无充气腋窝入路完全腔镜甲状腺手术的“三推进”悬吊建腔法

doi:10.3724/zdxbyxb-2021-0337

浙江大学学报（医学版）

2021, Vol. 50

Issue (6): 694-700 DOI: 10.3724/zdxbyxb-2021-0337

专题报道

无充气腋窝入路完全腔镜甲状腺手术的“三推进”悬吊建腔法

胡啸天^1,²,忻莹^2,³,郑传铭^2,³,孟可馨^2,³,葛明华^1,^2,^3,*(

)

1.青岛大学青岛医学院，山东青岛 266000
2.杭州医学院附属人民医院浙江省人民医院耳鼻咽喉-头颈外科中心头颈外科，浙江杭州 310014
3.浙江省内分泌腺体疾病诊治研究重点实验室，浙江杭州 310014

“Three-propulsion” suspension method for endoscopic thyroid surgery gasless axillary approach

HU Xiaotian^1,²,XIN Ying^2,³,ZHENG Chuanming^2,³,MENG Kexin^2,³,GE Minghua^1,^2,^3,*(

)

1. Medical College of Qingdao University, Qingdao 266000, Shandong Province, China;
2. Department of Head and Neck Surgery, Center of Otolaryngology, Head and Neck Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital of Hangzhou Medical College, Hangzhou 310014, China;
3. Zhejiang Provincial Key Laboratory of Endocrine Gland Diseases, Hangzhou 310014, China

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摘要：

无充气腋窝入路完全腔镜下甲状腺手术具有手术视野清晰、操作简便、术者学习曲线短、手术切口隐蔽以及患者术后颈部无疤痕、吞咽不适感轻微等优点。该术式由侧方入路，分离路径需经胸大肌表面、胸锁乳突肌肌间隙、颈内静脉等解剖结构，会面临颈部肌肉、血管和神经的各种变异，采用自腋窝—锁骨、锁骨—胸锁乳突肌肌间隙、胸锁乳突肌肌间隙—甲状腺三次拉钩推进，配合术中悬吊向上拉钩进行建腔的方法可以为手术操作打下良好基础。本文介绍“三推进”悬吊建腔法的主要步骤、要点及其注意事项。

关键词： 甲状腺切除术; 解剖异常; 内窥镜; 喉返神经; 肩胛舌骨肌

Abstract:

Gasless endoscopic thyroidectomy through unilateral axillary approach has advantages of clear vision, simple manipulation, short learning curve, hidden surgical incision, no postoperative neck scar, and less swallowing discomfort. During the procedure the separation path goes through thoracic muscle surface, sternocleidomastoid gap and jugular vein, which may meet various variations of neck muscles, blood vessels and nerves. With the “three-propulsion” suspension cavity construction method the procedure advances the dissection from the axillary incision to clavicle, from the clavicle to sternocleidomastoid gap and from the sternocleidomastoid gap to thyroid. Combined with intraoperative hanging upward hook it can establish a good cavity for the subsequent surgical operation. This article introduces the main steps, key points and attentions of the “three-propulsion”suspension cavity construction method in gasless endoscopic thyroidectomy through unilateral axillary approach.

Key words: Thyroidectomy Anatomical abnormality Endoscope Recurrent laryngeal nerve Omohyoid

收稿日期: 2021-10-30 出版日期: 2022-03-22

CLC:

R653.2

基金资助: 浙江省基础公益研究计划（LGC19H160001）；浙江省医学会临床科研基金项目（2017ZYC-A03）

通讯作者: 葛明华 E-mail: geminghua@hmc.edu.cn

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引用本文:

胡啸天,忻莹,郑传铭,孟可馨,葛明华. 无充气腋窝入路完全腔镜甲状腺手术的“三推进”悬吊建腔法[J]. 浙江大学学报（医学版）, 2021, 50(6): 694-700.

HU Xiaotian,XIN Ying,ZHENG Chuanming,MENG Kexin,GE Minghua. “Three-propulsion” suspension method for endoscopic thyroid surgery gasless axillary approach. J Zhejiang Univ (Med Sci), 2021, 50(6): 694-700.

链接本文:

https://www.zjujournals.com/med/CN/10.3724/zdxbyxb-2021-0337 或 https://www.zjujournals.com/med/CN/Y2021/V50/I6/694

图1 “三推进”悬吊法模式图以及患者术中体位A：“三推进”悬吊法模式图；B：患者术中体位.

图2 “三推进”悬吊法的建腔术野A：右侧喉上神经（箭头所示）；B：右侧甲状腺上静脉（箭头所示）；C：右侧上位甲状旁腺（箭头所示）；D：甲状腺切除后，原位保留的上位甲状旁腺（绿色箭头所示）及下位甲状旁腺（红色箭头所示）；E：喉返神经位置表浅（箭头所示）；F：自然暴露的右侧喉返神经（箭头所示）；G：右侧中央淋巴结清扫术后视野；H：左侧中央淋巴结清扫术后视野.

图3 “三推进”悬吊法推进中的重要结构A：锁骨上神经位置（箭头所示）；B：颈外静脉位置（箭头所示）.

图4 右侧颈外静脉变异形式及手术分离策略A、B：静脉角型；C：锁骨下静脉型；D：颈内静脉型. 箭头所指方向为颈内静脉与颈外静脉间分离钳分离组织所进入的方向.

图5 胸锁乳突肌锁骨头的起始存在的变异A：起始部肌肉形态融合型；B：起始部肌肉形态窄型；C：胸锁乳突肌变异——3头；D：胸锁乳突肌变异——4头. 箭头标注为不同变异类型胸锁乳突肌的肌间隙，即分离的正确方向.

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