0.3、7.8±0.8、7.8±1.5mm。类似于 TFTC，三位神经外科医生对 TCTC 的显露标志评分几乎都是“4”，除了漏斗隐窝是“3”。在 SFTL 入路中，除了穹窿外，大多数标志的评分都是“4”，除了漏斗隐窝是“3”。TCTC 手术自由度面积的平均值（0°内镜：220±47；30°：247±56mm）与 TFTC 入路的平均值（0°内镜：216±49；30°：245±53mm）差异无统计学意义，P>0.05。TCTC 的平均攻击角度（0°内镜：21±4°；30°：26±4°）明显大于 TFTC 入路（0°内镜：16±3°；30°：19±3°），P<0.05。
单纯内镜 TCTC 和 TFTC 入路可提供良好的前、中、后第三脑室显露。TCTC 入路的手术可操作性可能优于 TFTC 入路。尽管工作距离较长，但 SFTL 入路除了穹窿外，整个第三脑室都能很好地显露，手术操作也能顺利完成。
