内镜甲状腺手术的外科平面和解剖标志
发布时间：2018-11-02 18:06
【摘要】： 背景 近年来随着腹腔镜手术的发展,腔镜下解剖学研究成为了一门新兴的学科。传统的开放手术,其解剖学研究已经非常深入和透彻,而腔镜下解剖学的研究才刚刚开始。内镜甲状腺手术(endoscopic thyroidectomy, ET)开展了将近20年,但是我们查阅了相关文献,了解到内镜甲状腺手术的腔镜下解剖学研究非常之少。我们通过一系列的尸体及临床解剖学研究,找到了内镜甲状腺手术的相关外科平面和解剖标志,以期指导腔镜外科医生更安全地实施手术。 第一部分内镜甲状腺手术的尸体解剖学研究 一、研究目的 我们在本研究中,通过对尸体模拟经胸前壁径路的内镜甲状腺手术,找到了一系列组织层面和组织结构间的相互位置关系。对内镜甲状腺手术的解剖学研究进行了初步探讨,以指导下一步的研究工作。 二、研究方法 我们对3个尸体标本进行了内镜甲状腺手术的解剖学研究,其中1个为新鲜标本,2个为10%福尔马林固定的标本,均为广州南方医科大学解剖学教研室受捐赠的标本。3个标本均无甲状腺方面的病史体征。我们对标本模拟施行了内镜甲状腺手术,由于实验室使用二氧化碳(C02)条件的限制,我们将胸前和颈前的操作空间分离开后,将整个胸、颈的皮瓣向头侧翻起,使甲状腺区域的操作空间完全暴露,在对甲状腺区域进行解剖时,均遵循内镜手术下从尾侧到头侧的操作方向。解剖过程当中,我们对各解剖操作进行了全程拍照。 三、结果 (一)层面 1、胸前壁浅筋膜与胸大肌筋膜之间有一疏松的筋膜间隙,胸前壁操作层面位于此筋膜间隙。 2、颈阔肌与颈前深筋膜浅层之间有一疏松的间隙,颈前操作层面位于此间隙；颈阔肌尾侧起源于颈胸交界,位于皮下浅筋膜深面而紧贴皮下浅筋膜。 3、胸前壁的胸大肌筋膜与颈前的深筋膜浅层为一连续的筋膜层面。 4、内镜甲状腺分离三角是寻找甲状腺下动脉和甲状腺中静脉的一个重要层面,位于带状肌与甲状腺腺叶之间。 5、甲状旁腺被甲状腺外科被膜所包裹,甲状旁腺与甲状腺之间有一筋膜间隙。 6、在模拟内镜下颈中央区淋巴结清扫术中,我们发现有一层筋膜组织包裹着中央区淋巴结组,分离过程中完整保留此包膜,可以使淋巴结和其他组织(甲状旁腺、喉返神经以及胸腺组织等)安全地分离开；胸腺组织也有其自身包膜,紧贴包膜外分离可避免在清扫淋巴结时切除部分胸腺组织,或者避免淋巴结清扫不干净的情况。 (二)特殊的组织结构位置关系 1、喉返神经位于甲状旁腺的深面。 2、有一血管与喉返神经的走形平行,并位于喉返神经的浅面。 3、上甲状旁腺与甲状腺中静脉邻近,同时上甲状旁腺与喉返神经入喉位置处于相同水平面。 4、喉上神经的外支紧贴环甲肌于甲状软骨中下段入喉。 四、讨论 内镜甲状腺的外科平面在实际操作中是否正确,我们可以通过本研究发现的胸前和颈前组织层面来证实,答案是肯定的。我们研究中发现的其他疏松层面可以指导外科医生在实施内镜甲状腺手术时如何保护重要的组织结构,如在颈中央区淋巴结清扫术中保护甲状旁腺和喉返神经。在我们研究中发现的组织结构特殊的位置关系可以指导外科医生安全地施行内镜甲状腺手术,避免损伤重要的结构,同时还可以指导我们如何进一步寻找相关的解剖标志。 第二部分内镜甲状腺手术的临床解剖学研究 一、研究目的 在内镜甲状腺手术中,由于使用器械使外科医生缺乏手的触觉,以及操作方向的限制等缺点,寻找合适的外科平面以及解剖标志显得非常重要,本研究的目的即在于此。 二、研究方法 通过采集83例经胸前壁入路内镜甲状腺手术病例的手术录像及图片,观察并记录相关外科平面和解剖标志。其中女性74例,男性9例；手术在甲状腺右叶者69例,左叶者30例。其中7例患者的单侧手术标本被冰冻病理切片检查诊断为恶性肿瘤。 三、结果(一)外科平面 1、胸部的操作空间位于浅筋膜和胸大肌筋膜之间,颈前操作空间位于颈阔肌和颈深筋膜浅层之间,这两个操作平面为相互连续的。 2、内镜甲状腺分离三角位于带状肌和甲状腺叶之间,在该外科平面中可寻找到甲状腺下动脉(100.0%)和甲状腺中静脉(100.0%)。 (二)解剖标志 1、在甲状腺下动脉深面可发现下甲状旁腺(90.0%),甲状腺下动脉可作为寻找下甲状旁腺的解剖标志。 2、在下甲状旁腺深面可发现喉返神经(85.7%),下甲状旁腺可作为寻找喉返神经的解剖标志。 3、在甲状腺叶背侧、甲状腺中静脉附近可发现上甲状旁腺(90.0%),甲状腺中静脉可作为寻找上甲状旁腺的解剖标志。 4、甲状腺区域段的喉返神经恒定从甲状软骨后下角入喉(100.0%)。通常,在喉返神经入喉处浅面会发现一条与喉返神经走形垂直的血管(V1)(100.0%)；有时,在气管食管沟会发现一条与喉返神经走形平行的血管(V1),该血管深面可发现喉返神经(40.0%)。V1和V2均可作为寻找喉返神经的解剖标志。 四、讨论 由于内镜甲状腺手术中狭小的操作空间以及从尾侧到头侧限制性的操作方向,相关外科平面和解剖标志的知识对于外科医生来说尤其重要。正确的外科平面和解剖标志可以指导我们在手术中如何保护重要的组织结构,如喉返神经和甲状旁腺。 结论 在甲状腺手术中,内镜手术由于其术后较好的美容效果,已经越来越多地应用于临床。不同个体甲状腺肿瘤的位置变化多样,内镜甲状腺手术的系统解剖学知识,可以为外科医生在实施手术中提供一个清晰的手术思路,这一点对于初学者来说尤为重要。腔镜下解剖学今后应该成为腔镜外科医生的一门基础学科,相信随着腔镜手术应用的越来越广泛化,腔镜下解剖学的研究领域将逐渐扩大及深入。
[Abstract]:Background In recent years, with the development of laparoscopic surgery, the anatomy of the cavity has become a new subject Subject. Traditional open surgery, its anatomical study has been very deep and thorough, and the anatomy of the cavity has just been studied. The endoscopic thyroidectomy (ET) has just begun for nearly 20 years, but we have consulted the literature to learn about the anatomy of endoscopic thyroidectomy. Often less, we have found the surgical planes and anatomical landmarks of endoscopic thyroidectomy through a series of bodies and clinical anatomical studies, with a view to guiding the surgeon to be safer and more secure Operation. First partial endoscopic thyroidectomy anatomy of the body For the purpose of this study, we have found a series of tissues by simulating the endoscopic thyroidectomy via the chest wall approach. The interpositional relationship between the level and the structure of the tissue. The anatomical study of endoscopic thyroidectomy was initially studied. Step through to refer to Next, we studied the anatomy of endoscopic thyroidectomy in three body specimens. 1 fresh specimen and 2 samples of 10% formalin fixed to the anatomy teaching and research section of Guangzhou Southern Medical University The donated specimens showed no signs of thyroid history in the 3 specimens. We performed endoscopic thyroidectomy for the specimen simulation. As a result of the laboratory use of carbon dioxide (C02) conditions, we left the entire chest, neck, The flap is turned over to the head so that the operation space of the thyroid area is completely exposed, and in the thyroid area During dissection, follow the operation direction of the endoscope procedure from the tail side to the head side. Dissect Of course, I The anatomy was photographed all the way. 3. Results (i) Level 1, chest wall There is a loose fascial space between the superficial fascia and the pectoral muscle fascia, which is located at the operation level of the chest wall. There is a loose gap between the fascia and the superficial fascia of the neck. It is located in this gap; the tail side of the latissimus latissimus originates from the junction of the neck and the chest, and is located in the deep subcutaneous superficial fascia. subcuticular superficial fascia. The superficial fascia of the chest wall and the superficial fascia of the anterior cervical fascia are a continuous fascia layer. Endoscopic thyroidectomy is an important aspect of the search for thyroid artery and thyroid veins. Between the band muscle and the thyroid gland lobe. 5. The parathyroid gland is surrounded by a membrane of thyroid surgery. There is a fascia gap between the parathyroid glands and the thyroid gland. During the scan, we found that there was a layer of fascial tissue wrapped in the lymph node group, the complete retention of the envelope during the separation, and the safe separation of lymph nodes and other tissues (parathyroid, recurrent laryngeal nerve, and thymus tissue, etc.) The thymus tissue also has its own envelope, It is possible to avoid the dissection of lymph nodes in close contact with the outside of the capsule. Partial thymus tissue should be cut off, or dissection of lymph nodes should be avoided. (2) Special structural positional relationship 1. The recurrent laryngeal nerve is located at the deep surface of the parathyroid gland. There is a blood vessel that is parallel to the shape of the recurrent laryngeal nerve and is located at the back of the recurrent laryngeal nerve. Face. 3. The upper parathyroid gland is adjacent to the thyroid gland, while the upper parathyroid gland and the recurrent laryngeal nerve enter the laryngeal position at the same level. To discuss whether the surgical plane of endoscopic thyroidectomy is correct in actual operation, we can adopt the anterior chest and anterior cervical group found in this study. To confirm that the answer is positive, the other loose aspects found in our study can direct the surgeon to protect important tissue structures during endoscopic thyroidectomy, such as protecting a nail in cervical lymph node dissection. Dorsal glands and recurrent laryngeal nerve. Groups found in our study woven with special structure The positional relationship can guide the surgeon to safely perform endoscopic thyroidectomy, avoid damaging important structures, and also refer to How do we further look for relevant anatomical landmarks? Second part endoscopic thyroidectomy Clinical anatomy of Study I. The purpose of this study was in endoscopic thyroidectomy due to the use of the device to give the surgeon a lack of hand tactile sense, as well as operation It is very important to find suitable surgical planes and anatomical landmarks in order to find suitable surgical planes and anatomical landmarks. the purpose of the study is that this. 2, the method of study is obtained by collecting 83 cases, Endoscopic thyroidectomy via chest wall The surgical video and pictures of the surgical cases were recorded and recorded. The related surgical plane and anatomical landmarks were observed and recorded. Among them, 74 were female, 9 in men, 69 in right lobe of thyroid, left lobe, One-sided surgical specimen of 7 patients was diagnosed as malignant tumor by frozen pathological section. Results (1) Surgical plane (1) and chest (1) were located in the surgical plane (1). superficial fascia and pectoralis major Between the fascia and the superficial fascia of the neck, the anterior operating space of the neck is continuous with each other. Hypothyroid artery (100. 0%) can be found in the surgical plane. Intrathyroid vein (100. 0%). (2) Anatomical sign 1. Hypoparathyroidism can be found in deep surface of thyroid artery (90. 0%) and the lower thyroid artery can be used as the anatomical marker for finding the hypoparathyroidism. The recurrent laryngeal nerve (85.7%), hypoparathyroidism could be used as the anatomical marker for the search for recurrent laryngeal nerve. 3. On the back side of the thyroid lobe, the upper parathyroid gland (90. 0%) can be found near the vein of the thyroid gland. the thyroid gland veins can be used as the anatomical marker for finding the upper parathyroid gland. 4. The recurrent laryngeal nerve in the thyroid area segment constant from nail In general, a blood vessel (1) (100. 0%) perpendicular to the recurrent laryngeal nerve was found on the superficial side of the laryngeal nerve entering the larynx (100. 0%); At the same time, a blood vessel (V1) parallel to the recurrent laryngeal nerve is found in the tracheoesophageal groove, which can find the recurrent laryngeal nerve (40. 0%). V1 and V2 can be used as anatomical landmarks for the search for recurrent laryngeal nerve. IV. Discussion is due to Knowledge of surgical planes and anatomical landmarks is particularly important for the surgeon in the narrow operating space in endoscopic thyroidectomy and the direction of operation that is restricted from the tail side to the head side. The correct surgical plane and anatomical landmarks may How to protect important tissue structures such as recurrent laryngeal nerve and parathyroid gland during surgery. Conclusion In thyroid surgery, endoscopic surgery is a good cosmetic effect after surgery
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2010
【分类号】：R653;R322
，
本文编号：2306549
[Abstract]:Background In recent years, with the development of laparoscopic surgery, the anatomy of the cavity has become a new subject Subject. Traditional open surgery, its anatomical study has been very deep and thorough, and the anatomy of the cavity has just been studied. The endoscopic thyroidectomy (ET) has just begun for nearly 20 years, but we have consulted the literature to learn about the anatomy of endoscopic thyroidectomy. Often less, we have found the surgical planes and anatomical landmarks of endoscopic thyroidectomy through a series of bodies and clinical anatomical studies, with a view to guiding the surgeon to be safer and more secure Operation. First partial endoscopic thyroidectomy anatomy of the body For the purpose of this study, we have found a series of tissues by simulating the endoscopic thyroidectomy via the chest wall approach. The interpositional relationship between the level and the structure of the tissue. The anatomical study of endoscopic thyroidectomy was initially studied. Step through to refer to Next, we studied the anatomy of endoscopic thyroidectomy in three body specimens. 1 fresh specimen and 2 samples of 10% formalin fixed to the anatomy teaching and research section of Guangzhou Southern Medical University The donated specimens showed no signs of thyroid history in the 3 specimens. We performed endoscopic thyroidectomy for the specimen simulation. As a result of the laboratory use of carbon dioxide (C02) conditions, we left the entire chest, neck, The flap is turned over to the head so that the operation space of the thyroid area is completely exposed, and in the thyroid area During dissection, follow the operation direction of the endoscope procedure from the tail side to the head side. Dissect Of course, I The anatomy was photographed all the way. 3. Results (i) Level 1, chest wall There is a loose fascial space between the superficial fascia and the pectoral muscle fascia, which is located at the operation level of the chest wall. There is a loose gap between the fascia and the superficial fascia of the neck. It is located in this gap; the tail side of the latissimus latissimus originates from the junction of the neck and the chest, and is located in the deep subcutaneous superficial fascia. subcuticular superficial fascia. The superficial fascia of the chest wall and the superficial fascia of the anterior cervical fascia are a continuous fascia layer. Endoscopic thyroidectomy is an important aspect of the search for thyroid artery and thyroid veins. Between the band muscle and the thyroid gland lobe. 5. The parathyroid gland is surrounded by a membrane of thyroid surgery. There is a fascia gap between the parathyroid glands and the thyroid gland. During the scan, we found that there was a layer of fascial tissue wrapped in the lymph node group, the complete retention of the envelope during the separation, and the safe separation of lymph nodes and other tissues (parathyroid, recurrent laryngeal nerve, and thymus tissue, etc.) The thymus tissue also has its own envelope, It is possible to avoid the dissection of lymph nodes in close contact with the outside of the capsule. Partial thymus tissue should be cut off, or dissection of lymph nodes should be avoided. (2) Special structural positional relationship 1. The recurrent laryngeal nerve is located at the deep surface of the parathyroid gland. There is a blood vessel that is parallel to the shape of the recurrent laryngeal nerve and is located at the back of the recurrent laryngeal nerve. Face. 3. The upper parathyroid gland is adjacent to the thyroid gland, while the upper parathyroid gland and the recurrent laryngeal nerve enter the laryngeal position at the same level. To discuss whether the surgical plane of endoscopic thyroidectomy is correct in actual operation, we can adopt the anterior chest and anterior cervical group found in this study. To confirm that the answer is positive, the other loose aspects found in our study can direct the surgeon to protect important tissue structures during endoscopic thyroidectomy, such as protecting a nail in cervical lymph node dissection. Dorsal glands and recurrent laryngeal nerve. Groups found in our study woven with special structure The positional relationship can guide the surgeon to safely perform endoscopic thyroidectomy, avoid damaging important structures, and also refer to How do we further look for relevant anatomical landmarks? Second part endoscopic thyroidectomy Clinical anatomy of Study I. The purpose of this study was in endoscopic thyroidectomy due to the use of the device to give the surgeon a lack of hand tactile sense, as well as operation It is very important to find suitable surgical planes and anatomical landmarks in order to find suitable surgical planes and anatomical landmarks. the purpose of the study is that this. 2, the method of study is obtained by collecting 83 cases, Endoscopic thyroidectomy via chest wall The surgical video and pictures of the surgical cases were recorded and recorded. The related surgical plane and anatomical landmarks were observed and recorded. Among them, 74 were female, 9 in men, 69 in right lobe of thyroid, left lobe, One-sided surgical specimen of 7 patients was diagnosed as malignant tumor by frozen pathological section. Results (1) Surgical plane (1) and chest (1) were located in the surgical plane (1). superficial fascia and pectoralis major Between the fascia and the superficial fascia of the neck, the anterior operating space of the neck is continuous with each other. Hypothyroid artery (100. 0%) can be found in the surgical plane. Intrathyroid vein (100. 0%). (2) Anatomical sign 1. Hypoparathyroidism can be found in deep surface of thyroid artery (90. 0%) and the lower thyroid artery can be used as the anatomical marker for finding the hypoparathyroidism. The recurrent laryngeal nerve (85.7%), hypoparathyroidism could be used as the anatomical marker for the search for recurrent laryngeal nerve. 3. On the back side of the thyroid lobe, the upper parathyroid gland (90. 0%) can be found near the vein of the thyroid gland. the thyroid gland veins can be used as the anatomical marker for finding the upper parathyroid gland. 4. The recurrent laryngeal nerve in the thyroid area segment constant from nail In general, a blood vessel (1) (100. 0%) perpendicular to the recurrent laryngeal nerve was found on the superficial side of the laryngeal nerve entering the larynx (100. 0%); At the same time, a blood vessel (V1) parallel to the recurrent laryngeal nerve is found in the tracheoesophageal groove, which can find the recurrent laryngeal nerve (40. 0%). V1 and V2 can be used as anatomical landmarks for the search for recurrent laryngeal nerve. IV. Discussion is due to Knowledge of surgical planes and anatomical landmarks is particularly important for the surgeon in the narrow operating space in endoscopic thyroidectomy and the direction of operation that is restricted from the tail side to the head side. The correct surgical plane and anatomical landmarks may How to protect important tissue structures such as recurrent laryngeal nerve and parathyroid gland during surgery. Conclusion In thyroid surgery, endoscopic surgery is a good cosmetic effect after surgery
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2010
【分类号】：R653;R322
，
本文编号：2306549
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