前胸壁人路内镜甲状腺手术——7年临床经验总结

Endoscopic thyroid surgery via anterior chest wall approach--7 years experience

目的探讨前胸壁入路内镜甲状腺手术技巧和临床效果。方法回顾分析我院行前胸壁人路内镜甲状腺手术的病理结果、手术时间、并发症等。结果本组251例，肿块平均直径2．44cm，行单侧次全或全切除207例，部分切除9例，双侧手术35例。平均手术时间（85．7±37）min，平均住院6．22d。一过性喉返神经损伤6例，术后6周内自行恢复；一过性喉上神经损伤1例，2周后恢复；皮瓣下积液、血肿3例，穿刺抽吸后恢复；手术粘连致喉返神经牵拉声音嘶哑1例，手术松解粘连后恢复正常；术后永久性喉返神经损伤1例，系甲状腺癌浸润所致，手术修补神经后恢复正常发音。病理结果：结节性甲肿197例，腺瘤16例，甲状腺慢性炎11例，甲状腺癌27例（10例微小灶，其中乳头状癌8例，滤泡状癌2例）。均获随访，最长5年，未见复发。结论前胸壁入路内镜手术治疗甲状腺良性肿瘤安全可行，在处理甲状腺恶性肿瘤方面，微小灶癌的治疗亦属安全可行，术前发现颈部肿大淋巴结应是手术的反指征，但内镜甲状腺手术行中央组淋巴结清扫是可行的。手术不增加肿瘤细胞脱落种植风险。

Objective To sumarize the surgical skills and clinical outcomes of endoscopic thyroid surger- y via anterior chest wall approach. Methods The patients who received endoscopic thyroid surgery during 2003 May and 2009 December were analyzed retrospectively with respect to pathological results, operative time and complications, etc. Results 251 patients were included in this analysis, with a male to female ratio of 41：210 and an average age of 37.76 years old. The mean diameter of tumor was 2.44era. 207 patients received unilateral subtotal or total resection, 9 patients got partial resection, 35 patients underwent bilateral intervention. The mean operative duration was （ 85.7± 37 ） min and mean hospital stay was 6.22 days. Complications, 6 eases of transi- ent recurrent laryngeal nerve injuries were observed in our study, who then recovered in six weeks time with no extra intervention. One patient with superior laryngeal nerve injury was found, who recovered to normal function in 2 weeks time. Three cases of effusion and hematoma beneath skin flap were cured by pereutaneous aspiration. One patient＇s recurrent laryngeal nerve was excessively retracted because of postoperative adhesion, which re- quired an extra lysis operation to regain its normal function. One permanent recurrent laryngeal nerve injury was caused by invasion of thyroid carcinoma, a neural neoplasty was then carried out to help the patient get normal voice. Pathological results, 197 nodular goiters, 16 adenomas, 11 chronic thyroiditis, 27 thyroid carcinoma. 10 cases of the 27 thyroid carcinoma were mierocarcinoma, including 8 papillary carcinomas and 2 follicular carcino- mas, all those 10 cases were ended with only total resection of the lesion lobe. Another four patients of papillary carcinoma were converted to conventional modified radical operation, three of whom were concomitant with cervi- cal lymph node metastasis. 7 cases of papillary carcinoma received total endoscopic radical resection with central compartment lymph node dissection, one case had lymph node metastasis. Results of intraoperative frozen section were found to be misdaignostic in 6 patients by postoperative paraffin section, rescued conventional modified radi- cal resection was performed afterwards. All of those 6 were follicular carcinoma. The maximum following-up dura- tion lasted for 5 years, no recurrence was observed. Conclusions Endoscopic thyroidectomy is a safe and feasi- ble way to treat benign thyroid tumor. As for the malignancy, it＇s also safe to treat microcarcinoma. Although discovering enlarged cervical lymph nodes preoperatively could be a contraindication for the endoscopic procedure, it＇s still regarded as operable to carry out lymph dissection of central compartment.