Zuckerkandl结节与喉返神经位置关系的临床解剖学研究

目的 探讨Zuckerkandl结节的解剖及其在甲状腺手术中作为喉返神经解剖标志的临床意义.方法 147例患者(良性106例,恶性41例)甲状腺手术中解剖出喉返神经.测量Zuckerkandl结节大小并分级;辨认Zuckerkandl结节与喉返神经的关系并分型;解剖甲状腺下极并辨认喉返神经与甲状腺下动脉的关系.结果 共对233(左107、右126)侧甲状腺进行解剖.左侧成功解剖93.5％,右侧成功解剖96.0％.Zuckerkandl结节分级如下:0级,左16.0％右13.2％;Ⅰ级,左32.0％右27.3％;Ⅱ级,左46.0％右44.6％;Ⅲ级,左6.0％右14.9％.两侧Zuckerkandl结节分级之间无明显差异.Zuckerkandl结节与喉返神经的关系分型如下:A型,左92.9％,右93.3％;B型,左0右0;C型,左7.1％,右6.7％.左右两侧无明显区别.Zuckerkandl结节分级与喉返神经走行之间存在一定相关性:Zuckerkandl结节分级越高,喉返神经从其内后方走行越多;Zuckerkandl结节分级越低,喉返神经自其外侧通过者越多.右侧喉返神经危险型的发生率(19.0％)高于左侧(8.3％);Zuckerkandl结节与喉返神经的关系对评估甲状腺下极喉返神经通过甲状腺下动脉的方式无明显意义.结论 Zuckerkandl结节是甲状腺手术中定位与解剖喉返神经的重要标志,Zuckerkandl结节分级对喉返神经的解剖及术中损伤的预防有指导意义.     

甲状腺手术中喉返神经三种显露方法的比较

目的探讨在甲状腺切除手术过程中显露喉返神经三种方式的优缺点。 方法回顾性分析2016年6月至2019年6月中山大学附属第五医院甲乳外科住院实施单侧或双侧甲状腺腺叶切除的200例甲状腺患者的资料。 结果行一侧腺叶切除80例,行双侧腺叶切除120例。200例甲状腺切除患者手术中共解剖喉返神经320条,其中100条通过喉返神经入喉处寻找,120条通过Zuckerkandl结节寻找,100条通过甲状腺下极处寻找,寻找到喉返神经的平均时间分别为（5.5±2.5）、（4.5±3.0）、（6.0±3.5）min,各组喉返神经损伤例数分别为2例、1例、3例。在显露时间和喉返神经损伤率方面通过Zuckerkandl结节寻找与其他两组相比,差异有统计学意义（t=1.76,P=0.004;χ²=4.02,P=0.009）。 结论以Zuckerkandl结节为标志寻找及显露喉返神经是一种较为简易、安全的方法,对提高甲状腺手术的安全性具有重要意义。     

复发性结节性甲状腺肿再手术中喉返神经的保护探讨

【摘要】〓目的〓探索结节性甲状腺肿术后复发再手术中喉返神经的保护策略。方法〓选取我科32例复发性结节性甲状腺手术患者,回顾性分析其手术、临床资料。结果〓通过术中精细解剖,清晰暴露甲状腺解剖标志——Berry韧带和Zuckerkandl结节,明确喉返神经“起点”与“终点”,完整切除腺体,保护喉返神经完好;术后3例患者出现暂时性声音嘶哑,予以神经营养和理疗,2例患者术后两周内恢复正常,1例患者术后四周内恢复正常。结论〓结节性甲状腺肿术后复发再手术者,喉返神经毗邻结构因粘连而层次不清,术者掌握必要的手术技巧和精细操作,暴露关键的甲状腺解剖标志以显露喉返神经,是避免其医源性损伤的重要方法。     

甲状腺手术中常规显露喉返神经的意义

目的 探讨甲状腺手术中常规显露喉返神经(RLN)对保护神经的作用.方法 回顾性分析2009年至2010年间连续实施的232例甲状腺切除手术患者的资料.手术均由同一组医师实施,方式为甲状腺腺叶切除或全切除术,术中常规显露喉返神经.结果 共行腺叶切除181例,甲状腺全切除51例.术中解剖喉返神经280根(98.9%).术后10例患者(3.6%)出现声音嘶哑,其中7例术中证实了喉返神经的完整性,但声带检查出现患侧运动障碍,均在术后2个月内发音恢复正常.另外3例为术中离断性神经损伤并行即刻吻合者,在术后4个月内声音均恢复正常.结论 甲状腺手术中常规显露喉返神经是预防喉返神经永久性损伤的有效方法.     

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。     

甲状腺手术中常规显露喉返神经的意义

目的 探讨甲状腺手术中常规显露喉返神经(RLN)对保护神经的作用.方法 回顾性分析2009年至2010年间连续实施的232例甲状腺切除手术患者的资料.手术均由同一组医师实施,方式为甲状腺腺叶切除或全切除术,术中常规显露喉返神经.结果 共行腺叶切除181例,甲状腺全切除51例.术中解剖喉返神经280根(98.9%).术后...     

腔镜甲状腺切除术中喉返神经的显露

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法2011年4月～2012年4月,行胸乳晕人路腔镜下甲状腺切除术17例。于乳腺前皮下置入troear,注入CO2（压力6mmHg）建立操作空间,用超声刀显露喉返神经。结果17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术（6例双侧叶结节和1例甲状腺癌）,5例行一侧甲状腺叶切除术（一侧腺叶多发结节）,5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17．6％（3／17）、47．1％（8／17）和35．3％（6／17）,术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。     

喉返神经显露在甲状腺腺叶切除中的应用

目的：探讨甲状腺腺叶切除中喉返神经显露技术。方法：对382例甲状腺腺叶切除病例进行喉返神经显露,观察术后发音情况。结果：382例中出现暂时性声音嘶哑18例（4.7%）。结论：甲状腺腺叶切除时行喉返神经显露可以有效预防喉返神经的损伤。     

腔镜甲状腺手术中喉返神经显露与保护策略和经验

【摘要】 目的 探讨腔镜甲状腺手术中喉返神经暴露技巧与保护策略。方法 回顾性分析广州市白云区中医医院于2011年6月至2015年5月间施行的93例腔镜甲状腺手术病例资料,根据不同诊断分别进行甲状腺大部分切除术、甲状腺次全切除术、甲状腺腺叶切除术加峡部切除术或颈部淋巴结清扫术,术中采用气管食管沟、甲状腺下动脉及甲状软骨下角三个径路暴露喉返神经,总结显露成功率及观察手术并发症。结果〓本组全部病例均成功显露喉返神经,共计117例次,其中左侧喉返神经32例次,右侧喉返神经37例次,双侧喉返神经合计48例次,其中经气管食管沟径路显露喉返神经57例,占48.71%;经甲状腺下动脉径路显露48例,占41.03%;其余12例经甲状软骨下角径路显露,占10.26%。术后并发喉返神经暂时性麻痹3例,无喉返神经永久性损伤病例。结论〓腔镜甲状腺手术中显露喉返神经需掌握正确的解剖入路和技巧,遵循主动显露、严格保护的原则。     

甲状腺术中喉返神经的损伤和预防

喉返神经损伤是甲状腺术后严重的并发症之一,单侧损伤引起声音嘶哑、双侧损伤则导致呼吸困难,甚至发生危及生命的声门梗阻.分析甲状腺损伤的原因:喉返神经与甲状腺下动脉紧密复杂的关系、喉返神经存在分支及分支的变异、喉不返神经、以及甲状腺Zuckerkandl结节的存在等解剖因素造成其易损伤;喉返神经本身的脆弱性造成其易损;未能合理使用能量手术器械造成神经的热损伤.预防喉返神经损伤可从以下方面努力:在甲状腺术中解剖显露喉返神经,使其“可视化”;术中精细化解剖喉返神经,解剖程度适中;掌握能量器械的性能,安全使用能量器械以减少神经的热损伤;合理使用术中神经监测,使用连续性神经监测,有助于降低喉返神经损伤的风险.     

Zuckerkandl’s tubercle of the thyroid gland in association with pressure symptoms: a coincidence or consequence?

Background : The Zuckerkandl’s tubercle (ZT) of the thyroid gland is a well‐described anatomical landmark, but few studies have clearly defined its association with pressure symptoms. Methods : Sixty‐six consecutive patients who had primary thyroid surgery were prospectively included in the present study between late January and early August 1998. Results : A total of 96 capsular dissections were performed at thyroid surgery. Grades two and three ZT were recognized in 77 (80.2%) dissections. In general 49 (63.6%) of them were associated with significant pressure symptoms. In 43 (87.8%) of the dissections with pressure symptoms, grade 3 ZT was observed (mean weight of goitre: 154.8 g). Interestingly in this group, 16 (37.2%) patients with pressure symptoms had a goitre that was < 100 g and in one patient it was only 21 g. Conclusions : The pressure symptom of the thyroid gland does not always appear to be due to the large size of the goitre. In a relatively small‐size goitre the ZT may cause significant pressure symptoms. Observations in the present study supported a strong association of enlarged ZT with pressure symptoms. We believe this is unlikely to be simply a coincidence but rather a consequence of the enlarged tubercle. Nonetheless a prospective randomized study is called for to allow meaningful and objective evidence to be drawn.     

Recurrent laryngeal nerve in thyroid surgery: a critical appraisal

Background: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures. Methods: A total of 325 patients were accrued in this prospective non‐randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results. Results: Two hundred and seventy‐six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10?84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non‐recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%). Conclusions: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.     

Zuckerkandl's tubercle of the thyroid gland in association with pressure symptoms: a coincidence or consequence?

BACKGROUND: The Zuckerkandl's tubercle (ZT) of the thyroid gland is a well-described anatomical landmark, but few studies have clearly defined its association with pressure symptoms. METHODS: Sixty-six consecutive patients who had primary thyroid surgery were prospectively included in the present study between late January and early August 1998. RESULTS: A total of 96 capsular dissections were performed at thyroid surgery. Grades two and three ZT were recognized in 77 (80.2%) dissections. In general 49 (63.6%) of them were associated with significant pressure symptoms. In 43 (87.8%) of the dissections with pressure symptoms, grade 3 ZT was observed (mean weight of goitre: 154.8 g). Interestingly in this group, 16 (37.2%) patients with pressure symptoms had a goitre that was < 100 g and in one patient it was only 21 g. CONCLUSIONS: The pressure symptom of the thyroid gland does not always appear to be due to the large size of the goitre. In a relatively small-size goitre the ZT may cause significant pressure symptoms. Observations in the present study supported a strong association of enlarged ZT with pressure symptoms. We believe this is unlikely to be simply a coincidence but rather a consequence of the enlarged tubercle. Nonetheless a prospective randomized study is called for to allow meaningful and objective evidence to be drawn.     

Prevertebral soft tissue measurements in thyroid enlargement: the value of lateral neck radiographs

BACKGROUND: Measurement of prevertebral soft tissue is commonly used to assess prevertebral abnormalities, such as retropharyngeal abscess or injury to the cervical spine. In the presence of goitres, the widened prevertebral tissue seen on plain lateral neck radiograph may be diagnostic of an enlarged tubercle of Zuckerkandl (ZT), which may be responsible for most pressure symptoms. The aim of this study was to substantiate the value of plain lateral neck radiographs in preoperative demonstration of enlarged ZT. METHODS: Fifty patients who underwent thyroid surgery between June and December 2000 were included in this prospective, non-randomized study. Measurements of prevertebral soft tissue were taken at C4, C5 and C6, and were correlated with the weight of goitres and the grades of changes in the ZTs. RESULTS: Of patients, 44% had large goitres weighing more than 100 g; 52% of ZTs were classified as grade 3. Of the large ZTs, 82% were associated with large goitres and, of these, 88% were associated with significant pressure symptoms. Prevertebral measurements were abnormal, particularly at C4, C5 and C6. The most promising predictor of the presence of an enlarged ZT is the measurement taken at C4 (p<0.05). The ratio of the prevertebral space to the vertebral body (PVS/VB) in grade 3 ZT was also increased at C4, C5 and C6. However, these ratios were not statistically significant. A measurement of prevertebral soft tissue, particularly at C4, greater than 16.5 mm correlates 100% with an enlarged grade 3 ZT. CONCLUSIONS: The results of this study support the concept that the plain radiograph shows significant widening of the lateral neck in the presence of an enlarged ZT. Plain lateral radiography is a simple procedure that could provide valuable information for preoperative assessment of an enlarged ZT, particularly in patients with large goitres who have significant pressure symptoms.     

Relationship Between Zuckerkandl's Tubercle and the Inferior Laryngeal Nerve Including the Laryngeal Branches

PURPOSE: Zuckerkandl's tubercle (ZT) is the most posterior extension of the lateral lobes of the thyroid gland in the area of the ligament of Berry. We investigated the relationship between ZT and the inferior laryngeal nerve (ILN), including the laryngeal branches. METHODS: We examined 40 specimens (80 sides) from 24 male and 16 female cadavers aged between 40 and 89 years at the time of death. The ZTs were graded according to Pelizzo as grade 0, unrecognizable; grade 1, only a thickening of the lateral lobe; grade 2, smaller than 1 cm; or grade 3, larger than 1 cm. RESULTS: First, we classified ZT into three groups according to its location, and then we investigated the relationship between ZT and the ILN, including the laryngeal branches. Zuckerkandl's tubercle was located in the middle third of the thyroid gland in 46 of 52 sides defined as grade 2 or 3. We observed that some of the tubercles passed over the ILN, some passed over the laryngeal branches, and some passed over only the anterior laryngeal branch. ZT also indicated the ILN or only the anterior laryngeal branch. CONCLUSIONS: Zuckerkandl's tubercle indicated or passed over the ILN and the laryngeal branches. These findings suggest that an identifiable ZT could be used as a landmark to expose the ILN and the laryngeal branches.     

The Zuckerkandl tubercle

Identification and preservation of the recurrent laryngeal nerve is a major concern during thyroidectomies. The Zuckerkandl tubercle is an anatomic landmark that can be used for this purpose. It is generally found in 63% to 80% of patients undergoing thyroidectomy and is located between the superior and inferior lobes and points toward the tracheoesophageal groove. It is classified into three grades according to size: I <.5 cm, II .5 to 1 cm, III >1 cm. A grade III tubercle, present in 45% of patients, is sometimes associated with significant pressure symptoms in otherwise small-sized goiters.     

Reliable surgical landmarks for the identification of the recurrent laryngeal nerve.

OBJECTIVE: To obtain reliable landmarks for identification of the recurrent laryngeal nerve in human larynges. STUDY DESIGN AND SETTING: This is a prospective study, analyzing the laryngeal anatomic features. Structures easily palpable on the thyroid and cricoid cartilage (ie, the most prominent portion of the inferior cornu of the thyroid cartilage [IC], the inferior tubercle of the thyroid cartilage [ITT] and the most anterior portion of the arch of the cricoid cartilage [AC]) were accepted as landmarks and the distances of these structures to the entrance point of the RLN on the medial aspect of the inferior pharyngeal constrictor muscle (cross point [CP]) were measured in 65 adult autopsies. RESULTS: When a straight line is drawn 11 to 12 millimeters (mm) from the IC, 22 to 24 mm from the ITT, and 26 to 28 mm from the AC, the point at which they intersect indicates the point at which the RLN enters the medial side of the inferior pharyngeal constrictor muscle (ICM) and is easy to locate at this point. All of the RLN were seen to lie posterolateral to the Berry ligament. Thirty-eight of 65 cases possessed extralaryngeal bifurcation of the RLN. CONCLUSION: With such constant mathematic values, these 3 landmarks are reliable markers for identification of RLN. This study is important in the fact that it states constant mathematic values regarding surgical landmarks used to expose the RLN.     

Zuckerkandl结节的研究进展

Zuckerkandl结节是甲状腺腺体自身突起而形成的结节,近年来逐渐引起解剖学者与外科医师的重视.临床上行甲状腺手术时为了避免伤及喉返神经及其分支与上甲状旁腺,外科医师常需要借助于特定解剖学标志,如甲状软骨下角、甲状腺下动脉、甲状腺下极、气管食管沟和甲状腺悬韧带等,这些特定解剖学标志有以下共同的特点:(1)标志本身位...     

Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation

Extralaryngeal bifurcation and trifurcation of the recurrent laryngeal nerve (RLN) is not well described in anatomical texts. This significant anatomical variation is important because prevention of vocal cord paralysis requires preservation of all branches of the RLN. The aim of this study was to examine the prevalence of extralaryngeal bifurcation of the RLN seen during thyroid/parathyroid surgeries. All patients undergoing total thyroidectomy, hemithyroidectomy and parathyroidectomy (excluding all minimally invasive procedures) carried out by a single endocrine surgeon from November 2003 to December 2004 were included. Operative data obtained prospectively included the location of the nerve, number of branches and the distance in millimetres from the inferior border of the cricothyroid to the point of bifurcation. A total of 213 (right = 114, left = 99) RLN in 137 patients were studied. Seventy-seven (36%) nerves bifurcated or trifurcated before entry into the larynx. Bifurcations were more common on the right (43%) than on the left (28%) (P = 0.05). Trifurcations were seen in eight nerves, seven on the right and one on the left (P = 0.05). Bilaterally branched RLN were observed in 14 (18%) of 77 patients undergoing a bilateral procedure. One non-RLN was identified on the right. The median distance from the cricothyroid to the point of division was 18 mm on the right and 13 mm on the left. Extralaryngeal division of the RLN is a common anatomical variant occurring more frequently on the right. Unseen branches of the RLN are at risk of injury during surgery. Therefore, great care is required following presumed identification of the RLN to ensure that there are no other unidentified branches.     

甲状腺手术区喉返神经及其分支的应用解剖研究

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）喉返神经分支按其分布范围可分为喉支和喉外支,前者在入喉前多分为前支、后支。（2）87.0%的喉返神经分支呈树枝状,称树枝型（多支型）;13.0%喉返神经分支与分支或分支与交感神经链间吻合成袢状,称喉返神经袢。（3）59.8%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（10.1±7.2）?mm;8.5%的分支发出部位与甲状腺下极相平齐;31.7%在其平面以下,与之距离为（8.6±5.5）mm。（4）右喉返神经50.0%在甲状腺下动脉之前,22.0%在其之后,14.0%在动脉分支之间穿过,14.0%神经分支与动脉分支相互夹持;左喉返神经56.0%在动脉之后,14.0%在其之前,16.0%在动脉分支之间穿过,14.0%神经分支与动脉分支相互夹持。　结论　在甲状腺手术中,结扎甲状腺下动脉前,应仔细分离、单独结扎该动脉,以免损伤喉返神经和（或）其分支。