无充气经腋窝入路全腔镜甲状腺手术质量控制与安全管理

2003年韩国首次开展无充气单侧腋窝入路腔镜甲状腺手术（GUA-ET）至今已有20年历史,这是一种美容且微创的甲状腺手术术式。由于切口藏于腋窝皮纹,无须切开颈部皮肤、颈阔肌和颈白线,保证了颈部皮肤、颈阔肌、胸骨甲状肌与颈白线的完整性,避免了颈部疤痕与吞咽联动等颈部并发症的发生,从而达到美容效果。另外,空间建立在锁骨下皮肤与胸大肌锁骨部之间、胸锁乳突肌锁骨部与胸骨部之间的自然筋膜间隙,不切断肌肉等正常组织结构,虽然看似远程手术,实则能达到微创目的。但是,因远程操作,手术器械与锁骨头区域形成的杠杆作用,自带吸引器在拉钩外等因素导致手术垂直空间缩小,甲状腺悬吊不理想引起喉返神经显露不清,从而出现中央区胸腺后方淋巴结或ⅥB区淋巴结清扫不彻底现象。同时,颈外静脉属支、锁骨上神经、颈血管鞘、甲状腺中静脉等结构是空间建立的必经之地,容易出现出血、神经损伤等并发症。而且,对侧手术、部分胸锁乳突肌锁骨部与胸骨部肌腱融合紧密等增加了手术难度。因此,基于上述因素,该术式的手术质量控制与手术安全也受到部分业界同行的质疑。不容置疑的是,自2017年郑传铭教授将此技术引进国内后,短短7年时间,该术式在国内众多医疗机构纷纷开展,受到众多从事甲状腺外科工作医师们的高度认可,并于2022年发布了这一领域的国内首部专家共识,让该术式的推广更具规范性和可操作性。可见,技术日趋成熟后,该术式的优点逐步显现,避免了传统颈部切口疤痕疙瘩、颈部联动的并发症,避免了经口术式可能导致的嘴唇周围麻木感,相较国内最成熟的胸乳入路,单侧Ⅵ区淋巴结清扫和喉返神经的显露与保护变得更容易。毫无疑问,严格掌控手术适应证,坚守“根治疾病第一,功能保护第二,兼顾美容第三”的肿瘤治疗原则,做好手术质量控制与安全管理,才能更加科学、规范地推广这一术式,甚至不断扩展这一术式在甲状腺外科的适应证。本文结合文献报道和笔者团队在设备改良、细节管理方面的经验,对该术式的质量控制与安全管理做一阐述。

Surgical quality control and safety management of complete endoscopic thyroidectomy via gasless axillary approach

Since the first endoscopic thyroidectomy by a gasless unilateral axillary approach (GUA-ET) conducted in South Korea in 2003, it has now been 20 years. This is a cosmetic and minimally invasive surgical procedure for thyroidectomy. Due to the incision hidden in the axillary skin lines, there is no need to cut the skin, platysma muscle, and neck white line, ensuring the integrity of the neck skin, platysma muscle, sternothyroid muscle, and neck midline. This avoids complications such as neck scars and swallowing dysfunction, thus achieving cosmetic effects. Additionally, the surgical space is established in the natural fascial gap between the skin under the clavicle and the clavicular part of the pectoralis major muscle, and between the clavicular part of the sternocleidomastoid muscle and the sternum, without cutting normal tissue structures such as muscles. Although it appears to be a remote surgery, it actually achieves the goal of minimally invasive surgery. However, due to remote operation, the leverage effect of surgical instruments in the clavicular head region, the internal suction device outside the retractor, and other factors lead to a reduction in the vertical space of the surgery. This results in less-than-ideal suspension of the thyroid, causing unclear exposure of the recurrent laryngeal nerve, and incomplete clearance of lymph nodes in the central region posterior to the thymus or VIB region. At the same time, structures such as the tributaries of the external jugular vein, supraclavicular nerve, carotid vascular sheath, and middle thyroid vein are necessary pathways for establishing space, making it prone to complications such as bleeding and nerve damage. Moreover, contralateral procedures and the close fusion of certain portions of the sternocleidomastoid muscle with the sternal tendon increase the surgical complexity. Therefore, based on the above factors, the surgical quality control and safety of this procedure have been questioned by some peers. Nevertheless, since Professor Zheng Chuanming introduced this technique to China in 2017, this procedure has been widely adopted by many domestic medical institutions within just 7 years. It has received high recognition from many physicians engaged in thyroid surgery, and in 2022, the first domestic expert consensus in this field was released, making the promotion of this procedure more standardized and feasible. It is evident that as the technique matures, the advantages of this procedure gradually become apparent. It avoids the complications such as the keloid scar in the neck and neck joint movement after traditional neck incision, and numbness around the lips after oral procedures. Compared to the most mature thoracic/breast approach in our country, the unilateral VI region lymph node dissection as well as exposure and protection of the recurrent laryngeal nerve become easier. Without a doubt, strict control of surgical indications, adherence to the principles of "cure the disease first, protect function second, and consider cosmetic appearance third" in tumor treatment, and effective control of surgical quality and safety management are necessary for the scientific and standardized promotion of this procedure. It may even lead to continuous expansion of the indications for this procedure in thyroid surgery. This article, combining literature reports and the experience in equipment improvement and detail management of the authors'' team, elaborates on the quality control and safety management of this procedure.