浅筋膜间隙内分离的微创价值
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摘要
一、研究背景与目的：
经典的甲状腺手术切口由100多年前德国医师Kocher所定义，通常为胸骨上切迹3-4cm以上5-10cm长的弧形切口。随着社会的发展，包括生理微创和心理微创的全方面微创理念逐渐深入人心，隐藏颈部切口的内镜甲状腺手术也应运而生。1996年Gagner成功完成了世界首例内镜甲状旁腺次全切除术，随后，Miccoli于同年报道了首例内镜辅助甲状腺切除术，Hüscher等于1997年报道了首例颈外途径完全内镜甲状腺手术。随着技术的进步衍化出了包括单孔内镜、机器人、经自然孔道甲状腺切除术等不下20多种不同径路、不同类型的手术方式。有别于以自然腔隙(如胸腔、腹腔及关节腔等)为主要操作空间的腔镜微创手术，此种内镜外科手术多以皮下分离建立人造腔隙为基础，可以说是为微创外科的突破性发展创建了重要的平台。
目前，皮下人造腔隙内的内镜外科手术已被临床外科医师所重视，其中的典型代表便是颈外途径的胸乳径路内镜甲状腺手术(breast approach endoscopic thyroidectomy,BAET)。由于远离颈部、切口相对隐蔽，BAET非常迎合占主要患病群之青年女性的美容要求，达到了所谓的心理微创；同时，有别于耳后、腋窝及经口入路等相对复杂或受限于病变部位的内镜手术，BAET因较之具有一定的总体优势而受到临床医师的欢迎，尤以国内更甚。目前部分文献报道：BAET在密闭的空间中采用微创操作技术，具有降低手术创伤的因素；小于10mmHg的持续皮下CO2低压充气并不增加诸如高碳酸血症、酸中毒等血流动力学方面的并发症；BAET较开放手术并不增加手术时间、术中失血量少、术后伤口愈合更好更快，其生理和心理创伤总和小于传统手术；而颈部小切口手术在降低手术创伤的同时并不提高患者满意度。然而，BAET需行较广泛的前胸壁皮下分离，由此所致的生理创伤使众多临床医师习惯性视其为单纯的美容手术而非微创手术。皮下广泛人为分离作为争议焦点的同时也成为限制BAET进一步临床推广的主要因素。因此，在保证切口远离颈部、手术美容效果满意的前提下，寻找并证实皮下某个层次内的分离有相对的微创效果具有重要意义。
近年来，在对皮下浅筋膜相关结构的再认识过程中发现，浅筋膜深层的膜样层与深筋膜之间的筋膜间隙(fascial cleft, FC)被认为可能是行人造腔隙内微创手术的解剖基础。从胚胎起源上讲，隶属于浅筋膜的膜样层与其相邻的深筋膜层属不同胚层发育来源。这种不同胚层来源的组织互相附着多表现为疏松的粘连，从而形成了所谓筋膜之间的间隙。按照Ferreira等提出的体表地层学原理，人体与脊椎动物一样由相同或不同的连续组织层层叠加组成各种体表结构，这也是人体断层解剖的基础。Abu-Hijleh等经过大体结构及B超影像检查等证实了FC这一皮下的体表结构在人体内广泛存在。Zobrist等运用球囊扩张器在上下肢筋膜内隙内分离、操作，并推测FC内的手术与传统手术比较具有微创效果。然而，基于皮下各层次内分离操作的动物或临床对照研究以及相关结构的组织解剖学研究目前尚无报道，有必要进一步研究论证皮下FC的这一特定结构是人造腔隙内手术微创性的基础，从而指导和拓展包括BAET等人造腔隙内手术的临床应用。
本研究内容包括三部分。第一部分：通过随机对照不同皮下分离面积对BAET手术效果的影响，揭示BAET存在潜在微创性的可能；第二部分：观察并证实SD大鼠皮下FC的存在及间隙内微创操作可行性的解剖学基础；第三部分：随机区组对照大鼠皮肤不同切口及皮下不同层次内分离致血清炎症介质水平的变化，证实FC内分离具微创性。
二、资料与方法：
（一）按纳入、排除及剔除标准，将第二军医大学附属长征医院普外科2011年9月至2012年3月期间连续的BAET手术病例按皮下分离面积的大小随机分成2组，即标准分离组(n=32)和有限分离组组(n=33)。有限分离组手术为从中央切口经长隧道扇形建立3条皮下隧道，通过潜行通路与胸壁及颈前操作空间连接，使皮下组织分离局限于胸壁上部，从而显著减小皮下分离面积。比较组间在人口统计学(包括患者性别、年龄及体重指数)、病理解剖学(包括甲状腺肿块单侧抑或双侧、肿块最大直径和病理类型)及手术相关数据(包括术中情况、术后恢复情况及术后并发症发生情况)等方面的差异。
（二）取第二军医大学动物实验中心的SD大鼠雌雄各5只，以超声影像、大体解剖及HE染色法观察胸腹壁皮下结构。
（三）将32只雄性SD大鼠随机分为4组，即实验组1：常规切口+FC内分离；实验组2：常规切口+真皮下分离；实验组3：常规切口+FC内扩大分离；实验组4：扩大切口+FC内分离。比较各组在术后2h、12h、24h及48h血清IL-6和中性粒细胞弹性蛋白酶(neutrophil elastase, NE)变化水平。
三、结果：
（一）标准分离组与有限分离组在人口统计学和病理解剖学方面比较差异无统计学意义。有限分离组前胸壁皮下分离面积为93.87±14.84cm2，显著低于标准分离组的136.60±23.05cm2(p=0.000)，其他手术相关数据包括术中、术后及并发症情况两者间差异并无统计学意义。
（二）SD大鼠胸腹壁皮下FC结构超声影像清晰可见，表现为连续的极低回声区。大体解剖中见浅筋膜表现为散布细小血管的淡红色菲薄质韧膜样组织。其深面即FC内的分离极为容易。HE染色进一步证实FC的存在。
（三）血清IL-6和NE增量水平各组间比较，实验组1和3差异无统计学意义(分别为P=0.074，P=0.096)；实验组2和4差异亦无统计学意义(分别为P=0.747，P=0.897)；实验组1、3与2、4的IL-6及NE增量值交叉比较差异有统计学意义(均为P＜0.01)，表现为实验组2、4术后IL-6及NE各时相的增量值显著大于实验组1、3。
四、结论：
（一）皮下分离面积的大小并不是影响BAET术后效果及手术创伤的主要因素，而术中是否保持在皮下FC内的分离才是更为重要的影响因素。
（二）大鼠皮下组织内FC结构与人体类似，表现为浅深筋膜之间的疏松间隙；FC这一结构是间隙内分离操作具有相对微创性的解剖基础。
（三）相对于较大的皮肤切口或真皮下的分离，结合皮肤小切口在大鼠皮下FC内的分离操作具有微创性。
Background and objective: The typical incision of thyroidectomy was defined byGerman Dr. Kocher one hundred years age, which was described as a5-10cm curvilinearincision situating3-4cm above the suprasternal notch. With the development of the society,the whole concept of minimal invasion including physiological and psycological aspect hasbeen gradually popular. Endoscopic thyroidectomy which hides the incision in the neckarises at the right moment. In1996, Gagner accomplished the world’s first endoscopicsubtotal parathyroidectomy. Subsequently, Miccoli reported the first minimally invasivevideo-assisted thyroidectomy in the same year. Hüscher et al. reported the firstextracervical approach to endoscopic thyroidectomy in the next year. With the progress oftechniques, more than twenty different methods including single-port surgery, roboticmeans, natural orifice transluminal endoscopic surgery et al. have been developped. Otherthan laparoscopic surgery whose main operative space is natural lumen such as thoracic,abdominal and articular cavities, this kind of endoscopic means is majorly based onartificial space from subcutaneous dissecting. It has, in a certain sense, established animportant platform for the breakthrough of minimally invasive surgery.
Nowadays the application of subcutaneous artificial space has caught much attentionof surgeons. The most typical example is an extracervical operation named as breastapproach endoscopic thyroidectomy (BAET). Due to the relatively hidden incision farfrom the neck, BAET has catered most young female patients who need cosmetic outcome.Thus it has gained psycological minimal invasion. Oher than some relatively complicatedoperations such as dorsal, transaxillary and transoral approach, BAET, at the meantime,has been greeted by clinicians, especially in China, for its general superiority. Someliterature states that BAET operating in airtight space with minimally invasive techniquecan reduce surgical trauma, that subcutaneous continuous low CO2gas pressure less than10mmHg does not increase hemodynamic complications such as hypercapnia and acidosis,that BAET has less operating time, less operative blood loss, faster and better wound healing and gains more physiological and psycological minimal invasion in comparisonwith open thyroidectomy, that mini incision surgery in the neck does not improve patients’satisfaction. However, the physiological trauma from relatively extensive subcutaneousdissection make most clinicians regard it more as cosmetic surgery rather than minimallyinvasive one. The subcutaneous dissection as focus of controversy has limited clinicalpopularization of operations in artificial space such as BAET. Thus on the premise ofsatisfying cosmetic outcome that to find and confirm dissecting in some subcutaneousspace has relative mininal invasion is significant.
In recent years fascial cleft (FC) between deep stratum of superficial fascia, i.e.membranous layer and deep fascia has been considered to be a possible anatomic basis ofmininally invasive surgery in artificial space during reevaluating the superficial fasciarelated structure. The membranous layer affiliated to superficial fascia is different from theneighboring deep fascia on base of embryonic origin. These adjacent different originaltissues form so-called cleft between faciae. According to Ferreira’s surface stratigraphicalprinciple, human and vertebrate body surface structure comprises the same or differentlayer upon layer tissues, which is also basis of human sectional anatomy. Abu Hijlehconfirmed the structure of FC’s widespread existence in the human body through the grossanatomy and ultrasound imaging examination. Zobrist operated in FC in the upper andlower limbs with a balloon dilator and made his conjecture that FC in comparison withtraditional surgery has an effect of minimally invasive surgery. However neither animal orclinical control studies on subcutaneous dissection nor research on histological anatomy ofrelated structure has been reported. Thus further study should be implemented to confirmthat FC is the minimally invasive basis of operation in artificial space in order to guide andexpand its application.
This study includes three parts. Part1: Randomized study of the influence ofsubcutaneous dissection area on surgical outcomes of BAET is carried out so that potentialminimal invasion of BAET can be showed. Part2: To investigate and confirm the value ofminimal invasion of separation between fascial cleft of SD rats. Part3: To confirm the minimal invasion of separation between fascial cleft by randomized controlled study ofserum level of inflammatory mediator resulting from different skin incision andseparation between different subcutaneous layers of SD rats.
Materials and Methods:①The study prospectively enrolled65consecutive patientsfrom September2011to March2012in Shanghai Changzheng Hospital. These patientswho underwent BAET were randomized into standard dissection group (n=32) and limiteddissection group (n=33). Demographic (including patients’ gender, age and body massindex), pathoanatomical (unilateral or bilateral tumor mass, the maximum diameter ofmass and pathological type) and surgical data (including intraoperative, postoperative dataand complications) between the groups were compared.②Subcutaneous structures in thechest and abdominal wall of5male and5female SD rats were observes by ultrasound,gross anatomy and HE staining.③Thirty-two male SD rats were randomized into fourgroups, i.e., group1: normal incision plus separation beneath superficial fascia, group2:normal incision plus subdermal separation, group3: normal incision plus extendedseparation beneath superficial fascia and group4: extended incision plus separationbeneath superficial fascia. Blood sampling was taken preopeatively,2h,12h,24h and48hpostoperatively. The increase of serum IL-6and neutrophil elastase (NE) levels at the timeof2h,12h,24h and48h postoperatively were compared between different groups.
Results:①The outcomes of demographic and pathoanatomical data between standarddissection group and limited dissection group were not different statistically. Subcutaneousdissection area in the former was significantly larger than that in the later (136.60±23.05cm2vs93.87±14.84cm2, p=0.000). The other surgical data were not significantly differentbetween the two groups.②By ultrasonic examination the subcutaneous structure of FC inthe chest and abdominal wall of SD rats was distinct and manifested as most low echo area.Superficial fascia of gross anatomy shows as a thin reddish but strong membraneous tissuewith scattered small blood vessels. Dissecting in FC was very easy. HE staining confirmedits existence.③Compared with each other, the increase of serum IL-6and NE levels ingroup1vs3and group2vs4was not different significantly (P value was0.074,0.096and 0.747,0.897, respectively). However, the increase of serum levels in group1vs2,1vs4,3vs2and3vs4was different significantly (P＜0.01). The increase of serum IL-6and NElevels in group2and4was statistically greater than that in group1and3.
Conclusion:①Subcutaneous dissection area should not be regarded as a maininfluential factor resulting in postoperative outcomes in BAET. Dissecting in the rightplane on the chest wall may conduce to minimal invasion.②The subcutaneous structureof FC is similar to the human’s characterized as loose space between the superficial and thedeep fascia. It is anatomic fundament of mininally invisive dissection.③Operation ofseparating beneath superficial fascia plus small skin incision in rats conduces to relativelyminimal invasion.
经典的甲状腺手术切口由100多年前德国医师Kocher所定义，通常为胸骨上切迹3-4cm以上5-10cm长的弧形切口。随着社会的发展，包括生理微创和心理微创的全方面微创理念逐渐深入人心，隐藏颈部切口的内镜甲状腺手术也应运而生。1996年Gagner成功完成了世界首例内镜甲状旁腺次全切除术，随后，Miccoli于同年报道了首例内镜辅助甲状腺切除术，Hüscher等于1997年报道了首例颈外途径完全内镜甲状腺手术。随着技术的进步衍化出了包括单孔内镜、机器人、经自然孔道甲状腺切除术等不下20多种不同径路、不同类型的手术方式。有别于以自然腔隙(如胸腔、腹腔及关节腔等)为主要操作空间的腔镜微创手术，此种内镜外科手术多以皮下分离建立人造腔隙为基础，可以说是为微创外科的突破性发展创建了重要的平台。
目前，皮下人造腔隙内的内镜外科手术已被临床外科医师所重视，其中的典型代表便是颈外途径的胸乳径路内镜甲状腺手术(breast approach endoscopic thyroidectomy,BAET)。由于远离颈部、切口相对隐蔽，BAET非常迎合占主要患病群之青年女性的美容要求，达到了所谓的心理微创；同时，有别于耳后、腋窝及经口入路等相对复杂或受限于病变部位的内镜手术，BAET因较之具有一定的总体优势而受到临床医师的欢迎，尤以国内更甚。目前部分文献报道：BAET在密闭的空间中采用微创操作技术，具有降低手术创伤的因素；小于10mmHg的持续皮下CO2低压充气并不增加诸如高碳酸血症、酸中毒等血流动力学方面的并发症；BAET较开放手术并不增加手术时间、术中失血量少、术后伤口愈合更好更快，其生理和心理创伤总和小于传统手术；而颈部小切口手术在降低手术创伤的同时并不提高患者满意度。然而，BAET需行较广泛的前胸壁皮下分离，由此所致的生理创伤使众多临床医师习惯性视其为单纯的美容手术而非微创手术。皮下广泛人为分离作为争议焦点的同时也成为限制BAET进一步临床推广的主要因素。因此，在保证切口远离颈部、手术美容效果满意的前提下，寻找并证实皮下某个层次内的分离有相对的微创效果具有重要意义。
近年来，在对皮下浅筋膜相关结构的再认识过程中发现，浅筋膜深层的膜样层与深筋膜之间的筋膜间隙(fascial cleft, FC)被认为可能是行人造腔隙内微创手术的解剖基础。从胚胎起源上讲，隶属于浅筋膜的膜样层与其相邻的深筋膜层属不同胚层发育来源。这种不同胚层来源的组织互相附着多表现为疏松的粘连，从而形成了所谓筋膜之间的间隙。按照Ferreira等提出的体表地层学原理，人体与脊椎动物一样由相同或不同的连续组织层层叠加组成各种体表结构，这也是人体断层解剖的基础。Abu-Hijleh等经过大体结构及B超影像检查等证实了FC这一皮下的体表结构在人体内广泛存在。Zobrist等运用球囊扩张器在上下肢筋膜内隙内分离、操作，并推测FC内的手术与传统手术比较具有微创效果。然而，基于皮下各层次内分离操作的动物或临床对照研究以及相关结构的组织解剖学研究目前尚无报道，有必要进一步研究论证皮下FC的这一特定结构是人造腔隙内手术微创性的基础，从而指导和拓展包括BAET等人造腔隙内手术的临床应用。
本研究内容包括三部分。第一部分：通过随机对照不同皮下分离面积对BAET手术效果的影响，揭示BAET存在潜在微创性的可能；第二部分：观察并证实SD大鼠皮下FC的存在及间隙内微创操作可行性的解剖学基础；第三部分：随机区组对照大鼠皮肤不同切口及皮下不同层次内分离致血清炎症介质水平的变化，证实FC内分离具微创性。
二、资料与方法：
（一）按纳入、排除及剔除标准，将第二军医大学附属长征医院普外科2011年9月至2012年3月期间连续的BAET手术病例按皮下分离面积的大小随机分成2组，即标准分离组(n=32)和有限分离组组(n=33)。有限分离组手术为从中央切口经长隧道扇形建立3条皮下隧道，通过潜行通路与胸壁及颈前操作空间连接，使皮下组织分离局限于胸壁上部，从而显著减小皮下分离面积。比较组间在人口统计学(包括患者性别、年龄及体重指数)、病理解剖学(包括甲状腺肿块单侧抑或双侧、肿块最大直径和病理类型)及手术相关数据(包括术中情况、术后恢复情况及术后并发症发生情况)等方面的差异。
（二）取第二军医大学动物实验中心的SD大鼠雌雄各5只，以超声影像、大体解剖及HE染色法观察胸腹壁皮下结构。
（三）将32只雄性SD大鼠随机分为4组，即实验组1：常规切口+FC内分离；实验组2：常规切口+真皮下分离；实验组3：常规切口+FC内扩大分离；实验组4：扩大切口+FC内分离。比较各组在术后2h、12h、24h及48h血清IL-6和中性粒细胞弹性蛋白酶(neutrophil elastase, NE)变化水平。
三、结果：
（一）标准分离组与有限分离组在人口统计学和病理解剖学方面比较差异无统计学意义。有限分离组前胸壁皮下分离面积为93.87±14.84cm2，显著低于标准分离组的136.60±23.05cm2(p=0.000)，其他手术相关数据包括术中、术后及并发症情况两者间差异并无统计学意义。
（二）SD大鼠胸腹壁皮下FC结构超声影像清晰可见，表现为连续的极低回声区。大体解剖中见浅筋膜表现为散布细小血管的淡红色菲薄质韧膜样组织。其深面即FC内的分离极为容易。HE染色进一步证实FC的存在。
（三）血清IL-6和NE增量水平各组间比较，实验组1和3差异无统计学意义(分别为P=0.074，P=0.096)；实验组2和4差异亦无统计学意义(分别为P=0.747，P=0.897)；实验组1、3与2、4的IL-6及NE增量值交叉比较差异有统计学意义(均为P＜0.01)，表现为实验组2、4术后IL-6及NE各时相的增量值显著大于实验组1、3。
四、结论：
（一）皮下分离面积的大小并不是影响BAET术后效果及手术创伤的主要因素，而术中是否保持在皮下FC内的分离才是更为重要的影响因素。
（二）大鼠皮下组织内FC结构与人体类似，表现为浅深筋膜之间的疏松间隙；FC这一结构是间隙内分离操作具有相对微创性的解剖基础。
（三）相对于较大的皮肤切口或真皮下的分离，结合皮肤小切口在大鼠皮下FC内的分离操作具有微创性。
Background and objective: The typical incision of thyroidectomy was defined byGerman Dr. Kocher one hundred years age, which was described as a5-10cm curvilinearincision situating3-4cm above the suprasternal notch. With the development of the society,the whole concept of minimal invasion including physiological and psycological aspect hasbeen gradually popular. Endoscopic thyroidectomy which hides the incision in the neckarises at the right moment. In1996, Gagner accomplished the world’s first endoscopicsubtotal parathyroidectomy. Subsequently, Miccoli reported the first minimally invasivevideo-assisted thyroidectomy in the same year. Hüscher et al. reported the firstextracervical approach to endoscopic thyroidectomy in the next year. With the progress oftechniques, more than twenty different methods including single-port surgery, roboticmeans, natural orifice transluminal endoscopic surgery et al. have been developped. Otherthan laparoscopic surgery whose main operative space is natural lumen such as thoracic,abdominal and articular cavities, this kind of endoscopic means is majorly based onartificial space from subcutaneous dissecting. It has, in a certain sense, established animportant platform for the breakthrough of minimally invasive surgery.
Nowadays the application of subcutaneous artificial space has caught much attentionof surgeons. The most typical example is an extracervical operation named as breastapproach endoscopic thyroidectomy (BAET). Due to the relatively hidden incision farfrom the neck, BAET has catered most young female patients who need cosmetic outcome.Thus it has gained psycological minimal invasion. Oher than some relatively complicatedoperations such as dorsal, transaxillary and transoral approach, BAET, at the meantime,has been greeted by clinicians, especially in China, for its general superiority. Someliterature states that BAET operating in airtight space with minimally invasive techniquecan reduce surgical trauma, that subcutaneous continuous low CO2gas pressure less than10mmHg does not increase hemodynamic complications such as hypercapnia and acidosis,that BAET has less operating time, less operative blood loss, faster and better wound healing and gains more physiological and psycological minimal invasion in comparisonwith open thyroidectomy, that mini incision surgery in the neck does not improve patients’satisfaction. However, the physiological trauma from relatively extensive subcutaneousdissection make most clinicians regard it more as cosmetic surgery rather than minimallyinvasive one. The subcutaneous dissection as focus of controversy has limited clinicalpopularization of operations in artificial space such as BAET. Thus on the premise ofsatisfying cosmetic outcome that to find and confirm dissecting in some subcutaneousspace has relative mininal invasion is significant.
In recent years fascial cleft (FC) between deep stratum of superficial fascia, i.e.membranous layer and deep fascia has been considered to be a possible anatomic basis ofmininally invasive surgery in artificial space during reevaluating the superficial fasciarelated structure. The membranous layer affiliated to superficial fascia is different from theneighboring deep fascia on base of embryonic origin. These adjacent different originaltissues form so-called cleft between faciae. According to Ferreira’s surface stratigraphicalprinciple, human and vertebrate body surface structure comprises the same or differentlayer upon layer tissues, which is also basis of human sectional anatomy. Abu Hijlehconfirmed the structure of FC’s widespread existence in the human body through the grossanatomy and ultrasound imaging examination. Zobrist operated in FC in the upper andlower limbs with a balloon dilator and made his conjecture that FC in comparison withtraditional surgery has an effect of minimally invasive surgery. However neither animal orclinical control studies on subcutaneous dissection nor research on histological anatomy ofrelated structure has been reported. Thus further study should be implemented to confirmthat FC is the minimally invasive basis of operation in artificial space in order to guide andexpand its application.
This study includes three parts. Part1: Randomized study of the influence ofsubcutaneous dissection area on surgical outcomes of BAET is carried out so that potentialminimal invasion of BAET can be showed. Part2: To investigate and confirm the value ofminimal invasion of separation between fascial cleft of SD rats. Part3: To confirm the minimal invasion of separation between fascial cleft by randomized controlled study ofserum level of inflammatory mediator resulting from different skin incision andseparation between different subcutaneous layers of SD rats.
Materials and Methods:①The study prospectively enrolled65consecutive patientsfrom September2011to March2012in Shanghai Changzheng Hospital. These patientswho underwent BAET were randomized into standard dissection group (n=32) and limiteddissection group (n=33). Demographic (including patients’ gender, age and body massindex), pathoanatomical (unilateral or bilateral tumor mass, the maximum diameter ofmass and pathological type) and surgical data (including intraoperative, postoperative dataand complications) between the groups were compared.②Subcutaneous structures in thechest and abdominal wall of5male and5female SD rats were observes by ultrasound,gross anatomy and HE staining.③Thirty-two male SD rats were randomized into fourgroups, i.e., group1: normal incision plus separation beneath superficial fascia, group2:normal incision plus subdermal separation, group3: normal incision plus extendedseparation beneath superficial fascia and group4: extended incision plus separationbeneath superficial fascia. Blood sampling was taken preopeatively,2h,12h,24h and48hpostoperatively. The increase of serum IL-6and neutrophil elastase (NE) levels at the timeof2h,12h,24h and48h postoperatively were compared between different groups.
Results:①The outcomes of demographic and pathoanatomical data between standarddissection group and limited dissection group were not different statistically. Subcutaneousdissection area in the former was significantly larger than that in the later (136.60±23.05cm2vs93.87±14.84cm2, p=0.000). The other surgical data were not significantly differentbetween the two groups.②By ultrasonic examination the subcutaneous structure of FC inthe chest and abdominal wall of SD rats was distinct and manifested as most low echo area.Superficial fascia of gross anatomy shows as a thin reddish but strong membraneous tissuewith scattered small blood vessels. Dissecting in FC was very easy. HE staining confirmedits existence.③Compared with each other, the increase of serum IL-6and NE levels ingroup1vs3and group2vs4was not different significantly (P value was0.074,0.096and 0.747,0.897, respectively). However, the increase of serum levels in group1vs2,1vs4,3vs2and3vs4was different significantly (P＜0.01). The increase of serum IL-6and NElevels in group2and4was statistically greater than that in group1and3.
Conclusion:①Subcutaneous dissection area should not be regarded as a maininfluential factor resulting in postoperative outcomes in BAET. Dissecting in the rightplane on the chest wall may conduce to minimal invasion.②The subcutaneous structureof FC is similar to the human’s characterized as loose space between the superficial and thedeep fascia. It is anatomic fundament of mininally invisive dissection.③Operation ofseparating beneath superficial fascia plus small skin incision in rats conduces to relativelyminimal invasion.
引文
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[18] Slotema ET, Sebag F, Henry JF. What is the evidence for endoscopic thyroidectomy in themanagement of benign thyroid disease?[J] World J Surg,2008,32(7):1325-1332.
[19] Perigli G, Cortesini C, Qirici E, et al. Clinical benefits of minimalliy Invasive techniques in thyroidsurgery[J]. World J Surg,2008,32(1):45-50.
[20] Zobrist R, Aponte RL, Levin LS. Endoscopic access to the extremities: the principle of fascialclefts[J]. J Orthop Trauma,2002,16(4):264-271.
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