功能保护性甲状腺外科:技术难点与对策  

Key technologies for function protection of important tissue and organs in thyroid surgery

作　　者：袁芊芊 贺青卿 田文 吴高松 YUAN Qianqian;HE Qing-qing;TIAN Wen(Department of Thyroid and Breast Surgery,Zhongnan Hospital of Wuhan University,Wuhan 430071,China;不详)

机构地区：[1]武汉大学中南医院甲状腺乳腺外科,湖北武汉430071 [2]中国人民解放军联勤保障部队第九六〇医院甲状腺乳腺外科,山东济南250031 [3]中国人民解放军总医院第一医学中心普通外科医学部甲状腺(疝)外科,北京100853

出　　处：《中国实用外科杂志》2024年第6期625-629,共5页Chinese Journal of Practical Surgery

基　　金：湖北省卫生计生委联合基金立项项目(No.WJ2015MA003,No.WJ2018H0014,No.cxpy2017068);湖北省自然科学基金项目(No.2008CDB179,No.2012FFB02310);湖北省人社厅项目(No.LX1900000001)。

摘　　要：甲状腺癌是预后较好的实体肿瘤之一,手术是主要治疗方式。降低甲状腺术后并发症发生率,提高病人术后生活质量至关重要。手术中保护甲状腺及其周围重要组织器官的功能完整性,减少并发症,是甲状腺外科面临的重大挑战。功能保护性甲状腺外科强调在治疗甲状腺疾病的同时,尽可能保护甲状腺自身及周围组织器官的生理功能。为减少甲状腺病人术后发生出血和窒息,手术结束缝合切口时,保留颈白线下段3 cm敞开不缝闭,以保证气管前至颈部皮下疏松组织之间的通道通畅。甲状旁腺功能保护的关键是术中识别和保护其动静脉不被损伤。为提高甲状旁腺自体移植的生存率及分泌功能,建议采用带脂肪组织的甲状旁腺自体移植术,并应用个体化甲状旁腺移植位点技术提高评估移植物是否存活的敏感度及分泌功能评估的敏感度。对于喉返神经功能保护,除“包膜内切除技术”和神经监测仪等评估方法外,近年来出现了多种喉返神经监测评估新标准及新方法可更有效地评估喉返神经功能完整性。针对肿瘤侵犯喉返神经需要进行节段性切除的情况,劈离式选择性迷走神经-喉返神经吻合术可作为一种简单且效果明确的喉返神经损伤吻合修复方法。对于喉上神经外支保护,临床适用性喉上神经外支分型依据喉上神经外支最低点与甲状腺上极平面的最短距离进行分型,为术中喉上神经外支的常规显露、定位及功能保护提供了解剖学依据和方法。对于胸导管功能保护,针对胸导管意外损伤,除直接结扎胸导管等封堵策略外,胸导管显微修补术可作为一种疏通策略。对术后已发生乳糜漏的病人,可根据乳糜漏流量进行高、中、低流量分类,并采取个体化综合治疗方案,加速胸导管愈合。Thyroid cancer is one of the most favorable solid tumors in terms of prognosis,and surgery is the main treatment modality.Reducing postoperative complications and improving patients'quality of life after surgery are of paramount importance.Functional-protective thyroid surgery emphasizes the preservation of the physiological function of the thyroid gland itself and surrounding organs while treating thyroid diseases.To reduce postoperative bleeding and suffocation in thyroid surgery,the lower 3 cm of the subplatysma is left open and unsutured at the end of the operation to ensure a clear passage between the trachea and the loose subcutaneous tissue of the neck.The key to parathyroid function preservation is to identify and protect its blood vessels from damage during surgery.To improve the survival rate and secretory function of autologous parathyroid transplantation,autologous parathyroid transplantation with adipose tissue is recommended,and individualized parathyroid transplantation site technology is applied to improve the sensitivity of assessing the survival of the graft and the sensitivity of secretory function evaluation.In addition to the“encapsulated resection technique”and nerve monitoring instruments and other evaluation methods for recurrent laryngeal nerve function preservation,various new recurrent laryngeal nerve monitoring evaluation standards and new methods have emerged in recent years,which can more effectively evaluate the integrity of recurrent laryngeal nerve function.For cases where tumor invasion of the recurrent laryngeal nerve requires segmental resection,split-type selective vagus nerve-recurrent laryngeal nerve anastomosis can be used as a simple and effective method for repairing recurrent laryngeal nerve injury anastomosis.The clinical applicability of the suprahyoid nerve branch classification is based on the shortest distance between the lowest point of the suprahyoid nerve branch and the horizontal plane of the upper thyroid gland,providing anatomical basis and methods for the

关 键 词：甲状腺肿瘤 甲状旁腺 喉上神经外支 喉返神经 胸导管 功能保护性甲状腺外科 

分 类 号：R6[医药卫生—外科学]