无充气腋窝入路全腔镜下甲状腺切除术的“场景式”扶镜技巧与质量控制

doi:10.7659/j.issn.1005-6947.2024.05.007

首页 > 按期查看>2024年第5期 >742-752. DOI:10.7659/j.issn.1005-6947.2024.05.007

无充气腋窝入路全腔镜下甲状腺切除术的“场景式”扶镜技巧与质量控制
DOI:
                        10.7659/j.issn.1005-6947.2024.05.007
                    
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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:方茜，湖南省人民医院（湖南师范大学附属第一医院）主治医师，主要从事乳腺、甲状腺良恶性肿瘤外科诊疗方面的研究
通信作者:张超杰，Email: zhangchaojie74@126.com
王慧玲，Email: jonnce.1018@163.com
基金项目:

"Scene-based" camera-holding skills and quality control for gasless axillary total endoscopic thyroidectomy

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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:

随着腔镜甲状腺手术的发展及推广，该手术方式被越来越多的医疗中心和患者接受，但因其操作空间相对腹腔镜和胸腔镜更狭小，且镜头和主刀的操作器械共用空间，两者相互干扰及视角显露等问题，常成为影响手术的难点。为解决该问题，笔者从扶镜手的视觉角度出发，引入场景式的概念，通过三个部分规范无充气腋窝全腔镜下甲状腺切除手术中扶镜手的操作要点及质量控制。第一部分为规范术前准备及扶镜手操作区域的划分；第二部分为扶镜操作要点：“眼关六路、三个平面、进退展转”的十二字扶镜质量控制；第三部分为三层递进镜下视野场景的扶镜质量控制：将手术区域分为喉返神经区、甲状腺上极区、气管前区，借此来规范扶镜手在不同场景的扶镜要点和视角引导。通过扶镜技巧与质量控制，手术过程中的视野显露更充分、清晰，视觉引导更流畅，镜头、器械之间的相互干扰更小，术中平均擦拭或浸泡镜头次数显著减少，甚至手术过程中无需二次擦镜，保证操作的连续性，节省了手术时间。笔者就以上要点、操作技巧及细节进行阐述。

Abstract:

With the development and popularization of endoscopic thyroidectomy, this surgical approach is increasingly accepted by more medical centers and patients. However, due to its relatively narrow operating space compared to laparoscopy and thoracoscopy, as well as issues such as the shared space between the lens and the surgical instruments manipulated by the primary surgeon, mutual interference, and limited visibility, it often becomes a challenging aspect of the surgery. To address this issue, the authors, from the perspective of the camera-holding assistant, introduce the concept of scene-based guidance. This is achieved by standardizing the key points of operation and quality control for camera-holding assistant during gasless axillary endoscopic thyroidectomy in three parts. The first part standardizes preoperative preparation and the division of the operating area of the camera-holding assistant. The second part outlines the key points of endoscope operation: "YAN GUAN LIU LU, SAN GE PING MIAN, JIN TUI ZHAN ZHUAN" a twelve-character quality control mantra for the camera holding. The third part focuses on the quality control of the endoscopic view field in three progressively deeper levels: dividing the surgical area into the recurrent laryngeal nerve area, the upper pole of the thyroid area, and the pre-tracheal area, thereby standardizing the key points and visual guidance for the camera-holding assistant in different scenarios. Through camera-holding skills and quality control, the surgical field is more fully and clearly visible, visual guidance is smoother, mutual interference between the lens and instruments is reduced, the average number of lens wipes or soaks during surgery is significantly reduced, and even secondary wiping of the lens during surgery is unnecessary, ensuring continuous operation and saving surgical time. Here, the authors elaborate on the above points, operation techniques, and details

图1 以拉钩为顶端，平行于胸大肌表面为底面的三角形区域，助手的操作活动范围为腔隙建立后切口近头端1/2的区域（蓝色三角形）；术者的操作范围为腔隙建立后近足侧1/2的区域（黄色三角形）Fig.1 The triangular area, with the hook as the apex and parallel to the surface of the pectoralis major muscle as the base, defines the working area for the assistant, which covers the proximal half of the incision after the establishment of the working space (blue triangle); the surgeons working area covers the distal half of the incision after the establishment of the working space, towards the lateral aspect (yellow triangle)

图2 腋窝入路双手扶镜 A：右侧入路；B：左侧入路Fig.2 Axillary approach with two-handed endoscope holding A: Right-sided approach; B: Left-sided approach

图3 胸大肌平面 A：于胸大肌平面游离皮瓣；B：沿肌间沟找到胸锁乳突肌胸骨头、锁骨头之间的间隙；C：将拉钩置入胸锁乳突肌胸骨头、锁骨头之间的间隙（视角重点为黄色区域）Fig.3 Pectoralis major plane A: Dissecting the skin flap along the plane of the pectoralis major muscle; B: Identifying the space between the sternal head and clavicular head of the sternocleidomastoid muscle along the muscle interstice groove; C: Inserting the retractor into the space between the sternal head and clavicular head of the sternocleidomastoid muscle (focus on the yellow area)

图6 三层递进场景区域划分（上界为胸骨甲状肌，下界为颈血管鞘内侧缘，头侧分界为甲状腺上极，足侧分界为无名动脉上方，以肩胛舌骨肌下缘及气管水平分别为标记线，将上述操作范围分为喉返神经区、甲状腺上极区、气管前区）Fig.6 Three-layer progressive scene area division (with the upper boundary being the sternothyroid muscle, the lower boundary being the inner edge of the cervical vascular sheath, the cephalic boundary being the upper pole of the thyroid gland, and the caudal boundary being above the brachiocephalic trunk; using the lower border of the omohyoid muscle and the level of the trachea as reference lines, the above-mentioned operating area is divided into the recurrent laryngeal nerve area, the upper pole of the thyroid area, and the pre-tracheal area)

图7 喉返神经区域 A：找到甲状腺下动脉及喉返神经；B：视角角度为从近头侧向足侧及底面（浅黄色区域）；C：游离喉返神经；D：视角角度为从近头侧向足侧，光纤稍偏向足侧（浅黄色区域）；E：上下夹击，将食管前间隙与喉返神经后方的淋巴脂肪组织（右VIB区）游离；F：让视角角度从足侧到头侧（浅黄色区域）Fig.7 Recurrent laryngeal nerve area A: Identifying the inferior thyroid artery and recurrent laryngeal nerve; B: View angle from the cephalic side to the caudal and basal side (light yellow area); C: Dissecting the recurrent laryngeal nerve; D: Clamping and dissecting the lymphatic adipose tissue behind the recurrent laryngeal nerve and the pre-esophageal space (right VIB area); E: View angle from the cephalic side to the caudal side, with the fiber optic slightly inclined towards the caudal side; F: Changing the view angle from the foot side to the head side (light yellow area)

图8 甲状腺上极区 A：打开环甲间隙；B：离断甲状腺上极血管，将甲状腺上极完全游离；C：视角角度从头侧向足侧，同时显露术野的顶部和底部（浅黄色区域）Fig.8 Upper pole of the thyroid area A: Opening the cricothyroid space; B: Ligation of the superior thyroid vessels and complete isolation of the upper pole of the thyroid gland; C: View angle from the cephalad side to the caudad side, simultaneously exposing the top and bottom of the surgical field (light yellow area)

图9 气管前区 A：将甲状腺前被膜从带状肌上分离；B：视角角度从头侧向足侧，同时显露术野的顶部和底部（浅黄色区域）；C：于带状肌下将右中央区组织分离；D：在气管前将右中央区组织分离；E：由下而上分离甲状腺峡部；F：视觉角度从足侧至头侧（浅黄色区域）Fig.9 Pre-tracheal area A: Separating the thyroid pretracheal fascia from the strap muscle; B: View angle from the cephalic side to the caudal side, simultaneously exposing the top and bottom of the surgical field (light yellow area); C: Tissue separation of the right central area below the strap muscle; D: Tissue separation of the right central area in front of the trachea; E: Separating the isthmus of the thyroid gland from bottom to top; F: Visual angle from foot to head (light yellow area)