术中神经监测技术在甲状腺手术中的应用与进展

喉返神经损伤是甲状腺手术较常见及最严重的并发症,尤其在复杂甲状腺手术及再次甲状腺手术中,因解剖层次不清、喉返神经解剖变异等所导致的喉返神经损伤机会加大。术中神经监测(IONM)是应用电生理技术监测术中神经功能完整性的一种技术,近年来研究显示,甲状腺手术中喉返神经IONM较常规暴露喉返神经能明显降低暂时性及永久性喉返神经损伤率。笔者就有关喉返神经IONM在甲状腺手术中的应用与进展进行综述。     

腔镜辅助下巨大甲状腺肿物手术中喉返神经监测的临床效果分析

目的探讨喉返神经监测在腔镜辅助下巨大甲状腺肿物手术中的应用效果。方法回顾性分析2013年1月至2015年6月期间在腔镜辅助下治疗的158例巨大甲状腺肿物患者的临床资料,其中喉返神经监测79例(喉返神经监测组),喉返神经未监测79例(喉返神经未监测组)。对比分析2组在手术时间、术中出血量、术后引流量、术后住院时间、术后暂时性及永久性喉返神经损伤发生情况之间的差异。结果 158例患者均顺利完成腔镜辅助颈部小切口甲状腺手术。与喉返神经未监测组比较,喉返神经监测组的手术时间(min)明显缩短(76.2±23.4比89.2±29.8,P0.05),术中出血量(m L)和术后引流量(m L)均明显减少(术中出血量:16.3±13.6比20.6±10.7,P0.05;术后引流量:20.7±9.6比25.5±9.1,P0.05),但2组的术后住院时间(d)比较差异无统计学意义(3.2±1.3比3.3±1.9,P0.05)。术后随访8周,喉返神经监测组暂时性神经损伤发生率明显低于喉返神经未监测组〔5.6%(5/90)比21.8%(17/78),P0.05〕,但永久性神经损伤发生率在2组间比较差异无统计学意义〔0(0/90)比1.3%(1/78),P0.05〕。结论腔镜辅助巨大甲状腺结节手术中应用喉返神经监测技术可有效减少神经损伤发生率,缩短手术时间。     

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 Berry 韧带定位喉返神经在腔镜甲状腺手术中的应用

目的：探讨利用甲状腺 Berry 韧带定位喉返神经在腔镜甲状腺手术中的可行性和安全性。方法对80例甲状腺手术患者按手术方法分为观察组（24例）和对照组（56例）。观察组采取腔镜下胸乳路径,术中通过 Berry 韧带定位喉返神经;对照组采取开放手术,术中通过常规方法定位喉返神经。分析两组患者探查喉返神经所需时间、喉返神经损伤情况。结果观察组手术探查时间（20±6）min,喉返神经麻痹1例;对照组手术探查时间（10±5）min,3例轻度喉返神经麻痹症状。两组喉返神经损伤率比较,差异无统计学意义（χ2＝0．05,P ＞0．05）,两组手术探查时间差异无统计学意义（t ＝0．06,P ＞0．05）。结论腔镜甲状腺手术中,采取胸乳路径并利用甲状腺Berry 韧带定位喉返神经比较安全、可行。     

喉返神经分段解剖在经乳晕入路腔镜甲状腺切除中的研究

目的探讨喉返神经分段解剖在经乳晕入路腔镜甲状腺切除术中保护喉返神经的价值。 方法采用前瞻性、随机、对照方法,将90例需手术的良性甲状腺疾病患者分成两组,A组47例,术中根据甲状腺切除方式不同选择解剖显露相对应段喉返神经,残留甲状腺所覆盖段喉返神经不解剖显露;B组43例,术中按传统方法不解剖喉返神经。术后1周和1年内对患者临床观察和评估,并在3个月和1年时进行电话及门诊随访。 结果两组患者手术均获成功,喉返神经损伤A组少于B组,差异有统计学意义(P<0.05);喉上神经损伤、甲状旁腺损伤、术中出血量、手术时间、术后住院天数两组差异无统计学意义。 结论经乳晕腔镜甲状腺良性疾病切除术中,根据甲状腺切除方式不同选择喉返神经分段解剖的方法可降低喉返神经损伤的发生率。     

术中神经监测技术在腔镜甲状腺手术中的应用及进展

近年来,腔镜甲状腺手术以其美容的优势逐渐成为大多数甲状腺患者的首选术式,但由于腔镜甲状腺手术操作空间小、无法获得触感及不同入路中喉返神经(recurrent laryngeal nerve,RLN)走行的观察视角不同等原因,常规方法保护RLN难度较大,应用术中神经监测技术(intraoperative neuromonitoring,IONM)既可实时报警风险操作,又可发现RLN的损伤机制,有效降低RLN损伤率。IONM的重要性日益凸显且随着相关神经监测新技术的不断兴起,腔镜甲状腺手术将逐步趋于完善。笔者结合国内外报道就腔镜甲状腺手术中IONM的应用进展作一综述。     

腔镜甲状腺手术中喉返神经损伤预防

目的探讨腔镜甲状腺切除术中预防喉返神经损伤的方法。方法对2002年3月至2006年10月暨南大学附属第一医院采用胸乳入路施行腔镜甲状腺腺叶切除术的492例临床资料,及术中采用躲避喉返神经或解剖喉返神经技术进行分析。结果2例出现暂时性喉返神经损伤,无永久性喉返神经损伤。结论熟悉与甲状腺手术相关的解剖知识,掌握腔镜下组织结构清楚暴露和避免神经热损伤的手术技巧是预防喉返神经损伤的关键。     

早期分化型甲状腺癌腔镜辅助手术中喉返神经监测的应用

目的:探讨喉返神经监测在腔镜辅助手术治疗早期分化型甲状腺癌术的应用效果。方法:回顾分析2012年6月—2015年1月在腔镜辅助下手术治疗180例早期分化型甲状腺癌患者临床资料,其中喉返神经监测90例(监测组),非喉返神经监测90例(非监测组)。比较两组相关指标及术后暂时性及永久性喉返神经损伤发生率。结果:监测组平均手术时间、术中出血量、术后引流量明显少于非监测组[(90.2±20.2)min vs.(100.2±26.9)min;(16.3±13.2)mL vs.(24.4±9.8)mL;(25.5±8.5)mL vs.(29.7±5.6)mL,均P0.05];淋巴结清扫数量、术后住院时间两组间无统计学差异[(5.1±1.9)个vs.(4.9±1.2)个;(3.8±2.5)d vs(3.9±2.7)d,均P0.05]。术后随访12周,监测组暂时性神经损伤发生率7.4%(8/105),非监测组19.0%(18/95),差异有统计学意义(P0.05);监测组永久性神经损伤发生率1.0%(1/105),非监测组3.2%(3/95),差异无统计学意义(P0.05)。结论:腔镜辅助下早期分化型甲状腺癌手术中应用喉返神经监测技术可有效减少暂时性神经损伤发生率,缩短手术时间,减少术中出血量。     

甲状腺术中喉返神经监测的研究进展

术中神经监测(intraoperative neural monitoring,IONM)是应用电生理技术监测手术中神经系统功能的完整性。将IONM技术应用于甲状腺手术中,可协助定位和识别喉返神经,降低神经损伤的发生率,确认神经功能完整性,查找术中损伤点,预测术后的声带功能。     

喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用

目的:探讨喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用价值。方法:回顾分析2014年11月至2018年12月施行的141例腔镜甲状腺手术,术中均采用喉返神经隧道解剖法结合神经监测技术。其中甲状腺良性结节93例,甲状腺恶性肿瘤48例;行单侧腺叶切除术52例,单侧甲状腺癌根治术44例,双侧甲状腺癌根治术4例,41例部分切除术。结果:140例手术顺利完成,1例因喉返神经横断伤转开放手术行神经对端吻合;术后9例(9/141,6.38%)暂时性神经麻痹,无永久性声音嘶哑患者。结论:腔镜甲状腺手术中采用喉返神经隧道解剖法结合神经监测技术可快速定位喉返神经,降低手术难度,提高手术安全性,利于腔镜甲状腺手术更好地在基层医院推广普及。     

喉返神经监测技术在全腔镜cT_1N_(0～1a)分化型甲状腺癌根治术中的应用体会

目的:探讨喉返神经监测技术在全腔镜cT_1N_(0~1a)甲状腺癌根治手术中应用的必要性。方法:对比分析2013年2月至2016年10月完成的106例全腔镜cT_1N_(0~1a)分化型甲状腺癌根治术的临床资料,其中神经监测组54例,未监测组52例。对比分析两组喉返神经的辨识时间、辨识率、暂时性损伤及永久性损伤的差异。结果:非神经监测组中1例因误断喉不返神经而中转开放行神经吻合术;其他患者均顺利完成全腔镜手术。神经监测组在喉返神经辨识时间、辨识率方面明显优于未监测组,两组相比差异有统计学意义(P0.05)。未监测组中7条喉返神经未能明确确认。神经监测组中2条喉返神经发生暂时性损伤,其中1条于术后2周内恢复,另1条于术后4周恢复;未监测组中8条喉返神经出现暂时性损伤,其中6条于术后2周内恢复,2条于术后4周内恢复;在喉返神经暂时性损伤方面两组差异有统计学意义(P0.05)。在喉返神经永久性损伤方面两组差异无统计学意义(P0.05)。结论:喉返神经监测技术是cT_1N_(0~1a)甲状腺癌全腔镜根治手术的有效补充,可快速、有效定位喉返神经,避免出现神经损伤的严重并发症,尤其在全腔镜甲状腺癌根治术开展初期是不可或缺的。     

Influence of rocuronium on achieving optimal vagal stimulation during intraoperative nerve monitoring in thyroid surgery

BackgroundIn the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection.MethodsIncluded in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11–25%, (3) 26–50%, (4) 51–75% and (5) >75%.ResultsThe average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 μV, 463 μV, 543 μV, 513 μV and 551 μV, respectively. No difference between the groups was observed in this regard (p > 0.05).ConclusionIt can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve.     

显露喉返神经在非神经监测与神经监测下单侧甲状腺手术中的临床分析

目的 探讨显露喉返神经在非神经监测与神经监测下单侧甲状腺手术中的临床效果分析.方法 回顾性分析南方医科大学顺德医院2019年1月至2020年11月66例单侧甲状腺手术患者临床资料,根据是否应用喉返神经监测技术分为非神经监测组和神经监测组,每组各33例.非神经监测组钝性分离直接显露喉返神经,神经监测组在神经监测提示下逐步...     

精细被膜解剖联合纳米炭示踪负显影技术对经口腔镜甲状腺手术中甲状旁腺保护的临床研究

目的:探讨精细被膜解剖联合纳米炭示踪负显影技术在经口甲状腺手术中甲状旁腺保护的应用价值。方法:回顾分析2017年4月至2019年3月经口行腔镜甲状腺手术80例患者的临床资料。对照组经口行腔镜甲状腺癌根治术,研究组在此基础上应用精细被膜解剖联合纳米炭行甲状腺癌根治术。对比分析两组术中出血量、手术时间、术后引流总量、引流时间、术后住院时间、喉返神经损伤发生率及甲状旁腺误切率;统计血钙及甲状旁腺素水平。结果:两组患者术中出血量、手术时间、术后引流总量、引流时间、术后住院时间、喉返神经损伤发生率差异无统计学意义(P>0.05);对照组中甲状旁腺误切率高于研究组,差异有统计学意义(P<0.05);研究组术后血钙、甲状旁腺激素水平高于对照组,差异有统计学意义(P<0.05)。结论:精细被膜解剖联合纳米炭示踪负显影技术利于提升经口腔前庭腔镜甲状腺手术患者的甲状旁腺辨识度,避免甲状旁腺损伤或误切,从而有效保护甲状旁腺功能。     

Neuromonitoring in Thyroid Surgery: The View of the Laryngologist

BACKGROUND: In thyroid surgery, identifying the recurrent laryngeal and the superior laryngeal nerve under direct vision reduces the incidence of nerve injury. METHODS: Neuromonitoring, consisting of the continuous depiction of electromyography (EMG) signals and discontinuous nerve stimulation and interpretation during the surgical procedure, is an established part of standard ENT procedures, e.g. surgery of the parotid gland with monitoring of the facial nerve. This technique has been introduced into surgical procedures for the thyroid gland in many surgical centres. RESULTS: Also in thyroid surgery, neuromonitoring can be a useful tool for identifying and monitoring the laryngeal nerves. Reported limitations of neuromonitoring in thyroidectomy are often caused by inadequate use of the equipment and lack of knowledge about neurophysiology in EMG monitoring. Recent studies have raised questions and pointed out pitfalls concerning technical procedure, sensitivity, postoperative outcome, and documentation; these issues are addressed by the laryngologist with many years of experience in recurrent nerve palsy, its clinical diagnosis, and its conservative and surgical treatment. CONCLUSIONS: By understanding and using neuromonitoring techniques, the surgeon is able to minimize the risk of recurrent and superior laryngeal nerve injury.     

Cervico-mediastinal schwannoma of the vagus nerve: resection with intraoperative nerve monitoring

Schwannomas are usually benign, single, encapsulated, slow-growing tumours originating from cranial or spinal nerve sheaths. The vagus nerve involvement at the mediastinal inlet is very uncommon. For anatomical reasons, the resection of cervical and mediastinal schwannoma of the vagus nerve has a high risk of vocal fold paralysis. We describe the case of a 67-year-old female with a cervico-mediastinal schwannoma of the vagus nerve that we removed using the intraoperative neuromonitoring technique. The patient presented with mild hoarseness and complained of discomfort behind the jugular notch. Neck and chest computerized tomography described a 35 × 30 mm solid lesion behind the left clavi-sternal junction; preoperative fine needle aspiration cytology revealed schwannoma. Resection of the mass was performed with a cervical approach and the vagus nerve tumour was completely removed under continuous neuromonitoring (NIM-3^® System), preserving the vagus and the recurrent laryngeal nerve function. Pathology on the resected mass documented A-type schwannoma with “ancient schwannoma” areas. The intraoperative neurostimulation and neuromonitoring approach for the resection of vagus schwannoma are recommended because it may reduce the risk of injury to the vagus and to the recurrent laryngeal nerve.     

Recurrent Laryngeal Nerve Monitoring during Thyroid Surgery: Normative Vagal and Recurrent Laryngeal Nerve Electrophysiological Data

Objective Injury to the recurrent laryngeal nerve (RLN) remains a significant cause of morbidity during thyroid surgery. Intraoperative nerve monitoring (IONM) is being applied in many centers to facilitate nerve identification. The aim of this study was to elucidate normative human vagal and recurrent laryngeal nerve electromyograhic (EMG) parameters during standard IONM application. Study Design A prospective IONM study conducted over an 8-month period. Internal review board (IRB) approval was obtained. Settings Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary, Boston. Subjects and Methods All patients who were scheduled for routine thyroid, parathyroid, or neck exploration surgery were invited to participate. All patients had a preoperative and postoperative laryngeal examination to assess vocal cord function. Any patient with an abnormal preoperative laryngeal examination was excluded. Results Fifty-eight patients participated in this study. The right and left RLN latencies were similar. The left vagus latency was greater than the right vagus but was not significant. The RLN latency was significantly less than the vagus nerve. The right vagus nerve amplitude was significantly greater than the left. There was no difference between male and female amplitudes for either the RLN or vagus nerve. Conclusion This study highlights the electrophysiological/EMG differences and similarities between the RLN and vagus nerve. Normative amplitude measurements for bilateral RLN and vagus nerve stimulation are presented. There are limited data available in the literature on normal RLN and vagal EMG signals generated during thyroid surgery.     

Neuromonitoring of the external branch of the superior laryngeal nerve during thyroid surgery

Changes of the voice caused by injury of the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery may have essential consequences for a patient's life. Therefore, intraoperative effort has to be made to prevent EBSLN damage. Neuromonitoring has already been described as helpful to improve the identification rate of the recurrent laryngeal nerve. We describe our surgical procedure of upper thyroid pole preparation using neuromonitoring to avoid intraoperative damage of the superior laryngeal nerve. Neuromonitoring allowed safe preparation of the upper thyroid pole without injury of the ESBLN in 108 consecutive patients.     

全乳晕入路腔镜甲状腺切除术十步法学习曲线

目的探讨全乳晕入路腔镜甲状腺切除术(areola approach endoscopic thyroidectomy, AET)的学习曲线，探索影响手术熟练度的关键步骤，指导训练重点。 方法回顾性分析开展AET技术初期95例因甲状腺乳头状癌行全乳晕入路腔镜单侧甲状腺切除术的患者资料，术中全程录像。按照AET十步法进行操作：切口定位、穿刺建腔、寻找喉返神经、入喉点解剖、喉上神经外支保护、甲状旁腺原位保留、颈中央区清扫、标本取出、甲状旁腺自体移植、缝合引流。记录手术总时间，依据手术步骤时间上的重叠进一步分为6个时间段进行计时。 结果手术总时间拟合曲线在前20例即有明显下降，在20例以后曲线趋于平稳。按手术日期分为5组，第1～4组20例、第5组15例；第1组手术总时间(121.25±24.32)min，明显长于第2～5组(P<0.05)；十步法的前3步操作时间在第1、2组间降低(P<0.05)，在第2组以后相邻各组间无降低(P>0.05)；十步法的后7步操作时间在相邻两组间均无降低(P>0.05)。各组间低钙血症、喉返神经损伤等并发症比较无差异(P>0.05)。 结论对于具有熟练开放甲状腺手术和腹腔镜手术基础的医师，按照AET十步法进行操作，经过20例的积累后手术总时间明显下降并趋于稳定，其中关键步骤是前3步：切口定位、穿刺建腔、寻找喉返神经。