喉返神经与非返性喉返神经临床应用解剖学研究进展*

喉返神经变异复杂，其保护是甲状腺手术的难点。喉返神经损伤导致声音嘶哑，严重影响生活质量，也是 医疗纠纷的首要原因之一。非返性喉返神经是喉返神经罕见的解剖变异，是甲状腺手术后声带麻痹的极高危险因 素。现就喉返神经和非返性喉返神经走向与分布以及毗邻，并在甲状腺手术中喉返神经保护的现状及进展的临床 应用解剖研究加以综述。     

右侧同时存在喉不返神经和喉返神经一例及文献复习

目的 报道甲状腺术中发现右侧同时存在喉不返神经及喉返神经的罕见变异一例,结合相关文献探讨其解剖特点及术中注意事项.方法 回顾分析江苏省苏北人民医院甲乳外科收治的一例右侧同时存在喉不返神经及喉返神经结节性甲状腺肿患者的临床资料.在万方数据库、中国知网、Pubmed中,以"喉不返神经(non-re-current lary...     

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.     

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。     

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。     

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.     

甲状腺手术中如何保护喉返神经的解剖与临床

甲状腺手术并发症较多，其中喉返神经（RLN）损伤是最严重最令人沮丧的并发症。RLN的损伤率国内外报道不一，为0．3％-17％12。造成RLN损伤的原因多种多样，大多为手术操作不规范和解剖结构不熟悉所致。如何减少并发症尤其是喉返神经损伤的发生呢？充分了解和熟悉与手术相关的应用解剖学和掌握良好的手术技巧是避免并发症发生的关键。 1 甲状腺手术区的应用解剖     

与颈部手术相关的喉返神经的应用解剖

目的 :为颈部手术中喉返神经的定位和保护提供形态学和局部解剖学基础。方法 :解剖 5 0具 (10 0侧 )成人颈部尸体标本 ,对喉返神经及其分支进行定位观测。结果 :(1)喉返神经的分支有喉支和喉外支 ,前者在入喉前多分为前支、后支。 87%的喉返神经分支呈树枝状 ,13 %的喉返神经分支之间或分支与颈交感干之间相互吻合呈袢状。 (2 )有 2 %的双喉返神经和 1%的非返喉下神经。 (3 ) 94%的喉返神经的喉支多在距甲状腺下角尖端 (16.9± 7.6)mm处分为前、后支 ,喉外支多在其下 10 .4～ 70 .4mm范围内发出。 (4 )喉返神经与甲状腺下动脉的关系分为 5种类型。 (5 )喉返神经与颈部食管及颈动脉鞘的位置关系复杂。结论 :在颈部相关手术中应注意喉返神经的变异 ,通过显露和辨认喉返神经防止其损伤。     

神经内镜幕下小脑上入路松果体区解剖学研究

目的　神经内镜下分别模拟经正中和旁正中幕下小脑上手术入路,观察松果体区解剖结构特点,为内镜下处理该区域病变提供解剖学依据。 方法　选取福尔马林固定的成年尸头标本5具,在神经内镜下分别经正中和旁正中幕下小脑上入路,对松果体区进行观察和测量,比较两种入路术野显露情况。 结果　神经内镜下正中和旁正中幕下小脑上入路硬脑膜至小脑中脑裂静脉的距离分别为（58.14±1.62）mm、（76.51±2.25）mm,相对手术自由度分别为（0.09±0.01）、（0.05±0.01）,松果体的相对手术自由度分别为（0.47±0.01）、（0.35±0.09）,上丘的相对手术自由度分别为（0.26±0.05）、（0.40±0.07）,松果体左右可操作角度分别为（14.85±0.35）°、（17.86±1.03）°,其前后可操作角度分别为（21.40±1.41）°、（15.00±3.06）°,胼胝体压部左右可操作角度分别为（14.55±0.07）°、（17.04±1.57）°,其前后可操作角度分别为（14.60±0.71）°、（18.76±2.83）°,同侧上丘左右可操作角度分别为（15.63±5.08）°、（21.62±2.19）°,其前后可操作角度分别为（11.18±4.72）°、（18.94±4.08）°,差异均有统计学意义（P<0.05）。 结论　神经内镜经正中和旁正中幕下小脑上手术入路各有优点,临床需根据病变的具体位置酌情选择。     

Superior approach to the inferior laryngeal nerve in thyroid surgery: anatomy, surgical technique and indications

Goals of the study To describe the anatomical bases of the surgical access to the higher part of the thyroid lobe, with first location of the inferior laryngeal nerve at its laryngeal penetration, to discuss the advantages and disadvantages of this surgical technique and to determine the operational indications.Population and method A prospective study of surgical anatomy performed over a period of 18 months was conducted. A total of 25 (22 women and 3 men) patients with cervicothoracic goitre underwent total thyroidectomy. Thyroid lobectomies were performed using the technique of “capsular thyroidectomy”, with first location and complete dissection of the inferior laryngeal nerve. A neurostimulator was systematically used for the location of the inferior laryngeal nerve and also the external laryngeal nerve.Results The first detection of the inferior laryngeal nerve at the top of the thyroid lobe was positive in 49/50 cases. A superior parathyroid gland was found in 75% of cases and an inferior parathyroid gland in 37.5% of cases. The external laryngeal nerve was stimulated and respected in 12,5% of cases. No voice trouble, no laryngeal palsy and no definitive hypoparathyroidism occurred after surgery.Conclusion Safeguarding of the inferior laryngeal nerve is the principal and obligatory stake in thyroid surgery. Locating the inferior laryngeal nerve at the level of its laryngeal penetration at the superior pole of the thyroid region is necessary in cases of particular situations: huge cervicothoracic goitres, re-operative procedures and various anatomical variations. The use of a neurostimulator secures this technique.     

甲状腺手术中对喉返神经和喉上神经保护的临床研究

目的 探讨甲状腺手术中喉返神经(RLN)、喉上神经(SLN)的保护方法,以避免或减少术后永久性神经损伤的发生率。方法 对东南大学医学院附属南京同仁医院耳鼻咽喉头颈外科,2013年6月—2014年11月行甲状腺精细化操作手术治疗141例患者的临床资料进行回顾性分析。其中男37例、女104例,年龄9~78岁。行甲状腺全切54例,甲状腺腺叶切除58例,甲状腺腺叶切除+对侧部分切除29例;其中二次手术者10例,行Ⅵ区清扫者18例。术中RLN显露者121例,未显露者20例。结果 本组141例均顺利完成手术。术后并发RLN暂时性损伤5侧,占2.56%(5/195),给予激素、神经营养药物治疗,并配合发音训练,3个月内神经功能均恢复正常;其中RLN显露组占2.5%(3/121),未显露组占5%(1/20),组间比较差异无统计学意义(χ²=0.396, P＞0.05)。无一例并发RLN永久性损伤和SLN损伤。结论 熟悉RLN、SLN与甲状腺的正常解剖与变异情况,应用被膜解剖技术精细操作,术后可以避免神经的永久性损伤。一旦发生神经损伤,及时给予对症处理,提高患者的生活质量。     

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.     

Intrathoracic blood supply of the left vagus and recurrent laryngeal nerves

Abstract The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.     

甲状腺良性结节微波消融术中喉返神经及旁腺保护措施与解剖基础

目的 探讨超声引导下微波消融术治疗甲状腺良性结节过程中对喉返神经及甲状旁腺的损伤保护措施及其解剖基础。方法 选取2017年1月到2019年6月行1射频消融治疗的甲状腺疾病患者52例,观察术后结节大小、血流信号变化、甲状腺激素水平、并发症发生情况等。结果 术后超声随访结节的体积较治疗前不同程度缩小(P<0.05)。结论 加强隔离带技术可以有效保护喉返神经及甲状旁腺,降低损伤风险。     

The recurrent laryngeal nerve (RLN): application to transhiatal oesophagectomy

Summary To emphasize the risks of recurrent laryngeal nerve lesions during transhiatal oesophagectomy an anatomical study of the course of the recurrent laryngeal nerve (RLN) was performed. Twenty RLN were dissected in their thoracic portion. This work showed the constancy of the low origin of the nerve in the adult under the aortic arch, and its course in the tracheal angle. It confirmed the close connections of the nerve with the posterior mediastinal viscera. Lastly, it displayed oesophageal nerve branches arising from the RLN and a few anastomoses between them and the tracheal nerve branches. This anatomical disposition resulted into the difficulty of transhiatal oesophaphagectomies and the risk of injury of the recurrent laryngeal nerve. The possibility of nerve lesions can explain the respiratory complications of this surgical approach.

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Le nerf laryngé récurrent : Application à l'sophagectomie trans-hiatale

Résumé Pour souligner les risques de lésions récurrentielles dans l'oesophagectomie trans-hiatale une étude anatomique du nerf récurrent thoracique est réalisée. Vingt nerfs récurrents thoraciques ont été disséqués. Ce travail montre la constance de la naissance basse de ce nerf chez l'adulte, sous la crosse de l'aorte, et son trajet dans l'angle oeso-trachéal. Il confirme les rapports intimes de ce nerf avec les viscères du médiastin postérieur. Enfin, il met en évidence des branches nerveuses oesophagiennes naissant du nerf récurrent thoracique et quelques anastomoses entre celles-ci et les branches nerveuses trachéales. De cette disposition anatomique résulte la difficulté des oesophagectomies trans-hiatales et le risque de lésion récurrentielle. La possibilité de lésion nerveuse peut expliquer les complications respiratoires d'une telle technique chirurgicale.

     

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     

An applied anatomical study of the superior laryngeal nerve loop

The aim of this study was to provide some specific information about the morphology and topography of the superior laryngeal n., its branches, and its anastomoses with the cervical sympathetic chain, as well as its relations with the thyroid gland. Sixty adult cadavers, ie 120 superior laryngeal nn., were dissected and analysed. An anastomotic loop connecting the cervical sympathetic chain and the distal laryngeal n. was present in 111 of the 120 cases. The morphology of this loop made it possible to define 5 different groups. This study supplies information valuable in thyroid surgery.