无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术对侧处理改进三步法（附视频）

doi:10.7659/j.issn.1005-6947.2024.05.006

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无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术对侧处理改进三步法（附视频）
DOI:
                        10.7659/j.issn.1005-6947.2024.05.006
                    
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作者单位:[1. 湖南省人民医院(湖南师范大学附属第一医院) 乳甲外科，湖南 长沙 410024;2. 湖南省老年医学研究所，湖南 长沙 410024]
作者简介:王慧玲，湖南省人民医院（湖南师范大学附属第一医院）主任医师，主要从事乳腺、甲状腺疾病基础及临床方面的研究
通信作者:张超杰，Email: zhangchaojie74@126.com
王慧玲，湖南省人民医院（湖南师范大学附属第一医院）主任医师，主要从事乳腺、甲状腺疾病基础及临床方面的研究，Email: jonnce.1018@163.com
基金项目:

The improved three-step method for contralateral treatment in gasless unilateral axillary approach-endoscopic total thyroidectomy (with video)

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Affiliation:

[1. Department of Breast and Thyroid Surgery, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha 410024, China; 2. Hunan Research Institute of Geriatrics, Changsha 410024, China]

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摘要:

随着腔镜技术的发展，腔镜甲状腺手术也得以广泛应用，目前腔镜甲状腺手术的常见入路有经胸乳、经口、经腋等，其中无充气腋窝入路腔镜甲状腺手术受到众多从事甲状腺外科医生的高度认可。该技术能够满足患者的美容需求，同时能够利用颈前肌肉的自然间隙进行手术达到微创的目的。虽然目前无充气腋窝入路腔镜甲状腺手术操作越来越成熟规范，但是在无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术（GUA-ETT）过程中，切除对侧叶时，如何避免气管的遮挡、顺利暴露对侧喉返神经并保证对侧中央区淋巴结清扫的彻底性等都是需要直接面对的困难。本中心针对单侧叶切除后行对侧叶全切除术及对侧中央区淋巴结清扫术，提出对侧处理改进三步法。为了更方便甲状腺外科医生掌握该技术，笔者就该GUA-ETT中对侧处理改进三步法的手术方法、技术特点、操作技巧及细节与操作重点、难点及操作经验进行详细阐述及分享。

Abstract:

With the advancements in endoscopic techniques, endoscopic thyroid surgery has become widely utilized. Currently, common approaches for endoscopic thyroid surgery include breast, oral vestibular, and transaxillary approach. Among them, endoscopic thyroidectomy by a gasless unilateral axillary approach has been highly recognized by many thyroid surgeons. This technique can meet patients' cosmetic needs while utilizing the natural space between neck muscles for operation to achieve the goal of minimally invasive surgery. Although the transaxillary gasless endoscopic thyroidectomy has become increasingly mature and standardized, several challenges need to be directly addressed in contralateral treatment of bilateral lobectomy during performing gasless unilateral axillary approach-endoscopic total thyroidectomy (GUA-ETT), such as avoiding tracheal obstruction, smoothly exposing the contralateral recurrent laryngeal nerve, and ensuring thorough clearance of contralateral central lymph nodes. In the authors' center, an improved three-step method for contralateral treatment and contralateral central lymph node dissection after unilateral thyroidectomy is proposed. To help thyroid surgeons master this technique, here, the authors provide a thorough explanation and sharing of the surgical methods, technical characteristics, operative techniques and nuances, as well as operative key points, difficulties, and operative experiences of the improved three-step method for contralateral treatment in GUA-ETT.

图1 Z线切口设计法示意图 A：主切口、辅助Trocar孔及主要解剖标志；B：Z线与辅助Torocar孔所成30°夹角Fig.1 Schematic diagram of Zero-line incision design method A: Main incision, auxiliary Trocar hole, and main anatomical landmarks; B: 30° angle formed by the Z-line and the auxiliary Trocar hole

图2 第一步 A：拉钩悬吊位置以中央区淋巴脂肪组织后间隙为主，将对侧喉返神经悬吊较为表浅；B：利用“桥洞法”分离寻找神经Fig.2 Step 1 A: The suspension position of the hook is mainly in the posterior space of the central lymphatic adipose tissue, making the suspension of the contralateral recurrent laryngeal nerve relatively superficial; B: Using the bridging tunnel technique to separate and locate the nerve

图3 第二步 A：拉钩悬吊位置依然以中央区淋巴脂肪组织后间隙为主，对前间隙分离后，加大悬吊力量，对侧喉返神经的位置变得更为表浅；B：从气管侧向外侧分离中央区淋巴脂肪组织Fig.3 Step 2 A: The suspension position of the hook still mainly targets the posterior space of the central lymphatic adipose tissue, and after the separation of the anterior space, the position of the contralateral recurrent laryngeal nerve became more superficial by increasing the suspension force; B: Dissociating the central lymphatic fat tissue from the tracheal side outward

图4 第三步 A：拉钩悬吊位置以甲状腺区为主；B：甲状腺受到向外的拉力，利用辅助钳可以充分显露甲状腺上极Fig.4 Step 3 A: The suspension position of the hook is mainly in the thyroid area; B: With the thyroid under outward tension, the upper pole of the thyroid can be fully exposed by use of auxiliary forceps

图 Fig.

图5 对侧处理改进三步法第一步 A-B：“桥洞法”分离寻找神经；C-D：拉钩悬吊位置以中央区淋巴脂肪组织后间隙为主，将对侧喉返神经悬吊较为表浅Fig.5 Step 1 of the improved three-step method of contralateral treatment A-B: Separation and location of the nerve using the bridging tunnel technique; C-D: The suspension position of the hook is mainly in the posterior space of the central lymphatic adipose tissue, making the suspension of the contralateral recurrent laryngeal nerve relatively superficial

图 Fig.

图6 对侧处理改进三步法第二步 A-B：拉钩悬吊位置依然以中央区淋巴脂肪组织后间隙为主，加大悬吊力量；C-D：对侧喉返神经的位置变得更为表浅；E-F：从气管侧向外侧分离中央区淋巴脂肪组织Fig.6 Step 2 of the improved three-step method of contralateral treatment A-B: The suspension position of the hook still targets the posterior gap of the central lymphatic adipose tissue, with increased suspension force; C-D: The position of the contralateral recurrent laryngeal nerve becomes even shallower; E-F: Dissociating the central lymphatic adipos tissue from the tracheal side outward

图 Fig.

图7 对侧处理改进三步法第三步 A-B：拉钩悬吊位置以甲状腺区为主；C-D：利用辅助钳充分显露甲状腺上极Fig.7 Step 3 of the improved three-step method of contralateral treatment A-B: The suspension position of the hook is mainly in the thyroid area; C-D: Full exposure of the upper pole of the thyroid by using auxiliary forceps

图8 采用对侧处理改进三步法完成对侧处理后情况 A：经右侧腋窝入路手术对侧处理后；B：经左侧腋窝入路手术对侧处理后Fig.8 Completion of contralateral treatment using the improved three-step method A: Completion of contralateral treatment via the right axillary approach; B: Completion of contralateral treatment via the left axillary approach