甲状腺疾病再次手术中喉返神经的显露与保护

目的探讨甲状腺疾病再次手术中喉返神经的显露与保护。方法回顾性分析214例甲状腺疾病再次手术的临床资料，问隔较近再次手术或甲状腺癌外侵的患者从带状肌外侧、胸锁乳突肌前缘入路，在上纵膈气管食管沟外侧区或入喉处显露喉返神经，伴淋巴结转移的患者从肿大淋巴结旁显露喉返神经；再次手术间隔时间较长、良性或肿瘤未外侵的甲状腺癌从颈前中线显露甲状腺，从甲状腺中静脉平面的侧后方或甲状腺下动脉区显露喉返神经。结果全组共解剖显露喉返神经344条（右侧188条，左侧156条），单侧显露84例，双侧显露130例。喉返神经入喉处显露44条，甲状腺中静脉平面的侧后方显露104条，甲状腺下动脉区显露40条，上纵膈气管食管沟外侧区124条，肿大淋巴结旁32条。其中首次手术于外院，术后当天即声音嘶哑的2例，入院再次手术时发现喉返神经在入喉处被缝线结扎。全组喉返神经分支损伤0．87％（3／344）。结论甲状腺再次手术时，熟悉并识别喉返神经正常、变异或病理状况下的解剖，避开粘连、疤痕组织，选择适当的解剖途径显露喉返神经，可降低术中喉返神经的损伤发生。

Exposure and protection of recurrent laryngeal nerve in the reoperation for thyroid diseases

Objective To investigate the exposure and protection of recurrent laryngeal nerve （RLN） in the reoperation for thyroid diseases. Methods Clinical data of 214 cases undergoing thyroid reoperation were retrospectively analyzed. The patients with a short interval between the 2 thyroid operations or with external-infiltrated thyroid cancer were approached at the lateral strap muscles and the leading edge of the sternocleidomastoid. RLNs were exposed in the lateral region of superior mediastinum tracheoesophageal groove or at the point where RLN enters to throat. RLNs of patients with lymph node metastasis were exposed beside the enlarged lymph nodes. The patients with a long interval between the 2 thyroid operations and with benign tumor or tumor without external infiltration were exposed their thyroids at the anterior midline and then RLNs were exposed at the posteri- or lateral of the middle thyroid veins or at the inferior thyroid artery. Results Among the 214 cases, 344 RLNs were anatomically exposed including 188 right and 156 left. 84 cases had single exposure and 130 eases had bilateral exposure. 44 RLNs were exposed at the point where RLN enters to throat, 104 RLNs at the posterior lateral of the middle thyroid veins, 40 RLNs at the inferior thyroid artery, 124 RLNs at the lateral region of superior mediastinum traeheoesophageal groove, and 32 RLNs beside the enlarged lymph nodes. For the 2 cases suffering hoarse voice the day after they underwent thyroid operation in other hospital, suture ligation at the the entrance point was found when they received the reoperation in our hospital. Three of the total 344 RLNs （0. 87% ） had RLN branch injury in the entire group. Condusion It is possible to reduce RLN injury during the reoperation for thyroid disease if surgeons are familiar with the dissection of RLN under normal or pathological condition, a- void adhesive or scar tissues, and select the appropriate anatomic approach.