腔镜下甲状腺切除术的解剖标志和手术径路

目的探讨腔镜下甲状腺切除术的解剖标志和手术解剖路径。方法腔镜下甲状腺切除术28例,其中经胸乳入路22例,腋窝入路6例,于腔镜下使用超声刀游离胸前区、颈前肌群,超声刀处理血管及腺体,完整瘤体摘除或腺叶切除。术中在基本视野条件下,于设定的6个分区内,找到可被确认的恒定或相对恒定解剖标志作为术中选择手术解剖径路的依据:腺叶中上区恒定解剖标志为甲状软骨上缘,相对恒定标志为舌骨峡部上缘;腺叶中下区恒定标志为气管侧壁和颈鞘,相对恒定标志为下动脉和最下动静脉分属支;中线中上区恒定标志为甲状软骨上缘,相对恒定标志为舌骨峡部上缘;中线中下区恒定标志为气管前壁,相对恒定标志为峡部下缘和最下动静脉;腺叶背外侧区恒定标志为颈鞘,相对恒定标志为血管属支进出腺体被膜处;腺叶背内侧区恒定标志为气管侧壁,相对恒定标志为环勺关节。结果 28例手术成功,其中1例因术中快速冰冻病理检查示甲状腺癌中转开放手术。本组手术时间平均80.0(50～125)min;术中平均出血46.7(10～120)ml,无相关手术并发症。结论通过镜下视野的分区观察,可以在各步操作过程中找到一些相应的区域性邻近解剖标志。仔细辨认并将其组合利用,可以有效地实现小腔室内操作时的方位控制,选择合适的手术径路,避免误伤,有利于手术安全顺利地实施。

The Anatomical Characteristics and Surgical Approaches of Endoscopic Thyroidectomy

Objective To further evaluate the anatomical characteristics and surgical approaches of endoscopic thyroidectomy.Methods 28 cases were treated by endoscopic thyroidectomy including trans-thoracic approach in 22 cases and trans-axillary approach in 6 cases.The procedure was dissociation the anterior area of the chest and the muscles of the anterior of the neck with the ultrasonic harmonic scalpel through the two roads,then handling the vessels and the glands,and finally enucleating the glands completely or partly.Under the basic vision of intraoperative conditions,some anatomical markers were used in order to provide basic surgical approaches.Results 28 operations were all succeeded,and 1 case was converted to open operation.The operation time was 50～125 minutes,mean 80.0 minutes.The intraoperative blood loss was 10～120ml,mean 46.7ml.Conclusions Endoscopic vision through the partition is help to location in the operation by the corresponding regional anatomical markers.The careful identification and its combination use,may realize effectively in the loculus operations for the azimuth control and chooses of the appropriate surgery path without iatrogenic injury.