甲状腺结节腔镜外科治疗的变迁

目的总结腔镜甲状腺切除术的手术入路、适应证、禁忌证及手术并发症的变迁。方法复习国内外有关腔镜甲状腺切除术的文献,总结其入路、适应证、禁忌证及常见并发症的历史与现状。结果各腔镜甲状腺手术的入路均有其优点,其中胸乳入路及完全乳晕入路为主流术式;腔镜甲状腺切除术的适应证和术者及器械有紧密的关联,目前尚无统一的适应证;随着腔镜技术的提升,禁忌证会逐渐被克服;新器械的辅助和术者经验的累积降低了手术并发症的发生率,但仍有并发症发生。结论腔镜甲状腺切除术是治疗甲状腺结节的主要手段,随着技术的提升、器械的革新、适应证的扩大及禁忌证的克服,其会获得更广泛的应用。     

乳晕入路腔镜甲状腺切除术与开放手术的临床对比分析

目的：探讨腔镜技术用于甲状腺手术获得美容效果的临床应用价值及其安全性和可行性。方法：选择2008年1月-2011年08月行甲状腺良性肿物手术的患者80例,其中腔镜甲状腺手术40例（腔镜组）,单侧23例,双侧17例;传统开放甲状腺手术40例（开放组）,其中单侧22例,双侧侣例,2组行单侧大部分切除术或者双侧甲状腺大部分切除术,麻醉方法均采用气管插管全身麻醉。分别比较2种术式单侧和双侧的手术时间、术中失血量、术后住院时间、术后引流量、引流天数、住院费用、术后美容效果、术后并发症。结果：全部病例手术成功,2组均无术后大出血、喉返和喉上神经损伤、甲状旁腺损伤等严重并发症。腔镜组手术时间较长,2组单侧及双侧分别比较差异均无统计学意义（P〉0．05）;腔镜组术中出血量、住院时间、术后引流量、术后引流时间、术后并发症较开放组少,2组单侧及双侧分别比较差异均有统计学意义（P〉O．05）。虽然住院费用腔镜组高于开放组（P〈O,05）,但腔镜组取得较好美容效果。结论：乳晕入路腔镜甲状腺切除术与开放手术均是安全、有效的手术方法,腔镜手术有更加令人满意的美容效果,有着传统开放甲状腺手术不可比拟的优点,对适应证明确者,应该是值得推崇的手术方式。     

腔镜甲状腺手术现状与展望

传统甲状腺手术在颈部会遗留较长的手术瘢痕。为增强美容效果,上世纪90年代国内外学者开始探讨如何利用腔镜进行甲状腺手术。此后该技术发展迅速,出现了完全腔镜（endoscopicthyroidectomy,ET）和腔镜辅助的小切口甲状腺手术（minimallyinvasiverid．eoassistedthyroidectomy,MIVAT）。近年来,许多新观念、新技术、新方法在腔镜甲状腺手术领域得到应用,如术中喉返神经监测技术、机器人技术、腔镜下新解剖标志的认识、新路径的应用等等,所有这些共同促进了腔镜甲状腺外科的发展,本文就腔镜甲状腺手术的现状及展望做一介绍。     

经胸壁入路腔镜甲状腺切除术与开放手术的临床对比分析

目的：比较完全腔镜与常规开放甲状腺切除术之间的差别,探讨腔镜下甲状腺手术的可行性和实用性。方法选择甲状腺良性肿瘤130例,随机分为经胸壁入路腔镜甲状腺切除术58例（腔镜组）和开放切除术72例（开放组）。观察比较两组手术时间、术中出血量、术后住院时间、术后引流量、引流时间、住院费用、术后美容效果、术后并发症发生情况、术后疼痛评分及患者满意度等。结果开放组住院时间、切口长度显著多（长）于腔镜组（P ＜0．05）,出血量、手术时间、拔管时间、住院费用、引流量、术后疼痛 VAS 分值显著少（短）于腔镜组（P ＜0．05）。两组术后并发症发生率、肿瘤复发率比较,差异无统计学意义。腔镜组患者美观满意度显著高于开放组（P ＜0．05）。结论经胸壁入路腔镜甲状腺切除术临床效果优于开放切除术,在严格把握手术适应证的情况下是值得推崇的手术方式。     

分化型甲状腺癌的腔镜手术治疗

得益于20世纪末腹腔镜设备和技术的迅猛发展，1996年Gagner成功开展了世界上第一例腔镜甲状旁腺切除术，标志着腔镜颈部手术时代的开始。首例腔镜下甲状腺切除术（endoscopic thyroidectomy，ET）由Huscher等。于1997年完成，之后，ET迅速发展出多种手术径路和操作方法，其特点是切口较传统开放手术更小，或者隐藏在身体的隐蔽部分，美容效果好，并且取得了与开放手术相同的效果，受到患者的青睐。     

腔镜甲状腺手术的发展现状

多年来的临床实践证明,腔镜甲状腺手术是一项可行、安全的手术方式,与传统开放甲状腺手术相比有着创伤小、出血少、恢复快、美容效果好等明显的优势。已逐渐被广大患者所接受。目前,三种常用腔镜甲状腺手术方式为:颈入路、胸入路及腋入路。随着腔镜机械及技术的发展,腔镜甲状腺手术适应证的范围越来越广,手术并发症的发生率也越来越低。因此,相信经过一段时间的努力探索,腔镜甲状腺手术将有可能取代传统手术成为某些特定甲状腺疾病治疗的金标准。     

经胸乳入路全腔镜甲状腺手术的临床应用（附112例分析）

目的：探讨全腔镜甲状腺手术的临床应用价值。方法回顾性分析2012年2月至2013年5月112例全腔镜甲状腺手术及115例开放甲状腺手术患者的临床资料。结果112例全腔镜甲状腺手术中3例因术后病检切片报告为恶性行二次开放手术,其余109例顺利完成手术,手术时间（105．6±43．3）min,115例开放手术时间（81．3±35．5）min,两者差异有统计学意义（P ＜0．05）;术后引流量、手术并发症两者差异无统计学意义;术后外观满意度、术后平均住院时间两者差异有统计学意义（P ＜0．05）。结论有开放甲状腺手术经验的外科医师容易掌握全腔镜甲状腺手术,其中有一个学习曲线过程;全腔镜甲状腺手术具有较好的美容效果,对于一定人群有较大的应用价值。     

经乳晕入路的腔镜甲状腺切除术

腔镜甲状腺手术能实现传统手术无法达到的美容效果，倍受青年女性的青睐，而术后颈部无任何疤痕的乳晕入路是目前最理想的方法。本就乳晕入路腔镜甲状腺切除的方法、适应证及并发症等相关问题做一介绍。     

经胸乳途径腔镜甲状腺切除术30例报告

传统甲状腺手术会在颈部留下明显的手术瘢痕,影响美容,尤其对于处于高发人群的中青年女性来说,更是难以接受。1997年Huseher等完成首例腔镜甲状腺叶切除,从此腔镜甲状腺手术得到了迅速发展。2003年4月～2009年8月,我科应用经胸乳途径成功进行30例腔镜甲状腺切除术,取得很好的美容及手术效果,现报道如下。     

腔镜技术在甲状腺癌治疗中合理应用

随着腔镜甲状腺手术在国内外的广泛开展,腔镜技术在甲状腺癌手术中的应用颇受关注。相比传统的开放甲状腺手术,腔镜甲状腺手术,具有颈部无瘢痕、切口隐蔽及美容效果好等优点,但也存在手术操作复杂、培训时间长等缺点。临床上,术者必须注重选择合适的病人,掌握腔镜下的基本操作技能,并能合理应用腔镜甲状腺的各种特殊设备。要坚持“治愈疾病第一,美容第二”的手术原则。     

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??Controversy and consensus of endoscopic thyroidectomy WANG Ping,XIE Qiu-ping. Department of Thyroid Surgery, the 2nd Affiliated Hospital of Zhejiang University,Hangzhou310009,China
Corresponding author:WANG Ping??E-mail??p.wang_zju@foxmail.com
Abstract Endoscopic Thyroidectomy is a new procedure for thyroid disease, including video-assisted thyroidectomy (VAT) and scarless endoscopic thyroidectomy (SET). Compared with the traditional open thyroid surgery (OTS), it is characterized with cosmetic benefits. Due to recent developments in equipment and technology, ET indications expanded from benign disease to partial papillary carcinoma, and lymph node metastasis is not part of its contraindications. But the indications and contraindications of ET remains controversial. We believe that it belongs to oncoplastic surgery and it must adhere to the same principles as OTS. The complications of ET have its own characteristics. Practice has proved that ET is safe and feasible. Consummate laparoscopic surgery skills and rich experience in OTS is needed to achived successful ET, which required a relatively long learning curve.     

腔镜技术在甲状腺微小乳头状癌治疗中应用

经过20年的发展,腔镜甲状腺切除术适应证已经扩展至分化型甲状腺癌,尤其是甲状腺微小乳头状癌（PTMC）。术前评估是关键,评估的重点是原发肿瘤的位置以及转移淋巴结的大小、位置;腔镜PTMC手术关键是如何保护喉返神经（RLN）及甲状旁腺的功能。对于初学者,或遇到喉不返神经,或二次手术的时候,术中神经监测有明显的优势。对于PTMC病人,近全甲状腺切除术代替全切除术是防止甲状旁腺永久性损伤的有效术式。目前,对于PTMC行腔镜甲状腺手术治疗,在手术入路选择及淋巴结清扫范围等方面还存在争议。     

全腔镜甲状腺手术并发症及防治

全腔镜甲状腺手术（TET）具有手术操作相对简单、美容效果好等特点,目前最常用的入路方式是经胸前入路及经口入路,两种方式都已逐渐为甲状腺外科医生及病人接受。但开展手术的医院和医生的水平参差不齐,新手及经验不足者,容易引起各种并发症。而TET与传统开放手术（OT）相关并发症及防治措施不尽相同。对于TET并发症的防治,应严格掌握手术适应证,加强从业医师的培训。术者要求兼备OT手术经验及腔镜操作技巧,具有果断适时中转的决断,是防治严重并发症的关键。而高清设备及精细器械的应用将更有助于TET安全性的提高,甚至可优于OT。     

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??Endoscopic thyroidectomy for thyroid microcarcinoma WANG Ping??YAN Hai-chao. Department of Thyroid Surgery??the 2nd Affiliated Hospital of Zhejiang University School of Medicine??Hangzhou 310009??China
Corresponding author??WANG Ping??E-mail??p.wang_zju@foxmail.com
Abstract With twenty years’ development??scarless endoscopic thyroidectomy??SET?? indications have expanded from benign disease to differentiated thyroid carcinoma??DTC????especially papillary thyroid microcarcinoma??PTMC??. It is very important for preoperative evaluation??which emphases are location and size of tumor and metastatic lymph nodes. The key surgical procedure is protection of RLN and parathyroid glands. For beginners??reoperation and non-RLN??intraoperative neuromonitoring??IONM??has obviously advantage. For PTMC??near total thyroidectomy is recommended to avoid permanent hypoparathyroidism??instead of total thyroidectomy. At present??in endoscopic surgery of PTMC, the endoscopic approach and the scope lymph node dissection remain controversial.     

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??Technique of totally endoscopic neck dissection for thyroid carcinoma WANG Ping , YE Mao. Department of Thyroid Surgery??the 2nd Affiliated Hospital of Zhejiang University School of Medicine??Hangzhou 310009??China
Corresponding author??WANG Ping??E-mail??p.wang_zju@
foxmail.com
Abstract Thyroid carcinoma is the most common malignant tumor in neck and head. The incidence of thyroid carcinoma is increasing in recent years. Endoscopic thyroidectomy??ET?? has developed rapidly within twenty years. As an important part of radical thyroidectomy?? lymph node dissection via endoscopy demands rich experience of open surgery and endoscopic skill. It is important to know the anatomy of dissection area to avoid injury of nerves?? vessels and parathyroid glands. The use of IONM and carbon nanoparticles facilitates the procedure.     

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??Prevention and treatment of complications in totally endoscopic thyroidectomy WANG Ping, XIE Qiu-ping. Department of Thyroid Surgery, the Second Affiliated Hospital of Zhejiang University, Hangzhou 310009,China
Corresponding author??WANG Ping,E-mail??p.wang_zju@foxmail.com
Abstract Totally endocsopic thyroidectomy??TET????as a new procedure for thyroid disease??has been wildly welcomed by thyroid surgeons and patients due to its perfect cosmetic benefits and relatively simple manipulations.The most usual approach is transbreast and transoral in China. The complications of TET are different from open thyroidectomy??OT????and the novice and inexperienced are prone to have complications. Strictly controlled surgical indications, normatively regulated training of practitioners should be strengthened. It is the key to prevent and cure serious complications, that operators should have experienced OT and endoscopic techniques. The application of high definition equipment and fine equipment will be more helpful for the improvement of TET security, will make TET better than OT eventually someday.     

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??Reasonable application of endoscopy in the treatment of thyroid cancer WANG Ping, WANG Yong. Department of Thyroid Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
Corresponding author??WANG Ping, E-mail??p.wang_zju@foxmail.com
Abstract Scarless in the neck endoscopic thyroidectomy ??SET??has been widely used throughout the country nowadays. While the application of oncoplastic thyroidectomy for thyroid cancer??OTTC?? is still controversial. Compare to open thyroidectomy??SET is characterised with no scar in the neck and better cosmetic results. Its complexity of surgical procedures causes a long learning curve. Clinically??selection of appropriate patients for SET and grasping the endoscopic skills are the most important things for the operators. Experienced application of special endoscopic equipments is also necessary. Above all??every operator should keep it in mind that disease treatment is much more important than cosmetic result.     

经口腔前庭入路腔镜甲状腺全切除术治疗cN0甲状腺乳头状癌临床研究

目的 探讨经口腔前庭入路腔镜全甲状腺切除术（TOETVA）的有效性及安全性。方法 回顾性分析2017年7月至2019年7月浙江大学医学院附属第二医院甲状腺外科收治的行全甲状腺切除术且病理学检查确诊为甲状腺乳头状癌（PTC）的110例病人的临床资料,术前影像学检查提示无淋巴结转移（cN0）。其中51例行TOETVA（经口组）,59例行开放甲状腺手术（开放组）,对比两组临床病理学指标、手术效果以及随访情况。结果 两组病人术中喉返神经信号减弱比例、中央区淋巴结清扫数目、单双侧甲状腺清扫比例、淋巴结转移阳性率、阳性淋巴结数目及术后并发症（声音嘶哑、饮水呛咳、暂时性甲状旁腺功能减退及感染）差异均无统计学意义（P＞0.05）。术后随访6个月,经口组与开放组病人的Tg和PTH水平差异无统计学意义（P=0.560、0.206）,且均未发现两组有甲状腺残留及甲状腺癌复发转移征象。结论 TOETVA在有效性及安全性方面不劣于开放手术,且体表无手术瘢痕,尤其适合有美容要求的临床低危PTC病人。     

全甲状腺切除在甲状腺良性结节治疗中应用及评价

甲状腺结节临床常见,尽管大部分为良性,但有手术指征时应行手术治疗,手术方式主要包括腺叶切除、甲状腺次全切除和全（近全）甲状腺切除等。甲状腺良性结节的手术方式目前尚存争议,若切除范围过小,结节复发风险增加,可能须再次手术;切除范围过大,则可能增加喉返神经损伤及甲状旁腺功能减退等并发症发生风险。全甲状腺切除因其能彻底切除病变,降低复发风险,避免再次手术,且并发症无明显增加,已成为国外治疗结节性甲状腺肿等良性甲状腺结节的首选术式。在我国,应综合考虑医生的技术水平、病人的个体情况及意愿等因素,可以考虑对具有手术指征的双叶甲状腺良性结节采用全甲状腺切除术。