Nizzola Mariagrazia, Alam Yasaman, Leonel Luciano C P C, Torregrossa Fabio, Graepel Stephen P, Shinya Yuki, Pinheiro-Neto Carlos D, Link Michael J, Peris-Celda Maria
1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.
2Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota.
J Neurosurg. 2024 Dec 13;142(5):1338-1348. doi: 10.3171/2024.7.JNS24234. Print 2025 May 1.
The floor of the third ventricle and the interpeduncular and prepontine regions represent challenging surgical targets. The expanded endoscopic endonasal approach (EEA) with pituitary gland (PG) transposition has been proposed to provide direct access to these anatomical regions. Through the years, different endoscopic PG transposition techniques have been studied and presented. The goal of this study was to compare the techniques, relevant anatomy, and surgical exposure of extradural, intradural, and interdural PG transposition techniques.
Six formalin-fixed, latex-injected cadaveric head specimens were used to perform the EEA with extradural, unilateral interdural, and unilateral intradural PG transpositions. The interpeduncular and prepontine regions and the neurovascular structures located within these cisterns were carefully exposed and analyzed. The maximal cranial, caudal, and lateral accessible points within the surgical field were identified for each approach. Consequently, the relative craniocaudal and horizontal surgical axes were measured to quantify the extent of accessibility of each approach.
The extradural PG transposition technique provided the largest horizontal extensions and bilateral access to structures within the interpeduncular and prepontine regions; the mean horizontal axis was 17.9 (range 13.9-20.4) mm. The unilateral interdural PG transposition provided wider vertical exposure, with a mean craniocaudal axis of 16.2 (range 13.0-20.9) mm. In this approach, the surgical field was extended cranially above the ipsilateral mammillary body (MB). The unilateral intradural PG transposition provided a similar surgical exposure to the interdural approach, with a mean craniocaudal axis of 14.7 (range 12.9-15.8) mm. The approach required significant manipulation of the PG after opening both periosteal and meningeal dura layers.
The extradural PG transposition is indicated for lesions of the upper clivus region that extend bilaterally and do not have a cranial extension beyond the MBs. The inter- and intradural PG transpositions are beneficial for unilateral lesions that extend cranially to the MBs. Both techniques require coagulation of the ipsilateral inferior hypophyseal artery. The intradural technique requires more manipulation of the PG, while the interdural technique requires opening and access to the cavernous sinus. If needed, the intra- and interdural techniques can also be performed bilaterally.
第三脑室底部、脚间区和脑桥前区是具有挑战性的手术靶点。已提出采用扩大经鼻内镜入路（EEA）并移位垂体（PG）来直接进入这些解剖区域。多年来，已对不同的内镜下PG移位技术进行了研究和介绍。本研究的目的是比较硬膜外、硬膜内和硬膜间PG移位技术的技术、相关解剖结构及手术显露情况。
使用6个经福尔马林固定、注入乳胶的尸体头部标本进行硬膜外、单侧硬膜间和单侧硬膜内PG移位的EEA。仔细显露并分析脚间区和脑桥前区以及这些脑池内的神经血管结构。确定每种入路在手术视野内的最大颅侧、尾侧和外侧可达点。因此，测量相对的颅尾和水平手术轴以量化每种入路的可达范围。
硬膜外PG移位技术提供了最大的水平延伸范围以及对脚间区和脑桥前区内结构的双侧显露；平均水平轴为17.9（范围13.9 - 20.4）mm。单侧硬膜间PG移位提供了更宽的垂直显露范围，平均颅尾轴为16.2（范围13.0 - 20.9）mm。在这种入路中，手术视野向颅侧延伸至同侧乳头体（MB）上方。单侧硬膜内PG移位提供了与硬膜间入路相似的手术显露，平均颅尾轴为14.7（范围12.9 - 15.8）mm。该入路在打开骨膜和脑膜硬脑膜层后需要对PG进行大量操作。
硬膜外PG移位适用于向双侧延伸且颅侧未超过MBs的斜坡上部区域病变。硬膜间和硬膜内PG移位对颅侧延伸至MBs的单侧病变有益。两种技术都需要凝固同侧垂体下动脉。硬膜内技术需要对PG进行更多操作，而硬膜间技术需要打开并进入海绵窦。如有需要，硬膜内和硬膜间技术也可双侧进行。
