摘要
经口入路腔镜甲状腺手术(TOET)是一种经自然腔道的腔镜手术(NOTES)。2008年Witzel等首次在新鲜尸体和活体猪上完成经口底入路的腔镜甲状腺手术尝试,国内王存川教授则首次在国际上提出了三孔经口腔前庭的腔镜甲状腺手术(TOETVA)技术。这也是目前应用最广泛的TOET入路方式,其主要优势是对口底的结构损伤少,器械操作也较灵活;体表完全无疤痕,根治疾病的同时,能满足美容和隐私保护的双重需求。TOETVA拥有从上而下视角,由于其天然的视角优势,解决了中央区低位淋巴结清扫的问题。因此,TOETVA是分化型甲状腺癌合并中央区淋巴结转移病例的优选术式。自2013年该术式诞生,中国国内首先开始发展,2015年多个中心开始尝试,到目前为止,国内已经有数百家单位可以开展此术式。TOETVA的技术要点和难点主要包括:空间的建立与维持、喉返神经的显露与保护、甲状旁腺辨认及功能保留、淋巴结清扫。相比经胸前入路,TOET有更长的学习曲线,一般需要40~50例操作才能克服,同开放手术和其他入路的无瘢痕腔镜甲状腺手术比较,除了常规出血、神经损伤、旁腺损伤、皮瓣损伤等并发症外,尚有以下特殊的并发症,包括:颏神经损伤,感染,CO_(2)气体栓塞,胸膜损伤,下颌区域功能异常反应等。TOETVA具有较好的肿瘤根治和整形美容效果,在过去的十年中经历了飞速的发展。它作为NOTES手术体系的一部分,代表了内镜外科、微创外科发展的趋势,科学应用和推广TOETVA技术是未来工作的重点。毫无疑问,严格遵循手术适应证是重中之重,只有坚持“治病第一,功能保护第二,美容第三”的基本原则,才能科学、规范地推广TOETVA。此外,教学医院应发挥带头作用,积极推动指南共识的普及,并在临床工作中不断示教手术操作。适应证拓展、操作方法改进和新技术研发是TOETVA未来研究的热点。TOETVA的手术适应证并非绝对,随着操作者技术的不断提升,手术难度可以逐渐增大。但需要指出,任何超出当前指南专家共识的术式,都属于非常规手术,目前TOETVA适应证的拓展,主要以颈侧区清扫为代表,但清扫Ⅱ区相当困难。因此,对于TOETVA颈侧区清扫能否达到根治性效果,目前存在争议。本文结合国内外文献及本中心相关经验,对于该入路的现状及展望作一综述。
Transoral endoscopic thyroidectomy(TOET)is a type of natural orifice transluminal endoscopic surgery(NOTES).In 2008,Witzel et al.first attempted transoral endoscopic thyroidectomy through the oral floor in fresh cadavers and live pigs.Professor Wang Cunchuan in China was the first to propose the three-port transoral endoscopic thyroidectomy vestibular approach(TOETVA)internationally.Currently,this is the most widely used transoral endoscopic approach for thyroid surgery,with the main advantages of minimal damage to the oral floor structures and greater instrument maneuverability.It leaves no visible scars on the skin surface,meets the dual requirements of disease cure and aesthetic appearance,and ensures privacy protection.TOETVA provides a top-down view,which,due to its natural visual advantage,resolves the problem of low-level lymph node dissection in the central region.Therefore,TOETVA is the preferred surgical procedure for cases of differentiated thyroid cancer with central lymph node metastasis.Since its introduction in 2013,TOETVA has been initially developed in China,and multiple centers started attempting it in 2015.To date,there are already hundreds of institutions in China capable of performing this procedure.The technical key points and challenges of TOETVA mainly include the establishment and maintenance of space,exposure and protection of the recurrent laryngeal nerve,identification and preservation of the parathyroid glands,and lymph node dissection.Compared to the transthoracic approach,transoral endoscopic thyroid surgery has a steeper learning curve,typically requiring 40-50 cases to overcome.In comparison to open surgery and other scarless endoscopic thyroidectomy approaches,in addition to common complications such as bleeding,nerve injury,parathyroid injury,and flap injury,transoral endoscopic thyroid surgery has the following special complications:mental nerve injury,infection,CO_(2) gas embolism,pleural injury,and abnormal functional reactions in the mandibular region,among others.TOETVA has shown good tumor control and aesthetic outcomes,experiencing rapid development over the past decade.As part of the NOTES surgical system,it represents the trend of endoscopic and minimally invasive surgery.The future focus is on scientific application and promotion of TOETVA technology,with strict adherence to surgical indications being of utmost importance.Only by adhering to the basic principles of"treating the disease first,preserving function second,and considering aesthetics third"can TOETVA be scientifically and standardizedly promoted.Additionally,teaching hospitals should take the lead in actively promoting the dissemination of guidelines and consensus,while continually demonstrating surgical procedures in clinical practice.Expanding indications,improving surgical techniques,and developing new technologies are the hotspots of future research in TOETVA.The surgical indications for TOETVA are not absolute,and as the operator's skills improve,the surgical difficulty can gradually increase.However,it should be noted that any procedure beyond the current guidelines and expert consensus is considered unconventional surgery.Currently,the expansion of indications for TOETVA is mainly represented by lateral neck dissection,but dissection of levelⅡlymph nodes remains challenging.Therefore,there is controversy regarding whether TOETVA can achieve a radical effect with lateral neck dissection.This article provides an overview of the current status and prospects of this approach based on domestic and international literature and our center's relevant experience.
作者
马军杰
王平
MA Junjie;WANG Ping(Department of Thyroid Surgery,Second Affiliated Hospital,Zhejiang University School of Medicine,Hangzhou 310009,China)
出处
《中国普通外科杂志》
CAS
CSCD
北大核心
2023年第5期640-647,共8页
China Journal of General Surgery