经胸乳入路的内镜甲状腺切除术500例

Endoscopic thyroidectomy via chest and breasts approach with 500 cases

目的探讨经胸乳入路内镜甲状腺手术的技术方法、安全性和优缺点。方法2002年3月至2006年12月行胸乳入路内镜甲状腺切除术500例,其中原发性甲状腺机能亢进76例、甲状腺腺瘤111例、结节性甲状腺肿291例(10例有1～2次开放手术史)和甲状腺癌22例。结果成功完成手术492例。手术时间74.5(40～270)min,术中失血3～250 ml(平均5.5 ml),均未输血。术后2～3d拔除引流管。术后住院时间3～8d(平均4.2d),住院费用为7600～13 500元,平均10 510元,本院同期开放甲状腺手术患者住院费用平均为5700元,两者差异比较有统计学意义(t=13.755,P<0.05=0.000)。手术方式包括甲状腺肿瘤切除50例、甲状腺单叶次全切除210例,双叶次全切除212例(含原发性甲状腺机能亢进症手术治疗73例);22例甲状腺癌中,单叶腺体次全切除4例,根治性切除16例。甲状腺肿块长径最大8.0 cm。术后并发症方面,术后手术通道出血3例,皮肤灼伤1例,切口感染2例,皮肤淤血3例,皮下积液6例,1例出现甲亢危象,暂时生喉返神经麻痹2例,无神经或甲状旁腺永久性损伤等严重并发症,并发症发生率为3.5%(17/492)。术后随访,失访42例,358例随访3～57个月(平均27个月),3例结节性甲状腺肿术后复发小结节,1例原发性甲状腺机能亢进症术后复发。患者均对手术的美容效果满意。8例因为出血、腺体过大、甲状腺癌侵犯气管等原因中转为开放手术。22例甲状腺癌目前仍生存,1例甲状腺乳头状癌术后半年出现同侧颈淋巴转移,行开放颈清扫术后已无瘤生存至今3年,并继续随访。结论经胸乳入路内镜甲状腺切除术是一种安全而可行的手术方法,手术视野清晰,显露神经清楚,且具有显著的美容效果。此外,该方法仍有一定的并发症发生率,且费用较开放手术高。因此,本方法仍存在有待改进的地方。

Objective To discuss the method,the safety,the advantages and disadvantages of endoscopic thyroidectomy via chest and breasts.Methods From Mar.2002 to Dec.2006,Endoscopic thyroidectomy via anterior chest and breast approach was performed in 500 patients,including 74 cases of Grave＇s disease（1 case has an opened operation history）,111 cases of thyroid adenoma,293 cases of nodular goiter（10 cases have 1～2opened thyroidectomy history,2 cases secondary of hyperthyroidism）,and 22 cases of thyroid carcinoma.Results The endoscopic thyroidectomy was successfully carried out in 492 cases,including tumor dissection in 50 cases,one lobe partial thyroidectomy in 214 cases,subtotal thyroidectomy in 212 cases（including 73 cases of Graves＇ disease）,and radical thyroidectomy in 16 cases of thyroid carcinoma.The operative time length ranged from 40 to 270 min（mean 74.5 min）.Mean operative blood loss was 5.5（3～250）ml,no cases underwent blood transfusion.The drawing tube was pulled out during 2 to 3 days postoperation.Postoperative hospital stay ranged from 3 to 8 days（mean 4.2 days）.There were some compllications such as subcutaneous bleeding（3 cases,one case need a reoperation by endoscopic）,burn of the aderma（1 case）,inflammation of the incision（2 cases）,subcutaneous bruising（3 cases）,subcutaneous effusion（6 cases）,and temporarily damage of the recurrent laryngeal of 2 cases.There were no complications such as damage to recurrent laryngeal nerve or parathyroid glands.The complication rate is 3.5%.The hospital charges ranged from 7600 to 13 500 yuan（mean 10 510 yuan,the mean hospital charges of open thyroidecotmy patiens of the same term is 6700 yuan）.The post-operative following-up for 3 to 57 months indicated that all the patients were satisfied with the cosmetic results and the same curative effects as conventional surgery were obtained.However,3 cases of nodular goiter,1 case of thyroid carcinoma,and 1 case of Grave＇s disease were recurrented.The operations were converted into open surgery in 8 cases.The 22 carcinoma cases are still living.Conclusions Endoscopic thyroidectomy is a safe and effective method of thyroid surgery.Since all the minimal incisions are on concealed parts of the body,the obvious cosmetic effect of this method is guaranteed.Some disadvantages such as complications and more high costs are needed to be overcome.