喉返神经与甲状腺下动脉及其分支间关系的显微解剖研究

目的:探讨甲状腺术区喉返神经与甲状腺下动脉及其分支的显微解剖关系,为临床甲状腺手术中喉返神经的保护提供解剖学基础.方法:对临床中需行一侧或双侧甲状腺切除的85例头颈肿瘤患者(左45侧、右53侧,共98侧)的腺内段喉返神经及甲状腺下动脉进行显微解剖及观测.结果:98侧观测对象中,发现右侧喉不返神经1侧、左侧甲状腺下动脉缺如1侧.41.2%(40/97)的喉返神经在入喉前分为前、后两支,左侧为30%(15/45),右侧为48.1%(25/52),右侧高于左侧(P﹤0.05).59.8%(58/97)的甲状腺下动脉存在二级分支,其中42例(43.3%)甲状腺下动脉存在三级分支.有24侧甲状腺下动脉的三级分支中存在与喉返神经密切伴行的分支,其中8例为动脉分支与神经几乎并行,16例上行的动脉分支分别于喉返神经的前方或后方勾绕神经入喉.结论:腺内段喉返神经与甲状腺下动脉各次级分支解剖关系复杂.甲状腺手术中对于喉返神经近入喉处伴行的甲状腺下动脉后支的上行分支血管应给予高度重视,以避免出血时的盲目钳夹止血造成喉返神经损伤.     

喉返神经的应用解剖研究

目的为甲状腺手术术中对喉返神经的定位和保护提供解剖学基础。方法采用经福尔马林固定的60具成人标本(男40,女20)共120侧,用解剖学方法对喉返神经及其分支进行定位观测,以及观测甲状腺下动脉、甲状软骨下角和甲状腺下极等3种解剖标志与喉返神经的毗邻关系。结果(1)喉返神经的分支有喉支和喉外支,前者在喉前多分为前、后支。(2)喉返神经与甲状腺下动脉的关系分5种类型。(3)91.7%(110侧)喉返神经的喉支多在距甲状腺下角尖端(16.9±7.2)mm处分前、后支,喉外支多在其下(10.4~70.3)mm范围内发出。(4)59.2%的喉返神经分支发出部位在甲状腺下极平面以上,距甲状腺下极平面距离(11.25±7.1)mm。结论在甲状腺手术中应注意喉返神经的变异,通过暴露和辨认喉返神经及其分支防止其损伤。     

喉返神经的应用解剖

目的为甲状腺手术中误伤喉返神经提供解剖学基础。方法对50具成人尸体的颈前外侧区进行局部解剖,重点观察了喉返神经行程与甲状腺下动脉的关系,分布于喉的分支情况;测量了喉返神经、甲状腺下动脉的直径。结果喉返神经横径为(1.93+0.35)mm。喉返神经入喉支以2～5干型为多见,占70.0%。甲状腺下动脉的直径为(2.61+0.23)mm。喉返神经和甲状腺下动脉之间的关系,左右均有明显差异。喉返神经在甲状腺峡平面分支最为多见。喉返神经位于甲状腺动脉主干之后的有54.0%。结论左、右侧喉返神经与甲状腺动脉位置关系有明显差异,右侧喉返神经多行于动脉之前,左侧喉返神经多行于动脉之后,为临床颈部手术提供了参考。     

甲状腺手术中识别喉返神经的解剖标志

目的探讨甲状腺手术中用以识别喉返神经的5种有效的解剖标志,为手术中避免误伤喉返神经提供形态学资料。方法采用经福尔马林防腐固定的50具成人标本(男40例,女10例)共100侧,用解剖学方法观测甲状软骨下角尖、甲状腺下动脉、甲状腺下极、气管食管沟和甲状腺悬韧带等5种解剖标志与喉返神经的毗邻关系。结果甲状软骨下角距喉返神经入喉处(6.3±1.9)mm;甲状腺下动脉与喉返神经的毗邻关系有五种类型;右侧喉返神经有64.6%、左侧100%直行于气管食管沟内,在颈根部右侧喉返神经偏离气管食管沟2.1~10.2mm;喉返神经与甲状腺下动脉交叉处位于甲状腺下极之上者占81.1%;喉返神经行于甲状腺悬韧带后方者占92.0%。结论甲状腺手术识别喉返神经的五种解剖标志中,以甲状软骨下角尖(或环甲关节)和甲状腺悬韧带较可靠,其次为甲状腺下极、甲状腺下动脉和气管食管沟。     

喉返神经在颈部的应用解剖研究

目的　为在甲状腺手术中避免误伤喉返神经提供解剖学基础。方法　对 5 0具 (男 3 0具 ,女 2 0具 )成人尸体解剖喉返神经和甲状腺下动脉之间的关系进行解剖观测。结果　喉返神经平均横径为 ( 1.93± 0 .3 5 )mm。喉返神经入喉支以 2～ 5干型为多见 ,占 70 .0 0 %。甲状腺下动脉的直径为 ( 2 .61± 0 .2 3 )mm。喉返神经和甲状腺下动脉之间的关系 ,左右均有明显差异。结论　喉返神经横径平均在 ( 1.93± 0 .3 5 )mm之间 ;喉返神经在甲状腺峡平面分支的最为常见 ;神经位于动脉主干之后的为多见 ,占 5 4.0 0 % ;神经位于动脉前及动脉分支之间的例数相近 ,左侧神经位于动脉之后的多见 ,而右侧神经位于动脉之前的多见 ,左右有明显差异 ,为临床颈部外科手术时参考。     

喉返神经及其分支与甲状腺下动脉关系的应用解剖

目的为颈部手术中喉返神经及其分支的定位和保护提供形态学基础。方法对47具(男30具,女17具)成人尸体喉返神经和甲状腺下动脉之间的关系进行解剖、观测。结果喉返神经入喉支以2～5支型为多见,占69.15%;喉返神经和甲状腺下动脉之间的关系分为5种类型,左右侧有明显差异(P<0.01)。结论在颈部相关手术中应注意喉返神经的变异,结扎甲状腺下动脉前,应仔细分离、单独结扎该动脉,以免损伤喉返神经及其分支。     

常规解剖喉返神经在甲状腺手术中的作用

目的 探讨在甲状腺手术中解剖喉返神经从而防止喉返神经损伤的作用.方法 在143例甲状腺手术中常规解剖喉返神经.结果 共解剖喉返神经206条,3例病例术后声嘶,术后1～3月后均恢复,无永久性喉返神经损伤.结论 甲状腺手术中解剖喉返神经能有效避免喉返神经损伤,建议在甲状腺手术中常规解剖喉返神经.     

改良式甲状腺大部切除术的应用与探讨

甲状腺大部切除术为临床常用手术,但因甲状腺位于一个复杂的解剖区域,稍有不慎即可引起喉上神经和喉返神经的损伤,如何改进术式和预防喉上神经和喉返神经损伤一直是临床研究的重点.本文重点讨论如何避免喉上神经的损伤,将传统术式改进,即结扎甲状腺上动脉时保留极少部分甲状腺上极,再切除大部甲状腺腺体.现将具体改进方法报告如下.     

喉返神经的应用解剖

目的:为颈部手术特别是甲状腺手术中避免喉返神经损伤提供解剖学基础.方法:采用甲醛固定的50具成人标本(男30,女20)共100侧,对喉返神经的走行、分支及其与甲状腺下动脉、甲状软骨下角的位置关系进行解剖观测.结果:喉返神经按其分布分为喉支和喉外支,前者90%在距甲状软骨下角尖(16.7±7.5)mm处分为前、后两支,后者多在其下10.2～ 70.5 mm 范围内发出.左侧喉返神经82.0%走在甲状腺下动脉的后面,右侧76.0%走在动脉的前面,侧别差异有统计学意义(P＜0.005).结论:查明喉返神经的行径及其毗邻关系,有助于防止术中损伤喉返神经.     

喉返神经在颈部的局部解剖及临床应用

目的　为使在甲状腺手术中避免误伤喉返神经提供解剖学基础。方法　对 4 5具 (男 30具 ,女 15具 )成人尸体喉返神经和甲状腺下动脉之间的关系进行解剖、观测。结果　喉返神经平均横径为 1 93± 0 35mm。喉返神经入喉支以 2 - 5干型的为多见 ,占 6 8 9%。甲状腺下动脉的直径为 2 6 1± 0 .2 3mm。喉返神经和甲状腺下动脉之间的关系 ,左右侧有明显差异。结论　喉返神经横径平均在 1 93±0 35mm之间 ;喉返神经在甲状腺峡平面分支的最为普遍 ;神经行于动脉主干之后的有 4 8 9% ,为多见 ;神经行于动脉前及动脉分支间的例数差不多 ,左侧神经行于动脉之后的多见 ,而右侧神经行于动脉之前的多见 ,左右有明显差异 ,在颈部手术时参考     

Absence of the left inferior thyroid artery: clinical implications

Dissection of an adult male cadaver revealed an absence of the left inferior thyroid artery; its usual area of distribution to the thyroid gland was supplied by the right inferior thyroid artery. Absence of the left inferior thyroid artery occurs in 1-6% of cases. The inferior thyroid artery arises commonly from the thyrocervical trunk, passes posterior to the carotid sheath and supplies the inferior pole of the corresponding lobe of the thyroid gland; its branches can course anterior or posterior to or between branches of the recurrent laryngeal nerve. During thyroid surgery it is imperative to identify the relationship of the inferior thyroid artery to the recurrent laryngeal nerve or to establish its absence because injury to the nerve can be a major complication; awareness of significant variations of the surgical anatomy of the thyroid gland is vital for preserving the integrity of important structures.     

An anatomical study of the recurrent laryngeal nerve: its branching patterns and relationship to the inferior thyroid artery

Abstract: The aim of this study was to provide information about the morphology and topography of the recurrent laryngeal nerve (RLN), its external features and branches, as well as its relationship to the inferior thyroid artery, the inferior horn of the thyroid cartilage and the thyroid gland. The RLNs in 50 adult cadavers (100 sides) were dissected and analyzed. A communicating loop connecting one branch of the RLN to another or a twig originating from the cervical sympathetic trunk was present in 13 of 100 sides. A double left RLN appeared in 2 sides; a right non-recurrent inferior laryngeal nerve appeared in one side. All of the RLNs, including looped ones, bifurcated into laryngeal branches and extralaryngeal branches, with most of the former further dividing into the anterior and posterior branches entering the larynx. The relations of the RLN to the inferior thyroid artery, the inferior horn of the thyroid cartilage and the thyroid gland were inconstant. The information gained from this study will be of value in thyroid surgery.     

喉返神经喉外分支的显微解剖及临床意义

目的探讨甲状腺手术区域喉返神经(RLN)的解剖特点和方法。方法运用大体解剖的方法,对48例成人标本甲状腺手术区域的RLN及其周围毗邻结构进行了观测。结果 48例96侧成人标本中,29%RLN主干穿过环咽肌肌束至致密结缔组织膜下缘,71%RLN主干走行在环咽肌深面。69%RLN在距离甲状软骨下角尖端(15.2±5.5)mm处分为前、后两支,前支多于环状软骨侧方下缘距离甲状软骨下角尖端(5.9±1.8)mm处穿过结缔组织膜,后支入喉点距甲状软骨下角尖端(4.8±2.1)mm;31%RLN未见分支。结缔组织膜下缘RLN与甲状腺下动脉(ITA)分支的关系为:66%(63/96)RLN位于ITA前方,27%(32/96)位于ITA后方。结论大多数RLN具有喉外分支,在以甲状软骨下角作为标志寻找RLN时,要同时找寻RLN及喉外分支的入喉点。ITA与RLN的关系复杂多变,ITA不作为RLN定位的首选。     

喉返神经的应用解剖学

本文解剖115例喉返神经,从临床应用角度出发。对喉返神经的横径,终未分支;喉返神经与甲状软骨下角,甲状腺下动脉,气管食管沟,甲状腺,喉返神经三角的局部关系进行了研究。提出甲状软骨下角,气管食管沟,喉返神经三角是识别喉返神经的简便,可靠、实用的标志和手术中避免损伤喉返神经的解剖学依据。     

An anatomical study of the recurrent laryngeal nerve: its branching patterns and relationship to the inferior thyroid artery

The aim of this study was to provide information about the morphology and topography of the recurrent laryngeal nerve (RLN), its external features and branches, as well as its relationship to the inferior thyroid artery, the inferior horn of the thyroid cartilage and the thyroid gland. The RLNs in 50 adult cadavers (100 sides) were dissected and analyzed. A communicating loop connecting one branch of the RLN to another or a twig originating from the cervical sympathetic trunk was present in 13 of 100 sides. A double left RLN appeared in 2 sides; a right non-recurrent inferior laryngeal nerve appeared in one side. All of the RLNs, including looped ones, bifurcated into laryngeal branches and extralaryngeal branches, with most of the former further dividing into the anterior and posterior branches entering the larynx. The relations of the RLN to the inferior thyroid artery, the inferior horn of the thyroid cartilage and the thyroid gland were inconstant. The information gained from this study will be of value in thyroid surgery.     

喉返神经及其分支的变异与临床意义

目的：为甲状腺手术中对喉返神经的定位和保护提供解剖学基础.方法：解剖50具（100侧）人颈部尸体标本.在甲状腺手术区对喉返神经及其分支进行定位观测.结果：（1）86.0%的喉返神经分支呈树枝状,称树枝型（多支型）;14.0%喉返神经分支与分支或分支与交感神经链、喉上神经间吻合成袢状,称喉返神经袢.（2）根据不同的交通形式,可分为3型：A型,喉返神经分支与分支相交通者3侧（3%）;B型,其分支与交感链之间相交通者2侧（2%）;C型,分支与喉上神经交通者2侧（2%）;D型,分支与分支、分支与交感链、喉上神经之间相交通者7%（7侧）.结论：在甲状腺及颈部手术中,应仔细分离、注意喉返神经的各种变异,以免损伤喉返神经和（或）其分支.     

内镜下甲状腺手术的应用解剖

目的探讨内镜下甲状腺的应用解剖。方法对6例新鲜成人男性尸体标本,按照胸骨切迹小切口入路和胸前入路的手术步骤进行内镜下观察和记录。结果经颈部的自然间隙进行内镜下手术解剖,能清楚的显露与手术程序相关的结构和毗邻关系;更容易识别血管、喉返神经和甲状旁腺;提供了内镜下各部位的解剖和毗邻的图解;进行侧后面的解离及显露或侧缘与颈动脉鞘之间解离时,应用30°或70°镜更利于视野,采用经典的解剖标志来识别辨认喉返神经和甲状旁腺;内镜的放大作用给颈部的解剖结构提供了出色的可视性,更容易鉴别喉返神经和血管及甲状旁腺,利于防止喉返神经的损伤和保存甲状旁腺的血供;肩胛舌骨肌上腹是腋前入路一个重要的解剖标志。结论利用颈部的自然间隙进行内镜下手术解剖,能清楚的显露与手术程序相关的结构和毗邻关系。     

Interrelationships between the innervations from the laryngeal nerves and the pharyngeal plexus to the inferior pharyngeal constrictor

Purpose

The inferior constrictor is innervated by the pharyngeal plexus and the external and recurrent laryngeal nerves. The communication between these nerves may influence the innervations. However, the relations of their anastomoses with the innervations have been unclear. This gross anatomical study re-examined the configuration of the inferior constrictor and investigated the variations of the anastomoses and the innervations of the constrictor to clarify their interrelationships.

Methods

The inferior constrictor and the branches of the superior and recurrent laryngeal nerves and the pharyngeal plexus were examined under a binocular microscope in 30 Japanese cadavers.

Results

The inferior constrictor consisted of the oblique fibers from the thyroid and cricoid cartilages and the horizontal ones from the cricoid. The oblique fibers were innervated by the pharyngeal plexus from the dorsal and ventral surfaces. The external laryngeal nerve gave twigs to the oblique fibers and the cricothyroid from the lateral surface. The recurrent laryngeal nerve supplied the horizontal fibers from the ventral surface. The internal laryngeal nerve sometimes and the main trunk of the superior laryngeal nerve rarely supplied the upper oblique fibers. The communicating branches between the laryngeal nerves and the pharyngeal plexus sometimes gave twigs to the constrictor from the dorsal surface.

Conclusions

The innervations to the inferior constrictor from the laryngeal nerves and the pharyngeal plexus are classified into some types based on their branching patterns and anastomoses, suggesting that the dysfunctions of the laryngopharyngeal region vary according to the positional relationships between the affected part and the innervations types.     

环甲间隙在腔镜甲状腺手术中的重要意义

目的　探讨环甲间隙在颈部无瘢痕腔镜甲状腺手术（scarless in the neck endoscopic thyroidectomy,SET）中对保护喉上神经外支（external branch of superior laryngeal nerve,EBSLN）、喉返神经（recurrent laryngeal nerve,RLN）、甲状旁腺（parathyroid gland,PT）及处理甲状腺上极的重要意义。 方法　回顾分析本院2014年4月至2018年7月腔镜甲状腺手术128例,包括单侧或双侧切除、次全切除或部分切除等。在处理甲状腺上极时均采用环甲间隙入路,结合甲状腺下极及外侧操作完成甲状腺叶部分或腺叶全部切除术。 结果　全部SET在分离进入环甲间隙后处理甲状腺上极血管,其中59.3%（76例）显露EBSLN。在甲状腺下极区域首先显露RLN者82.8%（106例）,其余17.2%在经环甲间隙入路处理甲状腺上极血管后显露RLN入喉点。术中显露UPT位于近环甲关节处者83%（106例）,位于甲状腺上极背面者17%（22例）。84例随访至今,术后暂时性声音嘶哑并单侧喉返神经麻痹2例,无声音低钝及饮水呛咳者,无永久性低钙者。 结论　环甲间隙在SET中对于安全切断甲状腺上极血管和有效保护EBSLN、RLN及上甲状旁腺具有重要意义,因此结合甲状腺峡部、下极及外侧操作可以形成腔镜甲状腺的程式化手术步骤,提升了该术式的安全性,有利于该术式的推广。