目的探讨经峡部径路行甲状腺手术的优、缺点。方法回顾性总结分析近8年来我院收治的1 699例患者经峡部径路行甲状腺手术的临床资料。结果该术式术野暴露充分，手术时间平均65 min，术中出血量平均50 ｍl。术后喉返神经损伤8例(均为单侧)，68例术后出现短暂性低钙血症，3例术后出血，其中2例发生于术后2 h，出血量200 ml, 行手术止血； 1例发生于术后1 h，出血量100 ml，给予压迫止血和药物止血后，出血停止，余恢复均好。结论经峡部径路行甲状腺手术，能开阔术野和拓宽手术空间，能立即解除患者颈部紧缩感，保持术野清晰，减少术中出血和喉返神经损伤，减少低钙血症及继发性甲状腺功能低下，避免术后呼吸困难、窒息等并发症的发生。
Objective To understand anatomy of parathyroid gland and explore its application value in protection of parathyroid gland function during thyroidectomy. Methods The literatures, which were associated with the parathyroid anatomy and hypoparathyroidism were collected. The origin, function, anatomical location, number, blood supply, lymphatic system of the parathyroid gland and its relationship with surrounding tissues of parathyroid gland and its clinical significance in the thyroidectomy, were reviewed. Results The position of the superior parathyroid gland was relatively constant, and the inferior parathyroid gland was more likely to be ectopic. The number of the parathyroid gland was uncertain. The mainstream view was that the arterial supply of the parathyroid glands was mainly ensured by the inferior thyroid artery, a few by anastomosis of the superior and inferior thyroid arteries, or by the superior thyroid artery. However, the alternative view was that the blood supply of the parathyroid gland was not mainly derived from the inferior thyroid artery. The parathyroid gland was not easily distinguished from the adipose tissue and lymph node. Whether there was an independent lymphatic system in the parathyroid gland was still controversial. In the thyroidectomy, the parathyroid gland and its blood supply were reserved or protected by distinguishing from the Zuckerkandl tubercle, recurrent laryngeal nerve, and parathyroid specific attachment fat, which were identified by utilizing of the nanocarbon, loupe magnification, etc.. Especially in the central lymph neck dissection, the main thyroid artery trunk and its important branches should be carefully dissected or retained through the gentle capsular dissection and the correct use of energy devices for vessel sealing. The parathyroid gland in situ was reserved according to the parathyroid type. If it was not possible to be preserved, the parathyroid autotransplantation was necessary during the thyroidectomy. Conclusions Understanding origin and location of parathyroid gland, it could provide a direction for searching parathyroid gland during thyroidectomy. Being familiar with blood supply of parathyroid gland makes it possible to protect blood vessel and preserve parathyroid gland. Gentle capsular dissection, rational use of energy device, and indocyanine green angiography seem to be more important. Number of parathyroid gland allows us to treat each parathyroid gland as the last one, if it is not preserved in situ , parathyroid gland need to be autografted to avoid hypoparathyroidism.
ObjectiveTo discuss clinical significance of total endoscopic thyroidectomy (TET) via chest-breast approach. MethodsThe clinical data of 890 patients with thyroid diseases from September 2008 to September 2015 in this hospital were analyzed retrospectively. These patients were divided into TET group (received TET, n=420) and traditional group (received traditional thyroidectomy, n=470). The data of operation and postoperative recovery were compared between these two groups. ResultsThere was no significant difference between the TET group and the traditional group in the operation time [(73.571 4±28.533 9) min versus (70.212 8±27.199 8) min, t=1.80, P=0.072 7], bleeding volume [(30.714 3±14.225 1) mL versus (29.106 4±13.559 1) mL, t=1.73, P=0.084 8], postoperative drainage [(60.000 0±27.287 9) mL versus (56.595 7±27.803 5) mL, t=1.84, P=0.066 2], postoperative hospitalization time [(5.333 3±1.085 1) d versus (5.446 8± 1.089 0) d, t=1.55, P=0.120 4], postoperative 24 h pain score [(5.333 3±2.308 7) points versus (5.404 3±2.182 1) points, t=0.47, P=0.637 8] and postoperative injury rate of recurrent laryngeal nerve [0.714 2% (3/420) versus 0.851 1% (4/470), x2=0.053 2, P=0.817 6] and hypoparathyroidism rate [0.476 2% (2/420) versus 0.851 1% (4/470), x2=0.465 5, P=0.495 1]. The score of aesthetic effect of incision on day 7 after operation in the TET group was significantly higher than that in the traditional group [(7.809 5±1.296 9) points versus (3.361 7±1.391 8) points, t=49.14, P < 0.000 1]. ConclusionTET is safe and effective, and could improve cosmetic effect for patients with thyroid diseases.
目的 探讨经胸骨前径路内镜甲状腺手术的方法及其临床效果。 方法 采用经胸骨前径路内镜甲状腺手术治疗24例甲状腺良性肿瘤患者，并进行定期随访。 结果 23例手术顺利完成，1例因术中快速冰冻病理诊断为乳头状甲状腺癌而追加常规甲状腺癌根治术。平均手术时间为150 min，术中平均出血量30 ml。2例出现皮下气肿，4例出现胸部皮肤麻木。无喉返神经及甲状旁腺损伤,无术后出血、甲状腺危象等并发症出现。随访1~6个月，所有患者对美容效果非常满意，无近期肿瘤复发者。 结论 经胸骨前径路内镜甲状腺手术是一种美容效果较好的手术方法，手术操作空间的建立和术中控制出血是该术式的两大关键技术。
【Abstract】ObjectiveTo discuss how to identify and protect the parathyroid glands (PTGs) and their blood supplies during thyroidectomy. MethodsProtective measure of PTGs and their blood supplies were observed during the operation by eyes, as well as the occurrence of hypoparathyroidism after operation. Patients with syndrome of hypocalcaemia were given calcium and vitamin D3 supplementation until the serum calcium became normal. ResultsThere was no PTG found in 13 cases (13/259), 242 superior PTGs were found which were almost consistently (91.32%) located in the back sides of the thyroid glands and on the level of inferior edge of the thyroid cartilage. The blood supplies of 61 superior PTGs were often (68.85%) from the upper branch of inferior thyroid artery (ITA). Total 426 inferior PTGs were found, and the locations of which were more variable. Approximately 49.77% were located in the inferior 1/3 part of the back sides of the thyroids， 24.88% were positioned immediately to the inferior thyroid, where the ITA branches inserted into the thyroid. The blood supplies of 128 inferior PTGs were also mostly (80.47%) from the inferior branches of ITA system. There was no permanent hypoparathyroidism occurred and hypocalcemia after operation was happened to 27 patients, in which one patient of reoperation was underwent unilateral thyroidectomy, 3 patients were underwent unilateral thyroidectomy and contralateral subtotal thyroidectomy, 4 patients were underwent total thyroidectomy, 7 patients were underwent total thyroidectomy plus bilateral central neck dissection, 11 patients were underwent total thyroidectomy plus unilateral neck dissection, and one patient was underwent total thyroidectomy plus bilateral neck dissection. ConclusionThe blood supplies of PTGs are associated with their locations. The PTGs can be exposed and protected by eyes during operation. To prevent postoperative hypoparathyroidism, the PTGs should be protected in situ through meticulous dissection without
ObjectiveTo evaluate the safety and efficacy of gasless endoscopic thyroidectomy via transaxillary approach in treating papillary thyroid cancer (PTC). MethodsThe patients who underwent gasless endoscopic thyroidectomy (Abbreviated as the “endoscopic group”) and neck open surgery (Abbreviated as the “open group”), in the Zhejiang Provincial People’s Hospital from January 2018 to June 2023, were collected. The intraoperative and postoperative outcomes of the patients in the two groups were compared after propensity score matching (PSM). Statistical analysis was conducted using SPSS 26.0 software, with a test level of α=0.05. ResultsAfter PSM, there were 409 patients in the endoscopic group and 421 patients in the open group. There were no statistically significant differences in the baseline data between the two groups (P>0.05), except for tumor location, vascular invasion, intraglandular dissemination, and preoperative levels of total triiodothyronine and thyroid hormone (P<0.05). Compared with the open group, the patients in the endoscopic group had less intraoperative blood loss (P<0.05), higher points of incision satisfaction and cosmetic effect (P<0.05), but the number of lymph nodes dissected was less (P<0.05) and the operation time was longer (P<0.05) in the endoscopic group. The incidence of postoperative overall complications had no statistically significant difference between the endoscopic group and open group (3.6% versus 5.8%, P=0.127). There was no statistically significant difference in the recurrence rate between the endoscopic group and open group within one year of follow-up (0.2% versus 0.5%, P=0.099). ConclusionsFrom the results of this study, the gasless endoscopic thyroidectomy is safety and reliability in treatment of PTC. It can achieve the same effect as traditional open thyroidectomy. However, it can also be seen that young female patients are more willing to choose gasless endoscopic thyroidectomy as long as their condition permits (such as early tumor stage, low invasiveness).
Objective To compare the therapeutic effects between endoscopic thyroidectomy by anterior chest approach and modified Miccoli thyroidectomy. Methods Sixty patients with thyroid goiter were performed endoscopic thyroidectomy by anterior chest approach (endoscopic thyroidectomy by anterior chest approach group, n=30) and modified Miccoli thyroidectomy (modified Miccoli group, n=30) respectively. The operative time, the drainage volume, cosmetic benefit, the postoperative hospitalization time, the expenses of hospitalization and postoperative complications of two groups were compared. Results The operative time and the drainage volume after operation of endoscopic thyoidectomy by anterior chest approach group were significantly more than modified Miccoli group 〔(99.9±23.4) min vs. (74.0±29.6) min; (68.6±8.7) ml vs. (40.9±6.1) ml, respectively〕, Plt;0.05. The cosmetic benefit score of endoscopic thyoidectomy by anterior chest approach group was higher than that of modified Miccoli group 〔(4.7±0.2) points vs. (3.7±0.1) points〕, Plt;0.05. The postoperative hospitalization time and expenses of hospitalization were no significant differences between the two groups 〔(6.5±1.7) d vs. (5.5±0.9) d; (9 328.3±1 107.1) yuan vs. (8 568.2±1 032.3) yuan, respectively〕, Pgt;0.05. One case had transient hoarseness in 2 groups respectively, no other complications happened. Conclusions Modified Miccoli operation is both minimally invasive and cosmetic, but endoscopic thyroidectomy by anterior chest approach has better cosmetic benefit, which can release patients’ psychological trauma. The patients with specific cosmetic demand may choose endoscopic thyroidectomy by anterior chest approach.
【摘要】目的探讨经乳晕入路腔镜甲状腺手术的可行性。方法回顾分析2007年12月2009年4 月采用经乳晕入路行腔镜甲状腺手术15例临床资料。结果术后患者均痊愈出院。手术时间90～200 min,平均135 min;术中出血20～60 mL,平均32 mL；均未出现喉返神经及甲状旁腺损伤等并发症;术后平均住院5 d。随访6 ～ 20个月,均无复发,患者对伤口满意。结论经乳晕入路腔镜甲状腺手术,安全可靠、并发症少、美容效果好、住院时间短,有应用前景。
目的 探讨甲状腺手术方式和喉返神经损伤（RLN）的关系。 方法 回顾性分析2009年1月至2012年6月期间于笔者所在医院科室接受开放性甲状腺手术的985例患者的临床资料，探讨甲状腺手术方式和RLN损伤的关系。 结果 本组患者术后发生RLN损伤26例（2.6%），未发生RLN损伤959例（97.4%）。logistic回归分析结果显示，年龄、性别、超声刀应用、麻醉方式及肿块良恶性与RLN损伤均无关（P＞0.05），而手术范围（OR=3.726，P=0.007）和显露RLN（OR=0.302，P=0.006）则是RLN损伤的影响因素，行扩大性手术及未显露RLN者的RLN损伤率较高。 结论 在开放性甲状腺手术中，手术范围以及显露RLN是RLN损伤的独立影响因素，术中显露并注意保护RLN，对避免RLN损伤具有重要意义。