内镜下单鼻孔入路解剖训练流程的探讨  

Study on the training process of Uni-nostril approach by transnasal endoscopic skull base dissection process

作　　者：赵宇[1] 刘剑锋[1] 韩军[1] 杨大章[1] Zhao Yu;Liu Jian-feng;Han Jun;Yang Da-zhang(Department of Otolaryngology, China-Japan Friendship Hospital, Beijing 100029, China)

机构地区：[1]中日友好医院耳鼻咽喉科

出　　处：《中国耳鼻咽喉颅底外科杂志》2019年第2期209-213,共5页Chinese Journal of Otorhinolaryngology-skull Base Surgery

基　　金：国家自然科学基金(30801281,81870699);人社部留学人员科技活动择优资助项目(2013-QTL-026);中日友好医院青年科技英才计划(2014-QNYC-A-02)

摘　　要：目的探索单鼻孔入路解剖训练流程的设计原则与应用,旨在利用最少的尸头标本,完成尽可能多的临床手术解剖训练。指导初学者进行高效的训练,缩短学习曲线。方法流程的设计原则为:①前次手术暴露但不损伤后续手术的结构;②用一侧标本完成尽可能多的临床手术训练;③根据临床常用径路,设计分步操作;④临床上需要双鼻孔入路完成的手术暂不纳入本流程,故一侧全部完成后,对侧鼻腔结构无损伤。采用5例新鲜硅胶灌注尸头的双侧验证并完成流程,采用Storz公司0°,4 mm鼻内镜及HD IMAGE 1高清摄录系统全程录像。结果按上述原则设计单鼻孔入路解剖流程,可经同一侧鼻孔按顺序完成19项解剖操作。操作靶区集中在泪囊、鼻窦、翼腭窝及颞下窝。依次为:①钩突的精细切除术;②泪囊造口术;③Draf I型及Draf IIa型手术;④前组筛窦开放术;⑤后组筛窦开放术;⑥蝶窦开放术;⑦蝶腭动脉凝扎术;⑧制作HB瓣;⑨下鼻道开窗;⑩Draf IIb型手术;(11)制作游离中鼻甲黏膜瓣;(12)翼腭窝及经中鼻道部分颞下窝前壁开放术;(13)泪前隐窝入路;(14)经泪前隐窝部分颞下窝前壁开放术;(15)内镜下改良Denker入路;(16)经Denker入路颞下窝前壁开放术;(17)上颌窦内侧壁切除术;(18)翼腭窝手术;(19)颞下窝手术。本流程可在10侧标本中重复,所用时间亦随操作次数增加而缩短。结论本流程设计思路清晰,特点鲜明,可重复性高,可作为鼻颅底解剖学习的参考,值得推广和使用。Objective To explore the design principle and application of the anatomic training process through the Uni-nostril approach by using the fewest cadaver head specimens to complete the most surgical anatomy training, thus, it will guide more beginners to conduct efficient anatomical training.Methods The design principles of the process were as follows :① the structures of previous operations were revealed without damage of the structures of subsequent operations;② the anatomic training process was finished as many clinical operations as possible by using one side of the cadaver head specimens;③ According to clinical approach commonly, the anatomic training process was designed step by step operations;④ The operation of binostril approach is not included in this procedure. Once one side is completed, the contralateral nasal cavity is not damaged. Five cases of fresh silicone resin head were used, the process was verified and completed on both sides of the head. The entire process was recorded by the system of STORZ company HD video(0°, 4 mm nasal endoscopy and HD IMAGE 1) device.Results According to the principles, an uninostril approach was designed to conduct 19 anatomic operation in sequence. It is mainly focused on lacrimal suc, sinus, pterygopalatine fossa(PPF) and infratemporal fossa(ITF). They are:① Precise dissection of unicate process;② Dacryocystostomy;③ Draf I and Draf II frontal sinus operation;④ Anterior ethmoidotomy;⑤ Posterior ethmoidotomy;⑥ Sphenoidotomy;⑦ Ligation of sphenopalatine artery;⑧ Preparation of vascularized pedicled nasoseptal flap;⑨ Fenestration of inferior nasal meatus;⑩ Draf IIb frontal sinus operation;(11) Preparation of free middle turbinate mucosa flap;(12) Anterior wall resection of PPF and portion of ITF through middle meatus approach;(13) Prelacrimal recess approach;(14) Partial anterior wall resection of ITF through prelacrimal recess;(15) Endoscopic modified Denker surgery;(16) Anterior wall resection of ITF through Denker approach: Explore the late

关 键 词：鼻腔 鼻窦 翼腭窝 鼻内镜手术 解剖 局部 训练流程 

分 类 号：R765.9[医药卫生—耳鼻咽喉科]