无充气腋窝入路全腔镜下甲状腺切除术的“场景式”扶镜技巧与质量控制

"Scene-based"camera-holding skills and quality control for gasless axillary total endoscopic thyroidectomy

随着腔镜甲状腺手术的发展及推广,该手术方式被越来越多的医疗中心和患者接受,但因其操作空间相对腹腔镜和胸腔镜更狭小,且镜头和主刀的操作器械共用空间,两者相互干扰及视角显露等问题,常成为影响手术的难点。为解决该问题,笔者从扶镜手的视觉角度出发,引入场景式的概念,通过三个部分规范无充气腋窝全腔镜下甲状腺切除手术中扶镜手的操作要点及质量控制。第一部分为规范术前准备及扶镜手操作区域的划分;第二部分为扶镜操作要点:“眼关六路、三个平面、进退展转”的十二字扶镜质量控制;第三部分为三层递进镜下视野场景的扶镜质量控制:将手术区域分为喉返神经区、甲状腺上极区、气管前区,借此来规范扶镜手在不同场景的扶镜要点和视角引导。通过扶镜技巧与质量控制,手术过程中的视野显露更充分、清晰,视觉引导更流畅,镜头、器械之间的相互干扰更小,术中平均擦拭或浸泡镜头次数显著减少,甚至手术过程中无需二次擦镜,保证操作的连续性,节省了手术时间。笔者就以上要点、操作技巧及细节进行阐述。

With the development and popularization of endoscopic thyroidectomy,this surgical approach is increasingly accepted by more medical centers and patients.However,due to its relatively narrow operating space compared to laparoscopy and thoracoscopy,as well as issues such as the shared space between the lens and the surgical instruments manipulated by the primary surgeon,mutual interference,and limited visibility,it often becomes a challenging aspect of the surgery.To address this issue,the authors,from the perspective of the camera-holding assistant,introduce the concept of scene-based guidance.This is achieved by standardizing the key points of operation and quality control for cameraholding assistant during gasless axillary endoscopic thyroidectomy in three parts.The first part standardizes preoperative preparation and the division of the operating area of the camera-holding assistant.The second part outlines the key points of endoscope operation:"YAN GUAN LIU LU,SAN GE PING MIAN,JIN TUI ZHAN ZHUAN"a twelve-character quality control mantra for the camera holding.The third part focuses on the quality control of the endoscopic view field in three progressively deeper levels:dividing the surgical area into the recurrent laryngeal nerve area,the upper pole of the thyroid area,and the pre-tracheal area,thereby standardizing the key points and visual guidance for the camera-holding assistant in different scenarios.Through camera-holding skills and quality control,the surgical field is more fully and clearly visible,visual guidance is smoother,mutual interference between the lens and instruments is reduced,the average number of lens wipes or soaks during surgery is significantly reduced,and even secondary wiping of the lens during surgery is unnecessary,ensuring continuous operation and saving surgical time.Here,the authors elaborate on the above points,operation techniques,and details.