内镜甲状腺切除术仅是美容手术吗

甲状腺切除术是普通外科的常见手术。传统的甲状腺切除术会在颈部留下明显的手术瘢痕,给患者留下难以抹去的心理阴影。内镜甲状腺切除术的出现使得颈部手术后不留瘢痕或仅留下微不足道的瘢痕成为可能。目前我国广泛开展的技术是经胸壁入路内镜甲状腺切除术和在颈部前方做一小切口的内镜辅助甲状腺切除术（Miccoli手术）。     

内镜甲状腺、甲状旁腺切除术

内镜甲状腺、甲状旁腺手术是近年发展起来的一项新型手术技术。具有美观、创伤小以及术野清晰,能有效避免神经、血管损伤等特点。本就内镜甲状腺手术的实验与临床应用现状做一综述。     

内镜辅助的甲状腺切除术手术技巧

传统甲状腺切除术后会在颈部留下明显的手术瘢痕,给患者留下难以抹去的心理阴影.内镜甲状腺切除术的出现,使颈部手术后不留瘢痕或仅留微不足道的瘢痕成为可能.     

内镜辅助的甲状腺切除术

内镜辅助的甲状腺切除术（endoscopic assisted thyroidectomy,EAT）是由意大利比萨大学Miccoli建立的手术技术,其基本手术方法是经颈部小切口内镜辅助下完成甲状腺切除。颈部仅留下很短的手术瘢痕。我们于2002年9月开始尝试Miccoli手术,取得满意的微创和美容效果,现报告如下。     

内镜下甲状腺切除术11例报告

1996年Ganger、1997年Huscher分别在内镜辅助下完成了甲状旁腺及甲状腺的部分切除。2002年仇明等报道了国内第1例颈部无瘢痕内镜甲状腺切除术。2004年5月～2005年6月，我院采用胸骨前径路行内镜甲状腺部分切除术11例，效果满意，现报道如下。     

内镜下甲状腺瘤切除术的手术配合

随着医学的发展，微创手术越来越被患接受。内镜下甲状腺肿瘤切除术，其优点在于颈部无切口，有极佳的美容效果，深受广大病人特别是青年女性欢迎。该术式由美国Gagher教授首创于1996年，我院自2003年5月至今已实施11例内镜下甲状腺瘤切除术，效果满意。术中护士与医生密切配合是手术取得成功的关键。     

内镜甲状腺手术入路的选择

<正>传统甲状腺手术在颈部留有手术瘢痕,给患者(尤其年轻女性患者)带来心理负担,内镜甲状腺手术应运而生。1996年Gagner首次报道了内镜甲状旁腺切除术,1997年Hüscher等首次报道内镜甲状     

电视辅助微创甲状腺及甲状旁腺切除术

第一例颈部内镜手术由Gagner完成,他为一位由甲状旁腺增生引起的原发性甲状旁腺功能亢进(primary hyperparathyroidism,PHPT)患者实施了甲状旁腺切除术[1].     

微创手术治疗甲状腺疾病

<正>1996年Gagner[1]报道世界首例内镜甲状旁腺次全切除术至今,因内镜甲状腺手术疗效可靠及术后美容效果得到众多医师和患者的青睐,在我国发展非常迅猛。但由于手术难度较高,其并发症易致医疗纠纷,恶性肿瘤手术也有较多的争议,其发展并     

内镜甲状腺切除术的应用现状

随着内镜技术的快速发展,内镜手术已不再局限于腹腔、胸腔等自然的腔隙间,而是可以在人工制造的组织间隙中进行.现对内镜甲状腺切除术(endoscopic thyroidectomy,ET)的应用现状讨论如下.     

Long-term cosmetic results after minimally invasive video-assisted thyroidectomy

Background  

Minimally invasive video-assisted thyroidectomy (MIVAT) has been performed in the authors’ department since 2004. Many authors have described some of its advantages over conventional surgery in terms of cosmetic results. The published literature on this topic variously describes the average central incision as 1 to 3 cm. The end point of the cosmetic results (e.g. the question of keloids) cannot be documented during the inpatient stay. This report describes the long-term cosmetic results for this method and analyzes the subjective and objective outcomes after MIVAT.     

Endoscopic minimally invasive thyroidectomy: first clinical experience

Background

Since Theodor Kocher reduced the mortality rate of thyroidectomy from the 40% reported by Billroth to 0.2% in 1895, a collar incision with open removal of the thyroid gland is the standard procedure [1, 2]. In the past decade, efforts were made to reduce incision size and surgical access trauma by the use of endoscopic techniques. A first attempt was replacement of the central “Kocher incision” with lateral neck incisions and endoscopic removal of a thyroid lobe by Hüscher on 8 July 1996 [3]. This lateral access was limited to removing only one lobe of the gland. The most common technique to date is the one developed by Miccoli et al. [4]. These authors reduced the incision to a size of 20 to 25 mm and operated on the thyroid by the use of video-endoscopic assistance (MIVAT). Several groups have described an access outside the frontal neck region via a chest [5–8], axillary [9], or combined axillary bilateral breast approach [10]. These accesses only moved the entry point from the frontal neck region to other regions, where they are still visible. The aforementioned minimally invasive approach and the conventional open approach do not respect anatomically given surgical planes and may therefore result in patient complaints, especially swallowing disorders after the scaring of the subcutaneous tissues. These extracervical approaches are associated with an extensive dissection in the access area and thus are maximally invasive. Therefore, we developed an exclusively endoscopic approach for thyroid resection [11] with standard instruments used for minimally invasive surgery (diameter, 3.5 mm). This endoscopic minimally invasive thyroidectomy (eMIT) technique was evaluated carefully by anatomic and cadaver dissections as well as ultrasound studies for technical realization and needs for instrument design [12]. To verify the safety and feasibility of the method, an animal trial was conducted in August 2008. Surgery was performed securely on five pigs, with very low blood loss. The postoperative behavior with special regard for feeding and pain reaction was normal until dissection. Especially, no local infection in the oral cavity or cervical spaces was noted.

Methods

All the trials of eMIT showed good results, so we went on to its first clinical application in the spring of 2009. A 53-year-old man had experienced dysphagia for more than a year. During routine diagnosis, the thyroid hormones T3, T4, and TSH were controlled and within normal levels. Thyroid scintigraphy, B-mode ultrasound examination, and laryngoscopy were performed preoperatively. An euthyroid nodular chance of the right hemithyroid with a beginning focal autonomy was diagnosed. After the patient’s informed consent was received, surgery was performed on 18 March 2009 in an interdisciplinary collaboration between a general surgeon and a head and neck surgeon. The first incision was made in the midline sublingually. A 5-mm trocar was directed through the floor of the mouth muscles into the subplatysmal layer and positioned at the level of the cricoid. Carbon dioxide then was insufflated at 6 mmHg to build a tent above the thyroid gland. Next, a second trocar for insertion of the surgical instruments was placed over a vestibular incision into the same subplatysmal layer. This allowed the surgical field to be visualized fully and dissected with 3.7-mm standard minimally-invasive instruments. A third trocar for surgical instruments then was placed through an incision on the left side of the vestibule of the mouth. After a midline incision of the linea alba, the fibrous capsule of the thyroid gland could been seen. The isthmus then was prepared in total. Next, the strap muscles above the right hemithyroid were prepared, showing the right upper pole. With the Harmonic scalpel, the isthmus was divided on the left side. The gland was loosened from the trachea and the adjacent lamella. The vessels of the upper pole were divided by Ultracision (Ethicon-Endosurgery, Cincinnate/Ohio, USA). Under the adjacent lamella, the recurrent nerve was visualized and stimulated. Neuro-monitoring showed an intact function of the nerve. Finally, the lower pole was detached, allowing the thyroid to be freely movable. Recovery of the tumor was performed through the median trocar incision after the optic device was moved through a lateral trocar. The tumor volume was 5.5 ml. The operation site was checked for bleedings and lavaged with sodium chloride. After removal of all the trocars, the wounds were sutured with self-resorbable sutures. Plaster tape was applied for 24 h. No direct postoperative complications occurred. Postoperative histology showed a colloidal struma.

Results

The floor of the mouth healed well, with no local infections at the incision sites or in the cervical spaces. Vocal cord function, evaluated by direct video-laryngoscopy, was normal. The patient had minimal swelling of the neck and a small hematoma, which resolved within 2 weeks. He had neither swallowing disorders nor oral pain. His preoperative dysphagia was gone, and he left the clinic 2 days after surgery without any complaints.

Conclusion

With the development of an exclusively endoscopic approach for thyroid resection (eMIT) and its first clinical application, we could show the safety and feasibility of another natural orifice surgery procedure. One major concern before surgery was possible infection of the cervical spaces by introduction of oral flora to these regions. Investigating this infection risk, Hong and Yang [13] evaluated the surgical results associated with the intraoral approach for submandibulectomy in a series of 77 cases of chronic sialadenitis and benign mixed tumors. The infection rate was 2.6% (2 patients) compared with 7.3% in a control group of 251 patients who underwent a transcervical procedure [13]. Therefore, we estimated the infection risk to be lower than with conventional transcervical approaches. The clear advantages of this technique are its minimally invasive character, its reduction of surgical trauma, its direct access to surgical planes and spaces, its avoidance of swallowing disorders and postoperative dysphagia, and finally, its avoidance of any skin scars. Further trials are already being conducted.     

乳晕入路全腔镜下甲状腺癌根治术与小切口甲状腺癌根治术的临床对比分析

目的:对比全腔镜下甲状腺手术与小切口甲状腺手术治疗甲状腺癌的手术效果及美容效果。方法:将33例术前行甲状腺细针穿刺抽吸诊断为甲状腺乳头状癌的患者随机分为两组,其中16行乳晕入路腔镜下甲状腺癌根治术(腔镜组),17例行腔镜辅助小切口甲状腺癌根治术(小切口组)。对比分析两组患者手术时间、淋巴结清扫数量、术后引流时间、术后并发症发生率、患者切口满意度等指标。结果:小切口组手术时间、术后引流时间均明显少于腔镜组(P0.05);两组淋巴结清扫数量、术后并发症发生率差异无统计学意义(P0.05);而腔镜组患者满意程度明显优于小切口组(P0.05)。结论:小切口甲状腺手术与腔镜甲状腺手术均属于美容手术,两者均具有良好的手术安全性及根治效果,小切口手术在手术时间、术后引流等方面优于腔镜手术,但颈部仍有2~3 cm的瘢痕。腔镜手术具有术后颈部无瘢痕的美容效果,美容效果更佳,但应严格掌握适应证。     

The size criteria in minimally invasive video-assisted thyroidectomy

Background  

Thyroid size is a very important criteria of MIVAT exclusion because the working space provided by the technique is limited.     

An easier technique for minimally invasive video-assisted thyroidectomy

Because of the efforts of many pioneer surgeons, the minimally invasive video-assisted thyroidectomy (MIVAT) has been recognized as a safe procedure, offering advantages such as better cosmetic outcome and less analgesic need. The MIVAT technique was described in 51 selected patients in 2001. The technique was not therefore widely used because of the excess operating time compared with traditional thyroidectomy, and most importantly, this method needed a steep learning period. This study reports a modified MIVAT procedure, which can make this operation easier and shorten the time of learning. We compared the outcomes of the originally described methods with our modified method. The selection criteria for performing MIVAT were as follows: thyroid nodules in one lobe and less than 50 mm on their largest diameter, benign lesion proved by fine-needle biopsy, patient without history of thyroiditis, and no previous neck surgery or irradiation. All patients received lobectomy. Sixty patients were eligible for MIVAT during a period of 27 months. The patients were divided into two groups. Group A consisted of the 17 patients who underwent MIVAT using the original technique that was described previously. Group B consisted of the 43 patients who underwent MIVAT using a self-designed Army retractor with a mosaic ring. The mean operation time of Group A was 120 minutes and that of Group B was 59.2 minutes. The size of the incisions was no difference in either group. There were no postoperative complications except in one patient with transient recurrent laryngeal nerve palsy in Group A. There was one conversion to open thyroidectomy in Group A and none in Group B. The cosmetic results were no different between the two groups. In conclusion, the use of a modified Army retractor with a mosaic ring made the MIVAT procedure easier and offered similar advantages.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in sick patients. Establishment of CO₂ pneumoperitoneum produces adverse pathophysiological changes due to increased intra-abdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia with endotracheal intubation is the most common anaesthetic technique, but supraglottic airway devices can sometimes be used. Neuroaxial anaesthesia has been used in some laparoscopic procedures as the sole anaesthetic technique. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in those with significant co-morbidity. Establishment of carbon dioxide (CO₂) pneumoperitoneum produces adverse pathophysiological changes due to increased intraabdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia is most commonly used but neuraxial anaesthesia is possible, although spontaneous ventilation may be difficult. Endotracheal intubation has been a popular technique but supraglottic airway devices are less traumatic, easier to insert and more modern versions provide a good airway seal as well as gastric drainage, should it be required. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.