陳旭輝,關(guān)養(yǎng)時(shí),安文偉,劉 丹,江燕飛,方 圓 (深圳市羅湖區(qū)人民醫(yī)院普外科,廣東 深圳 518089)
全腔鏡與腔鏡輔助小切口術(shù)式在甲狀腺手術(shù)中的應(yīng)用
陳旭輝,關(guān)養(yǎng)時(shí),安文偉,劉丹,江燕飛,方圓(深圳市羅湖區(qū)人民醫(yī)院普外科,廣東 深圳 518089)
[摘要]目的研究對(duì)比全腔鏡(CE)與腔鏡輔助小切口術(shù)式(EASIO)在甲狀腺手術(shù)中的應(yīng)用。方法選擇2010年9月至2013年9月我院收治的甲狀腺患者279例作為研究對(duì)象,其中239例接受甲狀腺手術(shù),根據(jù)手術(shù)方式分為CE組(n=95)和EASIO組(n=144)。另40例接受甲狀旁腺手術(shù),根據(jù)手術(shù)方式分為CE組(n=5)和EASIO組(n=35)。對(duì)比CE及EASIO術(shù)式在甲狀腺病癥中的手術(shù)相關(guān)指標(biāo),CE及EASIO術(shù)式應(yīng)用于甲狀腺病癥的術(shù)后結(jié)果,以及CE及EASIO術(shù)式應(yīng)用于甲狀旁腺的情況。結(jié)果關(guān)于甲狀腺病癥,CE組的女性比例、腺瘤或單側(cè)腺葉切除者比例、甲狀腺體積、結(jié)節(jié)最長(zhǎng)徑、腺瘤或腺葉切除時(shí)間、雙葉次全切或全切時(shí)間及術(shù)中出血量均顯著高于EASIO組,而年齡、雙葉次全切或全切比例均顯著低于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。CE組的前胸不適比例、VAS術(shù)后疼痛評(píng)分、住院時(shí)間及美容效果的滿意評(píng)分均顯著高于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。關(guān)于甲狀旁腺病癥,CE組的年齡顯著低于EASIO組,但手術(shù)時(shí)間及住院時(shí)間均顯著高于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論甲狀腺手術(shù)中應(yīng)用CE及EASIO術(shù)式治療各有優(yōu)劣勢(shì),應(yīng)綜合考慮患者病情及自身要求,制訂最佳手術(shù)方案。
[關(guān)鍵詞]全腔鏡;腔鏡輔助小切口術(shù)式;甲狀腺手術(shù);優(yōu)劣勢(shì)
目前,甲狀腺以及甲狀旁腺的腔鏡術(shù)式依照是否通過(guò)頸部切口實(shí)施分為全腔鏡(complete endoscopic,CE)以及腔鏡輔助小切口術(shù)式(endoscope assisted small incision operation,EASIO)等[1]。腔鏡技術(shù)和以 往的開放性手術(shù)相比[2],有著切口小、創(chuàng)傷小及術(shù)后恢復(fù)時(shí)間較短等特點(diǎn)。然而,臨床上關(guān)于腔鏡技術(shù)的橫向研究則較少,為分析CE術(shù)式及EASIO術(shù)式應(yīng)用于甲狀腺疾病中的優(yōu)劣勢(shì)情況,更好地輔助臨床術(shù)者制訂治療方案,本文就全腔鏡與腔鏡輔助小切口術(shù)式在甲狀腺手術(shù)中的應(yīng)用展開研究,現(xiàn)報(bào)告如下。
1資料與方法
1.1臨床資料
選擇從2010年9月至2013年9月我院收治的甲狀腺患者279例作為研究對(duì)象,其中男55例,女248例,年齡30~69歲,平均(51.5±2.5)歲。279例患者中239例接受甲狀腺手術(shù),根據(jù)手術(shù)方式進(jìn)行分組,CE組95例,男3例,女92例,年齡30~64歲,平均(32.8±6.6)歲;EASIO組144例,男40例,女104例,年齡32~66歲,平均(39.9±12.2)歲。另40例接受甲狀旁腺手術(shù),根據(jù)手術(shù)方式進(jìn)行分組,CE組5例,男0例,女5例,年齡33~61歲,平均(50.3±5.5)歲;EASIO組35例,男12例,女23例,年齡35~69歲,平均(58.5±6.7)歲。
1.2方法
1.2.1甲狀腺的CE手術(shù)縱向切開患者的頸下白線及舌骨下肌群,將帶狀肌分離,再切開其甲狀腺被膜,并顯露出腫塊。單純的腺瘤切除經(jīng)無(wú)創(chuàng)傷抓鉗將甲狀腺組織提起,順腫塊邊緣經(jīng)超聲刀分離及凝切,完整切除相應(yīng)腫塊。單側(cè)腺葉切除者需極鈍性地游離其甲狀腺下極血管,進(jìn)而顯露喉返神經(jīng),在遠(yuǎn)離喉返神經(jīng)處經(jīng)超聲刀切斷其下極血管。自上向下游離出甲狀腺,進(jìn)而處理好甲狀腺中靜脈。內(nèi)側(cè)翻轉(zhuǎn)甲狀腺,保護(hù)旁腺。最后游離且顯露上極血管及喉上神經(jīng),順甲狀腺上極經(jīng)超聲刀切斷上血管。離斷患者的Berry韌帶,最終切斷器甲狀腺峽部,將標(biāo)本移出。雙側(cè)腺葉的次全切除同上,完成一側(cè)后再對(duì)另一側(cè)進(jìn)行處理。
1.2.2甲狀旁腺的CE手術(shù)自甲狀腺的下極方向入路,易發(fā)現(xiàn)旁腺腺瘤。上旁腺的腺瘤通常處在甲狀腺腺葉的后方,部分因重力作用,垂在甲狀腺下極下方處,且上方含細(xì)長(zhǎng)蒂。探至腺瘤之后,將其牽往一側(cè),將旁腺血管進(jìn)行分離,通過(guò)鈦夾夾閉并切斷,之后移除腺瘤。
1.2.3甲狀腺的EASIO手術(shù)通過(guò)Harmonic將甲狀腺中靜脈亦或是頸靜脈及被膜間小靜脈予以切斷,顯露出氣管食管溝,便于操作。腔鏡以30°旋轉(zhuǎn)向上,將甲狀腺的上極血管予以顯露,經(jīng)吸引分離器操作,鑒別上極血管和分支。拉鉤牽引腺葉至下方,保持適度張力。分離棒推上極血管至外側(cè),大部分喉上神經(jīng)外側(cè)支易于分辨。依照上極血管直徑和四周解剖情況經(jīng)Harmonic刀行集束亦或是分次結(jié)扎。向上牽拉患者的甲狀腺腺葉,腔鏡30°旋轉(zhuǎn)后向下,氣管食管溝中探尋喉返神經(jīng),分離喉返神經(jīng)及旁腺。將內(nèi)鏡及拉鉤移除,牽出甲狀腺的上極部分,使腺葉翻向內(nèi)側(cè),對(duì)小血管及Berry韌帶進(jìn)行分離,自氣管表面將甲狀腺的峽部切斷,顯露氣管,移除腺葉。一針縫合患者的舌骨肌群及頸闊肌,經(jīng)密封膠將皮膚切口進(jìn)行粘合。若進(jìn)行甲狀腺全切術(shù),則移除一側(cè)的腺葉后,對(duì)側(cè)亦經(jīng)同法實(shí)施。
1.2.4甲狀旁腺的EASIO手術(shù)手術(shù)入路與甲狀腺EASIO手術(shù)一致,發(fā)現(xiàn)腺瘤之后,切忌分破被膜,經(jīng)吸引分離器行鈍性分離,提拉腺瘤,經(jīng)2 mm血管鈦夾進(jìn)行夾閉處理,探尋腺瘤血管,切除腺瘤,檢查喉返神經(jīng)及同側(cè)正常旁腺,在關(guān)閉患者的皮膚切口之前需等待旁腺激素的測(cè)定結(jié)果,而后采取相應(yīng)處理。
1.3觀察指標(biāo)
對(duì)比CE及EASIO術(shù)式在甲狀腺病癥中的手術(shù)相關(guān)指標(biāo),CE及EASIO術(shù)式應(yīng)用于甲狀腺病癥的術(shù)后結(jié)果,以及CE及EASIO術(shù)式應(yīng)用于甲狀旁腺的情況。
1.4統(tǒng)計(jì)學(xué)方法
2結(jié)果
2.12種術(shù)式在甲狀腺病癥中的手術(shù)相關(guān)指標(biāo)對(duì)比
239例接受甲狀腺手術(shù)的患者中,關(guān)于甲狀腺病癥,CE組的女性比例、腺瘤或單側(cè)腺葉切除者比例、甲狀腺體積、結(jié)節(jié)最長(zhǎng)徑、腺瘤或腺葉切除時(shí)間、雙葉次全切或全切時(shí)間及術(shù)中出血量均顯著高于EASIO組,而年齡、雙葉次全切或全切比例均顯著低于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表1。CE組術(shù)前診斷為結(jié)節(jié)性甲狀腺腫占30.53%(29/95),濾泡樣腺瘤占63.16%(60/95),Graves病占6.32%(6/95),甲狀腺炎占2.11%(2/95),分別與EASIO組的27.08%(39/144),65.28%(94/144),7.64%(11/144),2.78%(4/144)相比,差異均無(wú)統(tǒng)計(jì)學(xué)意義。
2.22種術(shù)式應(yīng)用于甲狀腺病癥的術(shù)后結(jié)果對(duì)比
關(guān)于甲狀腺病癥,CE組的前胸不適比例、VAS術(shù)后疼痛評(píng)分、住院時(shí)間及美容效果的滿意評(píng)分均顯著高于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表2。
2.32種術(shù)式應(yīng)用于甲狀旁腺的情況對(duì)比
40例接受甲狀旁腺手術(shù)的患者中,關(guān)于甲狀旁腺病癥,CE組的年齡顯著低于EASIO組,但手術(shù)時(shí)間及住院時(shí)間均顯著長(zhǎng)于EASIO組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表3。
表1 CE及EASIO術(shù)式在甲狀腺病癥中的手術(shù)相關(guān)指標(biāo)對(duì)比
表2 CE及EASIO術(shù)式應(yīng)用于甲狀腺病癥的術(shù)后結(jié)果對(duì)比
表3 CE及EASIO術(shù)式應(yīng)用于甲狀旁腺的情況對(duì)比
3討論
臨床上,腔鏡技術(shù)已在膽囊、闌尾以及胸腺瘤等諸多手術(shù)中應(yīng)用,且可充分發(fā)揮出創(chuàng)傷小、恢復(fù)快等優(yōu)勢(shì),同時(shí)優(yōu)良的美容效果能夠較大程度地緩解患者心理創(chuàng)傷[3]?,F(xiàn)如今應(yīng)用在甲狀腺和甲狀旁腺疾病的外科手術(shù)中,CE技術(shù)較EASIO技術(shù)產(chǎn)生更晚。國(guó)外雖然有對(duì)二者進(jìn)行單獨(dú)報(bào)道[4],但鮮少涉及二者在臨床應(yīng)用過(guò)程中的優(yōu)劣勢(shì)分析,鑒于此,本文展開研究,旨在為臨床治療提供一些理論支持。
本文研究結(jié)果表明,CE手術(shù)及EASIO術(shù)式均有一定優(yōu)點(diǎn),與國(guó)外Ohno等[5]的報(bào)道結(jié)果一致。此外,本文研究還發(fā)現(xiàn),關(guān)于甲狀旁腺病癥,CE組的年齡顯著低于EASIO組,但手術(shù)時(shí)間及住院時(shí)間均顯著高于EASIO組,表明甲狀旁腺疾病利用CE手術(shù)以及EASIO術(shù)式治療時(shí)二者均有相應(yīng)的優(yōu)點(diǎn)[6]。具體而言,在CE手術(shù)方面,其優(yōu)勢(shì)在于適合較大的腫塊以及良性的病變。手術(shù)后患者的頸部美容效果更佳[7],原因在于CE手術(shù)能夠?qū)⑶锌谵D(zhuǎn)移至乳暈、腋窩或胸前壁等可被衣物加以掩蓋的位置,對(duì)患者術(shù)后的心理創(chuàng)傷相對(duì)更小[8]。這也解釋了CE組的女性比例明顯更高,以及平均年齡更小的原因。其劣勢(shì)在于手術(shù)過(guò)程易增大患者身體創(chuàng)傷,本文研究結(jié)果亦顯示CE組的手術(shù)時(shí)間相對(duì)更長(zhǎng),且前胸不適比例及術(shù)后的疼痛評(píng)分相對(duì)更高,患者的住院時(shí)間亦隨之更長(zhǎng)。究其原因,筆者認(rèn)為是因?yàn)槭中g(shù)切口距離頸部較遠(yuǎn),導(dǎo)致手術(shù)開始時(shí)需要大面積地分離患者前胸筋膜下的組織,建立隧道來(lái)維持必需的手術(shù)操作空間[9]。這就使得大面積分離組織成為了必要條件,同時(shí)延長(zhǎng)了術(shù)程,增大了疼痛程度。而操作空間又需通過(guò)CO2加以維持,增大了并發(fā)癥的風(fēng)險(xiǎn)[10]。而在EASIO術(shù)式方面,其優(yōu)勢(shì)主要為適合小結(jié)節(jié),對(duì)良性及惡性病變均適用。對(duì)于低風(fēng)險(xiǎn)高分化型甲狀腺癌更加安全有效。同時(shí),具有手術(shù)時(shí)間相對(duì)更短及術(shù)后疼痛更輕的特點(diǎn),給患者造成的創(chuàng)傷更小。針對(duì)甲狀旁腺疾病的手術(shù),例如治療旁腺功能性亢進(jìn)時(shí),此種方法具有快速、安全、有效的療效。其不僅繼承傳統(tǒng)開放性手術(shù)的路徑短、迅速及成熟的優(yōu)勢(shì),同時(shí)也吸收了腔鏡技術(shù)的微創(chuàng)和術(shù)后恢復(fù)較快等優(yōu)點(diǎn)[11]。在其劣勢(shì)方面,主要為術(shù)后患者的頸部存在瘢痕,部分患者因?yàn)轳:墼錾?,產(chǎn)生瘢痕疙瘩,對(duì)美觀產(chǎn)生一定影響,甚至導(dǎo)致心理創(chuàng)傷。此外,Rulli等[12]的報(bào)道亦有類似的結(jié)果可佐證。
綜上所述,甲狀腺手術(shù)中應(yīng)用CE及EASIO術(shù)式治療均有一定的優(yōu)劣勢(shì),臨床治療時(shí)應(yīng)綜合考慮患者病情及自身要求,從而制訂最佳手術(shù)方案,值得重視。
[參考文獻(xiàn)]
[1] 唐輝蓉,張建先,廖陳,等.經(jīng)胸乳入路腔鏡甲狀腺手術(shù)應(yīng)用與優(yōu)勢(shì)[J].中華腔鏡外科雜志(電子版),2014,2(1):139-143.
[2] Xi C,Xu XQ,Hong T,et al.Extrathyroidal implantation of thyroid hyperplastic/neoplastic cells after endoscopic thyroid surgery[J].Chin Med Sci J,2014,29(3):180-184.
[3] 馬向東,韓錫林,劉濤,等.甲狀腺手術(shù)行喉返神經(jīng)解剖顯露的臨床分析[J].中華普通外科學(xué)文獻(xiàn)(電子版),2014,1(1):20-22.
[4] Dehal A,Abbas A,Al-Tememi M,et al.Impact of surgeon volume on incidence of neck hematoma after thyroid and parathyroid surgery:ten years’ analysis of nationwide in-patient sample database[J].Am Surg,2014,80(10):948-952.
[5] Ohno T,Mizukoshi A,Kimura T,et al.Perioperative management of thyroid surgery in patients treated with drug-eluting stents[J].Nihon Jibiinkoka Gakkai Kaiho, 2014,117(8):1120-1125.
[6] 趙曉春,佟冬怡,龍波,等.不同劑量右美托咪定對(duì)甲狀腺手術(shù)全麻患者蘇醒質(zhì)量的影響[J].中華危重病急救醫(yī)學(xué),2014,26(4):239-243.
[7] 溫樹信,王斌全,張春明,等.甲狀腺手術(shù)致暫時(shí)性喉返神經(jīng)麻痹[J].中華內(nèi)分泌外科雜志,2014,4(1):342-343.
[8] Canonico S,Pellino G,Pameggiani D,et al.Thyroid surgery in the elderly:a comparative experience of 400 patients from an italian university hospital[J].Int Surg,2014,99(5):523-527.
[9] 費(fèi)國(guó)猛,李保良.甲狀腺手術(shù)后呼吸道梗阻21例臨床分析[J].中華解剖與臨床雜志, 2014,19(1):62-63.
[10] Huzurbazar S,Nahata S,Nahata PS,et al.Thyroid storm following anterior cervical spine surgery for tuberculosis of cervical spine[J].J Craniovertebr Junction Spine,2014,5(2):93-94.
[11] 沈漢斌,徐旭東,蔡曉棠,等.顯露喉返神經(jīng)腔鏡甲狀腺手術(shù)與開放手術(shù)的對(duì)比[J].中華實(shí)驗(yàn)外科雜志,2013,30(1):172-173.
[12] Rulli F,Ambrogi V,Dionigi G,et al.Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring[J].Acta Otorhinolaryngol Ital,2014,34(4):223-229.
(編輯:楊穎)
Comparison and application of complete endoscopic and endoscope assisted small incision in thyroid surgery
CHEN Xu-hui,GUAN Yang-shi,AN Wen-wei,LIU Dan,JIANG Yan-fei,F(xiàn)ANG Yuan(Department of General Surgery,People’s Hospital of Luohu in Shenzhen,Guangdong 518089,China)
Abstract:ObjectiveTo study the advantages and disadvantages of the application of complete endoscopic and endoscope assisted small incision in thyroid surgery. MethodsFrom September 2010 to September 2013,279 patients with thyroid diseases in our hospital were selected as the research object.Among them,239 cases of thyroid surgery were grouped according to the surgical method,the complete endoscopic group with 95 cases,endoscope assisted small incision surgery group with 144 cases.The other 40 cases of parathyroid surgery were grouped according to the surgical method,the complete endoscopic group with 5 cases,endoscope assisted small incision group with 35 cases.The results and indicators related to the surgery with the complete endoscopic and endoscope assisted small incision for the thyroid disease and parathyroid gland were compared. ResultsAbout thyroid disease,the proportion of women in the complete endoscopic group,the adenoma or unilateral gland leaf proportion,thyroid volume,the tumor nodules longest diameter,adenoma or glandular lobe resection time,double leaf full cut or full cutting time and intraoperative blood loss were significantly higher than that of endoscope assisted small incision group,and the age,double leaf time full cut or full cut rate were significantly lower than that of endoscope assisted small incision group,the differences were statistically significant (P<0.05).About thyroid disease,proportion of chest discomfort,VAS pain score,length of hospital stay and postoperative cosmetic effect of satisfaction scores in complete endoscopic group were significantly higher than that of endoscopy assisted small incision group,the differences were statistically significant (P<0.05).About parathyroid disease,the age of patients in the complete endoscopic group was significantly lower than that in endoscopy assisted small incision group,but the operation time and hospital stay were significantly higher than that of endoscopy assisted small incision group,the differences were statistically significant (P<0.05). ConclusionThe thyroid surgery with complete endoscopic and endoscopy assisted small incision has certain advantages and disadvantages,which should be considered for patients demands,so as to make the best operation program.
Keywords:complete endoscopic;endoscopy assisted small incision;thyroid surgery;advantages and disadvantages
[收稿日期]2015-02-27[修回日期] 2015-04-02
doi:10.11659/jjssx.12E014030
[中圖分類號(hào)]R615
[文獻(xiàn)標(biāo)識(shí)碼]A
[文章編號(hào)]1672-5042(2015)05-0542-04