腔镜甲状腺切除术中喉返神经的显露

Exposure of the Recurrent Laryngeal Nerve during Endoscopic Thyroidectomy

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法 2011年4月～2012年4月,行胸乳晕入路腔镜下甲状腺切除术17例。于乳腺前皮下置入trocar,注入CO2(压力6 mm Hg)建立操作空间,用超声刀显露喉返神经。结果 17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术(6例双侧叶结节和1例甲状腺癌),5例行一侧甲状腺叶切除术(一侧腺叶多发结节),5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17.6%(3/17)、47.1%(8/17)和35.3%(6/17),术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。

Objective To explore the exposure techniques of recurrent laryngeal nerve （RLN） during thyroidectomy, in order to avoid iatrogenic injury of the recurrent laryngeal nerve caused by exposure. Methods endoscopic Endoscopic thyroidectomy was performed in 17 cases from April 2011 to April 2012. The subcutaneous space in the breast and the subplatysmal space in the neck were bluntly dissected through a 10-mm incision between the nipples, and COs was insufflated at 6 mm Hg to make the operative space. Three trocars were inserted at the breast, and dissection of the thyroid and division of the thyroid vessels and parenchyma were performed endoscopically by using an uhrasonical scalpel. The recurrent laryngeal nerve, the superior laryngeal nerve, and the parathyroid glands were preserved properly. Results Totally 17 RLNs were dissected. Of them, 7 patients received bilateral thyroid operation（including 6 cases of bilateral node and 1 case of throid cancer） , 5 lobectomy and 5 unilateral subtotal lobectomy. Neither transient nor permanent RLN injury occured. The nerve passed anterior to the artery was 17.6% （3/17） , posterior to it was 47. 1% （8/17）, and between the branches of the artery 35. 3% （6/17）. Conclusion Although the anatomical relationship between RLN and the inferior thyroid artery is variable, application of thyroid extracapsular anatomy and upturning technology may help expose recurrent laryngeal nerve while removing the gland, thus reducing the recurrent laryngeal nerve injury.