Section 1. Parathyroid: Endoscopic neck surgery: current status for thyroid and parathyroid diseases

During the last 3 years, 59 patients underwent endoscopic neck surgery. We started the video-assisted neck surgery with the gasless skin-lifting method for benign thyroid and parathyroid diseases to avoid complications of carbon dioxide (CO₂) insufflation. Hemithyroidectomy was performed for benign thyroid tumors and subtotal thyroidectomy was selected for Graves’ disease. Parathyroid adenomas were extirpated for primary hyperparathyroidism with precise preoperative localization by imaging modalities. In order to obtain a better visual field and to improve the cosmetic results, we have adopted the complete endoscopic method via breast approach with low CO₂ insufflation pressure since August 2001. An intraoperative parathormone assay was introduced recently to confirm the complete removal of parathyroid adenomas. Both gasless and insufflation methods are feasible for endoscopic neck surgery with excellent cosmetic results.     

颈伸位下头颈三维重建在甲状腺手术中的应用

  目的  探究在颈伸位下三维重建头颈结构在甲状腺手术中的应用价值。  方法  选择20例已经由病理结果证实的甲状腺疾病患者在颈伸位下的平扫CT图像,应用三维重建软件3DVWorks,对甲状腺、甲状腺结节、甲状软骨、下颌骨、锁骨、皮肤等组织进行三维重建,测量多个空间角度及径线以评估疾病及治疗方案。  结果  通过在头颈三维重建模型中对下段气管所在的不同平面与甲状腺手术相关解剖结构的角度与距离测量,综合评估后在甲状腺结节 < 3 cm的11例患者中有3例患者不适合行经口腔镜术式,可行其他腔镜等术式;3例患者不适合行经口、经胸乳腔镜术式及经腋窝等腔镜手术,仅适合开放手术;1例患者因结节分期较高,不推荐行腔镜手术;另外4例患者各类手术均可施行。通过构建胸廓入口及以此平面准确分割巨大甲状腺体积,对6例含有结节 > 3 cm的巨大甲状腺进行预评估后发现均未达经颈胸联合切除甲状腺的指标要求,6例患者行传统单纯经颈切口即可完整切除甲状腺。对有残留甲状腺的3例患者,预评估显示3例残余甲状腺均可准确定位并能指导手术切除。  结论  通过在颈伸位下三维重建头颈结构并建立评估指标,对腔镜手术方式选择、巨大甲状腺肿诊治、残余甲状腺术中定位有独特优势,有助于形成良好的手术策略,更有益于医患交流。      

Total endoscopic thyroidectomy after open neck biopsy of the follicular lymphoma of the thyroid gland

Remote-access total endoscopic thyroidectomy (TET) is a recently established approach that can avoid producing scars in the neck. There are no clear surgical indications for TET for benign nodules or for malignant tumors at present. We report a successful TET in a 50-year-old Japanese woman with follicular lymphoma of the thyroid gland after an open neck biopsy. She had been referred to us with a neck tumor noted 2 months earlier. Because of adhesion, we performed a combined resection of the thyroid and partial right sternohyoid muscle. To the best of our knowledge, there is no other report of a TET performed after open neck surgery. Our patient's case demonstrates that (a) the cosmetic outcome of TET is clearly superior to that of conventional open neck surgery, and (b) a TET can be suitable even for reoperation if carefully selected.     

Section 2. Thyroid: Video-assisted minimally invasive endoscopic thyroid surgery using a gasless neck skin lifting method—153 cases of benign thyroid tumors and applicability for large tumors

Endoscopic surgery is often considered to be ‘minimally invasive surgery’ in the light of recent developments. In particular, endoscopic endocrine neck surgery is desirable from a cosmetic viewpoint. Here we compared the usefulness of our original endoscopic method of video-assisted neck surgery (the VANS method) with conventional surgery when challenged with the removal of thyroid tumors measuring more than 5 cm in diameter, based on our experience with 167 cases (162 thyroid tumors, five parathyroid tumors). The percentage of patients who underwent the VANS method of the total number of patients who underwent neck surgery was determined and the operative procedures used in the different surgeries were analyzed. The operating time and blood loss for 153 benign thyroid tumors were statistically compared between the small-tumor group (n = 130, <5 cm) and the large-tumor group (n = 23, ≥5 cm). More than 60% of the benign and 5.3% of the malignant thyroid tumors were operated on by the VANS method. Near- or subtotal lobectomy was the most common procedure (64.1%) for benign tumors. Malignancy was defined as papillary carcinoma less than 1 cm in diameter. Total lobectomy with lymph node clearance was performed for all malignant tumors. Although the operating time and the blood loss were statistically greater in the large-tumor group than the small-tumor group, with increased experience it was possible to remove tumors of up to 7.4 cm safely. Our findings support the idea that the VANS method is feasible, practical, and safe, and has great cosmetic benefits, even for the removal of large benign tumors.     

Thyroid storm induced by trauma due to spear fishing-gun trident impaction in the neck

A rare case of thyroid storm induced by thyroid gland injury because of penetrating neck trauma is reported. The injury was because of a spear fishing-gun trident impaction in the neck. The diagnosis of thyroid gland injury was suspected by preoperative clinical examination and established during neck exploration in the theatre. The gland injury led to thyroid storm owing to the rupture of acini and liberation of T4 into the bloodstream. Withdrawal of the impacted trident along with subtotal thyroid lobectomy and repair of soft tissue damage in addition to supported treatments, which corrected the hyperthyroid state, led to uneventful recovery.     

Neck schwannoma diagnosed by core needle biopsy: a case report

Here we present a case of a 58 year old man referred to our hospital to undergo neck and thyroid ultrasonography (US) following palpable neck mass. US revealed a solid hypoechoic nodule in right thyroid lobe, and a solid lesion on the right laterocervical neck region with ultrasound suspicious features of neoplastic lymph node. In order to achieve a diagnosis of the neck mass and to get a proper evaluation of the thyroid nodule, we decided to perform a fine-needle aspiration (FNA) of both lesions. At cytopathologic examination the thyroid nodule appeared as benign, while cytologic sampling of the neck lesion was inadequate for a proper evaluation. Thus, we performed core needle biopsy (CNB) of the neck lesion like recently proposed for thyroid lesions; also, to definitively exclude malignancy of thyroid nodule, this also underwent CNB. Histologic report of CNB confirmed benign thyroid nodule, while the neck lesion revealed a proliferation of neuronal type consistent with schwannoma. The patient has been addressed to clinical and ultrasonographic follow-up. CNB appears as a safe and minimally-invasive approach to diagnose indeterminate neck masses and avoid unnecessary diagnostic surgery.     

基层实用的颈部内镜微创甲状腺手术

目的探讨运用常规的双极电凝开展内镜辅助下颈部小切口甲状腺手术的可行性,以适应基层医院开展这一微创手术。方法以内镜辅助小切口甲状腺切除术（Miccoli手术）为基本框架,选用医用常规双击电凝做基本器械,辅以少数其他器械操作,对40例诊断为甲状腺腺肿、甲状腺腺瘤的患者行此种内镜下手术。术中采用游离甲状腺动静脉主要分支、属支的二、三级分属支进分离、牵移、电凝、切断的方法行甲状腺手术。结果 40例手术均获成功,无一例因术中出血失控需中转手术及无一例术后出血再次手术,2例术后声嘶分别在术后第2、第6个月完全恢复正常。术后随访6~37个月肿瘤无复发。结论应用常规的双极电凝在内镜辅助下行小切口甲状腺手术方法可行安全,止血确切,宜在基层医院普及推广。     

Pre-operative Detection of Thyroid Pyramidal Lobes by Ultrasound and Computed Tomography

This study aimed to assess the diagnostic accuracy of pre-operative ultrasound (US) and computed tomography (CT) for detecting thyroid pyramidal lobe (TPL). A single radiologist prospectively performed thyroid US and retrospectively reviewed neck CT to detect TPLs in 135 consecutive patients scheduled for thyroid surgery. The location, size and superior extent of each TPL and its separation or continuity with the main thyroid gland were assessed by thyroid US, neck CT and surgery. The prevalence of TPLs as diagnosed by thyroid US, neck CT and surgery was 58.5% (79/135), 56.3% (76/135) and 60% (81/135), respectively. We compared US and CT detection of TPLs with surgical data to determine their sensitivity (85.2% and 91.4%), specificity (81.5% and 94.4%), positive (87.3% and 96.1%) and negative (78.6% and 87.9%) predictive values and accuracy (83.7% and 92.6%). For detecting TPLs, both neck CT and thyroid US have good diagnostic value, although neck CT is more accurate than thyroid US.     

Papillary carcinoma of the thyroid

Cancer of the thyroid gland occurs infrequently, and, although the majority of lesions are papillary and well differentiated, some patients do die of the disease. Since mortality and morbidity for thyroidectomy are low, surgical treatment is advised for patients who have nodular goiters that might be cancerous and for those who have goiters that are suspected of being cancerous. Thyroidectomy is the treatment of choice for patients with known papillary thyroid cancer. Only when lymphatic metastases are present should a complimentary modified neck dissection be performed in addition to thyroid resection. Prognosis is related to extent of the primary lesion rather than to presence or absence of regional nodal metastases. Patients with intrathyroidal lesions fare better than those with extrathyroidal extension. Thyroid surgery in the hands of experienced surgeons should carry an exceedingly low risk and be capable of providing excellent long-term cure and palliation of thyroid cancer.     

Surveillance Neck Sonography After Thyroidectomy for Papillary Thyroid Carcinoma: Pitfalls in the Diagnosis of Locally Recurrent and Metastatic Disease

A sonographic examination of the neck performed 6 to 12 months after thyroid surgery in patients with differentiated thyroid cancer is strongly recommended by the American Thyroid Association and considered mandatory by the European Thyroid Association for locoregional surveillance. The aim of this article is to review the normal anatomic changes expected after thyroid surgery and the pathologic mimics of thyroid carcinoma recurrence in post‐thyroidectomy patients as they appear on neck sonography. We hope to offer some pearls to increase diagnostic confidence in this setting.     

加速康复外科理念在经胸前入路腔镜甲状腺外科领域中的临床应用

目的初步探讨加速康复外科(ERAS)理念在经胸前入路腔镜甲状腺外科手术应用中的可行性及有效性。方法回顾性分析2018年6月-2020年6月该院139例符合入组标准的经胸前入路腔镜甲状腺手术患者的临床资料,按时间段分为传统经胸前入路腔镜手术组(TES组)及加速康复手术组(ERAS组),比较两组患者术后并发症(出血、恶心呕吐)发生情况及应激指标。结果 ERAS组术后恶心呕吐等并发症明显少于传统组,疼痛评分、白细胞计数和C反应蛋白等明显低于TES组,两组患者比较,差异均有统计学意义(P 0.05)。结论多模式镇痛及超前镇吐等ERAS理念应用于经胸前入路腔镜甲状腺外科领域中安全可行,能有效降低术后并发症发生率,缩短住院时间,提高患者术后舒适度,值得临床应用及推广,但具体实施方案还有待进一步优化。     

舌根异位甲状腺的CT和MRI表现

目的 探讨舌根异位甲状腺的CT和MRI表现. 方法 回顾性分析8例经核素扫描或手术证实的舌根异位甲状腺患者的CT或MRI资料,其中6例接受颈部CT检查,2例接受颈部MR检查. 结果 8例病灶均位于舌根中线区,6例呈类圆形,2例呈分叶状,边界清楚,最大径16～36 mm,平均24 mm.与舌根肌肉比较,2例CT平扫呈高密度,其中1例密度不均匀;5例增强后明显强化,其中2例病灶内有散在的小囊状低密度区;3例病变密度不均匀,结合其他检查考虑伴发结节状甲状腺肿,其中1例经病理证实.2例MR T1WI、T2WI均呈较高信号,增强后明显强化,病变信号较均匀.颈部均未发现正常位置的甲状腺. 结论 舌根中线区高密度或高信号并明显强化的结节是舌根异位甲状腺的特征性影像学表现,密度或信号不均匀常提示其发生病变;结合颈部无正常位置甲状腺,比较容易作出诊断.     

甲状腺手术体位综合干预的观察与研究

目的：观察甲状腺手术中应用钢丝罗纹气管插管以降低颈部过伸的角度并进行综合体位干预,以减轻或避免病人术后颈过伸脑循环紊乱综合征的效果。方法将410例甲状腺手术病人随机分成两组,对照组216例,采用普通气管插管和常规体位;观察组194例,术中应用钢丝罗纹管并行综合体位干预。观察两组病人术后颈过伸脑循环紊乱综合征的发生率。结果观察组头痛、恶心呕吐、腰背痛等脑循环紊乱综合征的发生率均明显低于对照组（P＜0．01）。结论甲状腺手术中应用综合干预的手术体位,可避免或降低头痛、腰背痛等脑循环紊乱综合征的发生。     

Novel operative approach to double primary cancers of the breast and thyroid and its effects on cosmesis and the accuracy of follow‐up examinations

For the treatment of double primary cancer of the breast and thyroid, endoscopic thyroidectomy might be an excellent option in terms of cosmesis; however, it may not offer curability, and it makes the accuracy of follow‐up examinations difficult. The postoperative scars after endoscopic thyroidectomy may modify the estimation of recurrence. To achieve improve cosmesis and the accuracy of follow‐up examination, we developed a novel method for thyroid surgery: hybrid‐type endoscopic thyroidectomy (HET). Here we report two cases of double primary cancer, one synchronous and the other metachronous. HET lobectomy and HET total thyroidectomy were performed in combination with some modifications of breast surgery. In each case, the postoperative course was uneventful, and cosmetic satisfaction was very high. Furthermore, there were no problems during the follow‐up period. Based on our results, HET could become a standardized treatment of double primary cancers.     

胸乳入路腔镜甲状腺手术与传统手术的临床效果比较

目的比较胸乳入路腔镜甲状腺手术及传统手术两种方式治疗良性甲状腺疾病的临床效果。方法选取2014年7月-2019年12月河北省人民医院腺体外科行甲状腺手术的患者106例,分为腔镜组(n=53)与传统组(n=53)。比较两组患者手术时间、术中出血量、术后引流量、引流时间、术后住院天数、术后止痛药需求和手术并发症发生率。结果两组患者术中出血量、术后住院天数、术后止痛药需求和手术并发症发生率比较,差异均无统计学意义(P 0.05)。腔镜组手术时间和引流时间较传统组长,术后引流量较传统组多,两组比较,差异均有统计学意义(P 0.05)。结论胸乳入路腔镜甲状腺手术治疗良性甲状腺疾病在手术安全性、可行性方面与传统手术无明显差别;但手术时间长,引流量多,且引流时间较传统手术长。     

Transaxillary gasless robotic thyroid surgery with nerve monitoring: Initial two experince in a North American center

Abstract

Minimally invasive thyroid surgery using various techniques is well described. The present study reviews our initial experience with the technique with added intraoperative monitoring to assess its safety and feasibility. The study group consisted of ten consecutive patients with suspicious thyroid nodules who were candidates for thyroid lobectomy from September to December 2009. All patients underwent intraoperative nerve integrity monitoring and postoperative direct laryngoscopy. The patients' demographic information, operative times, learning curve, complications, and postoperative hospital stay were evaluated. All procedures were successfully completed with intraoperative nerve monitoring. No cases were converted to an open procedure. The median age was 38.5 years (σ = 13.5) and nine of the ten patients were females. The mean operating time was 131 minutes (range 101–203 minutes) and the mean operating time with the da Vinci system was 55 minutes. All patients were discharged home after an overnight stay. One patient developed transient radial nerve neuropathy that resolved spontaneously. There were no other postoperative complications. None of the patients complained of postoperative neck pain. Postoperative laryngoscopy showed intact and mobile vocal cords in all patients. Robotic endoscopic thyroid surgery with gasless transaxillary approach is feasible and safe in the treatment of suspicious thyroid nodules. Monitoring of the RLN during this approach is feasible.     

手足口病的辨证施护

目的 研究无注气式甲状腺内镜下手术的围手术期护理要点。方法 对采用无注气式甲状腺内镜手术的36例患者实施相应护理。结果 36例甲状腺肿物患者行非注气式内镜手术后，无一例发生并发症，随访648个月，均取得满意的治疗和美容效果。结论 术前加强心理护理，术后加强切口及呼吸道的护理，密切观察有无低钙血症、甲状腺危象等并发症，有利于患者康复。     

微波消融与腔镜手术在甲状腺良性肿块中的疗效对比

目的对比研究微波消融术与腔镜手术治疗甲状腺良性肿块临床效果。 方法回顾性分析2016年1月至2018年6月在汕头大学医学院第二附属医院行甲状腺手术治疗的66例患者的临床资料,其中34例行甲状腺肿块微波消融术为消融组,32例行腔镜甲状腺肿块切除术为腔镜组。比较两组手术时间、术中出血量、住院时间、住院费用、手术瘢痕、并发症及手术前后甲状腺激素变化等指标。组间数据比较采用t检验。 结果两组患者性别、年龄差异无统计学意义。消融组在手术时间、术中出血量、住院天数、手术瘢痕均少于腔镜组,且差别有统计学意义［分别为（74±26）min比（137±38）min、（3±8）ml比（16±24）ml、（5.3±4.3）d比（8.2±2.9）d、（0.29±0.08）cm比（2.92±0.18）cm,t=7.81、2.76、3.18、73.94,均P<0.01］。两组患者手术前后甲状腺激素变化无统计学意义。消融组并发症发生率为11.8%,与腔镜组的12.5%相比差异无统计学意义（χ²=0.927,P>0.05）。术后6个月消融组甲状腺结节体积明显缩小并瘢痕化。消融组住院费用较腔镜组增加,差异有统计学意义［（15 057±3288）元比（12 221±1735）元,t=-4.34,P<0.01］。 结论与腔镜手术相比,甲状腺微波消融术虽费用较高,但组织创伤小,手术时间短,出血少,住院天数少,瘢痕小,恢复快,是一种安全有效的手术方式。     

Technique of recurrent laryngeal nerve exposure within the scope of interventions of the thyroid gland]

In anatomical preparations performed during autopsy we developed a well-defined approach for the identification of the recurrent laryngeal nerve during surgery on the thyroid gland. The principle of this concept is to visualize the nerve near the branching of the inferior thyroid artery, where it shows a 30 degree angle to the trachea in a direction running from caudal lateral to cranial medial and lies in front of, behind, or between the branches of the artery. This preparation mode has been prospectively performed in 100 patients undergoing thyroid surgery. In 159 (= 97.6%) sides of the neck out of 163 we identified the nerve at the typical site. The topographical relation of the recurrent nerve to the inferior thyroid artery revealed the following differences for the right and left side of the neck: On the right side the nerve was found to be behind in 48%, in front in 33% and between the branches of the artery in 15% of cases. In contrast, on the left side the nerve was found to be dorsal in 53%, ventral in 23% and between the branches in 23%. Of 163 nerves at risk we observed primary nerve palsy in 2 cases (1.2%), and a definitive palsy rate of 0.6% at the 3-month follow-up. In conclusion, we recommend the described approach for the identification of the recurrent laryngeal nerve during thyroid surgery whenever complete mobilisation of the thyroid lobe (e.g. thyroidectomy, lobectomy, resection of retrotracheal adenomas) is necessary.     

Endoscopic surgery in Japan: The 12th national survey(2012–2013) by the Japan Society for Endoscopic Surgery

In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, operative procedures have been standardized, and the safety and usefulness of endoscopic surgery have been evaluated. With the acceptance of endoscopic surgery as less invasive than open surgery, the number of the endoscopic procedures continues to increase in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has had an important role in the development of endoscopic surgery in Japan. For example, JSES established a technical skills certification system for physicians to train instructors to teach safe endoscopic surgery. Additionally, JSES has performed a national survey every 2 years. In 2013, 178 084 patients underwent endoscopic surgery in all surgical domains, including abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The development and current status of laparoscopic surgery are reported here based on the results of the most recent questionnaire survey conducted by JSES.