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。

Experience of Exposure of Recurrent Laryngeal Nerve during Infraclavicular Approach Endoscopic Thyroidectomy

Objective To evaluate the feasibility and the safety of exposuring the recurrent laryngeal nerve during infraclavicular approach endoscopic thyroidectomy with gasless method . Methods We retrospectively analysed 46 patients from October 2006 to November 2013, who underwent gasless endoscopic thyroidectomy via infraclavicular approach .After the dissection of the platysma muscle by way of the infraclavicular region , we resected part of the anterior cervical muscles and exposed the recurrent laryngeal nerve behind the thyroid .Then tumors were removed completely . Results All of the 46 cases were successfully operated under endoscopic approach .The average time of operation was （53.5 ±8.7） min and intraoperative blood loss was （20.5 ±10.5） ml. The cervical segment of recurrent laryngeal nerve was exposed satisfactorily , without finding variations of the nerve .Two cases suffered temporary hoarseness and rapidly recovered after neurotrophic treatment for 2 weeks.Two patients were identified as having thyroid papillary carcinoma and matastasis during the operation , who were converted to open surgery for lymph node dissection .The 2 patients were followed up for 21 and 44 months, respectively, with no recurrence of the tumor .The pathological reports showed that 32 out of 44 cases were thyroid adenoma, 12 were nodular goiter.During follow-up visits for 1-84 months （mean, 45.6 months）, the patients received ultrasonic and thyroid hormone examinations .None of the patients suffered from tumor recurrence or hypothyroidism . Conclusion It is safe and reliable to expose the cervical segment of recurrent laryngeal nerve during infraclavicular approach endoscopic thyroidectomy with gasless method .