应用高频超声刀实施小切口无气腔室内镜下甲状腺手术

Using ultrasonically activated scalpels as major instrument for vessel dividing and bleeding control in minimally invasive video-assisted thyroidectomy

目的 探讨小切口无气腔室内镜下甲状腺手术的血管离断和出、渗血控制的新方法。方法 以Miccoli术式为基本框架 ,选择高频超声刀作为基本器械 ,辅以少数其他器械 ,双械配合操作 ,对 170例初诊为结节性甲状腺肿 ,甲状腺瘤和Graves病患者行此种内镜下手术。术中按自行设计的顺序式游离 凝闭 切断方法直接离断各较粗动、静脉分、属支 ;按预凝闭和切 吸 凝 分交替配合方法综合控制腺体分离过程中内断面出血。对这 2种方法的安全性和有效性进行观察。 结果 170例患者除 2例因术中冰冻报告为癌中转开放手术外 ,其余手术均顺利完成 ,无一例因术中出血失控或术后创口内出血再改为开放手术。按顺序式游离 凝闭 切断方法操作 ,可以用高频超声刀直接离断较粗大的甲状腺动、静脉血管分、属支 ,而不必结扎或用血管夹处理血管断端。切开前先用超声刀对切口附近血管及局部被膜血管网做适当的凝闭处理 ,可以显著减少切开分离时的出血量。 结论高频超声刀是一种适用于内镜下甲状腺手术的新型外科工具 ,不仅能显著提高手术安全性 。

Objective To establish new techniques on the control of vessel dividing and bleeding in minimally invasive video assisted thyroid surgeries. Methods One hundred and seventy volunteer patients with nodular goiter, adenoma and Graves′ disease consecutively received the endoscopic thyroid operation according to Miccoli′s mode from April 2002 to June 2003. The approach was designed to use ultrasonically activated scalpels [Harmonic Scalpel(R),Johnson & Johnson,USA] as a major, suction dissector or others as supplementary instruments during the whole process. During the operations, two methods,“sequenced dissect coagulate cut” and “pre coagulation + interlaced cut suck coagulate dissect”, were employed and separately evaluated for their safety or efficacy. Results All of the procedures, except that 2 (their lesions were proven to be “cancer” by frozen section and need different treatment), were successfully completed. None of them were interrupted and converted to open surgery due to uncontrolling bleeding or severe postoperative hematoma. Branches of major thyroid vessels can be directly divided by ultrasonic scalpel without ligation or using hemoclips, supposing the technique of “sequenced dissect coagulate cut” method was strictly used. Bleeding during intra gland dissection can be effectively controlled by the combined techniques of precoagulation of the vessels and the capsule vessel network near and around the incision, and then, by coordinating manipulation with a special multiple functional ultrasonic scalpel and a suction dissector, supposing the technique of “interlaced cut suck coagulate dissect” was properly employed. Conclusions Using ultrasonic scalpels as major, suction dissector or others as supplementary instruments, manipulating cooperatively during the whole process, can be an ideal fashion in the site of a narrow gasless working space via a small single incision in anterio inferior neck. And this may dramatically simplify the manipulation, and hence greatly reduce the operative difficulty. The reforms resolved two key technique problems in Miccoli′s endoscopic operation: vessel dividing and bleeding control, therefore, laying a sound basis for the clinical application of this special approach.