非返性喉返神经的解剖特点及术中损伤的预防

Anatomical Character and Intraoperative Prevention of Non-Recurrent Laryngeal Nerve

目的研究非返性喉返神经(non-recurrent laryngeal nerve,NRLN)的解剖学特点和变异,探讨甲状腺手术中发现NRLN的方法和总结预防其损伤的经验。方法对北京协和医院于2007年1月至2012年6月期间行单侧或双侧甲状腺腺叶全切手术的2 211例患者的资料进行回顾性分析,同时对国内文献报道的114例NRLN患者的资料进行分析。结果北京协和医院2 211例甲状腺手术中暴露喉返神经3 479条,11条确认为右侧NRLN(0.32%,11/3 479),其中Ⅰ型3例,ⅡA型7例,ⅡB型1例;1例为同时伴有返支和非返支的喉返神经,余10例均为完全型;手术中均未发生神经损伤。文献报道的114例NRLN占报道病例总数的0.14%～4%;其中右侧NRLN 109例,Ⅰ型4例(3.7%,4/109),ⅡA型75例(68.8%,75/109),ⅡB型9例(8.3%,9/109),分型不详21例(19.3%,21/109),同时伴有喉返神经返支3例(2.8%,3/109);左侧NRLN 5例,ⅡA型2例,分型不详3例,其中1例同时伴有喉返神经返支。论著或病例报道的104例患者中,手术导致NRLN麻痹共16例(15.4%,16/104),其中Ⅰ型1例,ⅡA型9例,分型不详6例。结论 NRLN少见,主要发生在右侧,术中易损伤,主要损伤类型为ⅡA型;外科医生应充分认识NRLN及其变异类型,预防其损伤。

Objective To investigate the anatomical character and variation of non-recurrent laryngeal nerve（NRLN）,and to explore measurement to identify and prevent injury of this nerve during thyroidectomy.Methods Clinical data of 2 211 patients who underwent thyroidectomy from Jan.2007 to Jun.2012 in Peking Union Medical College Hospital were analyzed retrospectively,and 114 patients with NRLN of related literature reviews were analyzed too.Results There were 3 479 recurrent laryngeal nerve（2 211 cases） which were exposed during thyroid operation in Peking Union Medical College Hospital,of which 11 cases were confirmed to be right NRLN（0.32%,11/3 479）.Of the 11 cases,3 cases were typeⅠ,7 cases were typeⅡA,and 1 case was typeⅡB,one case was also found to have a recurrent branch.None of them injured during operation.One hundred and fourteen cases of NRLN（0.14%-4%） were found in literature reviews.Of the 114 cases,109 cases were confirmed to be right NRLN,of which 4 cases were typeⅠ（3.7%,4/109）,75 cases were typeⅡA（68.8%,75/109）,9 cases were typeⅡB（8.3%,9/109）,21 cases were unclear（19.3%,21/109）,3 cases were also found to have a recurrent branch（2.8%,3/109）.Five cases were confirmed to be left NRLN,of which 2 cases were typeⅡA,3 cases were unclear,1 case was also found to have a recurrent branch.Of all the 104 cases reported by treatises and case reports,16 cases injured during operation,of which 1 case was typeⅠ,9 cases were typeⅡA,6 cases were unclear.Conclusions NRLN,which is a rare anomaly,usually happens on the right,and very vulnerable during thyroid surgery.The most usually injured type is typeⅡA.Fully acknowledgment of the NRLN and its variant types is very helpful to avoid damage during thyroid surgery.