完全经口内镜下甲状腺切除术的解剖学研究

Surgical anatomy of totally traMs-oral video-assisted thyroidectomy

目的确定经口路径的解剖通路、层次和相关的神经、血管结构，为舌下联合口腔前庭的完全经口内镜下甲状腺切除提供一个安全可行的经口入路。方法2009年11月至2011年5月，在25具固定标本上，行颈前部、下颌骨表面、口底解剖，确定经口路径的解剖通路、层次和相关的神经、血管结构。在20具冰冻新鲜标本上，模拟经口内镜甲状腺切除术，术后解剖标本，观察有无神经、血管的损伤。结果内镜通道为自舌下中线处开口，经颏舌骨肌、下颌舌骨肌、二腹肌前腹，至颈阔肌下。操作通道为口腔前庭处，第一磨牙根部纵行矢状切口，于面动脉、面静脉、面神经下颌缘支深面，颏神经外侧，紧贴下颌骨骨膜面，进入颈阔肌下。颏神经与下颌骨正中线的距离为（25．8±0．9）mm，颏神经与面动脉的距离为（29．4±0．9）mm。20例模拟手术，术后解剖观察，无神经、血管和口底肌的损伤。完全经口内镜通路中，可切除的甲状腺长径达50mm。结论舌下联合口腔前庭的完全经口入路具有解剖学的可行性，可安全到达甲状腺区并完成甲状腺的切除。

Objective To define the anatomical approach, anatomical planes and related vessels and nerves to create a safe and reproducible combined sublingual and bi-vestibular access for traMs-oral video-assisted thyroidectomy. Methods From November 2009 to May 2011, twenty-five embalmed human specimens were dissected for anatomical information of the cervical region, the mandible region and the supra-hyoid muscles. On twenty fresh frozen human specimens after an experimental traMs-oral endoscopic thyroidectomy, the related vascular, neural structures and muscles were evaluated. Results The optical access port was placed in the midline sublingual. The geniohyoid muscle, mylohyoid muscle and the anterior belly of the digastric muscle were divided in the midline in order to reach the plane under the platysma muscle. The mucosa was sagittal incised bilaterally in the vestibular of oral cavity for working trocar, at the level of the first molar of the mandible. The working trocar reached directly the periosteum of the mandible, under the facial vessel and the marginal branch of facial nerve, and then passed below the platysma muscle into the infra-laryngeal working area. The distance from mental nerve to mandibular midline and between mental nerve and facial artery were （25.8 ± 0. 9 ） mm and （ 29.4 ± 0. 9 ） mm respectively. Anatomical dissections showed that after an experimental traMs-oral combined sublingual and hi-vestibular access, all muscles of the floor of the oral cavity as well as the related vascular and neural structures are intact. The maximum nodule size of the resected specimens in the totally traMs-oral approach was up to 50 mm. Conclusion The combined sublingual and bi-vestibular access of traMs-oral video-assisted thyroidectomy is safe and reproducible.