环甲间隙在腔镜甲状腺手术中的重要意义

doi:10.13418/j.issn.1001-165x.2021.03.018

摘要/Abstract

摘要： 目的　探讨环甲间隙在颈部无瘢痕腔镜甲状腺手术（scarless in the neck endoscopic thyroidectomy，SET）中对保护喉上神经外支（external branch of superior laryngeal nerve，EBSLN）、喉返神经（recurrent laryngeal nerve，RLN）、甲状旁腺（parathyroid gland，PT）及处理甲状腺上极的重要意义。方法　回顾分析本院2014年4月至2018年7月腔镜甲状腺手术128例，包括单侧或双侧切除、次全切除或部分切除等。在处理甲状腺上极时均采用环甲间隙入路，结合甲状腺下极及外侧操作完成甲状腺叶部分或腺叶全部切除术。结果　全部SET在分离进入环甲间隙后处理甲状腺上极血管，其中59.3%（76例）显露EBSLN。在甲状腺下极区域首先显露RLN者82.8%（106例），其余17.2%在经环甲间隙入路处理甲状腺上极血管后显露RLN入喉点。术中显露UPT位于近环甲关节处者83%（106例），位于甲状腺上极背面者17%（22例）。84例随访至今，术后暂时性声音嘶哑并单侧喉返神经麻痹2例，无声音低钝及饮水呛咳者，无永久性低钙者。结论　环甲间隙在SET中对于安全切断甲状腺上极血管和有效保护EBSLN、RLN及上甲状旁腺具有重要意义，因此结合甲状腺峡部、下极及外侧操作可以形成腔镜甲状腺的程式化手术步骤，提升了该术式的安全性，有利于该术式的推广。

关键词: 甲状腺手术, 　腔镜, 　环甲间隙

Abstract: Objective　To investigate the significance of the cricothyroid space in protecting external branch of superior laryngeal nerve (EBSLN), recurrent laryngeal nerve (RLN) and parathyroid gland（PT）during scarless in the neck endoscopic thyroidectomy(SET) and the importance of treating upper pole of the gland in endoscopic thyroidectomy.　Methods　A retrospective analysis was performed based on clinical information of 128 cases of scarless in the neck endoscopic thyroidectomy(SET) from April 2014 to July 2018，including unilateral or bilateral subtotal thyroidectomy and unilateral or bilateral partial thyroidectomy. The thyroid gland was partially or completely excised with the operation of upper pole of the gland through cricothyroid space combining the operation of lower pole gland and the outside of the gland.　Results　All the 128 cases were treated with the upper thyroid vessels after entering the cricothyroid space. The EBSLN were exposed in 76 cases (59.3%), the RLN were exposed in 106 cases in the lower thyroid pole at first, and the other 22 cases were exposed by the cricothyroid l thyroid space approach. UPT was found in 106 cases (83%) near the cricothyroid joint and in 22 cases (17%) on the dorsal surface of the upper pole. 84 cases were followed up to now. 2 patients had postoperative hoarseness and unilateral recurrent laryngeal nerve paralysis. There was no voice blunt, no cough when eating and drinking, or no permanent low calcium detected.　Conclusions 　The cricothyroid space plays an important role in safely severing of the superior thyroid vessels and the effectively protecting the EBSLN, the RLN and the upper parathyroid gland（UPT）in endoscopic thyroidectomy. Therefore, the surgical operation on the upper pole of thyroid gland can combine with the operation on thyroid isthmus, the lower pole and the lateral side, to form a routine surgery procedure of the endoscopic thyroid gland, which improves the safety of the operation and facilitates the popularization of the operation.

Key words: Thyroidectomy, 　Endoscopy, 　Cricothyroid space

中图分类号:

R653
R323

张万宇, 陈骏星, 唐世龙, 卢强, 陈展辉, 陈荣军, 齐崧旭, 陈桂星, 邱铖. 环甲间隙在腔镜甲状腺手术中的重要意义[J]. 中国临床解剖学杂志, 2021, 39(3): 346-350.

Zhang Wanyu, Chen Junxing, Tang Shilong, Lu Qiang, Chen Zhanhui, Chen Rongjun, Qi Songxu, Chen Guixing, Qiu Cheng . Significance of cricothyroid space in endoscopic thyroid surgery [J]. Chinese Journal of Clinical Anatomy, 2021, 39(3): 346-350.

参考文献 26

[1]	Hüscher CS, Chiodini S, Napolitano C, et al. Endoscopic right thyroid lobectomy[J]. Surg Endosc,1997,11(8): 877. DOI: 10.1007/s004649900476.
[2]	仇明, 丁尔迅, 江道振, 等. 颈部无瘢痕内镜甲状腺腺瘤切除术一例[J]. 中华普通外科杂志, 2002, 17(2): 127. DOI: 10.3760/j.issn:1007-631X.2002.02.035.
[3]	Abdullah H, Bliss R, Reeve T, et al. Recognition of the avascular space medial to the upper pole of the thyroid and its surgical implications[J]. Asian J Surg, 2000, 23(1): 615-618. DOI: 10.1007/s101160050011.
[4]	Bliss RD, Gauger PG, Delbridge LW. Delbridge LW.Surgeon's approach to the thyroid gland:surgical anatomy and the importance of technique[J]. World J Surg, 2000, 24(8): 891-897. DOI: 10.1007/s002680010173.
[5]	刘家锋, 余济春, 彭韶平, 等. 环甲间隙入路甲状腺手术效果观察[J]. 实用医学杂志, 2010, 26(23): 4383-4385. DOI: 10.3969/j.issn.1006-5725.2010.23.055.
[6]	高雪松, 唐翀, 孙永强, 等. 环甲间隙入路解剖喉返神经在甲状腺手术中的应用[J]. 临床医药文献杂志(电子版), 2016, 3(48): 9492-9494. DOI: 10.3877/j.issn.2095-8242.2016.48.010.
[7]	高英茂. 组织学与胚胎学[M].北京: 人民卫生出版社, 2005: 229-230, 343.
[8]	应勇, 张坚红, 宋才鑫, 等. 腔镜甲状腺切除术中经环甲间隙入路喉上神经外支的显露[J]. 赣南医学院学报, 2018, 38(2): 140-141. DOI: 10.3969/j.issn.1001-5779.2018.02.011
[9]	刘家锋, 赖华英, 彭韶平, 等. 环甲间隙入路甲状腺手术对喉上神经的识别与保护的意义[J]. 中国医学创新, 2016, 1(35): 16-20. DOI: 10.3969/j.issn.1674-4985.2016.35.004.
[10]	Barczyński M, Randolph GW, Cernea CR, et al. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement[J]. Laryngoscope, 2013, 123(Suppl 4): S1-S14. DOI: 10.1002/lary.24301.
[11]	Ozlugedik S, Acar HI, Apaydin N, et al. Surgical anatomy of the external branch of the superior laryngeal nerve[J]. Clin Anat, 2007, 20(4): 387-391. DOI: 10.1002/ca.20399.
[12]	Barczyński M, Konturek A, Stopa M, et al. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy[J]. World J Surg, 2012, 36(6): 1340-1347. DOI: 10.1007/s00268-012-1547-7.
[13]	Ravikumar K, Sadacharan D, Muthukumar S, et al. EBSLN and Factors influencing its identification and its safety in patients undergoing total thyroidectomy: a study of 456 cases[J] . World J Surg, 2016, 40(3): 545-550. DOI: 10.1007/s00268-015-3383-z.
[14]	中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会, 中国医学装备协会外科装备分会甲状腺外科装备委员会. 甲状腺及甲状旁腺术中喉上神经外支保护与监测专家共识(2017版)[J]. 中国实用外科杂志, 2017, 37(11): 1243-1249.
[15]	Cernea CR, Ferraz AR, Nishio S, et al. Surgical anatomy of the external branch of the superior laryngeal nerve[J]. Head Neck, 1992, 14(5): 380-383. DOI: 10.1002/hed.2880140507.
[16]	Friedman M, LoSavio P, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy[J]. Arch Otolaryngol Head Neck Surg, 2002, 128(3): 296-03. DOI: 10.1001/archotol.128.3. 296.
[17]	聂鑫, 姚壮凯. 甲状腺手术中喉返神经监测的临床应用现状与前景[J].中国肿瘤外科杂志, 2014, 6(3): 180-182. DOI: 10.3969/j.issn. 1674-4136.2014.03.013.
[18]	张海添, 陆云飞, 廖清华, 等. 甲状腺手术中显露喉返神经价值的Meta分析[J]. 中华普通外科杂志, 2005, 20(4): 204-206. DOI: 10.3760/j.issn:1007-631X.2005.04.002.
[19]	王平, 燕海潮. 腔镜下全乳入路甲状腺腺叶切除的方法-王氏七步法[J].中国普通外科杂志, 2017, 26(5): 541-546. DOI: 10.3978/j.issn. 1005-6947.2017.05.001.
[20]	蒋进展, 陈浩浩, 邵大宝. 喉返神经分支与变异的临床解剖研究[J]. 四川解剖学杂志, 2011, 19(1): 13-15. DOI: 10.3969/j.issn.1005-1457.2011.01.005.
[21]	Williams SP, Wilkie MD, Tahery J. Microscope-assisted thyroidectomy: our experience in one hundred and twenty-one consecutive cases[J]. Clin Otolaryngol, 2014, 39(5): 307-311. DOI: 10.1111/coa.12284.
[22]	苏安平, 朱精强. 甲状旁腺解剖分型的意义[J]. 外科理论与实践, 2018, 23(2): 99-102. CNKI: SUN:WKLL.0.2018-02-004.
[23]	李志辉, 朱精强, 魏涛, 等. 甲状旁腺在人体中的分布特点及临床意义(附50例解剖研究报告)[J]. 中国普外基础与临床杂志, 2008, 15(5): 311-313. CNKI: SUN:ZPWL.0.2008-05-005.
[24]	刘胜新, 吴兰艳, 徐军辉, 等. 精细膜解剖技术在甲状腺手术中的应用体会(附211例报告)[J]. 临床外科杂志, 2018, 26(11): 839-841. DOI: 10.3969/j.issn.1005-6483.2018.11.012.
[25]	Nobori M, Saiki S, Tanaka N, et al. Blood supply of the parathyroid gland from the superior thyroid artery[J]. Surgery, 1994, 115(4): 417. PMID: 8165531.
[26]	Johansson K, Ander S, Lennquist S, et al. Human parathyroid blood supply determined by laser-Doppler flowmetry[J]. World J Surg, 1994, 18(3): 417. DOI: 10.1007/BF00316825.