由外向内显露喉返神经入喉处并逆行解剖喉返神经在甲状腺手术中的临床应用探讨

摘要

Objective To explore the optimal indication of anatomical exposure of recurrent larygeal nerve (RLN)at the palce where it enters laryx using outside to inside methods in thyroid surgery. Methods We made a retrospective study of 18 cases who received the outside to inside method of anatomical exposure of RLN at the palce where it enters laryx in thyroid surgery from January 2011 to July 2016. 15 cases were female and 3 cases were male, the age ranged from 17 to 78 years. 8 cases were the giant thyroid tumour (including substernal goiter), 7 cases were thyroid cancer with tracheoesophageal groove lymph node metastasis,4 cases were postoperative adhesion of tracheoesophageal groove surrounding area. (Among all cases, 1 case was at the same time the two times of operation with tracheoesophageal groove lymph node metastasis and adhesion), All cases had received the outside to inside method of anatomical exposure of RLN at the palce where it enters laryx. A total of 24 RLNs were exposed successfully for avoiding the injury of the nerve. Results RLNs of all cases were exposed successfully and the next step operations were completed successfully, while no one showed the clinical symptoms of the RLN injury. Conclusion When the case is the following condition, such as the giant thyroid tumour or substernal goiter made it hard to expose the lower-middle part of thyroid, postoperative adhesion of tracheoesophageal groove surrounding area, thyroid cancer with tracheoesophageal groove lymph node metastasis and adhesion, we recommend using thernoutside to inside method of anatomical exposure of RLN at the palce where it enters laryx, then retrograde dissect the RLN. This method can improve surgery efficiency and reduce the risk of RLN injury.%目的 探讨由外向内显露喉返神经入喉处并逆行解剖喉返神经在甲状腺手术中的最佳适应症.方法 选取2011年1月至2016年7月之间的在甲状腺手术中采用由外向内显露喉返神经入喉处并逆行解剖喉返神经的病例进行分析,共18例,其中男性3例,女性15例,年龄17岁到78岁,其中巨大甲状腺肿瘤(含胸骨后甲状腺肿)8例,甲状腺癌气管食管沟淋巴结转移7例,甲状腺中下部曾行手术致使下方气管食管沟处疤痕粘连的4例(所有病例中有1例同时为二次手术合并气管食管沟淋巴结转移并粘连),所有患者均采用由外向内显露喉返神经入喉处并逆行解剖喉返神经,共解剖喉返神经24侧.结果 所有病例均成功显露喉返神经入喉处并逆行解剖喉返神经后行相应手术,术后所有患者无一例出现喉返神经损伤的症状.结论 当甲状腺肿瘤巨大或胸骨后甲状腺肿导致甲状腺下极难以完全暴露、手术后气管食管沟中下部粘连、气管食管沟淋巴结肿大伴粘连的患者建议从喉返神经入喉处自外向内寻找喉返神经,后逆行向下解剖,该方法可提高手术效率,降低喉返神经损伤率.