扩大经蝶入路显微解剖与临床应用研究
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摘要
第一部分解剖学研究
目的评估不同方式扩大经蝶入路与Le fortⅠ型上颌骨截骨术(Le fort I osteotomy，LFO)对于颅底中线结构解剖学暴露范围。
方法成人头颅标本9例，在神经导航的指引下分别经鼻-鼻中隔入路(Transnasal septum approach，TNSA)、经唇下-鼻中隔入路(Sublabial septum approach，SLSA)、改良经唇下入路(Modified Sublabial approach，MSLA)扩大经蝶入路和LFO，显微镜下观察每种术式所能暴露的颅底重要结构，并借助神经导航仪测量上述各种方式向前颅底、双侧海绵窦和斜坡方向暴露的范围。对于测量结果运用统计学分析，以明确不同方式暴露距离的不同有无统计学意义。
结果对于前颅底结构的暴露，TNA与SLA无明显差别，MSLA和LFO均有不同程度的扩大，其中LFO更为明显；在双侧海绵窦和斜坡方向上，上述方式的暴露范围具有统计学意义上的差别，结合实际测得的结果，TNA＜SLA＜MSLA＜LFO。同时MSLA和LFO中，均可将垂体抬起打开三脑室底部，LFO还可暴露寰椎前弓。
结论不同方式的扩大经蝶入路和Le fortⅠ型上颌骨截骨术都能在一定程度上暴露颅底中线结构，较侧方入路更为直接，对正常组织损伤小。由于暴露范围的差别，临床中要根据病灶位置选择最佳入路。MSLA虽较LFO显露范围小，但对于大多数颅底中线部位肿瘤而言其暴露范围已经足够，且操作相对简单、对正常结构影响小，但临床效果有待进一步验证。
第二部分临床应用研究
目的明确不同方式扩大经蝶入路临床适应证及并发症的防治。
方法收集2007年6月至2009年2月于本中心行采用扩大经蝶入路显微手术切除颅底中线部位肿瘤病例21例(包括斜坡脊索瘤11例，侵犯海绵窦区垂体大腺瘤9例，鞍结节脑膜瘤1例)。术前采用虚拟现实技术，重建肿瘤及颅底结构(包括重要神经、血管)，并在虚拟现实环境下模拟手术入路，选择最佳手术路径。手术均行神经导航指引，部分结合术中MRI，以明确肿瘤与周围重要结构的关系以及切除程度。统计分析其手术方式、手术效果及并发症防治、预后等方面数据，以期验证解剖学研究所得出的结论，并进一步规范扩大经蝶入路的手术适应症和并发症的防治方法。
结果结合术中神经导航图像、iMRI影像学资料以及术后复查头部MRI，证实有11例斜坡脊索瘤中，3例肿瘤全切除，5例达到次全切除(切除比例＞90％)，3例大部切除(切除比例＜90％)；9例侵犯海绵窦区垂体大腺瘤，有5例做到肿瘤全切除，4例达到次全切除(切除比例＞90％)；1例鞍结节脑膜瘤达Simpson I类全切。术后并发症主要为脑脊液漏，发生率约20％(5／21)，经颅底重建及对症处理，均痊愈。术中未发生颈内动脉的损伤。
结论不同方式扩大经蝶入路可直接到达颅底中线结构，临床上操作简单、并发症较少，可获得很好的手术效果。在临床应用过程中发现，经鼻中隔入路、经唇下鼻中隔入路和改良经唇下入路在颅底中线结构的暴露范围上还是存在区别的，其结论是与解剖研究内容相一致的。
斜坡脊索瘤、侵犯海绵窦区垂体大腺瘤及及鞍结节脑膜瘤，在手术方式的选择上，首先应考虑肿瘤累及范围及不同方式扩大经蝶入路的暴露范围。具体来讲，肿瘤累及前颅底方向时，由于上颌窦后壁及粘膜的阻挡，经鼻入路暴露困难，经唇下入路和改良唇下入路可磨除鼻嵴和部分鼻底骨质，增大手术操作空间；肿瘤侵犯CS时，若仅累及CS内侧壁，可行经鼻入路切除，当肿瘤向CS下壁或外侧壁生长时，采用经唇下入路或改良唇下入路；对于斜坡区域肿瘤，累及中上斜坡者，采用经鼻入路或经唇下入路，对于下斜坡肿瘤，采用改良经唇下入路。
Le fortⅠ型上颌骨截骨术(LFO)可广泛暴露前颅底、海绵窦、整个斜坡直至颅颈交界处，但该术式操作复杂、费时，并发症多，临床应用受到了较大的限制，应用时应严格掌握手术适应症；改良经唇下入路操作简单、并发症少，亦能暴露蝶骨平台到下斜坡区域的广泛空间，临床适应范围更加广泛。
再者，选择手术方式时应该考虑到可能的肿瘤性质。不同性质肿瘤的生长方式及预后有着明显区别，手术方式也应“因瘤而异”。
扩大经蝶入路术后并发症，主要是颈内动脉损伤及脑脊液漏，经合理的术中、术后处理，可得到很好的控制。
PartⅠAnatomical research
Anatomical analysis of the exposure of the midline skull base by theextended transsphenoidal approaches and Le fort I osteotomy
OBJECTIVE To quantity and compare the surgical exposure of themidline skull base among the extended transsphenoidal approach and Lefort I osteotomy(LFO).
METHODS With the assistance of neuro-navigation system, the 3different extended transsphenoidal approaches including the transnasalapproach(TNA) , sublabial approach(SLA)and modified sublabialapproach(MSLA) respectively, and LFO were performed in 12 adult cadavericheads. Under the microscope, the midline skull base structures exposedby the four approaches were observed. With the assistance ofneuro-navigator, the surgical exposure to the anterior skull base,cavernous sinus area and clivus area by four approaches weremeasured .After that, the metered data was analyzed by the statisticssoftware in order to identify whether there were statistics differencesof the surgical exposure provided by the four approaches.
Results There was no distinctive difference of the surgical exposureto the anterior skull base provided by TNA and SLA, but wider exposurewas founded using MSLA and LFO, especially the LFO. Considering theexposure of the cavernous sinus and clivus area, there was statisticsdifference among the four approaches, according to the actual data, theexposure area was TNA＜SLA＜MSLA＜LFO respectively. Furthermore, by theMSLA and LFO, the floor of the third ventricle could be opened, and theanterior arch of atlas could be opened by the LFO.
CONCLUSION The 3 different extended transsphenoidal approaches andLFO can expose the midline skull base in different degree, which are moredirect and less invasive than the transcranial approach. Because of thedistinction of the surgical exposure, the better choice of the surgical approach should be depended on the localization of the tumor. With regardto the majority of the skull base tumors, MSLA can offer enough surgicalexposure, which was simpler and less invasive than the LFO. However, theclinical effect need to be verified progressively.
PartⅡClinical application
OBJECTIVE To evaluate the clinical application of 3 differentextended transsphenoidal approaches in microsurgery for tumors locatedalong the midline skull base. Meanwhile, the treatment of thecomplications after the extended transsphenoidal approach was discussed.
METHODS 21 patients ,form June 2007 to February 2009, with tumorsin the midline skull base, including 11 cases of clivus chordomas, 9 casesof pituitary macroadenomas invading CS and 1 case of tuberculum sellaemeningioma respectively, were surgically treated by microscopic extendedtranssphenoidal approach, with the assistance of neuro-navigationsystem. Among those, 3-D stereoscopic virtual reality images werereconstructed successfully before surgery, which could identify therelationship between the tumors and surrounding structures and conducedto the operations. The data of 3 different approaches, surgical effect,complications and prognosis after surgery was compared, in order tofurther verify the results of anatomical research of partⅠ. Furthermore,the indications of extended transsphenoidal approach and methods to dealwith the complications were be discussed and summarized here.
Results Total removal was achieved in 9 cases, subtotal removal in9 cases and most partial removal in another 3 cases, which was confirmedby the images of neuronavigation and iMRI combined with the imaging-scopyafter the operations. In the cases using the transnasal approach andsublabial approach, the resident tumors were found mostly in the cavernoussinus areas and the lower clivus, which could only found in the cavernoussinus areas in the cases by the modified sublabial approach. In 4cases ,the leakage of cerebrospinal fluid occurred, which recoverd completely after the reconstruction of the skull base and correspondingtreatment. Injury of the internal carotid artery did not occur in all thecases.
CONCLUSIONS The extended transsphenoidal approach can exposed themidline skull base directly. During the clinical progress, we canmanipulate this approach simplely and conveniently. And the clinicaleffect is satisfactory with modicus complications. However, we also findthat there are differences among the exposed scope afforded by the by thetransnasal approach, sublabial approach and modified sublabial approach,which is coincident with the anatomical conclusions.
Le fort I osteotomy can widely expose the midline skull base, fromthe anterior skull base to the cranio-cervico junction, but in theclinical ,the application of LFO is restricted because of thecomplications. In another side, the modified sublabial approach isworthing generalization considered its wide anatomical expose andrelatively simple manipulation.
In clinical, the choice of the surgical approaches about the ncludingclivus chordomas, pituitary macroadenomas invading CS and tuberculumsellae meningioma, should base on the following aspects:
1、The involved extent of the tumors and the surgical exposuresupplied by the approaches:
2、The pathology of the tumors. Because the different kinds oftumors have different growth pattern and prognosis, which hasan influence on the choice of surgical approaches:
3、The therapeutic schedules for tumors should be allround,including surgery, chemotherapy and radiotherapy. Theoveremphasize of surgery is not recommended.
The complications of extended transsphenoidal approach includeleakage of cerebrospinal fluid and injury of internal carotid artery,which can be well controlled by the suitable methods.
目的评估不同方式扩大经蝶入路与Le fortⅠ型上颌骨截骨术(Le fort I osteotomy，LFO)对于颅底中线结构解剖学暴露范围。
方法成人头颅标本9例，在神经导航的指引下分别经鼻-鼻中隔入路(Transnasal septum approach，TNSA)、经唇下-鼻中隔入路(Sublabial septum approach，SLSA)、改良经唇下入路(Modified Sublabial approach，MSLA)扩大经蝶入路和LFO，显微镜下观察每种术式所能暴露的颅底重要结构，并借助神经导航仪测量上述各种方式向前颅底、双侧海绵窦和斜坡方向暴露的范围。对于测量结果运用统计学分析，以明确不同方式暴露距离的不同有无统计学意义。
结果对于前颅底结构的暴露，TNA与SLA无明显差别，MSLA和LFO均有不同程度的扩大，其中LFO更为明显；在双侧海绵窦和斜坡方向上，上述方式的暴露范围具有统计学意义上的差别，结合实际测得的结果，TNA＜SLA＜MSLA＜LFO。同时MSLA和LFO中，均可将垂体抬起打开三脑室底部，LFO还可暴露寰椎前弓。
结论不同方式的扩大经蝶入路和Le fortⅠ型上颌骨截骨术都能在一定程度上暴露颅底中线结构，较侧方入路更为直接，对正常组织损伤小。由于暴露范围的差别，临床中要根据病灶位置选择最佳入路。MSLA虽较LFO显露范围小，但对于大多数颅底中线部位肿瘤而言其暴露范围已经足够，且操作相对简单、对正常结构影响小，但临床效果有待进一步验证。
第二部分临床应用研究
目的明确不同方式扩大经蝶入路临床适应证及并发症的防治。
方法收集2007年6月至2009年2月于本中心行采用扩大经蝶入路显微手术切除颅底中线部位肿瘤病例21例(包括斜坡脊索瘤11例，侵犯海绵窦区垂体大腺瘤9例，鞍结节脑膜瘤1例)。术前采用虚拟现实技术，重建肿瘤及颅底结构(包括重要神经、血管)，并在虚拟现实环境下模拟手术入路，选择最佳手术路径。手术均行神经导航指引，部分结合术中MRI，以明确肿瘤与周围重要结构的关系以及切除程度。统计分析其手术方式、手术效果及并发症防治、预后等方面数据，以期验证解剖学研究所得出的结论，并进一步规范扩大经蝶入路的手术适应症和并发症的防治方法。
结果结合术中神经导航图像、iMRI影像学资料以及术后复查头部MRI，证实有11例斜坡脊索瘤中，3例肿瘤全切除，5例达到次全切除(切除比例＞90％)，3例大部切除(切除比例＜90％)；9例侵犯海绵窦区垂体大腺瘤，有5例做到肿瘤全切除，4例达到次全切除(切除比例＞90％)；1例鞍结节脑膜瘤达Simpson I类全切。术后并发症主要为脑脊液漏，发生率约20％(5／21)，经颅底重建及对症处理，均痊愈。术中未发生颈内动脉的损伤。
结论不同方式扩大经蝶入路可直接到达颅底中线结构，临床上操作简单、并发症较少，可获得很好的手术效果。在临床应用过程中发现，经鼻中隔入路、经唇下鼻中隔入路和改良经唇下入路在颅底中线结构的暴露范围上还是存在区别的，其结论是与解剖研究内容相一致的。
斜坡脊索瘤、侵犯海绵窦区垂体大腺瘤及及鞍结节脑膜瘤，在手术方式的选择上，首先应考虑肿瘤累及范围及不同方式扩大经蝶入路的暴露范围。具体来讲，肿瘤累及前颅底方向时，由于上颌窦后壁及粘膜的阻挡，经鼻入路暴露困难，经唇下入路和改良唇下入路可磨除鼻嵴和部分鼻底骨质，增大手术操作空间；肿瘤侵犯CS时，若仅累及CS内侧壁，可行经鼻入路切除，当肿瘤向CS下壁或外侧壁生长时，采用经唇下入路或改良唇下入路；对于斜坡区域肿瘤，累及中上斜坡者，采用经鼻入路或经唇下入路，对于下斜坡肿瘤，采用改良经唇下入路。
Le fortⅠ型上颌骨截骨术(LFO)可广泛暴露前颅底、海绵窦、整个斜坡直至颅颈交界处，但该术式操作复杂、费时，并发症多，临床应用受到了较大的限制，应用时应严格掌握手术适应症；改良经唇下入路操作简单、并发症少，亦能暴露蝶骨平台到下斜坡区域的广泛空间，临床适应范围更加广泛。
再者，选择手术方式时应该考虑到可能的肿瘤性质。不同性质肿瘤的生长方式及预后有着明显区别，手术方式也应“因瘤而异”。
扩大经蝶入路术后并发症，主要是颈内动脉损伤及脑脊液漏，经合理的术中、术后处理，可得到很好的控制。
PartⅠAnatomical research
Anatomical analysis of the exposure of the midline skull base by theextended transsphenoidal approaches and Le fort I osteotomy
OBJECTIVE To quantity and compare the surgical exposure of themidline skull base among the extended transsphenoidal approach and Lefort I osteotomy(LFO).
METHODS With the assistance of neuro-navigation system, the 3different extended transsphenoidal approaches including the transnasalapproach(TNA) , sublabial approach(SLA)and modified sublabialapproach(MSLA) respectively, and LFO were performed in 12 adult cadavericheads. Under the microscope, the midline skull base structures exposedby the four approaches were observed. With the assistance ofneuro-navigator, the surgical exposure to the anterior skull base,cavernous sinus area and clivus area by four approaches weremeasured .After that, the metered data was analyzed by the statisticssoftware in order to identify whether there were statistics differencesof the surgical exposure provided by the four approaches.
Results There was no distinctive difference of the surgical exposureto the anterior skull base provided by TNA and SLA, but wider exposurewas founded using MSLA and LFO, especially the LFO. Considering theexposure of the cavernous sinus and clivus area, there was statisticsdifference among the four approaches, according to the actual data, theexposure area was TNA＜SLA＜MSLA＜LFO respectively. Furthermore, by theMSLA and LFO, the floor of the third ventricle could be opened, and theanterior arch of atlas could be opened by the LFO.
CONCLUSION The 3 different extended transsphenoidal approaches andLFO can expose the midline skull base in different degree, which are moredirect and less invasive than the transcranial approach. Because of thedistinction of the surgical exposure, the better choice of the surgical approach should be depended on the localization of the tumor. With regardto the majority of the skull base tumors, MSLA can offer enough surgicalexposure, which was simpler and less invasive than the LFO. However, theclinical effect need to be verified progressively.
PartⅡClinical application
OBJECTIVE To evaluate the clinical application of 3 differentextended transsphenoidal approaches in microsurgery for tumors locatedalong the midline skull base. Meanwhile, the treatment of thecomplications after the extended transsphenoidal approach was discussed.
METHODS 21 patients ,form June 2007 to February 2009, with tumorsin the midline skull base, including 11 cases of clivus chordomas, 9 casesof pituitary macroadenomas invading CS and 1 case of tuberculum sellaemeningioma respectively, were surgically treated by microscopic extendedtranssphenoidal approach, with the assistance of neuro-navigationsystem. Among those, 3-D stereoscopic virtual reality images werereconstructed successfully before surgery, which could identify therelationship between the tumors and surrounding structures and conducedto the operations. The data of 3 different approaches, surgical effect,complications and prognosis after surgery was compared, in order tofurther verify the results of anatomical research of partⅠ. Furthermore,the indications of extended transsphenoidal approach and methods to dealwith the complications were be discussed and summarized here.
Results Total removal was achieved in 9 cases, subtotal removal in9 cases and most partial removal in another 3 cases, which was confirmedby the images of neuronavigation and iMRI combined with the imaging-scopyafter the operations. In the cases using the transnasal approach andsublabial approach, the resident tumors were found mostly in the cavernoussinus areas and the lower clivus, which could only found in the cavernoussinus areas in the cases by the modified sublabial approach. In 4cases ,the leakage of cerebrospinal fluid occurred, which recoverd completely after the reconstruction of the skull base and correspondingtreatment. Injury of the internal carotid artery did not occur in all thecases.
CONCLUSIONS The extended transsphenoidal approach can exposed themidline skull base directly. During the clinical progress, we canmanipulate this approach simplely and conveniently. And the clinicaleffect is satisfactory with modicus complications. However, we also findthat there are differences among the exposed scope afforded by the by thetransnasal approach, sublabial approach and modified sublabial approach,which is coincident with the anatomical conclusions.
Le fort I osteotomy can widely expose the midline skull base, fromthe anterior skull base to the cranio-cervico junction, but in theclinical ,the application of LFO is restricted because of thecomplications. In another side, the modified sublabial approach isworthing generalization considered its wide anatomical expose andrelatively simple manipulation.
In clinical, the choice of the surgical approaches about the ncludingclivus chordomas, pituitary macroadenomas invading CS and tuberculumsellae meningioma, should base on the following aspects:
1、The involved extent of the tumors and the surgical exposuresupplied by the approaches:
2、The pathology of the tumors. Because the different kinds oftumors have different growth pattern and prognosis, which hasan influence on the choice of surgical approaches:
3、The therapeutic schedules for tumors should be allround,including surgery, chemotherapy and radiotherapy. Theoveremphasize of surgery is not recommended.
The complications of extended transsphenoidal approach includeleakage of cerebrospinal fluid and injury of internal carotid artery,which can be well controlled by the suitable methods.
引文
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[17] Yano S, Tsuiki H, Kudo M , et al. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol, 2007 , 67(1):59-64.
[18] Dusick JR, Esposito F, Malkasian D, et al. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery. 2007, 60(4 Suppl 2):322-8.
[19] Kitano M, Taneda M. Icing and multilayering technique of injectable hydroxyapatite cement paste for cranial base reconstruction after transsphenoidal surgery: technical note. Neurosurgery. 2007, 61(3 Suppl):E53-4.
[20] Kitano M, Taneda M. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery. 2004 , 54 (3): 653-60.
[21] Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J neurosurgery , 2005,102: 832-841.
[22] Kitano M, Taneda M. An adjustable nasal speculum for the extended transsphenoidal approach. J neurosurgery, 2007,106:932-933.
[23] Zimmer L, Hirsch B, Kassam A, et al . Resection of a Recurrent Paraganglioma Via an Endoscopic Transnasal Approach to the Jugular Fossa.Otology & Neurotology, 2006, 27:398-402.
[24] Esposito F, Dusick JR, Fatemi N, et al. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.Neurosurgery. 2007, 60(4 Suppl 2):295-303.
[25] Naoyuki Nakao, Toru Itakura. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. Journal of Clinical Neuroscience, 2007: 267-272.
[26] Steward D, Pensak M. Transpetrosal surgery techniques. Otolaryngol Clin N Am, 2002, 35:367-391.
[27] Colli B, Al-Mefty O. Chordomas of the craniocervical junction:follow-up review and prognostic factors.J Neurosurg,2001, 95:933-943.
[28] Yoneoka Y, Tsumanuma I, Fukuda M, et al. Cranial base chordoma-long term outcome and review of the literature. Acta Neurochir(Wien), 2008,(150):773-778.
[29] Fatemi N, Disick J, Gorgulho A, et al. Endonasal microscopic removal of clival chordomas. Surgical Neurology, 2008(69): 331-338.
[30] Fish U. The infratemporal fossa approach for nasopharyngeal tumors.Laryngoscope, 1983, 93(1):36-44.
[31] Peter Y, Chi Long Ho. Neuronavigation using an image-guided endoscopic transnasal-sphenoethmoidal approach to clival chordomas.Neurosurgery, 2007: 212-218.
[32] Naoyuki Nakao, Toru Itakura. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. Journal of Clinical Neuroscience, 2007: 267-272.
[33] 张晓硌，吴劲松，毛颖，等．虚拟现实技术在神经外科术前计划中的应用．中华显微外科杂志，2006：415-418．
[34] Nakao N, Itakura T. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. J Clin Neurosci. 2007, 14(3):267-272.
[34] Lewark TM, Allen GC, Chowdhury K, et al. Le Fort Ⅰ osteotomy and skull base tumors: a pediatric experience. Arch Otolaryngol Head Neck Surg.2000, 126(8):1004-8.
[35] Williams WG, Lo LJ, Chen YR. The Le Fort Ⅰ-palatal split approach for skull base tumors: efficacy, complications, and outcome. Plast Reconstr Surg. 1998, 102(7):2310-2319.
[36] Balasingam V, Anderson GJ, Gross ND, et al. Anatomical analysis of transoral surgical approaches to the clivus. J Neurosurg. 2006 , 105(2):301-308.
[37] Lewark TM, Allen GC, Chowdhury K, et al. Le Fort I osteotomy and skull base tumors: a pediatric experience. Arch Otolaryngol Head Neck Surg. 2000,126(8):1004-8.
[38] Kitano M, Taneda M, Shimono T, et al. Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg. 2008 , 108(1):26-36.
[39] Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: Towards Functional Endoscopic Pituitary Surgery (FEPS). Minim Invasive Neurosurg 41:66-73, 1998.
[40] Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: Outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 45:1-8, 2002.
[41] Cappabianca P, Cavallo LM, Colao A, et al. Surgical complications of the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:293-298, 2002.
[42] Ciric I, Ragin A, Baumgartner C, et al . Complications of transsphenoidal surgery: Results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225 - 237, 1997.
[43] de Divitiis E, Cappabianca P, Cavallo LM: Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery 51:699-707, 2002.
[44] Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832-841, 2005.
[45] Fahlbusch R, Honegger J, Paulus W, et al. Surgical treatment of craniopharyngioma: Experience with 168 patients. J Neurosurg, 1999 90:237-250.
[46] Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg ,2002, 96:235-243.
[47] Garcia AS, Rhoton AL Jr: Speculum opening in transsphenoidal surgery. Neurosurgery , 2006,59 [Suppl 1]: ONS35 - ONS40.20. Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: Areport on management on the basis of a surgical experience with 70 patients. Neurosurgery, 2002,51:1358 - 1564.
[48] JalloGI, Benjamin V. Tuberculum sellae meningiomas: Microsurgical anatomy and surgical technique. Neurosurgery, 2002,51:1432-1440.
[49] Jarrahy R, Cha ST, Berci G, et al. Endoscopic transglabellar approach to the anterior fossa and paranasal sinuses. J Craniofac Surg , 2000,11:412-417.
[50] Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. J Neurosurg, 1997, 87:44-51.
[51] Kassam AB, Snyderman C, Gardner P, et al. The expanded endonasal approach: Afully endoscopic transnasal approach and resection of the odontoid process: Technical case report. Neurosurgery , 2005, 57:E213.
[52] Kato T, Sawamura Y, Abe H, Nagashima M. Transsphenoidal- transtuberculum sellae approach for supradiaphragmatic tumors: Technical note. Acta Neurochir (Wien) 140:715-719, 1998.
[53] Kim J, Choe I, Bak K, Kim C, Kim N, Jang Y: Transsphenoidal supradiaphragmatic intradural approach: Technical note. Minim Invasive Neurosurg, 2000,43:33-37.
[54] Kouri JG, Chen MY, Watson JC, et al. Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg , 2000,92:1028-1035.
[55] Laws ER, Kanter AS, Jane JA Jr, et al. Extended transsphenoidal approach. J Neurosurg , 2005,102:825-828.
[56] Mason RB, Nieman LK, Doppman JL, et al. Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. J Neurosurg ,1997,87:343-351.
[57] Snyderman CH, Kassam AB. Endoscopic techniques for pathology of the anterior cranial fossa and ventral skull base. J Am Coll Surg , 2006,202:563.
[58] Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: Outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg , 2002,45:1-8.
[59] Cappabianca P, Cavallo LM, Colao A, et al. Surgical complications of the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg, 2002, 97:293 - 298.
[60] de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoidal surgery, in Pickard JD (ed): Advances and Technical Standards in Neurosurgery. New York, Springer-Verlag, 2002, vol 27, pp 137 - 177.
[61] de Divitiis E, Cappabianca P, Cavallo LM: Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery 51:699-707, 2002.
[62] Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg,2002, 96:235 - 243.
[63] Garcia AS, Rhoton AL Jr. Speculum opening in transsphenoidal surgery. Neurosurgery, 2006 , 59 [Suppl 1]: ONS35 - ONS40.
[64] Jho HD. Endoscopic endonasal approach to the optic nerve: Atechnical note. Minim Invasive Neurosurg, 2001,44:190-193.
[65] Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. J Neurosurg, 1997,87:44-51.
[66] Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 1—The midline anterior fossa skull base. Minim Invasive Neurosurg , 2004,47:1-8.
[67] .Perneczky A. Planning strategies for the suprasellar region. Neurosurgeons, 1992,11:343 - 348.
[1] Cavallo LM, de Divitiis O, Aydin S, et al. Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations-part 1. Neurosurgery. 2007, Sep;61(3 Suppl):24-33.
[2] Cavallo LM, Cappabianca P, Messina A, et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv Syst. 2007, Jun; 23(6): 665-71.
[3] Cavallo LM, Cappabianca P, Galzio R, et al. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study.. Neurosurgery. 2005 Apr;56(2 Suppl):379-89.
[4] de Divitiis E, Cavallo LM, Cappabianca P, et al. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2.Neurosurgery. 2007, Jan;60(1):46-58.
[5] Cho DY, Liau WR. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol. 2002 Dec;58(6):371-5.
[6] Catapano D, Sloffer CA, Frank G,et al. Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach:anatomical study. J Neurosurgery, 2006,104:419-425.
[7] Frank G, Sciarretta V, Calbucci F,et al. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Ncurosurgcry. 2006, Jul;59(1 Suppl 1):ONS50-7.
[8] Couldwell WT, Weiss MH, Rabb C, et al. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery. 2004, Sep;55(3):539-47.
[9] Kaptain GJ, Vincent DA, Sheehan JP, et al. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery. 2001, Jul;49(1):94-100.
[10] Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery. 2004 Jul;55(1):239-44.
[11] Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006 Jul;59(1 Suppl 1):ONS75-83.
[12]Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurgery, 2007,106:400-406.
[13] Laws ER, Kanter AS, Jane JA Jr, et al. Extended transsphenoidal approach.J Neurosurgery, 2005, 102:825-828.
[14] Kitano M, Taneda M, Nakao Y. Postoperative improvement in visual function in patients with tuberculum sellae meningiomas: results of the extended transsphenoidal and transcranial approaches. J neurosurgery, 2007,107:337-346.
[15] Kitano M, Taneda M. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. J Neurosurgery, 2001, 94:999-1004.
[16] Yano S, Tsuiki H, Kudo M , et al. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol, 2007 Jan;67(1):59-64.
[17] Dusick JR, Esposito F, Malkasian D, et al. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery. 2007, Apr;60(4 Suppl 2):322-8.
[18] Esposito F, Dusick JR, Fatemi N, et al. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery. 2007, Apr;60(4 Suppl 2) :295-303.
[19] Kitano M, Taneda M. Icing and multilayering technique of injectable hydroxyapatite cement paste for cranial base reconstruction after transsphenoidalsurgery: technical note. Neurosurgery. 2007 Sep;61(3 Suppl):E53-4.
[20] Kitano M, Taneda M. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery. 2004,Mar;54(3): 653-60.
[21] Dusick JR, Esposito F, Kelly DF,et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J neurosurgery,2005,102: 832-841.
[22] Kitano M, Taneda M. An adjustable nasal speculum for the extended transsphenoidal approach. J neurosurgery, 2007,106:932-933.
[23] Zimmer L, Hirsch B, Kassam A, et al. Resection of a Recurrent Paraganglioma Via an Endoscopic Transnasal Approach to the Jugular Fossa. Otology & Neurotology,2006, 27:398-402.
[2] Cavallo LM, Cappabianca P, Messina A,et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv Syst. 2007, 23(6): 665-71.
[3] Cavallo LM, Cappabianca P, Galzio R, et al. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study.. Neurosurgery. 2005 , 56(2 Suppl):379-89.
[4] de Divitiis E, Cavallo LM, Cappabianca P, et al. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2. Neurosurgery. 2007, 60(1):46-58.
[5] Cho DY, Liau WR. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol. 2002, 58(6) :371-5.
[6] Catapano D, Sloffer CA, Frank G , et al. Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach:anatomical study. J Neurosurgery, 2006, 104:419-425.
[7] Frank G, Sciarretta V, Calbucci F,et al. The Endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery, 2006:50-57.
[8] Naoyuki Nakao , Toru Itakura. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. Journal of Clinical Neuroscience, 2007: 267-272.
[9] Couldwell WT, Weiss MH, Rabb C, et al. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases.Neurosurgery. 2004, 55(3):539-47.
[10] Kaptain GJ, Vincent DA, Sheehan JP, et al. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery. 2001, 49(1):94—100.
[11] Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery. 2004 , 55(1): 239-44.
[12] Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006 , 59(1 Suppl 1):ONS 75-83.
[13] Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurgery, 2007,106:400-406.
[14] Laws ER, Kanter AS, Jane JA Jr, et al. Extended transsphenoidal approach. J Neurosurgery, 2005,102:825-828.
[15] Kitano M, Taneda M, Nakao Y. Postoperative improvement in visual function in patients with tuberculum sellae meningiomas: results of the extended transsphenoidal and transcranial approaches. J Neurosurgery, 2007, 107:337-346.
[16] Kitano M, Taneda M. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. J Neurosurgery, 2001, 94:999-1004.
[17] Yano S, Tsuiki H, Kudo M , et al. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol, 2007 , 67(1):59-64.
[18] Dusick JR, Esposito F, Malkasian D, et al. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery. 2007, 60(4 Suppl 2):322-8.
[19] Kitano M, Taneda M. Icing and multilayering technique of injectable hydroxyapatite cement paste for cranial base reconstruction after transsphenoidal surgery: technical note. Neurosurgery. 2007, 61(3 Suppl):E53-4.
[20] Kitano M, Taneda M. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery. 2004 , 54 (3): 653-60.
[21] Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J neurosurgery , 2005,102: 832-841.
[22] Kitano M, Taneda M. An adjustable nasal speculum for the extended transsphenoidal approach. J neurosurgery, 2007,106:932-933.
[23] Zimmer L, Hirsch B, Kassam A, et al . Resection of a Recurrent Paraganglioma Via an Endoscopic Transnasal Approach to the Jugular Fossa.Otology & Neurotology, 2006, 27:398-402.
[24] Esposito F, Dusick JR, Fatemi N, et al. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.Neurosurgery. 2007, 60(4 Suppl 2):295-303.
[25] Naoyuki Nakao, Toru Itakura. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. Journal of Clinical Neuroscience, 2007: 267-272.
[26] Steward D, Pensak M. Transpetrosal surgery techniques. Otolaryngol Clin N Am, 2002, 35:367-391.
[27] Colli B, Al-Mefty O. Chordomas of the craniocervical junction:follow-up review and prognostic factors.J Neurosurg,2001, 95:933-943.
[28] Yoneoka Y, Tsumanuma I, Fukuda M, et al. Cranial base chordoma-long term outcome and review of the literature. Acta Neurochir(Wien), 2008,(150):773-778.
[29] Fatemi N, Disick J, Gorgulho A, et al. Endonasal microscopic removal of clival chordomas. Surgical Neurology, 2008(69): 331-338.
[30] Fish U. The infratemporal fossa approach for nasopharyngeal tumors.Laryngoscope, 1983, 93(1):36-44.
[31] Peter Y, Chi Long Ho. Neuronavigation using an image-guided endoscopic transnasal-sphenoethmoidal approach to clival chordomas.Neurosurgery, 2007: 212-218.
[32] Naoyuki Nakao, Toru Itakura. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. Journal of Clinical Neuroscience, 2007: 267-272.
[33] 张晓硌，吴劲松，毛颖，等．虚拟现实技术在神经外科术前计划中的应用．中华显微外科杂志，2006：415-418．
[34] Nakao N, Itakura T. Sublabial transnasal approach combined with a partial resection of the nasal floor for midline skull base tumors. J Clin Neurosci. 2007, 14(3):267-272.
[34] Lewark TM, Allen GC, Chowdhury K, et al. Le Fort Ⅰ osteotomy and skull base tumors: a pediatric experience. Arch Otolaryngol Head Neck Surg.2000, 126(8):1004-8.
[35] Williams WG, Lo LJ, Chen YR. The Le Fort Ⅰ-palatal split approach for skull base tumors: efficacy, complications, and outcome. Plast Reconstr Surg. 1998, 102(7):2310-2319.
[36] Balasingam V, Anderson GJ, Gross ND, et al. Anatomical analysis of transoral surgical approaches to the clivus. J Neurosurg. 2006 , 105(2):301-308.
[37] Lewark TM, Allen GC, Chowdhury K, et al. Le Fort I osteotomy and skull base tumors: a pediatric experience. Arch Otolaryngol Head Neck Surg. 2000,126(8):1004-8.
[38] Kitano M, Taneda M, Shimono T, et al. Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg. 2008 , 108(1):26-36.
[39] Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: Towards Functional Endoscopic Pituitary Surgery (FEPS). Minim Invasive Neurosurg 41:66-73, 1998.
[40] Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: Outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 45:1-8, 2002.
[41] Cappabianca P, Cavallo LM, Colao A, et al. Surgical complications of the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:293-298, 2002.
[42] Ciric I, Ragin A, Baumgartner C, et al . Complications of transsphenoidal surgery: Results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225 - 237, 1997.
[43] de Divitiis E, Cappabianca P, Cavallo LM: Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery 51:699-707, 2002.
[44] Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832-841, 2005.
[45] Fahlbusch R, Honegger J, Paulus W, et al. Surgical treatment of craniopharyngioma: Experience with 168 patients. J Neurosurg, 1999 90:237-250.
[46] Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg ,2002, 96:235-243.
[47] Garcia AS, Rhoton AL Jr: Speculum opening in transsphenoidal surgery. Neurosurgery , 2006,59 [Suppl 1]: ONS35 - ONS40.20. Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: Areport on management on the basis of a surgical experience with 70 patients. Neurosurgery, 2002,51:1358 - 1564.
[48] JalloGI, Benjamin V. Tuberculum sellae meningiomas: Microsurgical anatomy and surgical technique. Neurosurgery, 2002,51:1432-1440.
[49] Jarrahy R, Cha ST, Berci G, et al. Endoscopic transglabellar approach to the anterior fossa and paranasal sinuses. J Craniofac Surg , 2000,11:412-417.
[50] Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. J Neurosurg, 1997, 87:44-51.
[51] Kassam AB, Snyderman C, Gardner P, et al. The expanded endonasal approach: Afully endoscopic transnasal approach and resection of the odontoid process: Technical case report. Neurosurgery , 2005, 57:E213.
[52] Kato T, Sawamura Y, Abe H, Nagashima M. Transsphenoidal- transtuberculum sellae approach for supradiaphragmatic tumors: Technical note. Acta Neurochir (Wien) 140:715-719, 1998.
[53] Kim J, Choe I, Bak K, Kim C, Kim N, Jang Y: Transsphenoidal supradiaphragmatic intradural approach: Technical note. Minim Invasive Neurosurg, 2000,43:33-37.
[54] Kouri JG, Chen MY, Watson JC, et al. Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg , 2000,92:1028-1035.
[55] Laws ER, Kanter AS, Jane JA Jr, et al. Extended transsphenoidal approach. J Neurosurg , 2005,102:825-828.
[56] Mason RB, Nieman LK, Doppman JL, et al. Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. J Neurosurg ,1997,87:343-351.
[57] Snyderman CH, Kassam AB. Endoscopic techniques for pathology of the anterior cranial fossa and ventral skull base. J Am Coll Surg , 2006,202:563.
[58] Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: Outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg , 2002,45:1-8.
[59] Cappabianca P, Cavallo LM, Colao A, et al. Surgical complications of the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg, 2002, 97:293 - 298.
[60] de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoidal surgery, in Pickard JD (ed): Advances and Technical Standards in Neurosurgery. New York, Springer-Verlag, 2002, vol 27, pp 137 - 177.
[61] de Divitiis E, Cappabianca P, Cavallo LM: Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery 51:699-707, 2002.
[62] Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg,2002, 96:235 - 243.
[63] Garcia AS, Rhoton AL Jr. Speculum opening in transsphenoidal surgery. Neurosurgery, 2006 , 59 [Suppl 1]: ONS35 - ONS40.
[64] Jho HD. Endoscopic endonasal approach to the optic nerve: Atechnical note. Minim Invasive Neurosurg, 2001,44:190-193.
[65] Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. J Neurosurg, 1997,87:44-51.
[66] Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 1—The midline anterior fossa skull base. Minim Invasive Neurosurg , 2004,47:1-8.
[67] .Perneczky A. Planning strategies for the suprasellar region. Neurosurgeons, 1992,11:343 - 348.
[1] Cavallo LM, de Divitiis O, Aydin S, et al. Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations-part 1. Neurosurgery. 2007, Sep;61(3 Suppl):24-33.
[2] Cavallo LM, Cappabianca P, Messina A, et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv Syst. 2007, Jun; 23(6): 665-71.
[3] Cavallo LM, Cappabianca P, Galzio R, et al. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study.. Neurosurgery. 2005 Apr;56(2 Suppl):379-89.
[4] de Divitiis E, Cavallo LM, Cappabianca P, et al. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2.Neurosurgery. 2007, Jan;60(1):46-58.
[5] Cho DY, Liau WR. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol. 2002 Dec;58(6):371-5.
[6] Catapano D, Sloffer CA, Frank G,et al. Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach:anatomical study. J Neurosurgery, 2006,104:419-425.
[7] Frank G, Sciarretta V, Calbucci F,et al. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Ncurosurgcry. 2006, Jul;59(1 Suppl 1):ONS50-7.
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