生物可吸收医用膜在甲状腺手术中的运用

目的　研究生物可吸收医用膜在甲状腺手术中的运用价值。方法　甲状腺癌和甲状腺侧叶以及双侧甲状腺切除术后 ,在气管与颈部皮瓣之间或气管与颈部肌群间、颈前肌群与皮瓣间放置相应厚度 (0 .0 2cm)的生物可吸收医用膜。结果　实验组 15 3例患者术后随访 6周 ,其切口下皮瓣粘连远少于 139例对照组 (P<0 .0 5 ) ;而两组间术后并发症发生率差异无统计学意义 (P>0 .0 5 )。结论　生物可吸收医用膜术中运用可以有效地防止粘连而不增加手术的并发症。     

喉返神经显露在开放性甲状腺手术中的应用

目的:探讨开放性甲状腺手术中喉返神经显露的技术及意义.方法:回顾性分析本院2007.1-2011.1对104例开放性甲状腺手术病例进行喉返神经显露,观察术后发音情况.结果:104例手术中l例出现暂时性声音嘶哑.结论:开放性甲状腺手术时常规行喉返神经显露可有效预防喉返神经损伤.     

精细化被膜解剖法在甲状腺全切手术中的应用

目的探讨精细化被膜解剖法在甲状腺全切手术中的应用。方法回顾性分析四川省肿瘤医院头颈外科2012年1月至12月118例应用精细化被膜解剖法行甲状腺全切术患者的临床资料。结果所有病例术中均发现并保留l～4枚甲状旁腺。其中16例未发现明确的下旁腺;术中发现上甲状旁腺197枚,其中42枚由甲状腺上动脉分支供血,131枚由甲状腺下动脉上行支供血;下甲状旁腺163枚,明确的下动脉分支血管供血的136枚。术后有62例（52.5%）甲状腺激素（PTH）值低于正常值（一过性甲状旁腺功能低下）,其中56例于术后第7天恢复正常,其余6例于术后2～4周恢复正常;23例有暂时性低钙血症症状的患者,术后4 d～1月都恢复正常,无永久性低钙血症。所有病例术中均解剖并显露双侧喉返神经,除术前喉返神经受侵或损伤的患者,其余患者均未发生永久性喉返神经损伤。结论采用精细化被膜解剖法行甲状腺全切除术,能较好地原位保留甲状旁腺及其血供、避免喉返神经损伤的发生,减少甲状腺全切除术的并发症。     

甲状腺手术中的喉返神经显露体会

我院自2006年1月至2008年1月行甲状腺手术时显露喉返神经70例,疗效满意.报告如下.     

甲状腺手术中喉不返神经的手术操作技巧

目的了解喉不返神经解剖特点和变异,总结甲状腺手术中发现喉不返神经的方法和预防损伤的经验。方法分析5例甲状腺手术中发现的喉不返神经患者的临床资料,分析喉不返神经手术操作技巧。结果经手术证实本组5例喉不返神经均位于右侧,术中有3例切断了喉不返神经,2例出现了声音嘶哑,1例神经吻合后声音无明显变化。结论甲状腺手术中在颈动脉鞘和喉之间,除外甲状腺中静脉之外的任何横行索状结构均不能首先切断,需显露喉返神经后再作处理;甲状腺手术中如探查喉返神经缺如,均需显露颈段迷走神经,以寻找是否存在喉不返神经。     

甲状腺手术区解剖的外科应用

目的寻求甲状腺手术中对喉上神经和喉返神经提供定位和保护的应用解剖标志。方法解剖100具(200侧)颈部尸体标本,在甲状腺手术区对喉上神经和喉返神经及其分支进行定位观测。结果①喉上神经在咽上缩肌外面分为两支内支与喉上动脉伴行穿甲状舌骨膜入喉;外支伴随甲状腺上动脉后内方下行。②右喉返神经在甲状腺下动脉之前、之后、在动脉分支之间以及神经与血管相互夹持穿过者分别为48条(48%)、24条(24%)、14条(14%)、14条(14%),左喉返神经则分别为15条(15%)、57条(57%)、15条(15%)及13条(13%)。③117条(58.5%)喉返神经在甲状腺下极平面以上平均(9.9±7.3)mm,19条(9.5%)在甲状腺下极平面,64条(32%)在其平面以下平均(8.5±5.6)mm。④喉返神经前支入喉处距甲状软骨下角尖端平均(7.4±3.7)mm,其中72侧(36%)在其前平均(1.6±0.8)mm,58侧(29%)在其后平均(1.8±0.5)mm,70侧(35%)在其正下方入喉。后支入喉处距甲状软骨下角尖端平均(7.3±3.2)mm,16侧(8%)在其前平均(1.7±0.9)mm,134侧(67%)在其后平均(1.8±1.2)mm,50侧(25%)在其正下方入喉。结论在甲状腺手术中,结扎甲状腺上动脉要紧靠甲状腺侧叶上极;结扎甲状腺下动脉需仔细分离、单独结扎,以免损伤喉返神经或其分支而发生并发症。     

喉返神经探测仪实时监测在再次甲状腺手术中的应用

目的探讨喉返神经探测仪在甲状腺再次手术中实时神经监测的使用方法及应用价值。方法对101例甲状腺再次手术患者在全麻手术中使用喉返神经探测仪(NIM-Response肌电图监测仪)进行实时喉返神经监测,显露喉返神经。结果 101例再次手术患者中,共探测喉返神经192条,均成功显露;10例术前已证实有单侧喉返神经损伤的患者,术中未刻意探查该侧喉返神经。192条喉返神经中190条完整保护无损伤,2条因肿瘤侵犯予以切除。术后患者无声嘶加重和呼吸困难。结论使用喉返神经探测仪能较好地帮助发现和保护喉返神经,减少医源性喉返神经损伤发生率,值得在甲状腺再次手术中应用。     

喉返神经显露在甲状腺手术中的临床应用

目的 探讨甲状腺手术中如何降低喉返神经损伤的发生率和预防措施.方法 回顾分析我院手术治疗267例甲状腺手术肿瘤病例,术中常规显露喉返神经.结果 267例甲状腺手术喉返神经损伤发生率为0.38%.结论 甲状腺手术中为避免喉返神经损伤,应熟悉喉返神经的解剖和变异,掌握喉返神经的解剖方法 ,常规显露喉返神经是降低喉返神经发生率的有效方法 .     

术中神经监测技术在复杂甲状腺手术中的应用

目的 探讨应用术中神经监测技术（intra operative neuromonitoring,IONM）,以减少复杂甲状腺手术喉返神经损伤。方法 吉林大学中日联谊医院甲状腺外科2009年3~7月对132例复杂甲状腺手术病人,共186支高风险喉返神经行术中神经监测。在甲状腺切除前后分别探测迷走神经及喉返神经肌电信号。甲状腺手术前后常规检查声带活动度。结果 除术前声带麻痹4例,余182支喉返神经均可在甲状腺切除后测得明显肌电信号,未发生缝合切口前神经肌电信号消失,提示神经电传导功能良好。精确检出非返性喉返神经2例。结论 术中喉返神经监测使喉返神经显露更加便捷,更加确切,并可验证喉返神经功能完整性。在高风险、复杂甲状腺术中应用神经监测是降低喉返神经损伤率的一种重要辅助措施。     

甲状腺癌术后早期残留甲状腺再次手术中喉返神经监测的作用

目的探讨术中神经监测术在甲状腺癌术后5~15天行残留甲状腺切除术中的应用,对术后血清甲状腺球蛋白、喉返神经及甲状旁腺功能的影响。方法回顾性分析中山大学孙逸仙纪念医院甲状腺外科2010年1月至2016年12月甲状腺手术的患者资料,对符合纳入标准的病例进行分析,并根据术中是否使用神经监测术分为神经监测组和非神经监测组,统计分析术后暂时性及永久性喉返神经损伤性声音嘶哑、暂时性及永久性甲状旁腺功能低下发生率、术前及术后血清甲状腺球蛋白(Tg)浓度。结果符合纳入标准患者435例,其中神经监测组227例、非神经监测组208例。神经监测组平均术前血清Tg浓度为18.66±2.3 ng/mL,非神经监测组平均术前Tg浓度为17.43±1.4 ng/mL,差异无统计学意义(P0.05)。非神经监测组8.67%(18/208)患者出现暂时性声嘶,神经监测组2.2%(5/227)患者出现暂时性声嘶,有统计学差异(P0.05)。非神经监测组1.92%(4/208)患者出现永久性声嘶,神经监测组0.44%(1/227)患者出现永久性声嘶,无统计学差异(P0.05);非神经监测组18.75%(39/208)患者出现暂时性甲状旁腺功能减退,神经监测组7.49%(17/227)患者出现暂时性甲状旁腺功能减退,有统计学差异(P0.05);非神经监测组1.92%(4/208)患者出现永久性甲状旁腺功能减退,神经监测组0.88%(2/227)患者出现永久性甲状旁腺功能减退,两组比较没有统计学差异(P0.05)。非神经监测组术后1月平均Tg浓度为2.82±0.2 ng/mL,神经监测组术后1月平均Tg浓度为1.37±0.2 ng/mL,有统计学差异(P0.05)。非神经监测组45.06%(94/208)患者术后1个月平均Tg浓度小于1 ng/mL,神经监测组67.4%(153/227)患者术后1个月平均Tg浓度为小于1 ng/mL,有统计学差异(P0.05)。结论残留甲状腺切除术中应用术中神经监测术可降低喉返神经损伤及甲状旁腺功能低下发生率,提高残留甲状腺组织及癌组织切除的彻底性,可将初次术后残余甲状腺手术的"窗口期"由5天延长至15天。     

Recurrent laryngeal nerve in thyroid surgery: a critical appraisal

Background: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures. Methods: A total of 325 patients were accrued in this prospective non‐randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results. Results: Two hundred and seventy‐six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10?84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non‐recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%). Conclusions: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.     

喉返神经的显露在甲状腺癌根治术中的意义

目的探讨喉返神经的显露在甲状腺癌根治性手术中的意义。方法回顾分析2003年7月至2006年12月间186例主动显露喉返神经的甲状腺癌根治手术病例资料。结果186例甲状腺癌均施行甲状腺全切或近全切除术。术中均成功显露双侧喉返神经,其中1例右侧非返喉下神经。喉返神经永久性损伤1例,暂时性损伤1例,永久损伤率为0．54％。结论甲状腺癌根治术中应常规在甲状腺下动脉周围寻找喉返神经,主动显露喉返神经不仅可减少喉返神经损伤的发生率,并可提高甲状腺癌手术的彻底性。     

Complications in the surgery of benign thyroid disease

Summary   Background: Thyroid surgery has developed from a life-threatening intervention in the last century to an efficient, wide-spread, and safe procedure for half a million goitre patients per year in Europe. The mortality of thyroid surgery has been reduced to a very low percentage due to progress in the control of bleeding and experience in the management of tracheal problems. It is the purpose of this report to review the actual problems in surgery of the benign thyroid. Methods: Data were collected from a large series (n = 5961 patients operated in our department between 1986 and 1998) and the literature. Results: The major specific complications in surgery of benign thyroid disease are palsy of the recurrent laryngeal nerve (RLN) at a rate of about 0.5–2.5 % in primary surgery, about 3 % in recurrent goitre, and 1.5–5 % in retrosternal and recurrent retrosternal goitre. Whereas temporary hypocalcaemia is observed in about 30 % of patients during the first postoperative days, temporary hypoparathyroidism necessitating substitution of calcium and active vitamin D is observed in about 6 % of patients, its frequency increasing in more extended procedures and recurrences. Permanent hypoparathyroidism occurs in 0.5–4.0 % of patients and may be reduced to below 1 % by meticulous surgical technique and deliberate autotransplantation of all parathyroid glands with potentially compromised blood supply. Damage to the superior laryngeal nerve is an important, annoying, avoidable, but insufficiently recognized feature of thyroid surgery that needs further work-up. Conclusions: The risk of complications depends on the extent of surgery, the nature of the underlying disease, and the experience of the surgeon. Particular surgical problems are raised by recurrent thyroid disease, large glands, thyroid autonomy, retrosternal or even mediastinal localisation, and previous damage to the RLN or parathyroids. In such instances the patient should be referred to a specialised centre since the surgeon’s experience can help to bring the rate of surgical complications down to those of ordinary procedures.      

External laryngeal nerve in thyroid surgery: recognition and surgical implications

Background : Injury to the external laryngeal branch of the superior laryngeal nerve during thyroid surgery is not uncommon. Most surgeons tend to avoid rather than expose and identify the external laryngeal nerve (ELN). The aim of the present study was to analyse the frequency and types of ELN crossing the avascular space in relationship to the structures to the upper pole of the thyroid and related thyroid pathology. Methods : One hundred and fifty‐one consecutive patients who had thyroid surgery from February 1998 to February 1999 and who met the required preoperative criteria were included into this prospective study. The frequency and type of ELN was documented as it crossed the potential avascular space. Results : A total of 202 ELN (92.7%) nerves were identified during thyroid surgery. The frequency of the ELN documented crossing the avascular space were: type 1 nerve, 35 (17.3%); type 2a, 113 (56%); and type 2b, 54 (26.7%). Sixteen (7.3%) ELN were not seen despite an extensive search; seven (3.2%) were cases of secondary thyroid surgery and six (2.8%) were cases of malignant related pathology. In 78 cases the goitres weighed more than 100 g and the frequencies of ELN distribution seen were: type 1, six (7.7%); type 2a, 32 (41%); and type 2b, 40 (51.3%). There was a considerably higher frequency of type 2b ELN (51.3%) in large goitres of more than 100 g. Conclusions : The various technical problems in preserving the ELN need to be considered. Recognition of the potential avascular space aids the exposure and preservation of ELN. As such every attempt should be made to ensure safe dissection in order to reduce morbidity related to thyroid surgery.