胸锁乳突肌缝线定位联合肌间隙注水分离在经腋窝无充气腔镜甲状腺手术中的应用

背景与目的 目前较为常用的腔镜甲状腺手术入路主要有经腋窝入路、经胸乳入路及经口入路等。经腋窝入路相较于其他术式，其利用颈部肌肉的自然间隙建腔，在颈前带状肌深面显露甲状腺并进行手术操作，对颈部功能影响较小，而且无需充CO₂，对心脑血管影响较小，因此近年来越来越被临床医生所接受。经腋窝入路腔镜甲状腺手术中寻找胸锁乳突肌肌间隙是该术式的一大难点，在此步骤中较多初学者不能准确定位肌间隙，进而增加了手术时间及创伤。为此，笔者中心对经腋窝无充气腔镜甲状腺手术作了一定的改进，降低术中寻找肌间隙的难度。本研究对该改良术式的近期疗效与安全性进行评估，为其在临床中的应用提供依据。方法 回顾性分析2023年1月—2023年5月江苏省宿迁市第一人民医院甲乳外科收治的46例甲状腺癌患者的临床资料。其中，23例接受改良经腋窝入路免充气腔镜下甲状腺手术（观察组），另23例接受常规经腋窝入路免充气腔镜下甲状腺手术（对照组）。观察组患者术前超声引导下在胸锁乳突肌胸骨部与锁骨部之间的间隙内注水分离，扩大肌间隙，然后缝线定位胸锁乳突肌胸骨部后缘，准确进入肌间隙后，按照常规经腋窝入路腔镜甲状腺手术方法实施手术。结果 两组患者一般资料无明显差异（均P>0.05），具有可比性。观察组平均手术时间明显短于对照组（65.6 min vs. 87.2 min，P<0.05），而两组的术中出血量、术后引流量、中央区清扫淋巴结数及住院时间差异均无统计学意义（均P>0.05）。观察组有1例出现腋窝皮下血肿，经抽液、包扎后改善，余患者均无呼吸困难、声音嘶哑、手足麻木、饮水呛咳等并发症发生。术后3个月，两组患者颈部疼痛评分及颈部损伤指数、吞咽障碍指数比较，差异均无统计学意义（均P>0.05）。所有患者术后均口服左旋甲状腺素钠片行个体化促甲状腺激素（TSH）抑制治疗，随访期间无患者出现复发转移。结论 术前行超声引导下胸锁乳突肌缝线定位联合肌间隙注水分离操作方便、实用，便于术中寻找肌间隙，降低了经腋窝无充气腔镜甲状腺手术整体手术难度，具有较好的临床应用价值。

Application of sternocleidomastoid muscle suture positioning plus muscle space water injection separation in gasless axillary endoscopic thyroidectomy

Background and Aims Currently, the commonly used endoscopic thyroidectomy approaches include the axillary approach, transthoracic breast approach, and transoral approach. Compared with other approaches, the axillary approach creates a natural space between neck muscles. It exposes the thyroid gland in the deep surface of the anterior cervical banded muscle to operate, which minimizes the impact on neck function and avoids the need for CO₂ insufflation, thus reducing the cardiovascular and cerebrovascular effects. Therefore, the axillary approach has been increasingly accepted by surgeons in recent years. However, finding the sternocleidomastoid muscle space is a major challenge in the axillary approach to endoscopic thyroidectomy. Many beginners cannot accurately locate the muscle space in this step, leading to increased surgical time and trauma. In response, our center has made certain improvements to gasless axillary endoscopic thyroidectomy to reduce difficulty finding muscle space during surgery. This study evaluated this modified approach''s short-term efficacy and safety to provide a basis for its clinical application.Methods The clinical data of 46 patients with thyroid cancer treated in the Department of Thyroid and Breast Surgery, Suqian First People''s Hospital, from January 2023 to May 2023, were retrospectively analyzed. Among them, 23 patients underwent improved gasless endoscopic thyroidectomy via the axillary approach (observation group), while the other 23 patients underwent conventional gasless endoscopic thyroidectomy via the axillary approach (control group). In patients in the observation group before surgery, saline was injected into the space between the sternal and clavicular attachments of the sternocleidomastoid muscle under ultrasound guidance to separate and expand the muscle space. Then, the posterior edge of the sternocleidomastoid muscle at the sternal part was sutured for positioning. After accurate entry into the muscle space, the operation was performed according to the conventional axillary approach endoscopic thyroidectomy method.Results The two groups had no significant differences in general data (all P>0.05), indicating comparability. The average operative time in the observation group was significantly shorter than that in the control group (65.6 min vs. 87.2 min, P<0.05). At the same time, there were no significant differences in intraoperative blood loss, postoperative drainage volume, number of central lymph nodes removed, and length of hospital stay between the two groups (all P>0.05). One patient in the observation group developed a subcutaneous hematoma in the axilla, which was resolved by aspiration and compression. There were no complications, such as difficulty breathing, hoarseness, numbness in the limbs, or coughing while drinking in the remaining patients. Three months after surgery, the two groups had no significant differences in neck pain score, neck injury index, and swallowing disorder index (all P>0.05). After surgery, all patients received individualized thyroid-stimulating hormone (TSH) suppression therapy with oral levothyroxine sodium tablets. During the follow-up period, none of the patients experienced recurrence or metastasis.Conclusion Preoperative ultrasound-guided suture positioning of the sternocleidomastoid muscle combined with saline injection to separate the muscle space is convenient and practical, facilitating the identification of the muscle space during surgery. This approach reduces the surgical difficulty of gasless endoscopic thyroidectomy via the axillary approach and has good clinical application value.