甲状腺手术中喉返神经的显露方法及疗效研究

目的 分析甲状腺手术中喉返神经的显露对预防喉返神经损伤的效果.方法 150例甲状腺疾病患者采用解剖显露喉返神经方法行甲状腺腺叶切除或次全切除,解剖显露喉返神经270条.结果 术中发现喉不返神经6例,其中喉返神经损伤2条,术后恢复良好,顺利出院.结论 在甲状腺良恶性疾病手术中,熟悉喉返神经正常解剖及变异,常规解剖和显露可大大降低并发症,减少喉返神经的损伤.     

甲状腺手术中喉返神经显露的意义

目的探讨甲状腺手术中喉返神经显露的方法和利弊.方法对235例甲状腺切除术患者分两组进行前瞻性研究,其中术中显露喉返神经107例,不显露喉返神经128例.结果显露喉返神经术式者喉返神经损伤率(0.93%),低于不显露喉返神经术式者(3.9%)(P＜0.05).结论甲状腺切除术中显露喉返神经可以降低喉返神经损伤的发生率;术者必须遵循规范化操作原则,紧靠甲状腺体结扎甲状腺下动脉分支,减少喉返神经损伤的机会.     

甲状腺术后喉返神经损伤的原因分析与预防

喉返神经损伤导致声音嘶哑是甲状腺手术后主要并发症之一,会对患者生活质量产生明显影响[1],我院在2003年6月至2007年3月间共收治了48例甲状腺术后喉返神经损伤患者,所有患者均接受喉返神经探查术,其中43例患者接受了喉返神经松解术或修复术,现总结报道如下.     

显露喉返神经在甲状腺手术中预防喉返神经损伤的作用

目的探讨显露喉返神经在甲状腺手术中预防喉返神经损伤的作用。方法随机将100例接受甲状腺手术的患者分为对照组和观察组,各50例。对照组术中不显露喉返神经,观察组在术中解剖、显露喉返神经。对比两组患者喉返神经损伤情况。结果对照组有3例患者出现了同程度喉返神经损伤,观察组患者无1例发生喉返神经损伤。结论在甲状腺手术过程中解剖显露喉返神经,可有效减少对喉返神经的损伤。     

甲状腺手术中喉返神经损伤的预防

目的 通过回顾性分析,评价甲状腺手术中解剖喉返神经的必要性.方法 将手术治疗的甲状腺疾病患者512例按术中是否解剖喉返神经分为解剖组和未解剖组,比较两组间喉返神经损伤的发生率.结果 全组解剖喉返神经组189例,术后出现声嘶3例(1.59%),未解剖神经组323例,术后出现声嘶5例(1.55%).两组差异无统计学意义(P＞0.05);但在存在有喉返神经损伤高危因素的患者中解剖与未解剖神经患者神经损伤率则有差异(1.02%vs.3.95%,P＜0.05).结论 是否解剖喉返神经应根据具体情况决定,对大多数甲状腺良性病变尽可能不暴露喉返神经,但对于巨大甲状腺肿瘤、二次或多次手术及甲状腺癌应暴露喉返神经.     

甲状腺术中喉返神经损伤的原因分析及预防措施

喉返神经损伤是甲状腺手术严重的并发症,双侧喉返神经损伤时可引起患者呼吸困难甚至窒息,目前对喉返神经损伤尚无较理想的重建方法,因此术中如何避免喉返神经损伤成为甲状腺外科的重要课题。我院2007年8月—2010年8月共完成甲状腺手术290例,暂时性喉返神经损伤6例,永久性喉返神经损伤1例。现就解剖学因素及手术操作对喉返神经损伤的影响,总结如下。     

甲状腺手术中显露喉返神经的安全性探讨

目的 探讨甲状腺手术中显露喉返神经对术后并发症的影响.方法 对397例甲状腺切除术患者分两组进行回顾性分析,其中显露喉返神经210例,不显露187例.比较两组术后喉返神经损伤和低钙血症发生情况.结果 显露组喉返神经损伤率低于不显露组,差异有统计学意义(P<0.05);甲状腺功能亢进的患者喉返神经损伤率高于甲状腺功能正常和甲状腺功能减退者,差异有统计学意义(P<0.05);显露组暂时性低钙血症的发生率高于不显露组,差异有统计学意义(P<0.05);显露组永久性并发症发生率低于不显露组,差异有统计学意义(P<0.05).结论 甲状腺手术中全程显露喉返神经可减少其损伤,并可降低永久性并发症的发生率.     

甲状腺手术中喉返神经损伤的临床分析

目的探讨甲状腺手术中喉返神经损伤的原因和预防治措施。方法对2004-01—2012-01甲状腺手术中12例喉返神经损伤患者的临床资料进行回顾性分析。结果 12例患者均为单侧喉返神经损伤,其中5例为胸骨后巨大结节性甲状腺肿,向上提拉一侧甲状腺腺叶时,喉返神经收到牵拉所致。4例为甲状腺乳头状腺癌行中央区淋巴结清扫时,在解剖喉返神经过程中,钳夹喉返神经所引起。3例在甲状腺结节复发行2次甲状腺残留腺叶切除时,分别由钳夹、误扎、烧灼喉返神经所致。10例暂时性喉返神经损伤(牵拉、钳夹)者,经对症治疗后1～2个月声嘶完全恢复。2例永久性喉返神经损伤(缝结扎、烧灼)者,术后3个月,对侧声带活动代偿,声嘶逐渐恢复。结论喉返神经损伤后,虽然声嘶均可有程度不等的恢复,但永久性喉返神经损伤对于从事戏曲、音乐表演者或教师,是一灾难性打击,必须引起临床足够重视。损伤后至声音恢复时间以牵拉、钳夹、缝结扎、烧灼依次延长。对于胸骨后巨大结节性甲状腺肿、甲状腺腺癌或2次甲状腺手术时,熟悉喉返神经的解剖,术中解剖游离出喉返神经,直视下予以保护,可有效预防喉返神经损伤。     

喉肌电活动实时监测喉返神经在再次甲状腺手术中的应用

目的探讨实时监测技术对预防喉返神经损伤的意义及应用价值。方法对55例再次甲状腺手术患者在全麻手术中使用喉返神经探测仪进行实时喉返神经监测（IONM）,术中分离显露喉返神经,并以神经刺激探针探测证实喉返神经在甲状腺后段行程及功能状态以保护其免受损伤,评估患者术后喉返神经损伤和声带功能恢复情况。结果共探测喉返神经107条,均成功显露。4例术前已证实有单侧声带麻痹的患者,术中探查该侧喉返神经证实3例被离断,另有1例被结扎,经松解后喉返神经肌电信号恢复,术后声带功能恢复。2例（3.64%）完整显露喉返神经的病例,手术结束前肌电信号消失,术后出现暂时性声带麻痹,均于2个月内恢复。结论使用喉返神经探测仪利于显露和保护喉返神经,有助于发现导致喉返神经损伤的原因并能较好地预测术后声带功能恢复的情况,减少医源性喉返神经损伤发生率,值得在再次甲状腺手术中推广。     

甲状腺手术中喉返神经损伤原因分析

喉返神经损伤是甲状腺外科常见的术后并发症。手术中显露喉返神经的操作过程是否会增加喉返神经的损伤率 ,尚有一定争议。现回顾性分析我院 1998～ 2 0 0 0年 2 0例甲状腺手术中喉返神经损伤的原因 ,以探讨手术方法对喉返神经的影响。1　临床资料我院 1998～ 2 0 0 0年共施行甲状腺手术者 118例 ,男 42例 ,女 76例 ,年龄 14～ 73岁 ,平均年龄 42 .5岁。甲状腺术后发生喉返神经损伤者 2 0例 ,其中良性肿瘤 17例 ,恶性肿瘤 3例 ;甲状腺术后无喉返神经损伤者 98例 ,其中良性肿瘤 81例 ,恶性肿瘤 17例。两组在性别、年龄和原发肿瘤疾病之间无统…     

显露喉返神经在甲状腺手术中的应用价值及预防其损伤的对策

【摘要】〓目的〓探讨常规显露喉返神经在甲状腺手术中的应用价值以及预防其损伤的对策。方法〓回顾性分析本科近5年来336例在初次行甲状腺手术患者的临床资料,根据术中是否显露喉返神经将其分为显露喉返神经组205例和未显露喉返神经组131例。根据喉返神经损伤的判断标准,比较两组患者术后喉返神经损伤情况。结果〓显露喉返神经组205例中有2例(0.98%)出现暂时性声音嘶哑,1个月未经特殊处理后声音恢复,无永久性损伤病例。未显露喉返神经组131例中有6例(4.58%)出现喉返神经损伤,其中4例为暂时性损伤,2例为永久性损伤。组间比较差异有统计学意义(P<0.05)。结论〓在甲状腺手术中规范化显露并保护喉返神经可有效预防与减少喉返神经的损伤。     

甲状腺手术中显露喉返神经的方法与价值

目的:探讨甲状腺手术中显露喉返神经的方法及其临床价值。方法:将116例甲状腺手术患者分为喉返神经显露组(60例)和未显露组(56例),比较2组术后喉返神经损伤情况。结果:显露组1例(2%)出现暂时性的声音嘶哑;未显露组4例(7%)出现神经损伤,其中2例出现暂时性的声音嘶哑,2例出现永久性的声音嘶哑。结论:甲状腺手术中常规显露喉返神经,可以降低喉返神经损伤的发生率,亦是预防其损伤的有效方法。     

甲状腺手术喉返神经与甲状旁腺的识别与保护183例分析

目的:探讨甲状腺手术中识别与保护喉返神经与甲状旁腺的技术改进方法及其临床效果.方法:回顾性总结分析183例甲状腺手术病例,以暴露喉返神经方法分组:对照组81例,于甲状腺下动脉下方解剖暴露喉返神经;治疗组102例,以寻找Zuckerkandl结节为主要途径暴露喉返神经.比较两组病人术后喉返神经的损伤、甲状旁腺功能及并发症等方面情况.结果:治疗组102例均临床治愈,术后并发暂时声嘶1(0.9%)例.2例(1.9%)甲状腺次全切除术加颈廓清扫术后出现暂时性甲状旁腺功能低下,32例(31.3%)术后2 d内血钙水平较术前一过性降低.对照组81例有6例(7.4%)损伤喉返神经,4例(4.9%)出现甲状旁腺功能低下.两组差异有统计学意义.结论:甲状腺手术技巧的一系列改进,尤其是对喉返神经和甲状旁腺的识别和保护,可控制术中出血量,减少术后并发症,促进术后康复.     

Importance of identifying the course of the recurrent laryngeal nerve in total and near-total thyroid lobectomies

In our clinic, near-total thyroidectomy is the principal surgical procedure performed for benign thyroid diseases. We conducted a single-institution study on 176 consecutive patients who underwent near-total thyroidectomy due to various thyroid diseases. We compared the incidence of recurrent laryngeal nerve injury between total and near-total thyroid lobectomy sides in each patient. Our hypothesis was that the incidence of recurrent laryngeal nerve injury after total thyroid lobectomy would be similar to that of near-total thyroid lobectomy when the course of the recurrent laryngeal nerve was identified during surgery. The temporary recurrent laryngeal nerve palsy rates on the total and near-total thyroid lobectomy sides were 3.9 per cent (7 of 176 nerves) and 2.2 per cent (4 of 176 nerves), respectively. The difference was not statistically significant. Permanent recurrent laryngeal nerve palsy did not occur in any of our patients. In conclusion, the incidence of recurrent laryngeal nerve injury in total versus near-total thyroid lobectomy is not different when the course of the recurrent laryngeal nerve is identified during surgery.     

分化型甲状腺癌不同术式术后主要并发症的分析

目的对比分析分化型甲状腺癌不同手术方式术后主要并发症的情况。方法回顾性分析河北医科大学第二医院2004年1月至2012年1月经手术治疗的264例分化型甲状腺癌资料。结果患侧腺叶及峡部切除术77例,术后喉返神经损伤1例（占1.3%）,低钙血症1例（占1.3%）;患侧腺叶及峡部＋对侧大部切除术137例,术后喉返神经损伤4例（占2.9%）,低钙血症9例（占6.6%）;甲状腺全切术50例,术后喉返神经损伤2例（占4.0%）,低钙血症11例（占22.0%）。结论甲状腺全切术、患侧腺叶及峡部切除术与患侧腺叶及峡部＋对侧大部切除术术后喉返神经损伤率无统计学差异;甲状腺全切术术后低钙血症发生率明显高于患侧腺叶及峡部切除术与患侧腺叶及峡部＋对侧大部切除术。     

��̸��״�������������˵��������

??Further discussion on relative factors of recurrent laryngeal nerve injury during thyroid operations ZHU Yi-ming, LIU Shao-yan. Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
Corresponding author??LIU Shao-yan??E-mail??shaoyanliu.bj@263.net
Abstract Recurrent laryngeal nerve injury is one of the most common complications of thyroid surgery and can seriously affect the quality of life of patients. However??recurrent laryngeal nerve injury is not only related to intraoperative maneuvers.A review of the literatures found that there are many factors related to recurrent laryngeal nerve injury during thyroid surgery??including anatomy of the nerve??characteristics of cases??perioperative assessment??intraoperative procedures??extent of surgery??application of energy devices??and application of IONM technology. Adhering to adequate preoperative evaluation??establishing a reasonable surgical plan and extent of resection??intraoperative meticulous membrane dissection??proper and rational application of energy devices??and standardized use of IONM technology can minimize recurrent laryngeal nerve injury and improve postoperative patient quality of life.     

甲状腺良性病变术中损伤喉返神经的原因及预防(附2 266例分析)

目的探讨甲状腺良性病变手术所致喉返神经（RLN）损伤的原因及预防措施。方法回顾分析2000年1月至2004年7月2266例甲状腺良性痛变的手术资料，对甲状腺良性病变的位置及手术方法与RLN损伤的关系进行比较分析。结果位于甲状腺背侧的良性病变RLN损伤率为8．62％（81／940），显著高于甲状腺其他部位病变的手术损伤率（0．15％）。位于甲状腺背侧的结节性甲状腺肿、甲状腺腺瘤，显露RLN组的喉返神经损伤率为1．56％（1／64）、0（0／33），显著低于未显露喉返神经的损伤率[8．53％（59／692）、13．9l％（21／151）]。位于甲状腺其他部位的良性病变，显露RLN组与未显露喉返神经组的RLN损伤率差异无显著性。结论甲状腺良性病变手术，喉返神经损伤与病变位置有关；结节性甲状腺肿、甲状腺腺瘤位于甲状腺背侧，手术应常规显露RLN，而位于其他部位则不需常规显露RLN，可采用RLN区域保护法。     

神经探测仪在甲状腺手术中的应用与评价

目的 探索甲状腺复杂手术中应用神经探测仪探寻和保护喉返神经的方法。方法 应用神经探测仪在20例复杂甲状腺手术中探寻和保护喉返神经。结果 20例复杂甲状腺手术患者术后无一例出现喉返神经受损的临床症状。结论 神经探测仪应用于复杂的甲状腺手术中，对于保护喉返神经免于误伤有着较大的临床意义。其方法简便易行，可靠有实效。     

The recurrent laryngeal nerve related to thyroid surgery.

BACKGROUND: Iatrogenic injury of inferior laryngeal nerve is one of the most serious concerns in thyroid surgery. Paralysis of vocal cords is a common sequela of thyroidectomy. It represents a serious complication inducing, when bilateral, serious functional sequelae such as phonatory, respiratory and psychological problems that limit working capacities and social relationships of patients. We carried out an intraoperative study aimed to define anatomical relationships between the recurrent laryngeal nerve and the adjacent structures (the inferior thyroid artery in particular), intraoperative identification of which may allow prevention of iatrogenic injuries of the laryngeal nerve. METHODS: One hundred ninety-two patients (165 females, 27 males whose age was between 18 and 90 years, median age 55) who had undergone thyroidectomy in our department in the last 3 years. Among them, 179 patients underwent total extracapsular thyroidectomy, and of the 13 remaining, 12 were completions of thyroidectomy in patients who had previously undergone a first thyroid surgical intervention and underwent istmo-lobectomy. RESULTS: Despite a systematic intraoperative search, we identified the recurrent laryngeal nerve in 158 of 192 patients (82.3%), while in the remaining 34 (17.7%), the recurrent laryngeal nerve was not identified. In 122 out of the 158 patients (77.2%) in whom the recurrent laryngeal nerve had been detected, the nerve was identified bilaterally: in 19 of 158 (12%) only on the right side; in 17 of 158 (10.7%) only on the left. Concerning the postoperative results we noticed only one case (0.5%) of recurrent laryngeal nerve injury for neoplastic infiltration of its own branch, one case (0.5%) of monolateral cordal hypomotility, and two cases (1.04%) of bilateral cordal hypomotility with temporary disphonia, which regressed in 6 months of time. CONCLUSION: The results of our study may confirm that iatrogenic injury to the recurrent laryngeal nerve, or to its branches, might be better avoided by searching, identifying, and exposing the nerve itself and by following its course with care. In our view, total extracapsular thyroidectomy, with systematic search for the nerve, is the best approach. We believe that deep knowledge of the thyroid region's surgical anatomy and the awareness of the extremely varying course of the recurrent laryngeal nerve and the inferior thyroid artery and their relations should be taken into account by surgeons.