甲状腺癌右侧颈淋巴结清扫术

取胸骨切迹上两横指切口,左侧至胸锁乳突肌前缘,右侧至胸锁乳突肌后缘,依次切开皮肤、皮下组织及颈阔肌,于颈阔肌深面游离皮瓣上至甲状软骨和颌下腺,下至锁骨和胸骨上凹。打开胸锁乳突肌外侧缘,打开颈动脉鞘,暴露右侧颈动脉、颈内静脉,清扫Ⅱ、Ⅲ、Ⅳ、Ⅴ区淋巴结。术中解剖显露二腹肌、舌下神经降支和静脉角,注意保护副神经、膈神经和颈丛。3-0丝线缝合颈阔肌,医用胶水关闭皮肤切口。     

胸锁乳突肌缝线定位联合肌间隙注水分离在经腋窝无充气腔镜甲状腺手术中的应用

背景与目的 目前较为常用的腔镜甲状腺手术入路主要有经腋窝入路、经胸乳入路及经口入路等。经腋窝入路相较于其他术式,其利用颈部肌肉的自然间隙建腔,在颈前带状肌深面显露甲状腺并进行手术操作,对颈部功能影响较小,而且无需充CO₂,对心脑血管影响较小,因此近年来越来越被临床医生所接受。经腋窝入路腔镜甲状腺手术中寻找胸锁乳突肌肌间隙是该术式的一大难点,在此步骤中较多初学者不能准确定位肌间隙,进而增加了手术时间及创伤。为此,笔者中心对经腋窝无充气腔镜甲状腺手术作了一定的改进,降低术中寻找肌间隙的难度。本研究对该改良术式的近期疗效与安全性进行评估,为其在临床中的应用提供依据。方法 回顾性分析2023年1月—2023年5月江苏省宿迁市第一人民医院甲乳外科收治的46例甲状腺癌患者的临床资料。其中,23例接受改良经腋窝入路免充气腔镜下甲状腺手术（观察组）,另23例接受常规经腋窝入路免充气腔镜下甲状腺手术（对照组）。观察组患者术前超声引导下在胸锁乳突肌胸骨部与锁骨部之间的间隙内注水分离,扩大肌间隙,然后缝线定位胸锁乳突肌胸骨部后缘,准确进入肌间隙后,按照常规经腋窝入路腔镜甲状腺手术方法实施手术。结果 两组患者一般资料无明显差异（均P>0.05）,具有可比性。观察组平均手术时间明显短于对照组（65.6 min vs. 87.2 min,P<0.05）,而两组的术中出血量、术后引流量、中央区清扫淋巴结数及住院时间差异均无统计学意义（均P>0.05）。观察组有1例出现腋窝皮下血肿,经抽液、包扎后改善,余患者均无呼吸困难、声音嘶哑、手足麻木、饮水呛咳等并发症发生。术后3个月,两组患者颈部疼痛评分及颈部损伤指数、吞咽障碍指数比较,差异均无统计学意义（均P>0.05）。所有患者术后均口服左旋甲状腺素钠片行个体化促甲状腺激素（TSH）抑制治疗,随访期间无患者出现复发转移。结论 术前行超声引导下胸锁乳突肌缝线定位联合肌间隙注水分离操作方便、实用,便于术中寻找肌间隙,降低了经腋窝无充气腔镜甲状腺手术整体手术难度,具有较好的临床应用价值。     

经口腔前庭腔镜下甲状腺手术空间建立方法的改进

目的:探讨经口腔前庭腔镜下甲状腺手术如何建立良好的空间便于操作。方法:2019年1—12月佛山市南海区人民医院共开展经口手术63例,建立空间方法为膨胀液注射在胸锁乳突肌下段浅层,后用分离棒去扩张该区域,再用超声刀分离空间,最终把胸锁乳突肌放在操作空间的下方,与经胸壁建空间方法相似。结果:患者手术时间(122.8±25.2)min,术中建腔时间(从切开口唇黏膜至切开颈部白线的时间)为(19.8±3.4)min;建腔过程中皮肤热灼伤1例、颈前交通静脉出血2例。结论:经口腔前庭腔镜下甲状腺手术,把胸锁乳突肌放在操作空间的下方,有助于手术实施。     

锁骨下小切口经胸锁乳突肌颈前肌间隙腔镜辅助甲状腺部分切除术15例报告

目的探讨锁骨下小切口经胸锁乳突肌颈前肌间隙入路腔镜辅助甲状腺部分切除的方法和效果。方法15例单侧甲状腺良性结节，锁骨下小切口2-3cm，经胸锁乳突肌颈前肌间隙入路，腔镜辅助下行甲状腺部分切除。结果15例均获成功，手术时间40—80min，平均50min。术中出血10～50ml，平均20ml，无并发症。术后3-4d出院。15例随访1～12个月，平均7个月，无复发。结论经锁骨下小切口胸锁乳突肌颈前肌间隙入路腔镜辅助甲状腺部分切除手术损伤小，出血少，并发症发生率低，安全，术后恢复快。     

内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈4例报告

目的探讨内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈的方法和疗效。方法2005年1~8月,我院应用内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈4例,年龄5~11岁,平均8.5岁。患侧腋窝前缘置入10 mm trocar,在颈阔肌筋膜下、胸锁乳突肌胸骨头与锁骨头浅面钝性分离,注入CO2气体(压力6 mm Hg),建立颈前皮下间隙,置入30°内镜。分别在患侧颈后近锁骨上缘处及对侧胸壁近锁骨下缘处置入5 mm trocar至颈前皮下间隙,置入分离钳与电凝钩,距胸锁骨附着处1 cm电凝横断胸锁乳突肌胸骨头与锁骨头的肌纤维束,并松解胸锁乳突肌周围紧张的纤维组织。结果4例手术均获成功,手术时间分别为90、75、70、45 m in。术中出血均<1 m l。术后第1天开始功能锻炼,第2天出院。第1例颈部皮肤轻微电灼伤,2周后痊愈。1例术后出现面部皮下气肿,次日自行吸收。随访2、4、6、10个月,斜颈均矫正,切口小且隐蔽,瘢痕不明显,颈部皮肤弹性良好,对面部表情活动无影响。结论内镜下胸锁乳突肌切断松解术疗效确切,且具有微创的特点,值得临床推广。     

小切口甲状腺结节摘除术

我院采用小切口行甲状腺结节摘除术１４例,手术顺利,无并发症,美容效果满意。 一般资料：１４例均为女性。１９～５６岁,平均３２．５岁。均为孤立性甲状腺结节,直径０．８～３．０ｃｍ,平均２．６ｃｍ。位于左侧叶者９例,右侧叶者４例,峡部１例。 手术方法：颈丛阻滞麻醉或局麻。颈根后加垫呈颈后伸位。取结节水平处顺皮纹横切口,长２～３ｃｍ。切开皮肤,电刀切开浅筋膜颈阔肌。以手指在颈深筋膜浅层的浅面钝性上下分离。沿胸锁乳突肌前缘（结节在侧叶）或颈白线（结节在峡部）切开颈深筋膜浅层、如遇颈前静脉则切断、结扎。钝性…     

胸乳入路完全腔镜甲状腺右侧腺叶切除术

手术要点：采用胸乳入路,直视下用超声刀在颈阔肌深面建立空间,两侧达胸锁乳突肌外缘,上界达甲状软骨上缘;使用超声刀纵向切开颈白线,在真、假被膜之间疏松间隙内分离甲状腺前方、下极和外侧面,使用腔镜拉钩拉开颈前肌群来扩大手术操作的空间,充分暴露甲状腺分离气管前间隙,靠健侧离断峡部,沿甲状腺被膜精细化解剖游离患侧腺叶,避免损伤甲状旁腺;应用神经探测四步法寻找并监测喉返神经信号;保持超声刀工作刀头距神经>3 mm,将患侧腺叶完整游离;夹闭并切断甲状腺上动脉,防止迟发出血;标本袋取出标本送检。可吸收线缝合颈前带状肌,留置引流管。     

内镜下甲状腺手术皮下隧道的制备及其并发症的防治

目的探讨内镜下经胸骨前径路甲状腺手术皮下隧道制备的技巧。方法回顾性总结92例经胸骨前径路行内镜下甲状腺手术经验。皮下隧道的制备要点：穿刺棒应沿胸前壁深、浅筋膜间隙进行钝性分离；采用自制15cm长带螺纹trocar分别从左、右乳晕切口置入；再沿颈阔肌深层与颈深筋膜浅层之间进行锐性分离；游离范围上至喉结水平，外至两侧胸锁乳突肌外侧缘，下至胸骨切迹（近似倒梯形）。结果所有手术均成功。无中转开放手术，手术时间100—150min，平均120min。术后腔内出血1例，胸壁皮下积液4例，无其他并发症，治疗和美容效果满意。结论制备好皮下隧道是内镜下甲状腺手术成功的关键。     

充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术临床效果分析

背景与目的 传统的充气式经腋窝胸锁乳突肌前缘入路全腔镜甲状腺手术,由于受胸锁乳突肌的阻挡,暴露甲状腺不充分,为操作带来一定的难度。为此,笔者近年来将该手术改良为充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术。本研究比较该改良术式与传统术式的应用效果,以期为临床提供借鉴。方法 选取2020年1月—2023年6月于河北省沧州市人民医院甲状腺头颈外科进行充气式经腋窝入路腔镜甲状腺手术患者78例为研究对象,其中39例行充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术（改良入路组）,另39例行充气式经腋窝胸锁乳突肌前缘入路全腔镜甲状腺手术（传统入路组）。比较两组患者手术和术后恢复情况、术后1、3 d的视觉模拟评分法（VAS）、并发症发生情况及术后满意度。结果 两组手术时间差异无统计学意义（P>0.05）,但改良入路组的术中出血量、术后1 d引流量、术后拔管时间、颈部恢复活动时间及术后住院时间均优于传统入路组（均P<0.05）。改良入路组术后1、3 d的VAS评分均明显低于传统入路组（均P<0.05）。改良入路组并发症发生率5.13%,传统入路组12.82%,差异无统计学意义（P>0.05）。改良入路组总满意度明显高于传统入路组（89.74% vs. 66.67%,P<0.05）。结论 充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术操作相对更容易,可以改善手术状况,患者术后恢复更快,术后疼痛感低,并发症较少,患者术后满意程度也更高,值得在临床推广应用。     

腔镜辅助锁骨下途径甲状腺手术中喉返神经的显露及保护

目的：探讨腔镜甲状腺切除术中喉返神经的暴露和保护的可行性。方法2006年10月～2013年11月对46例甲状腺肿瘤采用免注气锁骨下途径腔镜手术,经锁骨下区向上沿颈阔肌深面分离至颈部,部分横断颈前肌群,暴露甲状腺后方喉返神经,完整切除肿瘤。结果46例腔镜下完成手术,手术时间（53．5±8．7）min,出血量（20．5±10．5）ml。46例暴露颈段喉返神经,未见变异的喉不返神经。术后2例出现声音嘶哑,营养神经治疗2周后痊愈。2例术中冰冻病理检查甲状腺乳头状癌合并颈部淋巴结转移,中转行淋巴结清扫;分别随访21、44个月,无肿瘤复发。44例行甲状腺次全切除术,术后病理：32例甲状腺腺瘤,12例结节性甲状腺肿,随访时间1～84个月,平均45．6月,术后每6个月复查彩超及甲状腺功能,均无肿瘤复发及甲状腺功能低下。结论腔镜下甲状腺肿瘤切除术暴露颈段喉返神经可行、安全。     

颈阔肌肌皮瓣五瓣Z成形术矫治重度肌性斜颈

目的介绍一种安全、实用的重度肌性斜颈修复术。方法以蹼状挛缩突出的胸锁乳突肌为轴，两端分别为胸锁乳突肌的乳突起点和下端锁骨头点，设计3瓣在内下、2瓣在外上的五瓣，每瓣臂跃大致为轴长的一半。局部麻醉下切开皮瓣至颈阔肌下层，直视下锐性分离各肌皮瓣，慎勿使颈阔肌与皮肤脱离，松解蹼状皮肤，即可见已经变细且纤维化的胸锁乳突肌及挛缩的颈鞘、颈浅静脉。于肌肉中点完全切断胸锁乳突肌，两断端回缩，切断并结扎颈浅静脉，松解挛缩的颈鞘，显露出短缩的颈动脉、神经，将头尽量摆正，在注意保护动脉、神经的前提下，松解其周围牵拉的筋膜组织，止血后将肌皮瓣对位缝合覆盖外露的动脉、神经、肌肉组织，放置橡皮引流条包扎固定。结果5例中有1例达到良，4例为中度。皮瓣均成活，效果满意。瘢痕不明显。结论采用颈阔肌肌皮瓣五瓣Z成形术，可良好地纠正同侧肌性斜颈畸形，用颈阔肌覆盖外露的神经、血管，就地取材，既能防止术后肌皮瓣区粘连、局部凹陷畸形，又能确保皮瓣的血供。     

Modified Radical Neck Dissection for Differentiated Thyroid Cancer: Operative Technique

Our standard surgical approach to patients with papillary thyroid cancer is subtotal thyroidectomy with modified radical neck dissection (MRND) on the affected side. MRND preserves the jugular vein, the sternocleidomastoid muscle, and the accessory nerve, effectively conserving function and cosmesis. Knowledge of the anatomy of the neck, precise staging, prognostic evaluation, and experience are needed for a surgeon to perform MRND. Radical neck dissection should not be performed unless the tumor invades the jugular vein and sternocleidomastoid muscle. Berry picking is not indicated for patients with thyroid cancer. The skin incision used is an extended collar incision. If lymph node metastasis is present at the upper bifurcation of the carotid artery, a modified MacFee incision is used. Taping of the carotid artery or sternocleidomastoid muscle is avoided unless the tumor invades these tissues. MRND is a safe procedure when performed by skilled, experienced surgeons.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Total endoscopic thyroidectomy

We have developed endoscopic thyroidectomy procedures using anterior chest and axillary approaches. Both of our procedures differ significantly from the usual thyroidectomy, which involves lifting both the platysma and the sternohyoid muscle. Because only the platysma is lifted during our procedures, a CO(2) insufflation pressure of less than 4 mmHg is sufficient. While the sternohyoid muscle is transected to obtain greater exposure of the thyroid gland in minimally invasive procedures in the neck, we do not divide it so as to prevent adhesions to the platysma, unless the nodule is large. As we accumulated experience with these procedures in 58 patients, typical operation time decreased to less than 120 minutes for the anterior approach and to less than 150 minutes for the axillary approach. Large follicular tumours can be extracted using the axillary approach, with all of its cosmetic advantages, whereas the anterior chest approach is advocated for removal of bilateral multinodular goitres and parathyroid lesions. Both approaches result in minimal postoperative hypoaesthesia, paraesthesia, and discomfort during swallowing. We conclude that endoscopic neck surgery is the procedure of choice in carefully selected patients with thyroid disease.     

Video-assisted thyroidectomy

OBJECTIVE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained. METHODS: Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules 相似文献   

侧方入路小切口甲状腺手术的临床应用

目的探讨侧方入路小切口甲状腺切除术的可行性和手术技巧。方法 2009年5月～2011年10月,对30例单侧甲状腺肿物行胸锁乳突肌内缘肿物表面横行小切口(长2～2.5 cm),经胸锁乳突肌前缘切开带状肌,于甲状腺前外侧开始解剖,完成侧方入路小切口甲状腺切除术。结果 30例手术均顺利完成,甲状腺腺叶切除16例,单侧甲状腺次全切除术14例。切口长2～3 cm,平均2.5 cm,平均手术时间53 min(45～65 min),术中出血量均<10 ml。术后均未出现并发症,患者术后伤口疼痛程度和吞咽不适感均较轻。30例平均随访13个月(1～22个月),切口美观,无复发。结论侧方入路小切口甲状腺切除术可行,美容效果好。     

A clinical analysis of gasless endoscopic thyroidectomy

Gasless endoscopic surgery was applied to a thyroidectomy. Compared with the previous method of endoscopic thyroidectomy, this method is superior in obtaining hemostasis and minimizing the possible complications of gas-insufflating surgery, such as a hypercapnia or massive subcutaneous emphysema. We successfully removed 37 thyroid tumors in 35 patients by gasless endoscopic surgery without any significant complications. No scars remained in the neck, and all patients were satisfied with the cosmetic results. Gasless endoscopic thyroidectomy is a safe and technically feasible alternative to conventional thyroidectomy for cases of benign thyroid tumors and has good cosmetic results.     

Video-assisted thyroidectomy

BACKGROUND: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this article we report on the entire series of patients who underwent VAT and discuss the results obtained. STUDY DESIGN: Forty-seven patients were selected for VAT. Eligibility criteria were: thyroid nodules of 35 mm or less in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; neither previous neck surgery nor irradiation; and no thyroiditis. After a learning period, VAT was proposed also for completion thyroidectomy (of previous video-assisted lobectomy) and nodules with maximum diameter up to 45 mm. The procedure is performed by a totally gasless video-assisted technique through a single 1.5- to 2.0-cm skin incision. Dissection is performed under endoscopic vision using a technique very similar to conventional operation. RESULTS: Fifty-three VATs were attempted on 47 patients. Thirty-three lobectomies, 10 total thyroidectomies, and 6 completion thyroidectomies were successfully performed. Six patients with papillary carcinoma underwent central neck lymph node removal by the same access. Mean operative time was 86.8 minutes for lobectomy, 116.0 minutes for total thyroidectomy, and 77.5 minutes for completion thyroidectomy. Conversion rate was 7.5%. Postoperative complications included one transient recurrent nerve palsy, three transient symptomatic postoperative hypocalcemias, and one wound infection. The cosmetic result was considered excellent by most of the patients who successfully underwent VAT. CONCLUSIONS: VAT is feasible and safe and allows for an excellent cosmetic result. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.     

腔镜甲状腺手术临床分析(附26例报告)

目的:探讨腔镜技术用于甲状腺手术,以避免甲状腺手术后颈部留有永久疤痕,获得美容效果的临床应用价值。方法:回顾总结26例腔镜甲状腺手术方法、手术适应证及体会。结果:经腋路途径为26例甲状腺单发良性肿瘤行切除术,全部获得成功,术后颈前无手术疤痕,无皮肤色泽改变,未发生并发症。结论:腔镜甲状腺手术可获得很好的美容效果,手术安全、恢复快,有着传统开放甲状腺手术不可比拟的优点,是治疗女性甲状腺良性肿瘤的首选方法之一。     

经乳晕入路行腔镜甲状腺切除术的应用价值

目的:探讨行腔镜乳晕入路手术治疗甲状腺疾病的价值。方法:2008年11月至2009年12月为15例患者行经双侧乳晕三孔法腔镜甲状腺手术,通过分离胸前皮下和颈阔肌深面,注入CO2(压力6～8mmHg),建立操作空间。用超声刀切割、分离甲状腺组织和血管;术中保护喉返神经、喉上神经及甲状旁腺。结果:15例手术均获成功,其中甲状腺囊肿切除术1例,甲状腺腺瘤切除术5例,单侧甲状腺部分切除术3例,双侧甲状腺部分切除术3例,甲状腺次全切除术3例。手术时间(110.0±31.3)min,术中出血(70±20.5)ml,术后1例颈部皮肤灼伤,1例胸部少量皮下积液,无中转开放手术。结论:经乳晕径路行腔镜甲状腺手术具有极佳的美容效果,值得临床推广应用。