前胸壁径路腔镜甲状腺手术经验总结(附77例报告)

Experience in performing endoscopic thyroid surgery via the anterior chest wall approach:a report of 77 cases

目的：探讨前胸壁径路腔镜甲状腺手术的手术技巧和临床效果。方法：回顾分析2004年5月至2005年 8月我院行前胸壁径路、三孔法，术中不断离颈前肌的腔镜甲状腺手术病例的病理结果、手术时间、失血量及术后引 流量及喉返神经麻痹等情况。结果：本组病人共77例，男19例，女58例，平均年龄43． 1(22～66) 岁，甲状腺肿块平均 直径2． 3(0． 9～5． 0) cm，行单侧次全切除65例；部分切除3例；双侧甲状腺手术9例；暴露患侧喉返神经45例。平均手 术时间82． 4(35～230) min，术中失血量29． 2(14～68) ml，术后第1天的引流量84． 0(33～155) ml，术后第1天平均体 温37． 4(36． 2～38． 5) ℃，平均住院天数6． 7(3～11) d。病理结果：结节性甲状腺肿59例，腺瘤5例，甲状腺慢性炎症3 例，术中冷冻切片提示甲状腺乳头状癌5例，另有5例术后石蜡切片提示乳头状癌，其中3例术后1～2周内行传统 患侧全切除加对侧次全切除术；术后第1～2天发生声音嘶哑5例，观察随访2～6周后恢复正常发音。结论：前胸壁径 路腔镜甲状腺手术过程中，对肿块＜5． 0cm 的病例不需常规切断颈前肌；在行甲状腺次全及全切除时，应尽量暴露并 保护喉返神经，同时尽可能避免超声刀热力对喉返神经的损伤。对病灶较小的甲状腺乳头状癌，尤其是微灶癌的病 例行腔镜手术是可行的；但其远期临床疗效需进一步观察。

Objective To summarize the surgical skills and the clinical outcomes of endoscopic thyroid surgery via the anterior chest wall approach. Methods Seventy-seven cases of endoscopic thymidectomy via the anterior chest wall approach between May 2004 and Aug 2005 were retrospectively analyzed with respect to pathologic results, duration of operation, blood loss, postoperative drainage and recurrent laryngeal nerve palsy. Results The 77 cases （58 females, 19 males）, with a mean age of 43.1（22-66） years were included in this study. The mean diameter of the tumor was 2.3（0.9-5.0） cm. Sixty-five patients underwent hemithyroidectomy, 3 partial thyroidectomy, and the rest 9 bilateral intervention. In 45 cases, the recurrent laryngeal nerve was exposed. The mean operative time was 82.4（35-230） rain. The mean blood loss was 29.2（14-68） ml. The mean drainage within the first day after the operation was 84.0（33-155） ml. The highest postoperative body temperature was 37.4 （36.2-38.5）℃. The mean postoperative hospital stay was 6.7 （3-11）days. Pathologic data： nodular goitar in 59 cases, adenoma in 5 cases, chronic thyroiditis in 3 cases, papillary carcinoma indicated intraoperatively by frozen section in 5 cases and other 5 cases of papillary carcinoma confirmed postoperatively by paraffin section and 3 of them underwent the convetional total thyroidectomy of the lesion side ＋subtotal thyroidectomy of the opposite side in 1-2 weeks after the operation. The transient hoarseness occurred in 5 patients during the first and second day after the operation and recovered well 2-6 weeks later. Conclusions In the endosopic thyroid surgery via the anterior chest wall approach, the exposure of tumors less than 5.0 cm in diameter routinely requires no incision of the platysma. During the total thyroidectomy or subtotal thyroidectomy, the protection of the recurrent laryngeal nerve should be emphasized. It is important to avoid the usage of ultrasonically activated scalpels which are liable to produce too much heat noxious for the nearby the nerve. Moreover, It is safe to treat the papillary carcinoma （microcarcinoma） by endoscopic method.