微创甲状腺切除的研究进展(文献综述)

世界范围内的内镜技术飞速发展 ,将外科带入了“微创时代”。其技术及观念渗入到甲状腺外科 ,从而也开启了微创甲状腺外科。本文主要从手术适应证、术式、手术径路及手术操作方法等方面简述微创甲状腺外科的进展     

内镜辅助下甲状腺手术12例报告

目的　探讨微创内镜辅助下甲状腺手术可行性及优点。方法　自 2 0 0 3年 9月至2 0 0 3年 12月进行微创内镜辅助下甲状腺手术 12例。其中结节性甲状腺肿 7例 ,甲状腺腺瘤 5例。结果　 12例病人均完成手术 ,无一例中转为常规手术 ,无明显术后并发症。手术时间 3 8～ 110min ,平均约 65min。所有病人经过 1～ 3个月的随访 ,对切口的美容效果感到满意。结论　微创内镜辅助下甲状腺手术安全 ,切实可行 ,具有良好的切口美容效果。     

甲状腺疾病的内镜手术治疗

1995年11月Gagner成功完成了首例内镜下甲状旁腺手术以来,内镜甲状腺手术已经有十多年的历史。内镜手术治疗甲状腺疾病并不是一种真正意义上的微创方法,而是一种美容手术。随着超声刀的问世及人们对美观的追求,内镜甲状腺手术在国内外得以较广泛开展。我国人口众多且甲状腺疾病有较高的发病率,因此,该手术有着良好的发展前景。一、内镜甲状腺手术径路选择目前内镜甲状腺手术主要有3个径路:(1)锁骨上径路:在胸骨切迹上作一5mm小切口,持续灌注CO2来维持操作空间,应用小切口悬吊法(Miccoli法)在胸骨切迹上做一2.5cm长的切口放置内镜及器械,用…     

内镜甲状腺手术现状与评价

内镜甲状腺手术充分体现了内镜外科技术的美容和微创理念,其克服了传统甲状腺手术的一些缺陷,如术后颈部瘢痕、颈前皮肤感觉异常以及吞咽不适等。该技术得益于Gagner 1996年开创性的内镜甲状旁腺次全切除术．并由Huscher等于1997年率先开展。近年内镜甲状腺手术的临床应用日益广泛。这与外科医师对内镜下颈部解剖结构的深入了解、对手术径路选择的多元化探索以及内镜手术器械的不断改进密不可分。     

微创甲状腺切除的研究进展

世界范围内的内镜技术飞速发展，将外科带入了“微创时代”。其技术及观念渗入到甲状腺外科，从而也开启了微创甲状腺外科。本文主要从手术适应证、术式、手术径路及手术操作方法等方面简述微创甲状腺外科的进展。     

内镜在甲状腺切除术的临床应用

目的 探讨应用内镜外科技术施行甲状腺手术的可行性及效果。方法 采用须部无瘢痕内镜甲状腺切除术(SET)和微创电视辅助甲状腺切除术(MIvA)。SET切口选择在乳晕上缘、胸骨旁，钝性游离胸前和颈前皮下腔隙，在内镜下行甲状腺肿瘤或腺体次全切除术。MIvA切口选择在胸骨切迹上1cm处长约3cm，在电视辅助下行甲状腺肿瘤或腺体次全切除术。结果 SETl0例和MIvAl2例全部手术成功，无并发症。术后恢复良好，无声嘶、呛咳，颈部水肿、隆起明显改善。结论 对甲状腺切除手术，SET具有明显的美容效果，MIVA是一种微创和有效方法。     

微创手术切除甲状腺及甲状旁腺病灶的关键技术

甲状腺及甲状旁腺微创手术能明显缩小手术切口,或同时将其隐藏在身体的隐蔽部位,在一定程度上降低或消除了传统手术疤痕对病人颈部美观的影响，从而使美容和微创的理念同样能在颈部外科手术中得以体现。该技术得益于Gagnerr于1996年进行的开创性内镜甲状旁腺次全切除术及Htischer等于1997年率先开展的内镜甲状腺手术。     

腔镜甲状腺手术

近年腹腔镜及内镜手术在许多领域已有长足进步 ,诸如胆囊摘除术、脾脏摘除术及胃酸逆流手术等皆能以极小的伤口完成极其复杂的手术步骤 ,在内分泌手术领域 ,内镜下甲状旁腺摘除术已在国际上广泛开展 ,而内镜技术运用于甲状腺手术的发展则相对较迟 ,其原因为颈部不易充气、甲状腺体积较大、血管丰富、易损伤喉返神经及甲状旁腺等 ,凡此种种皆加大了内镜下甲状腺手术的难度。日本Ｓｈｉｍｉｚｕ于 1998年最早报告内镜下甲状腺手术 ,虽其强调颈部无疤 ,但在胸部却作了大范围的分离且有不少的切口 ,并不符合微创手术 (ｍｉｎｉ ｍａｌｌｙｉｎｖ…     

内镜甲状腺切除术的手术要点

目的：探讨应用内镜外科技术施行甲状腺手术的可行性及手术要点。方法：采用颈部无疤痕内镜甲状腺切除术(SET)和微创电视辅助甲状腺切除术(MIVA)。SET切口选择在乳晕上缘、胸骨旁，钝性游离胸前和颈前皮下腔隙，在内镜下行甲状腺肿瘤切除或腺体次全切除术。MIVA切口选择在胸骨切迹上1cm处，长约3cm，在电视辅助下行甲状腺肿瘤切除或腺体次全切除术。结果SET、12例和MIVA 12例全部手术成功，术后恢复良好，无声嘶、呛咳等并发症，颈部水肿隆起明显改善。结论：内镜下甲状腺切除术是可行的，SET具有明显的美容效果，MIVA是一种微创和有效的方法，手术应由有内镜外科经验的医师进行，关键在于良好的显露和止血。     

内镜甲状腺手术术式评价

20世纪后期,随着提倡“三保留”（即保留胸锁乳突肌、颈内静脉、副神经）的改良颈淋巴结清扫术,甲状腺癌的手术治疗向微创化美容化迈进一大步。但传统的甲状腺手术仍给良性甲状腺疾病患者留下6～10cm的切口瘢痕,影响颈部美观,甚至给中青年女性造成较大的心理压力。近10年来,内镜甲状腺手术的开展使甲状腺疾患的手术更向美容化微创化发展。现将国内外内镜甲状腺手术治疗的进展综述如下。     

Video-assisted endocrine neck surgery: state of the art

During the last two decades, several minimally invasive approaches for endocrine neck surgery have been developed. Minimally invasive video-assisted approaches (minimally invasive video-assisted parathyroidectomy and minimally invasive video-assisted thyroidectomy) gained a quite large worldwide diffusion, maybe because these techniques combine the advantages related to the endoscopic magnification with those due to the close similarity with the conventional surgery that makes these surgical approaches reproducible and feasible in different surgical settings. Several comparative studies have demonstrated the advantages of minimally invasive video-assisted neck surgery in terms of reduced postoperative pain, better cosmetic result, and higher patients’ satisfaction over the conventional endocrine neck surgery. An accurate patients’ selection plays a key role to ensure the success of minimally invasive video-assisted approaches. To date, in selected cases and in experienced Center, minimally invasive video-assisted endocrine neck surgery could be considered the standard treatment or at least a safe and effective surgical option.     

Operative Technique of Endoscopic Thyroidectomy: A Narration of General Principles

Endoscopic thyroidectomy is fast becoming a reality with increasing experience in endocrine surgery. Many techniques of minimally invasive video-assisted thyroidectomy through cervical and extra-cervical routes such as chest wall, transaxillary, trans-oral, post-auricular, trans-luminal approach have been attempted. At present anterior chest wall or trans-axillary routes are favourite extra-cervical routes. In this context, we describe our operative technique of endoscopic thyroidectomy through chest wall to highlight the surgical steps of practical importance.     

“Scarless” (in the Neck) Endoscopic Thyroidectomy (SET): An Evidence-based Review of Published Techniques

BACKGROUND: Excision of the thyroid through a skin crease incision in the anterior neck provides good direct exposure to facilitate safe dissection and a quick operation with low morbidity and minimal mortality. However, these patients still have a scar in the neck. Technologic innovations have allowed surgeons to remove the thyroid gland from a remote site, providing a scarless outcome in the neck. This study was designed to assess the different techniques of scarless (in the neck) endoscopic thyroidectomy (SET) by reviewing the current literature. METHODS: A computer-assisted search of the Medline database through September 2007 was undertaken. The combination of terms used included the following: endoscopic thyroidectomy; minimally invasive thyroidectomy; minimally invasive endocrine surgery; thyroidectomy via the axillary approach; thyroidectomy via the anterior approach; and thyroidectomy via the breast approach. Additional data were provided based on previously unpublished experience from our own unit with SET. RESULTS: There were seven studies that involved 186 patients in whom the thyroid was excised via the axillary method and five published series that involved 169 patients who had thyroidectomies performed via the anterior approach. There were four published series of thyroidectomies performed via a hybrid approach, which is a combination of both the anterior and axillary approach, involving 180 patients. Four studies compared SET and another approach for a thyroidectomy. In our unpublished series of SET, we performed 20 cases during a 2-year period comprising 11 cases via the axillary approach and 9 cases via the anterior/breast approach. Nineteen cases were lobectomies and one case was an isthmusectomy. SET was associated with a longer operative time and increase postoperative pain. Patients who had SET were satisfied with the aesthetic outcome of the procedure. CONCLUSION: Scarless (in the neck) endoscopic thyroidectomy is not a minimally invasive technique but a maximally invasive one that involves a longer operative time and greater postoperative pain. What it does provide is a safe excision of the thyroid pathology with the absence of a scar in the neck. However, there is a steep learning curve. With experience and newer surgical instruments, the operative time and postoperative pain might decrease.     

Video-assisted endoscopic thyroidectomy

BACKGROUND: Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS: In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle's tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS: All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS: VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results.     

无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术对侧处理改进三步法（附视频）

随着腔镜技术的发展,腔镜甲状腺手术也得以广泛应用,目前腔镜甲状腺手术的常见入路有经胸乳、经口、经腋等,其中无充气腋窝入路腔镜甲状腺手术受到众多从事甲状腺外科医生的高度认可。该技术能够满足患者的美容需求,同时能够利用颈前肌肉的自然间隙进行手术达到微创的目的。虽然目前无充气腋窝入路腔镜甲状腺手术操作越来越成熟规范,但是在无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术（GUA-ETT）过程中,切除对侧叶时,如何避免气管的遮挡、顺利暴露对侧喉返神经并保证对侧中央区淋巴结清扫的彻底性等都是需要直接面对的困难。本中心针对单侧叶切除后行对侧叶全切除术及对侧中央区淋巴结清扫术,提出对侧处理改进三步法。为了更方便甲状腺外科医生掌握该技术,笔者就该GUA-ETT中对侧处理改进三步法的手术方法、技术特点、操作技巧及细节与操作重点、难点及操作经验进行详细阐述及分享。     

颈部无疤痕内镜甲状腺手术的价值

目的介绍应用腹腔镜作颈部无疤痕甲状腺孤立的良性肿瘤切除术.方法于乳晕上缘、胸骨旁作小切口导人腹腔镜及配套设施,建立人为操作空间进行内镜操作切除肿物.结果15例病人均达到预期疗效,且无手术并发症.结论腹腔镜作甲状腺手术具有美容、创伤小、术野清晰、安全的优点.     

内镜时代的胆石症治疗

随着微创外科技术的发展,腹腔镜胆囊切除(laparoscopic cholecystectomy,LC),内镜逆行性胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)及内镜乳头括约肌切开取石(endoscopic sphincterotomy,EST)胆管镜(choledechoscopy)在临床上应用日益广泛,它们在胆囊、胆总管结石治疗中的作用日益明显.本文通过查阅国内外文献,对这些外科微创技术进行综述评价.     

Robot-Assisted Cardiac Surgery

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.     

Minimally invasive open thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize tissue trauma by obviating unnecessary neck exploration. This report describes our technique of performing minimally invasive open thyroidectomy and compares the results with those of conventional thyroidectomy. Minimally invasive open thyroidectomy was performed by making a small skin incision, 3.0–4.5 cm long, and approaching the thyroid directly via a transverse divi-sion of the strap muscles without raising skin flaps. The outcomes of 466 patients who underwent a minimally invasive open thyroidectomy were retrospectively compared with those of 437 patients who underwent conventional thyroidectomy for various types of thyroid nodules. There was no significant difference in the extent of surgery between the group of patients who underwent minimally invasive thyroidectomy and the group of patients who underwent conventional thyroidectomy. However, the length of the skin incision, at 3.7 ± 0.7 vs 9.6 ± 3.3 cm, respectively, operative time, at 57.6 ± 11.7 vs 85.2 ± 32.3 min, respectively, blood loss, at 18.4 ± 15.3 vs 43.1 ± 21.8 ml, respectively, and hospital stay, at 1.6 ± 0.5 vs 4.3 ± 1.6 days, respectively, were significantly reduced in the minimally invasive open thyroidectomy group (P < 0.05). Moreover, the number of patients who required postoperative analgesia was significantly less in the minimally invasive open thyroidectomy group. These results show that minimally invasive open thyroidectomy provides surgeons with a clear operative field, and that it has proven to be simple, safe, and practical for selected patients. Received: September 11, 2000 / Accepted: March 6, 2001     

单孔腔镜甲状腺手术应用现状与前景

随着腔镜甲状腺手术的发展及患者美容要求的提高,单孔腔镜甲状腺手术(SSET)应运而生。该技术在安全、有效的基础上,兼具微创、美容的特点,顺应当代外科学发展趋势。近年来,该技术在东亚地区迅速发展,但仍存在诸多亟待达成共识的问题,包括手术入路的选择、操作技巧的提高、意识观念的更新、器械设备的研发等。当前,要根据医生技术与患者病情进行综合评估,为患者提供个体化的SSET治疗方案。