甲状腺周围筋膜及筋膜间隙的应用解剖学观察

doi:10.13418/j.issn.1001-165x.2014.04.004

摘要/Abstract

摘要：

目的　从临床应用解剖角度重新认识甲状腺周围筋膜及筋膜间隙的解剖特点，为甲状腺癌中央区清扫术的手术范围、入路层面等提供可以借鉴的解剖依据。方法　5具10侧标本，对甲状腺周围筋膜和筋膜间隙进行观察；10例甲状腺癌患者进行手术解剖验证观察。结果　气管前筋膜分为前后两层，两层之间是脂肪淋巴组织及甲状腺下静脉等；气管前间隙是气管前筋膜后层与气管之间的无血管的间隙。气管旁脂肪组织与气管前脂肪组织相延续，甲状腺血管、淋巴系统走行其中。气管旁、气管前脂肪淋巴组织前后均有一层筋膜覆盖，前后筋膜在外侧与血管鞘相融合，并开口于甲状腺血管根部，内侧与甲状腺相连，其结构与功能均类似肠系膜。气管旁脂肪组织在前方与甲状腺之间存在一间隙，后方与椎前筋膜之间存在一间隙。结论　甲状腺有系膜且呈“U”分布于气管前及气管旁。甲状腺系膜切除能达到彻底清扫中央区淋巴组织的目的。甲状腺系膜与脏器之间的筋膜间隙是进行手术操作的外科平面。

关键词: 甲状腺, 筋膜, 解剖, 淋巴清扫术

Abstract:

Objective　Through cadaveric dissection and intra-operative observation, the anatomical features of fascia and fascial space around the thyroid gland was redefined，which in combination with the metastasis path and the region of central compartment lymph node dissection, aims to provide anatomical basis for the dissection of the central compartment lymph nodes and the accurate surgical planes.　Methods　5 specimen with 10 sides were fixed in 10% formalin and used to study the fascia, fascial space around the thyroid gland. 10 patients with thyroid cancer are used to define the fascia and fascial space during the operation.　Results　Pretracheal fascia, sandwich-like in structures, was divided into two layers, the interspace of which had fat tissues, lymph nodes, lymphatic vessels, inferior thyroid vein, et al. There was a vessel-free space between the posterior layer of pretracheal fascia and the trachea, which was perteacheal space. The paratracheal fat tissue was connected to the pretracheal fat tissue and also had a sandwich-like construction with two layers of fascia covering at the front and back, containing vessels, lymphatic system; The anterior and posterior fasciae were in continuation with the carotid sheath on the external surface and were in contact with the thyroid gland on the internal surface, which were similar to the mesentery in structure and function. There was a space between paratracheal fat tissue and thyroid, and between paratracheal fat tissue and prevertebral fascia, respectively. Conclusions The thyroid gland has mesentery which is located in the pretracheal and paratracheal areas. Mesothyroid excision can achieve the purpose of thoroughly removing the lymphoid tissue in the center. Fascial space between mesothyroid and viscera is the surgical plane of the operation.

Key words: Thyroid, Fascia, Anatomy, Lymph node dissection

中图分类号:

R323.1

雷尚通, 丁自海, 李国新. 甲状腺周围筋膜及筋膜间隙的应用解剖学观察[J]. 中国临床解剖学杂志, 2014, 32(4): 387-391.

LEI Chang-Tong, DING Zi-Hai, LI Guo-Xin. Applied anatomic observation of fascia and fascial space surrounding the thyroid gland[J]. Chinese Journal of Clinical Anatomy, 2014, 32(4): 387-391.

参考文献

[1] Udelsman R, Zhang Y. The epidemic of thyroid cancer in the United States: the role of endocrinologists and ultrasounds
[J].Thyroid, 2014,24(2):472-479.

[2] Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973–2002
[J]. JAMA, 2006, 295(18):2164-2167.

[3] Morris LG, Sikora AG, Tosteson TD, et al. The increasing incidence of thyroid cancer: the influence of access to care
[J]. Thyroid, 2013, 23(7):885-891.

[4] Enewold LR, Zhou J, Devesa SS, et al. Thyroid cancer incidence among active duty U.S. military personnel,1990-2004
[J]. Cancer Epidemiol Biomarkers Prev 2011,20(11):2369-2376.

[5] Zhu C, Zheng T, Kilfoy BA, et al. A birth cohort analysis of the incidence of papillary thyroid cancer in the United States,1973–2004
[J]. Thyroid,2009,19(10):1061-1066.

[6] American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised management guidelines for patients with thyroid nodules and differentiated thyroid cancer
[J]. Thyroid, 2009,19(11):1167-214.

[7] Grodski S, Cornford L, Sywak M, et al. Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique
[J]. ANZ J Surg, 2007,77(4):203-208.

[8] Moo TA, Umunna B, Kato M, et al. Ipsilateral versus bilateral central neck lymph node dissection in papillary thyroid carcinoma
[J]. Ann Surg, 2009, 250(3):403-408.

[9] Grebe SK, Hay ID. Thyroid cancer nodal metastases: biologic significance and therapeutic considerations
[J]. Surg Oncol Clin N Am,1996,5(1):43-63.

[10]Scheumann GF, Gimm O, Wegener G, et al. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer
[J]. World J Surg,1994,18(4):559-567.

[11]Machens A, Holzhausen HJ, Dralle H. Skip metastases in thyroid cancer leaping the central lymph node compartment
[J]. Arch Surg, 2004,139(1):43-45.

[12]Qubain SW, Nakano S, Baba M, et al. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma
[J]. Surgery, 2002, 131(3):249-256.

[13]Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence
[J] ? Br J Surg,1982,69(10):613-616.

[14]Hohenberger W, Weber K, Matzel K. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation-technical notes and outcome
[J].Colorectal Dis, 2009, 11(4):354-364.

[15]刘玉村,高红桥,万远廉.胃全系膜切除术治疗胃癌
[J].中华胃肠外科杂志, 2003, 6(3):206-208.

[16]杜泽森，傅俊惠. 食管癌淋巴结清扫的沿革及新概念：食管全系膜切除
[J].外科, 2013, 2(1):1-5.

[17]Gockel I, Domeyer M, Wolloscheck T, et al. Resection of the mesopancreas (RMP):a new surgical classification of a known anatomical space
[J]. World J Surg Oncol, 2007, 5:44.

[18]Policeni BA, Smoker WR, Reede DL, et al. Anatomy and embryology of the thyroid and parathyroid glands
[J]. Semin Ultrasound CT MRI, 2012, 33(2):104-114.

[19]American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised management guidelines for patients with thyroid nodules and differentiated thyroid cancer
[J]. Thyroid, 2009,19(11):1167-214.