以锁骨上窝特殊脂肪组织为标记指引无充气腋窝入路腔镜甲状腺手术的临床效果（附视频）

背景与目的 目前，无充气腋窝入路腔镜下甲状腺手术（GUA-ET）逐渐被广泛采用，但建腔因其分离皮瓣时存在损伤重要血管和神经的可能性而一直是该手术的重难点。笔者中心近年发现位于锁骨上窝的脂肪团（笔者将其命名为freedom脂肪，简称F脂肪）在GUA-ET手术中有示踪颈外静脉及属支、锁骨上神经和皮下神经分支的作用。因此，本文探讨以F脂肪为指引标记在GUA-ET手术中的临床应用价值。方法 回顾分析2022年5月—2022年12月在湖南省人民医院乳甲外科二病区接受GUA-ET手术的177例甲状腺乳头状癌患者的临床数据。其中，93例术中采用F脂肪作为指引标记（观察组），84例术中未采用F脂肪指引标记（对照组），比较两组患者的初始建腔时间、建腔出血例数、中转开放以及皮肤烧灼伤等并发症的发生率。结果 两组患者的性别与年龄差异均无统计学意义（均P>0.05）。观察组患者GUA-ET手术初始建腔时间明显少于对照组［（12.84±2.218）min vs.（30.49±5.871）min，P<0.05］；观察组建腔过程中出血4例（4.3%），对照组6例（7.1%），差异无统计学意义（P>0.05）；观察组未发生术中出血转开放及皮肤烧灼伤等并发症，对照组发生术中出血转开放与皮肤烧灼伤各1例，但差异均无统计学意义（均P>0.05）。结论 以F脂肪为标记指引GUA-ET手术可避免因保护颈外静脉及其属支等结构而进行的分离与暴露，从而有效缩短初始建腔时间，并可能减少并发症的发生，建议临床推广应用。

Clinical efficacy of endoscopic gasless axillary approach thyroidectomy using distinctive fat tissue in the supraclavicular fossa as a landmark guidance (with video)

Background and Aims Currently, the gasless unilateral axillary approach endoscopic thyroidectomy (GUA-ET) is gradually gaining widespread adoption. However, the creation of the working space has consistently been a challenge in this operation due to the potential risk of damaging crucial blood vessels and nerves during subcutaneous dissection. Our center recently discovered a fat pad located in the supraclavicular fossa (referred to as freedom fat by the authors, abbreviated as F fat) that can be used for tracing the external jugular vein and its tributaries, supraclavicular nerves, and subcutaneous nerve branches during GUA-ET surgery. This study was conducted to determine the clinical application value of using F fat as a guide marker in GUA-ET surgery.Methods The clinical data of 177 patients with papillary thyroid carcinoma who underwent GUA-ET surgery in the Second Ward of the Department of Breast and Thyroid Surgery of Hunan Provincial People''s Hospital from May 2022 to December 2022 were retrospectively analyzed. Among them, the F fat was used as a guide marker during surgery in 93 cases (observation group), and was not used during surgery in 84 cases (control group). A comparison was made between the two groups in terms of time for creation of the initial working space, number of cases of bleeding during space creation, rates of conversion to open surgery, and the incidence of complications such as skin burns.Results There were no statistically significant differences in sex and age between the two groups (both P>0.05). The time for the creation of the initial working space in the observation group was significantly shorter than that in the control group (12.84±2.218) min vs. (30.49±5.871) min, P<0.05]. During the creation of the working space, there were 4 cases of bleeding in the observation group (4.3%) and 6 cases in the control group (7.1%), with no statistically significant difference (P>0.05). No conversion to open surgery required due to intraoperative bleeding and no complications such as skin burns occurred in the observation group, while there were 1 case each of open conversion due to intraoperative bleeding and skin burns in the control group, but the differences were not statistically significant (both P>0.05).Conclusion Using F fat as a landmark to guide GUA-ET surgery can avoid the need of dissection and exposure for protecting structures such as the external jugular vein and its tributaries. This effectively shortens the time for the creation of the initial working space and may also reduce the occurrence of complications. So, it is recommended to be commonly used in clinical practice.