甲状腺疾病再次手术喉返神经解剖入路探讨：附55例报道

Anatomic approaches of the recurrent laryngeal nerve in reoperative thyroidectomy： 55 clinical cases reporter

目的 探讨甲状腺再次手术喉返神经的解剖入路方法.方法 回顾性分析55例因甲状腺疾病再次手术患者的临床资料.结果 55例甲状腺再次手术患者,甲状腺良性疾病术后接受再次手术16例,甲状腺癌术后接受再次手术39例.其中接受第3次手术4例,均为甲状腺癌术后.手术采用气管插管全身麻醉,原手术切口适度延长、正中入路游离皮瓣,横断手术侧舌骨下肌群,充分显露手术视野,再以气管、残余甲状腺组织、甲状软骨下角及颈总动脉作为解剖喉返神经入路标志进行解剖喉返神经,5例术中辅助应用喉返神经探测仪.其中,以气管、残余甲状腺为标志,由内向外解剖出喉返神经32例;以甲状软骨下角为标志,由上向下解剖出喉返神经9例;以颈总动脉为标志,由外向内解剖出喉返神经14例.术后患者恢复基本良好,发生说话声音改变8例,包括声音嘶哑3例,均于术后2个月内恢复.结论 甲状腺疾病再次手术,解剖喉返神经十分必要,气管、残余甲状腺、甲状软骨下角及颈总动脉可作为解剖喉返神经入路的解剖标志.

Objective To investigate the anatomic method of recurrent laryngeal nerve （RLN） in thyroid operation again.Methods From Jun.2002 to Sep.2012,55 patients who had received reoperative thyroidectomy were enrolled in this retrospective study.We analyzed the protection of RLN at the time of thyroidectomy reoperation,reasons for recurrent thyroid disease.Results Reoperative thyroidectomy was performed in 55 patients.Of whom,16 cases with benign and 39 cases with malignant were for second operation and 4 cases with malignant were underwent the third operation.Thyroidectomy was done under general anesthesia through a horizontal incision at the original collar line.Separating and cutting the Strap Muscles （sternohyoid,omohyoid and sternothyroid muscles） and exposing the anterior surface of the thyroid were performed.It is the most important anatomic sign,including the trachea,residual thyroid tissue,the inferior comu of thyroid cartilage and carotid artery,and then identified the RLN.Laryngeal nerve monitoring was performed in 5 of these 55 cases.We separated the RLN respectively by the sign of trachea and residual thyroid tissue for 32 cases.9 cases were underwent the inferior cornu of thyroid cartilage（from up to down）,and 14 cases were performed at the carotid artery from outside to inside.We analyzed the all cases with good postreoperative outcomes.Forty-seven cases are alive with no complication,and 8 cases with voice changing,in which 3 cases occurred unintentional RLN paralysis and get recovery within 2 months.Conclusion More care should be taken while separating the tissue so as to avoid injury to the external laryngeal nerve.The trachea,residual thyroid tissue,the inferior comu of thyroid cartilage and Carotid artery are the important anatomic signs to identify the RLN.