基于解剖分析的梨状窝瘘微创手术方法探讨

目的　探讨儿童梨状窝瘘解剖学特征，比较在此基础上设计的改良手术方法与传统手术的疗效。 方法　回顾分析2012年7月~2018年7月诊断为梨状窝瘘的54例患儿，手术入路为甲状腺或外瘘口平面34例（传统组），手术入路为甲状软骨下角平面20例（改良组），研究改良组术中梨状窝瘘管解剖特点。比较两组手术切口长度、手术时间、术中出血量、住院时间、根治率，并发症发生率及术后复发率。 结果　梨状窝瘘管分为漏斗部和移行部，漏斗部固定位于甲状软骨下角后或侧方，瘘管走行有3种类型：终止于甲状腺上极、经甲状腺旁到达皮肤、直接到达皮肤形成外瘘口。改良组切口长度、手术时间、术中出血及住院时间、术后复发率均小于传统组（P＜0.01）。术后随访6~18月，传统组复发率29.4%，改良组未见复发。 结论　经甲状软骨下角入路的梨状窝瘘管切除术，具有手术路径短、瘘管易寻、术后恢复快，切口美观，复发率低等优点，是可以借鉴的一种梨状窝瘘根治手术方法。

Minimally invasive surgery for pyriform sinus fistula based on anatomical analysis

Objective　To investigate the anatomical characteristics of congenital piriform sinus fistula (PSF) in children, and design a minimally invasive surgical method. Method From July 2012 to July 2018, 54 cases of PSF were divided into two groups. In the traditional group the thyroid or external fistula plane approach was adopted in 34 patients, while in modified group the inferior horn of thyroid cartilage approach was adopted in 20 patients. The anatomical characteristics about PSF were then studied. The following data were compared and analyzed between the two groups: the incision length, surgical duration, intraoperative blood loss, hospitalization length, the rate of radical operation, complication and postoperative recurrence.　Results　Fistula was divided into infundibular and transitional parts. Infundibular was located behind or on the side of the posteroinferior cornu. Fistula had three types. Type I had terminal at the upper pole of the thyroid, Type II had terminal reaching the skin via the thyroid, and Type III had terminal reaching the skin directly. The incision length, surgical duration, intraoperative bleeding, hospitalization length and recurrence rate in the modified group were lower than those in the traditional group (P<0.01). After following-up of 6~18 months, the recurrence rate was 29.4% in the traditional group, but no recurrence was found in the modified group. Conclusion　Piriform fossa fistulectomy is performed through posteroinferior cornu with advantages such as short operation path, quick recovery, and low recurrence rate. It is a better choice in management of PSF owing to its safety and effectiveness.