经胸乳入路腔镜甲状腺切除的手术技巧

目的探讨经胸乳入路行腔镜下甲状腺切除的可行性与安全性并总结手术技巧。方法对我院2010年8月至2012年8月期间的40例经胸乳入路行腔镜下甲状腺切除患者的临床资料进行回顾性分析。结果40例患者均经胸乳入路完成腔镜下甲状腺切除,无中转开放病例,无大出血、高碳酸血症、严重皮下气肿及胸前皮肤坏死的病例。未发生永久性喉返神经损伤及永久性甲状旁腺功能低下。1例患者术后2 d出现声音嘶哑,对症处理后恢复正常。1例患者术后2d出现四肢末端麻木,予以静脉及口服补钙治疗3d后症状缓解。1例患者术后有颈胸部皮肤发紧不适感,1个月后自行缓解。手术时间（102±28.4）min（55～182min）,术中出血量为（46±16.6）mL（30～106mL）,术后引流管留置时间（4±2.2）d（2～7d）,术后住院时间（4±1.1）d（3～8 d）。术后平均随访13个月,无低钙、低甲状旁腺激素的病例,无声音嘶哑及局部甲状腺肿复发的病例;2例患者出现甲状腺功能低下,给予调整口服甲状腺素剂量后恢复正常。所有患者对美容效果满意。结论经胸乳入路行腔镜下甲状腺切除是安全、可行的,美容效果满意。＂Y＂形的穿刺隧道、＂上黄中白下红＂的胸前间隙分离和倒梯形的颈部间隙标志是建立操作空间的关键,而充分的暴露、循序渐进的操作顺序和寻准间隙锐钝结合的分离是腔镜下腺体切除的手术要点。

Operation Skill for Endoscopic Thyroidectomy Via Chest-Breast Approach

Objective To explore the feasibility and safety of endoscopic thyroidectomy via chest-breast approach and summarize the operation skill.Method The clinical data of 40 cases performed endoscopic thyroidectomy via chest-breast approach from August 2010 to August 2012 in this hospital were analyzed retrospectively.Results The endoscopic thyroidectomies via chest-breast approach were successfully performed in all 40 patients without conversion to open surgery,massive haemorrhage,hypercapnia,severe subcutaneous emphysema,cutaneous necrosis on chest, permanent impairment of recurrent laryngeal nerve,and permanent hypoparathyroidism.One case of hoarseness was found on 2？d after operation,who returned to normal after symptomatic treatment.One case of numbness in the extremities happened on day 2 after operation and the symptom was relieved through intravenous and oral administration of calcium treatment in 3？d.One case of cutaneous tightness on chest happened,and it was spontaneous remission in a month.The operation time was（102±28.4） min（55-182 min）,intraoperative bleeding was（46±16.6） mL（30-106 mL）,and the drainage tube was removed postoperative 2-7？d with an average（4±2.2） d,the postoperative hospitalization was 3-8 d with an average（4±1.1） d.All of the cases were followed-up after operation without low calcium,low parathyroid hormone,hoarseness,and local goiter recurrence.Two cases of hypoparathyroidism returned to normal after oral thyroxine dose adjustment.All the patients were satisfied with the cosmetic results.Conclusions The endoscopic thyroidectomy via chest-breast approach is safe and feasible with good cosmetic results.The subcutaneous Y tunnel,the ＂upper yellow middle white lower red＂ appearance on the chest,and the landmark of inverse trapezium on the neck are the key points for creation of operation compartment.Sufficient exposure,stepwise procedure,blunt dissection combined with sharp dissection in the precise gap are the surgical skills for endoscopic thyroidectomy.