腔镜甲状腺手术的研究进展

<正>自1997年Hüscher等[1]率先施行腔镜甲状腺腺叶切除术并获得成功以来,腔镜甲状腺手术的发展已经历了17个春秋。期间,腔镜技术的迅猛发展不断推动甲状腺领域外科技术的进步,各种新术式层出不穷,经历了颈部入路[2]、颈前小切口腔镜辅助入路[3]、锁骨下入路[4]、腋窝入路[5]、腋窝乳晕入路[6]、胸乳入路[6]、完全乳晕入路[7]、耳后入路[8]、经口入路等,逐渐实现从颈前皮肤小切口,颈外皮肤     

锁骨下小切口经胸锁乳突肌颈前肌间隙腔镜辅助甲状腺部分切除术15例报告

目的探讨锁骨下小切口经胸锁乳突肌颈前肌间隙入路腔镜辅助甲状腺部分切除的方法和效果。方法15例单侧甲状腺良性结节，锁骨下小切口2-3cm，经胸锁乳突肌颈前肌间隙入路，腔镜辅助下行甲状腺部分切除。结果15例均获成功，手术时间40—80min，平均50min。术中出血10～50ml，平均20ml，无并发症。术后3-4d出院。15例随访1～12个月，平均7个月，无复发。结论经锁骨下小切口胸锁乳突肌颈前肌间隙入路腔镜辅助甲状腺部分切除手术损伤小，出血少，并发症发生率低，安全，术后恢复快。     

经口腔前庭内镜下甲状腺切除术(附5例报告)

目的:总结经口腔前庭入路行内镜甲状腺切除术的手术价值及治疗体会。方法:回顾分析2015年9月至2016年12月为5例甲状腺良性病变患者采用经口腔前庭入路行内镜下甲状腺切除术的临床资料。结果:5例患者均完成手术,4例行单侧甲状腺部分切除术,1例行单侧甲状腺大部分切除术,手术时间95~126 min,平均(120.3±36.5)min;术中出血量15~35 ml,平均(25.5±11.5)ml,术后住院3~6 d,平均(3.9±1.4)d。术后切口下少量积液1例,无术区感染、神经及甲状旁腺损伤等并发症发生。结论:经口腔前庭内镜下甲状腺切除术具有较好的美容效果,前期内镜下甲状腺切除经验是保证手术成功的前提。     

腔镜下甲状腺切除术36例报告

目的探讨经乳晕入路腔镜甲状腺切除术中出血和喉返神经损伤的原因和预防经验。方法2006年1月～2008年1月,采用经乳晕入路行腔镜甲状腺切除术36例。两乳头间偏右侧及左右乳晕上缘分别做穿刺口,在颈外丝线缝扎悬吊颈前肌群,充分显露甲状腺,超声刀由下极向上极行甲状腺腺瘤切除或甲状腺次全切除。结果36例均在腔镜下完成手术,无中转开放手术。手术时间50～180min,平均105min;术中出血量20～150ml,平均30ml。行甲状腺肿瘤切除12例,单侧甲状腺次全切除22例,双侧甲状腺大部分切除2例。术后出现脂肪液化1例,皮下气肿1例,无神经或甲状旁腺损伤等并发症。术后24～72h拔除引流管。术后住院3～7d,平均4d。术后病理诊断：甲状腺腺瘤7例,结节性甲状腺肿29例。36例随访3～24个月,平均12个月,感觉胸前明显不适3例,持续约3～7个月逐渐好转,美容效果满意,均未发现局部肿瘤复发。结论经乳晕入路腔镜甲状腺手术近期疗效及美容效果满意。熟悉镜下解剖和操作技巧,能有效避免神经、血管损伤等严重并发症发生。     

腔镜下甲状腺切除术的现状

甲状腺疾病是一种以年轻女性为多见的疾病,传统的外科手术需要在颈前留下一条难看的手术瘢痕。1997年Huscher等[1]开创的腔镜下甲状腺切除术(endoscopic thyroidectomy,ETE),利用腔镜手术图像放大和远距离操作的特点不但使手术更精细,而且将手术切口微小化并隐藏起来,达到颈部无手术瘢痕的美观效果。从2002年到现在的6年时间,国内约有250家医院的普通外科和头颈外科已经开展了近万例ETE。ETE的手术入路主要有乳晕乳沟入路、颈前小切口腔镜辅助、腋窝乳晕入路、腋窝入路、锁骨下途径和颈部入路等。颈部入路方法是将腹腔镜手术方法应用到…     

腋窝双乳晕入路与胸乳入路腔镜甲状腺切除术的对比研究

目的:研究经腋窝双乳晕入路腔镜甲状腺切除术治疗甲状腺良性结节的有效性及安全性。方法:将60例需手术治疗的良性甲状腺结节女性患者随机分为两组,30例经腋窝双乳晕入路行甲状腺切除术(实验组),30例经胸乳入路行甲状腺切除术(对照组),观察两组手术时间、术中出血量、术后引流量、术后引流时间、术后住院时间、住院费用、美容满意度、并发症等指标。结果:两组手术时间、出血量、术后引流量、术后引流时间、术后住院时间、住院费用、并发症发生率等差异无统计学意义(P>0.05);实验组美容满意度[(4.76±0.51)分]高于对照组[(4.11±0.57)分](P<0.05)。结论:经腋窝双乳晕入路与胸乳入路腔镜甲状腺切除术具有相同的有效性与安全性,但经腋窝双乳晕入路具有更好的美容效果。     

经胸骨前入路腔镜甲状腺手术临床分析

目的:探讨经胸骨前入路行腔镜甲状腺手术的方法、适应证及安全性.方法:回顾分析为22例甲状腺疾病患者经胸骨前入路行腔镜甲状腺手术的临床资料.结果:21例成功完成手术,其中腺瘤摘除术4例,单侧腺叶次全切除术12例,双侧腺叶次全切除术5例,1例甲状腺癌中转开放手术,行双侧甲状腺全切除及颈淋巴结廓清术.手术时间70～170mi...     

经腋乳入路腔镜在甲状腺外科手术的应用

目的：探讨经腋乳入路腔镜甲状腺手术的方法、技巧及美学效果。 方法：回顾性分析2010年3月—2011年12月经腋乳入路行腔镜甲状腺手术39例患者的临床资料。其中甲状腺瘤16例，结节性甲状腺肿18例，原发性甲状腺机能亢进2例，甲状腺乳头状癌3例。行单侧甲状腺部分切除术12例，单侧甲状腺次全切除8例，双侧甲状腺次全切除16例，单侧甲状腺全切除+第VI组淋巴结切除+对侧甲状腺次全切除术3例。 结果：手术过程均顺利，手术时间为65~98 min，术中出血量20~90 mL，无中转开放手术，术后无声嘶或甲状旁腺损伤等并发症发生。住院时间5~7 d。术后随访6~21个月，无复发病例。 结论：经腋乳入路腔镜甲状腺手术是安全可行的，且具有良好的美学效果。     

经腋窝入路与经胸乳入路腔镜单侧甲状腺叶切除的对比研究

目的:对比分析经腋窝入路与胸乳入路腔镜单侧甲状腺叶切除术的临床效果。方法:回顾分析21例经腋窝入路腔镜甲状腺叶切除、25例经胸乳入路腔镜甲状腺叶切除患者的临床资料,对比分析两组手术时间、术中出血量、术后引流量、住院时间、并发症、切口满意度等指标。结果:经腋窝入路手术时间[(129.0±17.91)min]较胸乳入路[(142.0±22.75)min]短,术后引流量[(61.0±43.84)ml]较胸乳入路[(94.0±59.46)ml]少,术后患者对切口满意度较胸乳入路高,差异均有统计学意义(P<0.05);两组术中出血量、术后住院时间、并发症发生率差异无统计学意义。结论:经腋窝入路在处理单侧甲状腺叶疾病方面优于胸乳入路,美容效果较好,两种入路的并发症发生率差异无统计学意义,值得临床推广应用。     

腔镜甲状腺手术在甲状腺癌的应用探讨

腔镜甲状腺切除术首先由Huscher等[1]于1997年报道,由于该手术方法比传统的手术方法有明显的优点,如手术图像放大、局部图像清楚、用超声刀切割甲状腺组织和甲状腺血管无出血、喉返神经损伤机会减少、裸露的颈前区不会留下难看的手术瘢痕等而深受患者特别是年轻女患者的欢迎,经过8年的发展,目前手术方法有乳晕乳沟入路、腋窝入路、腋窝乳晕入路、锁骨下途径入路、颈前小切口的腔镜辅助手术和颈部入路等手术方法,手术适应证仍然在不断探索中,当然手术适应证范围和术者的经验和手术熟练程度是有直接关系的,目前手术的范围包括结节性甲状腺肿…     

Postauricular and Axillary Approach Endoscopic Neck Surgery: A New Technique

Background  While the bilateral axillo-breast approach (BABA) to endoscopic neck surgery resolves various benign and malignant thyroid and parathyroid diseases with minimal adverse effects and excellent cosmetic outcomes, it involves circumareolar incisions. Many patients, especially young female patients, are reluctant to have their breast involved. Consequently, we developed the postauricular and axillary approach (PAA) that uses postauricular incisions. Methods  From June 2006 to December 2007, we treated 10 patients with PAA endoscopic neck surgery. After subcutaneous infiltration with diluted epinephrine solution, the subplatysmal and subcutaneous spaces were dissected. Two axillary ports and two postauricular ports were used and low-pressure CO₂ insufflation generated operative space. After dividing the midline between the strap muscles, the isthmus was divided and the thyroid lobe was dissected with ultrasonic shears and excised after careful identification of the recurrent laryngeal nerve and parathyroid glands. Malignant lesions were treated with contralateral thyroid lobectomy. For parathyroid adenomas, we performed parathyroidectomy after dividing the strap muscles in the midline. Results  Two thyroid lobectomies, one parathyroidectomy, one subtotal thyroidectomy, and six total thyroidectomies were performed by PAA endoscopic neck surgery. The mean operation time was 210.0 ± 43.7 min. There were no cases of conversion to open surgery, permanent vocal cord palsy, or facial nerve palsy. None of the thyroidectomy patients exhibited hypocalcemia. The cosmetic outcomes were excellent and all patients were satisfied. Conclusions  PAA endoscopic neck surgery is a feasible method for thyroid and parathyroid surgery that permits good operative visualization and has minimal adverse effects and excellent cosmetic outcomes.     

Initial experience with a gasless unilateral axillo-breast or axillary approach endoscopic thyroidectomy for papillary thyroid microcarcinoma: comparison with conventional open thyroidectomy

The efficacy of various endoscopic thyroidectomy has not been determined for papillary thyroid microcarcinoma (PTMC). We compared 31 consecutive patients with PTMC who underwent endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach, and the 36 PTMC patients who underwent conventional open thyroid lobectomy from August 2005 to December 2008. There were more female patients (P=0.004) in the endoscopic group, and the mean age of endoscopic group was younger than that of the open thyroidectomy group (P=0.006). The entire endoscopic thyroidectomy was successfully completed in all the patients. The operative time was longer for those undergoing endoscopic thyroidectomy (P<0.001). The complication rate did not differ between the 2 groups. The cosmetic satisfaction, as evaluated by questionnaire, was greater in the endoscopic group (P<0.001). Endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach for selected cases of PTMC is a feasible, safe, and cosmetically superior procedure.     

Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison with Conventional Open Thyroidectomy

Background Endoscopic techniques have recently been applied to thyroid surgery. We developed the bilateral axillo-breast (BAB) approach for total thyroidectomy. The aims of this study were to evaluate the completeness of this approach for total thyroidectomy and to compare complications between endoscopic thyroidectomy and conventional open thyroidectomy. Methods We analyzed 198 patients who underwent open thyroidectomy and 103 patients who underwent endoscopic thyroidectomy for papillary thyroid microcarcinoma between January 2003 and June 2006 at Seoul National University Hospital. The postoperative thyroglobulin (TG) level was used to assess the completeness of the two methods. Complications such as hypocalcemia or vocal cord palsy were also evaluated. Results The mean hospitalization period was 3.18 days following open thyroidectomy and 3.04 days after endoscopic thyroidectomy. The 3-month postoperative TG levels were <1.0 ng/ml in 90.4% of patients after open total thyroidectomy and in 88.9% following endoscopic total thyroidectomy. Transient hypocalcemia occurred in 17.7% and 25.2% of patients, respectively. Permanent hypocalcemia occurred in 4.5% and 1.0% of patients, respectively. Permanent vocal cord palsy frequencies were 0.5% and 0%, respectively. There were no significant differences in postoperative TG levels, hypocalcemia, or permanent vocal cord palsy. Transient vocal cord palsy occurred in 2.5% of patients after open thyroidectomy and in 25.2% after endoscopic thyroidectomy (p < 0.0001), but it disappeared within 3 months. Cosmetic results were excellent after endoscopic thyroidectomy. Conclusions The bilateral axillo-breast (BAB) approach for endoscopic thyroidectomy shows insignificant postoperative complications, except transient vocal cord palsy, as well as good cosmetic results. It is also a feasible method for total thyroidectomy. Therefore, the BAB approach for endoscopic total thyroidectomy can be the surgical treatment of choice for selected cases of thyroid cancer.     

Increasing the Size Limit of Benign Thyroid Lesions Resectable by Endoscopic Thyroidectomy via a Unilateral Axillo-breast Approach Without Gas Insufflation

Background  

Endoscopic thyroidectomy is rarely attempted in patients with large goitrous lesions. We examined the feasibility and safety of endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for resection of large thyroid tumors (≥4 cm).     

Tiroidectomía sin incisión cervical por abordaje endoscópico biaxilo-biareolar. Primeras impresiones tras su introducción en una unidad especializada. Revisión de la literatura

Introduction

The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature.

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??Analysis of superior thyroid pole through the cervical strap muscles approach??A clinical analysis of 55 patients WANG Chao, ZHANG Song-tao, ZHAI Yi-fei, et al. Department of Thyroid??Head and Neck Surgery, Tumor Hospital Affiliated to Zhengzhou University; Henan Cancer Hospital??Zhengzhou 450000, China
Corresponding author: QIN Jian-wu, E-mail??qinjianwu62@163.com
Abstract Objective To investigate the feasibility and advantages of treatment of the superior thyroid pediclevia the cervical strap muscles approach. Methods The clinical data of 55 patients undergoing thyroidectomy in Henan Cancer Hospital fromApril 2016 toOctober 2016 were reviewedretrospectively. External branch of the superior laryngeal nerve ??EBSLN?? should be exposed viacervical strap muscles approach. Finally?? 55 patients with 86 lobectomies were identified. Results The identification rate of EBSLN was 96.5% ??83/86??. All the patients had no voice impairment due to EBSLN injury.No permanent hypoparathyroidism occurred in all patients.Conclusion Via the natural space between the anterior cervical muscles?? the superior thyroid pedicle can be exposed completely??which will greatly improve the safety of surgery.     

Endoscopic thyroidectomy via bilateral axillo-breast approach (BABA): review of 512 cases in a single institute

Background

Various techniques for endoscopic thyroidectomy have been introduced in the past decade, and the cosmetic superiority of these techniques has been universally acknowledged. We developed the endoscopic thyroidectomy via bilateral axillo-breast approach (BABA) and have performed more than 500 operations. The aims of this study are to analyze the surgical outcomes and to evaluate the effectiveness and safety of BABA endoscopic thyroidectomy.

Patients and methods

Between February 2004 and March 2008, 512 patients with thyroid diseases underwent BABA endoscopic thyroidectomy. The criteria analyzed were clinicopathologic characteristics, types of operation, operation time, tumor–node–metastasis (TNM) stage on the basis of the 7th edition of the American Joint Committee on Cancer (AJCC), results after radioactive ablation therapy, and recurrence of disease in these patients.

Results

Of 512 patients, 397 had a malignant tumor and 115 had benign thyroid disease. Eight patients were diagnosed with Graves’ disease, and nine patients underwent completion thyroidectomy. Three cases were subjected to open thyroidectomy due to uncontrolled bleeding. Mean operation time was 151.2?±?38.1?min for total and near-total thyroidectomy, and 141.7?±?50.1?min for subtotal thyroidectomy and lobectomy. Regarding postoperative complications, transient hypocalcemia occurred in 31.1% of patients and permanent hypoparathyroidism occurred in 4.2% of patients. Transient hoarseness occurred in 20.3% of patients, and permanent vocal cord palsy occurred in 1.7%. Mean hospital stay after operation was 3.34?±?0.8?days (range 3–7?days), and mean follow-up period was 57.1?±?17.6?months (range 38.5–71.7?months). There were eight cases of recurrent thyroid carcinoma, and no mortality has occurred up to the present time.

Conclusions

Endoscopic thyroidectomy via bilateral axillo-breast approach is a safe and effective method that gives good surgical completeness, a low rate of postoperative complications and recurrence, and an excellent cosmetic result. Therefore, this method is a good choice for patients with surgical thyroid diseases.     

腔镜辅助锁骨下途径甲状腺手术中喉返神经的显露及保护

目的：探讨腔镜甲状腺切除术中喉返神经的暴露和保护的可行性。方法2006年10月～2013年11月对46例甲状腺肿瘤采用免注气锁骨下途径腔镜手术,经锁骨下区向上沿颈阔肌深面分离至颈部,部分横断颈前肌群,暴露甲状腺后方喉返神经,完整切除肿瘤。结果46例腔镜下完成手术,手术时间（53．5±8．7）min,出血量（20．5±10．5）ml。46例暴露颈段喉返神经,未见变异的喉不返神经。术后2例出现声音嘶哑,营养神经治疗2周后痊愈。2例术中冰冻病理检查甲状腺乳头状癌合并颈部淋巴结转移,中转行淋巴结清扫;分别随访21、44个月,无肿瘤复发。44例行甲状腺次全切除术,术后病理：32例甲状腺腺瘤,12例结节性甲状腺肿,随访时间1～84个月,平均45．6月,术后每6个月复查彩超及甲状腺功能,均无肿瘤复发及甲状腺功能低下。结论腔镜下甲状腺肿瘤切除术暴露颈段喉返神经可行、安全。     

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??Application and evaluation of endoscopic technique in the surgical treatment of thyroid nodules FAN Lin-jun. Breast Disease Center, Southwest Hospital, the Third Military Medical University, Chongqing 400038, China Thyroid nodules are common in clinical practice. Majority of patients with thyroid nodules need surgical treatment in order to remove the focus or to acquire a final diagnosis. The postoperative cervical appearance could be improved with the application of endoscopic technique in thyroid surgery. With the improvement of the
operative technique, almost all types of thyroidectomy could be completed under endoscope. Endoscopic subtotal thyroidectomy is the most common method in the treatment of thyroid nodules. The common approaches of endoscope include video-assisted thyroidectomy via cervical small incision and total endoscope thyroidectomy via breast approach or axillary approach. Comparing with the total thyroidectomy, endoscopic near-total thyroidectomy for low risk differentiated thyroid carcinoma could get better safety, lower incidence of recurrent laryngeal nerve paralysis and the same therapeutic effect. But the clearance of cervical lymph nodes is still controversial. On account of its remarkably cosmetic advantages, endoscopic operation has become the preferred method for the treatment of thyroid nodules.     

Endoscopic Thyroidectomy Using a New Bilateral Axillo-Breast Approach

Introduction Endoscopic techniques have recently been applied in thyroid surgery using cervical, axillary, and breast approaches. We modified the axillo-bilateral breast approach (ABBA) and developed the bilateral axillo-breast approach (BABA) to obtain optimal visualization for total thyroidectomy. Methods We used two 12-mm ports through bilateral circumareolar incisions for flexible videoscopy and Harmonic scalpel and two 5-mm ports through both axillae for graspers and dissectors. Thyroidectomy was performed under full visualization of the superior and inferior thyroidal arteries, parathyroid glands, and recurrent laryngeal nerves. Results After performing 25 ABBA endoscopic thyroid surgeries, we developed BABA and performed 110 operations using this method. The BABA operations included 52 total thyroidectomies, 2 near-total thyroidectomies, 8 subtotal thyroidectomies, 43 lobectomies, and 3 subtotal lobectomies. Pathology revealed 41 benign lesions and 69 cancers. Mean operation time was 165.3 ± 43.5 minutes. There were 2 cases of conversion to open surgery, 1 due to cancer with capsular invasion and the other due to tracheal injury. Nine postoperative complications developed: transient unilateral vocal cord palsy in 4 cases, transient hypocalcemia in 4 cases, and postoperative infection in 1 case. The 2-month postoperative thyroglobulin level was less than 1 ng/ml in all examined cases of total thyroidectomy. Cosmetic results were excellent. Conclusions The BABA technique for endoscopic thyroid surgery is a feasible method of total thyroidectomy with a low rate of postoperative complications and, additionally, excellent cosmetic results. Therefore, in selected cases of thyroid cancer, the BABA endoscopic total thyroidectomy should be considered as a valid surgical option.