下位甲状旁腺原位保留新探索——胸甲韧带精细解剖法  

A new protecting method for the inferior parathyroid gland in situ: the meticulous thyrothymic ligament dissection technique

作　　者：斯岩 蔡晶昇 张浩 方海生[2] 沈美萍 Si Yan;Cai Jingsheng;Zhang Hao;Fang Haisheng;Shen Meiping(Department of Thyroid Surgery,the First Affiliaied Hospital with Nanjing Medical University,Nanjing 210029,China;Department of Pathology,the First Affiliaied Hospital with Nanjing Medical University,Nanjing 210029,China)

机构地区：[1]南京医科大学第一附属医院甲状腺外科,210029 [2]南京医科大学第一附属医院病理科,210029

出　　处：《中华内分泌外科杂志》2019年第4期278-282,共5页Chinese Journal of Endocrine Surgery

基　　金：江苏省卫生厅面上项目(H201203).

摘　　要：目的探索胸甲韧带(thyrothymic ligament,TTL)的形态学特点及其解剖方法,探索其对下位甲状旁腺(inferior parathyroid gland,IPTG)术中保护的临床意义。方法对2017年5月至2017年12月南京医科大学第一附属医院甲状腺外科行初次甲状腺手术的患者进行前瞻性研究,术中采用胸甲韧带精细解剖法,解剖胸甲韧带TTL,识别并定位IPTG,描述胸甲韧带的解剖结构,统计TTL与IPTG的位置关系,探索通过胸甲韧带精细解剖法原位保留IPTG的可行性。结果对121例接受首次甲状腺的手术患者术中进行胸甲韧带解剖,共解剖194侧,其中左侧96例,右侧98例;成功发现韧带143侧(73.7%),左侧78例(81.3%),右侧65例(66.3%)。通过胸甲韧带精细解剖法在术中定位到70.6%的IPTG本研究发现TTL为下宽上窄的条索状脂肪结缔组织结构,多与甲状腺下静脉伴行,起点为胸腺的颈段尖端,止点位于甲状腺,其中76.2%的TTL止于甲状腺下极及下1/3背侧的区域内,韧带包含脂肪组织及韧带内血管。33.5%的IPTG位于TTL的甲状腺止点周围,25.3%的IPTG位于TTL内,4.6%的IPTG位于胸腺颈段内,7.2%的IPTG位于TTL周围。术后暂时性甲状旁腺功能减退的发生率为14.9%,无永久性甲状旁腺功能减退的发生。结论胸甲韧带在人群中普遍存在,且与IPTG的位置密切相关,胸甲韧带作为胸腺颈段与下位甲状旁腺与甲状腺之间的连接使之成为一个结构复合体(胸腺颈段-胸甲韧带-下位甲状旁腺复合体)。通过胸甲韧带精细解剖法在甲状腺手术中可有效定位和原位保留IPTG,明显降低甲状旁腺功能减退的发生率。Objective To explore the anatomical features and the dissection technique of thyrothymic ligament (TTL), and to explore the clinical significance of protecting the inferior parathyroid gland (IPTG) with this structure. Methods Patients who received the initial thyroid surgery in the Department of Thyroid Surgery of the First Affiliated Hospital with Nanjing Medical University from May. 2017 to Dec. 2017 were prospectively analyzed. We dissected TTL, identified and located the IPTG, described the structural features of TTL, and investigated the position relationship of TTL and IPTG to evaluate the possibility and value of protecting IPTG in situ. Results About 121 patients underwent the dissection, totally 194 sides dissected that included 96 left sides and 98 right sides. TTL was found in 143 sides (73.7%), 78 left sides (81.3%) and 65 right sides (66.3%). Nearly 70.6% IPTG can be proactively identify and located by the TTL during the operation. TTL was a kind of adipose connective tissue that was wide at the bottom and narrow at the top, accompanying with the inferior thyroid vein, from the thymus to the thyroid. 76.2% TTL were attached to the lower pole and the lower 1/3 dorsal of thyroid, containing fat and vessels. 33.5% IPTGs were located in the area surrounding around the ends of the TTL. 25.3% IPTGs were located in the TTL. 4.6% IPTGs were located in the thymus and 7.2% IPTGs surrounding around the TTL. The incidence rate of post-operation hypoparathyroidism was 14.9%. Conclusions TTL commonly exists and has significant relationship with IPTG. TTL connects thymus and IPTG, which would be considered a complex (thymus-thyrothymic ligament-IPTG complex, TLIC). The meticulous TTL dissection technique will help proactively identify, locate and protect IPTG during operation, and reduce the incidence rate of post-operation hypoparathyroidism.

关 键 词：甲状旁腺 胸甲韧带 甲状旁腺功能减退 胸腺颈段-胸甲韧带-下位甲状旁腺复合体 

分 类 号：R653[医药卫生—外科学]