完全内镜颈外不同径路甲状腺手术的临床疗效及对比研究
摘要
背景
内镜技术应用于治疗甲状腺疾病具有美容效果好、疼痛轻、恢复快的优点而受到广大患者的青睐,因此内镜甲状腺手术得到快速的发展,出现了各种各样的手术径路,各种手术方法都有其优缺点,目前尚无一种大家公认的最好的内镜甲状腺手术方法。一种比较完善的内镜甲状腺手术方法应在具备安全性和可行性的基础上,还要具备手术创伤小、美容效果佳,操作容易,并发症少,预后好、易推广的特点,而国内常用的双乳晕内镜甲状腺手术由于胸前皮肤组织韧而致密,血液循环不丰富,因此术后该部位常出现一手术疤痕,最大的有2-3cm长,影响了美观,而内镜甲状腺手术最大的好处就是美容效果好,这样的疤痕使该径路的内镜甲状腺手术的效果大大折扣,也给患者带来局部搔痒隐疼不适的感觉,为了克服这个不足,有学者对该手术切口进行了改进,即将原正中的横切口改为一侧胸骨旁的竖切口,这样的改进有一定的效果,但不明显,有的患者仍出现疤痕疙瘩,为了克服这些缺点,有必要探索一种美容效果更好,创伤小,恢复快,预后好而操作难度与乳晕径路相当的内镜甲状腺手术方法。为改善美容效果我们将乳晕径路的胸壁切口转移到腋窝,进行了内镜经腋窝单孔甲状腺手术(Trans-axillary single-port endoscopic thyroidectomy(TASPET))和内镜双乳晕同侧腋窝径路甲状腺手术(bilateral breast and ipsilateral axillary approach(BBIAA)),本课题对这两种手术方法进行研究,探讨其安全可行性,并与标准的乳晕径路内镜甲状腺手术进行比较分析,分析不同手术径路的的创伤大小,并发症情况及美容效果等情况,提出神经和甲状旁腺保护应坚持的原则,探索一种合理的内镜甲状腺手术方法。
第一章：完全内镜双乳晕同侧腋窝径路甲状腺手术的临床疗效
目的探讨内镜双乳晕同侧腋窝径路甲状腺手术(BBIAA)的安全性、可行性。
方法对2011年5月-2012年8月单个手术者所开展的34例内镜双乳晕同侧腋窝径路甲状腺手术的病例资料进行分析。并介绍该手术方法。
结果34例均成功的完成手术,无中转手术,手术时间104±25.3min;术中出血量10.5±3.69m1；手术分离皮瓣的面积78.6±8.64c m2；术后无并发症,术后第一天引流量84.5±62.56ml。术后住院时间2-3天,术后第一天VAS疼痛评分0-2分,术后随访2-12个月,无复发,对美容效果满意。
结论内镜双乳晕单侧腋窝径路甲状腺手术(BBIAA)是安全的、可行的。具有美容、疼痛轻、易推广的优点。
第二章：完全内镜经腋窝单孔甲状腺手术的临床疗效
目的探讨完全内镜经腋窝单孔甲状腺手术的安全性、可行性。
方法对2011年4月-2012年10月单个手术者开展的53例完全内镜经腋窝单孔颈前肌外侧入路甲状腺手术的病例资料进行分析,并介绍该手术方法。
结果52例均成功的完成手术,1例由于出血中转手术,手术时间124.6±32.98min (70-195min)术中出血量24.8±42.29ml (5-200ml);手术分离皮瓣的面积147.85±9.32cm2(128-170cm2)术后第一天引流量103.33±69.02ml(10-270ml)。术后住院时间3-4天,术后VAS疼痛评分2.29±1.7(0-7)分,术后胸前皮肤麻木感8例,喉返神经损伤3例,喉上神经损伤1例,无永久性神经损伤。低钙血症2例,术后随访4-20个月,无复发,对美容效果满意。
结论内镜经腋窝单孔甲状腺手术(BAIBA)是安全的、可行的,具有美容效果好、疼痛轻、恢复快的优点
第三章：BBIAA、TASPET及内镜双乳晕径路甲状腺手术的对比研究
目的比较BBIAA、TASPET、内镜双乳晕径路((bilateral breast approach endoscopic throidectomy(BBAET))三种甲状腺手术的临床效果,以探索内镜甲状腺手术的合理方案。
方法回顾性分析2010年8月-2012年8月90例单侧良性甲状腺疾病单个手术者行内镜单侧甲状腺切除术的临床资料,其中TASPET(TASPET组)42例、BBIAA(BBIAA组)20例和BBAET(BBAET组)28例。比较三组的手术时间、出血量、手术分离皮瓣的面积,术后第一天引流量、术后住院时间、术后第一天VAS疼痛评分、术后并发症,术后第一天C-反应蛋白(CRP),并对手术时间、出血量、手术分离皮瓣的面积与术后指标作相关性分析。
结果三组的年龄、手术时间、出血量、术后第一天引流量、肿瘤大小比较没有显著差异。BBIAA组与BBAET组的手术时间、出血量、分离皮瓣面积、术后第一天VAS评分、术后并发症、术后第一天CRP及术后住院时间等指标比较均没有显著差异,BBAET组的术中出血量为12.3±4.1ml,而TASPET组的术中的出血量为23.69-42.54m1,两组比较有统计学差异(t=-2.13,p=0.03)。两组手术时间及术后第一天引流量比较没有统计学差异,BBA组分离皮瓣的面积为84.1±4-1.34cm2,而TASPET组为150.57±10.63cm2,两者比较有显著差异(t’=40.31,p<0.05),术后第一天VAS评分BBAET组为0.35±0.5,TASPET组为1.95±1.84,两组比较有显著差异(t’=5.50,p<0.05)。两组术后第一天CRP比较有差异(t=3.89,p<0.05),术后并发症BBAET组为1例。为喉返神经损伤,发生率为3%,而TASPET组有12例,发生率为28.6%,其中术后胸前皮肤麻木感6例,喉返神经损伤2例,喉上神经损伤1例,无永久性神经损伤。低钙血症1例,切口感染2例。两者比较有显著差异(x2=6.94,p=0.01)。两组患者均于术后3-4天出院。术后随访2-20个月,无复发,两组均对美容效果满意。
BBIAA组的手术时间(102.5±29.15min)明显少于TASPET组(128.07±41.7min),差异显著(t=3.14,p<0.05)。BBIAA组分离皮瓣的面积为85±7.56cm2,而TASPET组为150.57±10.63cm2.两者比较有显著差异(t=25.35,p=0.00),术后第一天VAS评分BBIAA组为0.25±0.46,TASPET组,1.95±1.84,两组比较有显著差异(t’=5.77,p<0.05)。两组术后第一天CRP比较有差异(t=3.14,p<0.05),术后并发症BBIAA组为0例。发生率为0%,而TASPET组有12例,发生率为28.6%,其中术后胸前皮肤麻木感6例,喉返神经损伤2例,喉上神经损伤1例,无永久性神经损伤。低钙血症1例,切口感染2例。两者比较有显著差异(x2=5.37,p=0.02)。两组患者均于术后3-4天出院。
BBIAA组及BBAET组各项指标相关性分析无意义,而TASPET组各项指标相关性分析发现：手术时间与分离皮瓣面积的大小正相关(1-=0,321,p=0.038),术后并发症与术中出血量多少呈正相关(,r=0.309,p=0.047),术后第一天的CRP与分离皮瓣面积大小正相关(r=0,379,p=0.013),VAS疼痛评分与术后第一天的CRP呈正相关(r=0.321,p=0.038)。术后随访2-20个月,无复发,两组均对美容效果满意。
结论与常用的内镜甲状腺手术(BBAET)相比,BBIAA与TASPET两种手术方法也是安全可行的,都具有很好的美容效果。就手术时间、分离皮瓣面积大小、并发症和相应的损伤程度而言,TASPET组大于BBIAA,因此TASPET操作难度大,并发症多,学习曲线长,而BBIAA则相对操作容易,并发症少,易推广,可以作为BBAET的替代手术方式。
Endoscoic thyroidectomy is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery and an excellent cosmetic result. Therefore,This method is a good choice for patients with surgical thyroid diseases.Since the first reported endoscopic parathyroidectomy for hyperparathyroidism in1996, various endoscopic techniques have been applied to benign thyroid diseases including those that involve access via breast, anterior chest wall, axilla, breast-axilla,single-port,and trans-oral.which had advantages and disadvantaes separately.Endoscopic thyroidectomy by the breast approach is a populary surgery now, but there was usually a scar in the chest wall, which induced discomfortable and bad cosmetic result.there were some measures to improve this disadvantages,but the result were not ideal. However, ideal approch of endoscopic thyroidectomy should be safe, simple maniplation, less postoperative complications minimal invasion, quick recovery, an excellent cosmetic result and easy spread. So it is necessary to explore a ideal approch of endoscopic thyroidectomy. For this reasion,Trans-axillary single-port endoscopic thyroidectomy (TASPET) and endoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA) had been developed,The aims of this study are to analyze their surgical outcomes and to evaluate the effectiveness and safety,the results of two approchs were made a systematic comparative analysis.
Part I Total endoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA):a clinical feasibility study
Objective To explore the feasibility and safety of totalendoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA), and evaluate the outcomes of this procedure.
Methods Between May2011and august2012,34patients with thyroid diseases underwent endoscopic thyroidectomy via BBIAA.The patients clinical data,operative time,blood loss,drainage amounts,complications, hospital stay,area of skin flap,postoperative visualanalog pain score(VAPS) were analyzed retrospectively. We describe here the details of our operative technique.
Results Of34patients,33were diagnosed with benign thyroid disease by pathologic diagnosis.1patient were diagnosed with early thyroid papillary carcinoma,The patient returned to the operating room to have a complete endoscopic radical thyroidectomy via the breast approach.34patients successfully underwent endoscopic thyroidectomy. No postoperative complications,Mean Operation time was104±25.3min. Mean blood loss was10.5±3.69ml. The average area of skin flap was78.6±8.64cm2. Mean postoperative drainage amounts on day1were84.5±62.56ml. The average hospital stay after opearation was3to4days. The postoperative VAS on day1were0-2. Follow-up visits range from2to12months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusions Endoscopic thyroidectomy via BBIAA is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery,simple maniplation,less postoperative complications and an excellent cosmetic result. Therefore,This method is a good choice for patients with surgical thyroid diseases.
Part Ⅱ Total trans-axillary single-port endoscopic thyroidectomy: a clinical feasibility study
Objective To explore the feasibility and safety of trans-axillary single-port endoscopic thyroidectomy(TASPET), and evaluate the outcomes of this procedure.
Methods Between April2011and October2012,53patients with thyroid diseases underwent TASPET.The patients clinical data,operative time,blood loss,drainage amounts,complications,hospital stay,postoperative visualanalog pain score(VAPS) were analyzed retrospectively. We describe here the details of our operative technique.
Results Of53patients,51were diagnosed with benign thyroid disease by pathologic diagnosis.2patients were diagnosed with early thyroid papillary carcinoma, The2patients returned to the operating room to have a complete endoscopic radical thyroidectomy via the breast approach. Of the53patients,52patients successfully underwent endoscopic thyroidectomy. One case were subjected to open thyroidectomy due to uncontrolled bleeding.Mean Operation time was124.6±32.98min (70-195min). Mean blood loss was24.8±42.29ml(5-200ml). The mean area of skin flap was147.85±9.32cm2(128-170cm2). Mean postoperative drainage amounts on day1were103.33±69.02ml(10-270ml). The mean hospital stay after opearation was3to4days. The postoperative VAS were2.29±1.7(0-7).Regarding postoperative complications, postoperative incision infection occurred in7%of patients,transient hypocalcemia occurred in3.8%of patients and no permanent hypoparathyroidism occurred.,Chest skin numbness occurred in15%of patients, nerve injury occurred in7.6%of patiets,included3patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage. Follow-up visits range from4to20months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusions TASPET is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery and an excellent cosmetic result. Therefore,This method is a choice for patients with surgical thyroid diseases.
Part Ⅲ Endoscopic thyroidectomy by BBAET, BBIAA and TASPET: a prospective study
Objective To compare the clinical efficency of endoscopic thyroidectomy via BBIAA BBAET and TASPET in a prospective study, and to explore the rational approch.
Methods Between August2010and August2012, ninety patients were underwent endoscopic thyroidectomy:20cases were underwent BBIAA (group BBIAA),42patients were underwent (TASPET)(group TASPET)and28cases were underwent (BBAET). Operative time, blood loss,the volume of drainage,time of postoperative stay, postoperative complications,postoperative visualanalog score(VAPS) and the level of postoperative CRP were compared among three groups. Each indexes were made rank correlation analysis.
Results There were no significantly differences in old, operation time, volume of blood loss,the diameterof thyroid tumer, time of postoperation stay and postoperative drainage amounts on day1. There were no significantly of every indexes between group BBIAA and group BBAET. Mean blood loss of during operation was significantly less in group BBAET(12.3±4.1ml) than in group TASPET (23.69±42.54ml)(P=0.03),Mean Operation time was no significantly between group BBAET and group TASPET, The mean area of skin flap in group TASPET were more than that in group open (150.57±10.639cm2vs84.1±1.346cm2)(p<0.05), postoperative visualanalog score(VAS) and the level of postoperative CRP was less in group BBAET than that in group TASPET.there was1case postoperative complications in group BBAET.however,there were12cases in group TASPET, included2cases of postoperative incision infection,1cases of transient hypocalcemia, and no permanent hypoparathyroidism occurred.,6cases of Chest skin numbness,3cases of nerve injury,included2patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage.
There were no significantly differences in blood loss, time of postoperation stay and postoperative drainage amounts on day1between group BBIAA and group TASPET. Mean Operation time was significantly less in group BBIAA(102.5±29.15min) than in group TASPET (128.07±41.7min)(P <0.05),The mean area of skin flap in group TASPET were more than that in group open (150.57±10.639cm2vs85±7.56cm2)(p=0.00)) postoperative visualanalog score(VAS) and the level of postoperative CRP was less in group BBIAA than that in group TASPET.there was no postoperative complications in group BBIAA.however,there were12cases in group TASPET, included2 cases of postoperative incision infection,1cases of transient hypocalcemia, and no permanent hypoparathyroidism occurred.,6cases of Chest skin numbness,3cases of nerve injury,included2patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage.
The rank correlation analysis is no significantly in group BBIAA and group BBAET.but which had some significantly in group TASPET, included Operative time was positive correlation to the area of skin flap (r=0,321,p=0.038);postoperative complication was positive correlation to the volume of blood loss (r=0.309,p=0.047),the level of postoperative CRP was positive correlation to the area of skin flap (r=0,379,p=0.013).postoperative visualanalog score(VAS) was positive correlation to the level of postoperative CRP (r=0.321,p=0.038).Follow-up visits range from4to20months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusion compared to the common approch of BBAET, BBIAA and TASPET are also safe and feasible for endoscopic thyroideetomy, and all with excellent cosmetic benefits.The degree of injury and postoperative complications were more serious in group TASPET,which are maybe related to the dissecting area for creating subcutaneous tunnel and the chang of field of vision. So the processing of TASPET are maybe more hard and difficulty than thats of BBIAA.
内镜技术应用于治疗甲状腺疾病具有美容效果好、疼痛轻、恢复快的优点而受到广大患者的青睐,因此内镜甲状腺手术得到快速的发展,出现了各种各样的手术径路,各种手术方法都有其优缺点,目前尚无一种大家公认的最好的内镜甲状腺手术方法。一种比较完善的内镜甲状腺手术方法应在具备安全性和可行性的基础上,还要具备手术创伤小、美容效果佳,操作容易,并发症少,预后好、易推广的特点,而国内常用的双乳晕内镜甲状腺手术由于胸前皮肤组织韧而致密,血液循环不丰富,因此术后该部位常出现一手术疤痕,最大的有2-3cm长,影响了美观,而内镜甲状腺手术最大的好处就是美容效果好,这样的疤痕使该径路的内镜甲状腺手术的效果大大折扣,也给患者带来局部搔痒隐疼不适的感觉,为了克服这个不足,有学者对该手术切口进行了改进,即将原正中的横切口改为一侧胸骨旁的竖切口,这样的改进有一定的效果,但不明显,有的患者仍出现疤痕疙瘩,为了克服这些缺点,有必要探索一种美容效果更好,创伤小,恢复快,预后好而操作难度与乳晕径路相当的内镜甲状腺手术方法。为改善美容效果我们将乳晕径路的胸壁切口转移到腋窝,进行了内镜经腋窝单孔甲状腺手术(Trans-axillary single-port endoscopic thyroidectomy(TASPET))和内镜双乳晕同侧腋窝径路甲状腺手术(bilateral breast and ipsilateral axillary approach(BBIAA)),本课题对这两种手术方法进行研究,探讨其安全可行性,并与标准的乳晕径路内镜甲状腺手术进行比较分析,分析不同手术径路的的创伤大小,并发症情况及美容效果等情况,提出神经和甲状旁腺保护应坚持的原则,探索一种合理的内镜甲状腺手术方法。
第一章：完全内镜双乳晕同侧腋窝径路甲状腺手术的临床疗效
目的探讨内镜双乳晕同侧腋窝径路甲状腺手术(BBIAA)的安全性、可行性。
方法对2011年5月-2012年8月单个手术者所开展的34例内镜双乳晕同侧腋窝径路甲状腺手术的病例资料进行分析。并介绍该手术方法。
结果34例均成功的完成手术,无中转手术,手术时间104±25.3min;术中出血量10.5±3.69m1；手术分离皮瓣的面积78.6±8.64c m2；术后无并发症,术后第一天引流量84.5±62.56ml。术后住院时间2-3天,术后第一天VAS疼痛评分0-2分,术后随访2-12个月,无复发,对美容效果满意。
结论内镜双乳晕单侧腋窝径路甲状腺手术(BBIAA)是安全的、可行的。具有美容、疼痛轻、易推广的优点。
第二章：完全内镜经腋窝单孔甲状腺手术的临床疗效
目的探讨完全内镜经腋窝单孔甲状腺手术的安全性、可行性。
方法对2011年4月-2012年10月单个手术者开展的53例完全内镜经腋窝单孔颈前肌外侧入路甲状腺手术的病例资料进行分析,并介绍该手术方法。
结果52例均成功的完成手术,1例由于出血中转手术,手术时间124.6±32.98min (70-195min)术中出血量24.8±42.29ml (5-200ml);手术分离皮瓣的面积147.85±9.32cm2(128-170cm2)术后第一天引流量103.33±69.02ml(10-270ml)。术后住院时间3-4天,术后VAS疼痛评分2.29±1.7(0-7)分,术后胸前皮肤麻木感8例,喉返神经损伤3例,喉上神经损伤1例,无永久性神经损伤。低钙血症2例,术后随访4-20个月,无复发,对美容效果满意。
结论内镜经腋窝单孔甲状腺手术(BAIBA)是安全的、可行的,具有美容效果好、疼痛轻、恢复快的优点
第三章：BBIAA、TASPET及内镜双乳晕径路甲状腺手术的对比研究
目的比较BBIAA、TASPET、内镜双乳晕径路((bilateral breast approach endoscopic throidectomy(BBAET))三种甲状腺手术的临床效果,以探索内镜甲状腺手术的合理方案。
方法回顾性分析2010年8月-2012年8月90例单侧良性甲状腺疾病单个手术者行内镜单侧甲状腺切除术的临床资料,其中TASPET(TASPET组)42例、BBIAA(BBIAA组)20例和BBAET(BBAET组)28例。比较三组的手术时间、出血量、手术分离皮瓣的面积,术后第一天引流量、术后住院时间、术后第一天VAS疼痛评分、术后并发症,术后第一天C-反应蛋白(CRP),并对手术时间、出血量、手术分离皮瓣的面积与术后指标作相关性分析。
结果三组的年龄、手术时间、出血量、术后第一天引流量、肿瘤大小比较没有显著差异。BBIAA组与BBAET组的手术时间、出血量、分离皮瓣面积、术后第一天VAS评分、术后并发症、术后第一天CRP及术后住院时间等指标比较均没有显著差异,BBAET组的术中出血量为12.3±4.1ml,而TASPET组的术中的出血量为23.69-42.54m1,两组比较有统计学差异(t=-2.13,p=0.03)。两组手术时间及术后第一天引流量比较没有统计学差异,BBA组分离皮瓣的面积为84.1±4-1.34cm2,而TASPET组为150.57±10.63cm2,两者比较有显著差异(t’=40.31,p<0.05),术后第一天VAS评分BBAET组为0.35±0.5,TASPET组为1.95±1.84,两组比较有显著差异(t’=5.50,p<0.05)。两组术后第一天CRP比较有差异(t=3.89,p<0.05),术后并发症BBAET组为1例。为喉返神经损伤,发生率为3%,而TASPET组有12例,发生率为28.6%,其中术后胸前皮肤麻木感6例,喉返神经损伤2例,喉上神经损伤1例,无永久性神经损伤。低钙血症1例,切口感染2例。两者比较有显著差异(x2=6.94,p=0.01)。两组患者均于术后3-4天出院。术后随访2-20个月,无复发,两组均对美容效果满意。
BBIAA组的手术时间(102.5±29.15min)明显少于TASPET组(128.07±41.7min),差异显著(t=3.14,p<0.05)。BBIAA组分离皮瓣的面积为85±7.56cm2,而TASPET组为150.57±10.63cm2.两者比较有显著差异(t=25.35,p=0.00),术后第一天VAS评分BBIAA组为0.25±0.46,TASPET组,1.95±1.84,两组比较有显著差异(t’=5.77,p<0.05)。两组术后第一天CRP比较有差异(t=3.14,p<0.05),术后并发症BBIAA组为0例。发生率为0%,而TASPET组有12例,发生率为28.6%,其中术后胸前皮肤麻木感6例,喉返神经损伤2例,喉上神经损伤1例,无永久性神经损伤。低钙血症1例,切口感染2例。两者比较有显著差异(x2=5.37,p=0.02)。两组患者均于术后3-4天出院。
BBIAA组及BBAET组各项指标相关性分析无意义,而TASPET组各项指标相关性分析发现：手术时间与分离皮瓣面积的大小正相关(1-=0,321,p=0.038),术后并发症与术中出血量多少呈正相关(,r=0.309,p=0.047),术后第一天的CRP与分离皮瓣面积大小正相关(r=0,379,p=0.013),VAS疼痛评分与术后第一天的CRP呈正相关(r=0.321,p=0.038)。术后随访2-20个月,无复发,两组均对美容效果满意。
结论与常用的内镜甲状腺手术(BBAET)相比,BBIAA与TASPET两种手术方法也是安全可行的,都具有很好的美容效果。就手术时间、分离皮瓣面积大小、并发症和相应的损伤程度而言,TASPET组大于BBIAA,因此TASPET操作难度大,并发症多,学习曲线长,而BBIAA则相对操作容易,并发症少,易推广,可以作为BBAET的替代手术方式。
Endoscoic thyroidectomy is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery and an excellent cosmetic result. Therefore,This method is a good choice for patients with surgical thyroid diseases.Since the first reported endoscopic parathyroidectomy for hyperparathyroidism in1996, various endoscopic techniques have been applied to benign thyroid diseases including those that involve access via breast, anterior chest wall, axilla, breast-axilla,single-port,and trans-oral.which had advantages and disadvantaes separately.Endoscopic thyroidectomy by the breast approach is a populary surgery now, but there was usually a scar in the chest wall, which induced discomfortable and bad cosmetic result.there were some measures to improve this disadvantages,but the result were not ideal. However, ideal approch of endoscopic thyroidectomy should be safe, simple maniplation, less postoperative complications minimal invasion, quick recovery, an excellent cosmetic result and easy spread. So it is necessary to explore a ideal approch of endoscopic thyroidectomy. For this reasion,Trans-axillary single-port endoscopic thyroidectomy (TASPET) and endoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA) had been developed,The aims of this study are to analyze their surgical outcomes and to evaluate the effectiveness and safety,the results of two approchs were made a systematic comparative analysis.
Part I Total endoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA):a clinical feasibility study
Objective To explore the feasibility and safety of totalendoscopic thyroidectomy via bilateral breast and ipsilateral axillary approach(BBIAA), and evaluate the outcomes of this procedure.
Methods Between May2011and august2012,34patients with thyroid diseases underwent endoscopic thyroidectomy via BBIAA.The patients clinical data,operative time,blood loss,drainage amounts,complications, hospital stay,area of skin flap,postoperative visualanalog pain score(VAPS) were analyzed retrospectively. We describe here the details of our operative technique.
Results Of34patients,33were diagnosed with benign thyroid disease by pathologic diagnosis.1patient were diagnosed with early thyroid papillary carcinoma,The patient returned to the operating room to have a complete endoscopic radical thyroidectomy via the breast approach.34patients successfully underwent endoscopic thyroidectomy. No postoperative complications,Mean Operation time was104±25.3min. Mean blood loss was10.5±3.69ml. The average area of skin flap was78.6±8.64cm2. Mean postoperative drainage amounts on day1were84.5±62.56ml. The average hospital stay after opearation was3to4days. The postoperative VAS on day1were0-2. Follow-up visits range from2to12months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusions Endoscopic thyroidectomy via BBIAA is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery,simple maniplation,less postoperative complications and an excellent cosmetic result. Therefore,This method is a good choice for patients with surgical thyroid diseases.
Part Ⅱ Total trans-axillary single-port endoscopic thyroidectomy: a clinical feasibility study
Objective To explore the feasibility and safety of trans-axillary single-port endoscopic thyroidectomy(TASPET), and evaluate the outcomes of this procedure.
Methods Between April2011and October2012,53patients with thyroid diseases underwent TASPET.The patients clinical data,operative time,blood loss,drainage amounts,complications,hospital stay,postoperative visualanalog pain score(VAPS) were analyzed retrospectively. We describe here the details of our operative technique.
Results Of53patients,51were diagnosed with benign thyroid disease by pathologic diagnosis.2patients were diagnosed with early thyroid papillary carcinoma, The2patients returned to the operating room to have a complete endoscopic radical thyroidectomy via the breast approach. Of the53patients,52patients successfully underwent endoscopic thyroidectomy. One case were subjected to open thyroidectomy due to uncontrolled bleeding.Mean Operation time was124.6±32.98min (70-195min). Mean blood loss was24.8±42.29ml(5-200ml). The mean area of skin flap was147.85±9.32cm2(128-170cm2). Mean postoperative drainage amounts on day1were103.33±69.02ml(10-270ml). The mean hospital stay after opearation was3to4days. The postoperative VAS were2.29±1.7(0-7).Regarding postoperative complications, postoperative incision infection occurred in7%of patients,transient hypocalcemia occurred in3.8%of patients and no permanent hypoparathyroidism occurred.,Chest skin numbness occurred in15%of patients, nerve injury occurred in7.6%of patiets,included3patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage. Follow-up visits range from4to20months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusions TASPET is a safe and effective method that gives good surgical completeness, minimal invasion, quick recovery and an excellent cosmetic result. Therefore,This method is a choice for patients with surgical thyroid diseases.
Part Ⅲ Endoscopic thyroidectomy by BBAET, BBIAA and TASPET: a prospective study
Objective To compare the clinical efficency of endoscopic thyroidectomy via BBIAA BBAET and TASPET in a prospective study, and to explore the rational approch.
Methods Between August2010and August2012, ninety patients were underwent endoscopic thyroidectomy:20cases were underwent BBIAA (group BBIAA),42patients were underwent (TASPET)(group TASPET)and28cases were underwent (BBAET). Operative time, blood loss,the volume of drainage,time of postoperative stay, postoperative complications,postoperative visualanalog score(VAPS) and the level of postoperative CRP were compared among three groups. Each indexes were made rank correlation analysis.
Results There were no significantly differences in old, operation time, volume of blood loss,the diameterof thyroid tumer, time of postoperation stay and postoperative drainage amounts on day1. There were no significantly of every indexes between group BBIAA and group BBAET. Mean blood loss of during operation was significantly less in group BBAET(12.3±4.1ml) than in group TASPET (23.69±42.54ml)(P=0.03),Mean Operation time was no significantly between group BBAET and group TASPET, The mean area of skin flap in group TASPET were more than that in group open (150.57±10.639cm2vs84.1±1.346cm2)(p<0.05), postoperative visualanalog score(VAS) and the level of postoperative CRP was less in group BBAET than that in group TASPET.there was1case postoperative complications in group BBAET.however,there were12cases in group TASPET, included2cases of postoperative incision infection,1cases of transient hypocalcemia, and no permanent hypoparathyroidism occurred.,6cases of Chest skin numbness,3cases of nerve injury,included2patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage.
There were no significantly differences in blood loss, time of postoperation stay and postoperative drainage amounts on day1between group BBIAA and group TASPET. Mean Operation time was significantly less in group BBIAA(102.5±29.15min) than in group TASPET (128.07±41.7min)(P <0.05),The mean area of skin flap in group TASPET were more than that in group open (150.57±10.639cm2vs85±7.56cm2)(p=0.00)) postoperative visualanalog score(VAS) and the level of postoperative CRP was less in group BBIAA than that in group TASPET.there was no postoperative complications in group BBIAA.however,there were12cases in group TASPET, included2 cases of postoperative incision infection,1cases of transient hypocalcemia, and no permanent hypoparathyroidism occurred.,6cases of Chest skin numbness,3cases of nerve injury,included2patients experienced injury of recurrent nerve and1patient experienced injury of superior laryngeal nerve. No permanent neurological damage.
The rank correlation analysis is no significantly in group BBIAA and group BBAET.but which had some significantly in group TASPET, included Operative time was positive correlation to the area of skin flap (r=0,321,p=0.038);postoperative complication was positive correlation to the volume of blood loss (r=0.309,p=0.047),the level of postoperative CRP was positive correlation to the area of skin flap (r=0,379,p=0.013).postoperative visualanalog score(VAS) was positive correlation to the level of postoperative CRP (r=0.321,p=0.038).Follow-up visits range from4to20months suggested that no one had relapse. Furthermore, the patients were uniformly pleased with the cosmetic results of the operation.
Conclusion compared to the common approch of BBAET, BBIAA and TASPET are also safe and feasible for endoscopic thyroideetomy, and all with excellent cosmetic benefits.The degree of injury and postoperative complications were more serious in group TASPET,which are maybe related to the dissecting area for creating subcutaneous tunnel and the chang of field of vision. So the processing of TASPET are maybe more hard and difficulty than thats of BBIAA.
引文
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18.Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T,Kitajima M (2000) Scarless endoscopic thyroidectomy:breastapproach for better cosmesis. Surg Laparosc Endosc PercutanTech 10:1-4
19.Yamamoto M, Sasaki A, Asahi H, Shimada Y, Sato N, NakajimaJ, Mashima R, Saito K (2001) Endoscopic subtotal thyroidectomy for patients with Graves'disease. Surg Today 31:1-4
20.Takami H, Ikeda Y (2002) Minimally invasive thyroidectomy.ANZ J Surg 72:841-842
21.Park YL, Han WK, Bae WG (2003) 100 cases of endoscopic thyroidectomy:breast approach. Surg Laparosc Endosc PercutanTech 13:20-25
22.Cho YU, Park IJ, Choi KH5 Kim SJ, Choi SK, Hur YS, Lee KY,Ahn SI, Hong KC, Shin SH, Kim KR, Woo ZH (2007) Gasless endoscopic thyroidectomy via an anterior chest wall approach using a flap-lifting system. Yonsei Med J 48:480-487
23.Henry JF, Sebag F (2006) Lateral endoscopic approach for thy-roid and parathyroid surgery. Ann Chir 131:51-56 (in French)
24.Palazzo FF, Sebag F, Henry JF (2006) Endocrine surgical tech-nique: endoscopic thyroidectomy via the lateral approach. Surg Endosc 20:339-342
25.Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E,Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13:196-201
26.Barlehner E, Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy:axillo-bilateral-breast approach (ABBA). Surg Endosc 22:154-157
27.Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601-606
28.Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thy-roidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions. Surg Endosc 23:2053-2060
29.Lee KE, Kim HY, Park WS, Choe JH, Kwon MR, Oh SK, YounYK (2009) Postauricular and axillary approach endoscopic neck surgery:a new technique. World J Surg 33:767-772
30.Thomas Wilhelm, Andreas Metzig.Endoscopic minimally invasive thyroidectomy:first clinicalexperience.Surg Endosc,2010,24:1757-1758
31.Fan Youben, MD, Guo Bomin, MD, Wu Bo, Kang Jie, MD, et al.Trans-areola Single-incision Endoscopic Thyroidectomy. Surg Laparosc Endosc Percutan Tech,2011,21(4):192-195.
32.Su-jin Kim, MD,Kyu Eun Lee, MD, Jun-Ho Choe, MD, et al.Endoscopic Completion Thyroidectomy by the Bilateral Axillo-Breast Approach.Surg Laparosc Endosc Percutan Tech,2010,20(5):312-316.
33.姚宏伟,修典荣,王立新,等。经腋窝途径的单孔内镜下甲状腺切除术.中国微创外科杂志,2011,11(8)：687-690.
34.Shimizul K, Kitagawa W, Akasu H, et al. Indications for and limitations of endoscopic thyroid surgry.Nippon Geka Gakkai Zasshi.2002;103: 708.712.
35.华泸玮,芩均华,范慧光,等.颈部无疤痕腔镜甲状腺切除手术要点.现代 临床医学生物工程学杂志.2000；8：35—352.
36.池畔,林惠铭.免气体锁骨下径路腔镜甲状腺切除术探讨.腹腔镜外科,2005；10(2)：16-17.
37.William B, Gagner M,et al.Endoscopic thyroidectomy. The Journal of Otolaryngology,2001,30(1):41-42.
38.王存川,吴东波,陈鏊,等.150例经乳晕入路的腔镜甲状腺切除术临床研究.中国腔镜杂志.2003,9(11)：50-52.
39.Miccoli P,Rafaelli M,et al. Minimally invasive video-assisted thyroidectomy.Am J Surg,2001,181(6):567-570.
40.Yeh IS,Jan YY,Hsu BIL et a 1.Vidco-assisted endoscopies thyroidectomy. Am J Surg.2000,180(2):82-85
41.ZhiYu Li, Ping Wang, Yong Wang, et al. Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma:a preliminary report.Surg Endosc,2011,25:890-896
42.JS Bae, WC Park, BJ Song,et al. Endoscopic thyroidectomy and sentinel lymph node biopsy via an anterior chest approach for papillary thyroid cancer.Surg Today, January 1,2009; 39(2):178-81.
43.Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc,2000, 10(1):1-4.
44.28m JS, Kim KH, Ahn CH, et al. A clinical analysis of gasless endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech,2001,11:268-72.
45.Miccoli P, Berti P, Raffaelli M, et al. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy:A prospective randomized study. Surgery,2001,130(6):1039-1043.
46.Gauger PG, Reeve TS, Delbridge LW. Endoscopically assisted, minimally invasive parathyroidectomy. Br J Surg,1999,86:1563-6.
47.Miccoli P, Berti P, Raffaelli M. Minimally invasive video-assisted thyroidectomy. Am J Surg,2001,181:567-70.
48.Miccoli P, Rocco Bellantone, Michel Mourad,et al. Minimally Invasive Video-assisted Thyroidectomy:Multiinstitutional Experience, World J. Surg,2002,26:972-975.
49.Yong Lai MD, Won Kon MD, Won Gil MD, et al.100 Cases of Endoscopic Thyroidectomy:Breast Approach. Lippincott Williams & Wilkins, Inc.2003,13(1):20-25
50.Gottlieb A, Sprung J, Zheng XM, et al. Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg 1997; 84(5):1154-1156.
51.Yamamoto M, Sasaki A,Asahi H,et al. Endoscopic subtotal thyroidectomy for patients with Graves' disease. Surg Today,2001,31(1):1-4.
52.Sung Mo Hur, Sung Hoon Kim, Se Kyung Lee, et al.Is a Thyroid Follicular Neoplasm a Good Indication for Endoscopic Surgery?Surg Laparosc Endosc Percutan Tech,2011,21(3):148-151.
53.Jung Han Kim, MD, Young Jin Choi, MD, Ji A. Kim, MD,et al.Thyroid Cancer That Developed Around the Operative Bed and Subcutaneous Tunnel After Endoscopic Thyroidectomy via a Breast Approach.Surg Laparosc Endosc Percutan Tech,2008,18(2):198-201.
54.Ikeda Y, Takami H, and Sasaki Y, et al. Comparative study of thyroidectomies:Endoscopic surgery VS conventional open surgery. Surg Endosc.2002; 16:1741-1745.
55.Bellantone R,Lombardi CP,Raffaelli M,et a 1. Video-assisted thyroidectomy.J Am Cool Surg.2002; 194:610-614.
56.CT Tan, WK Cheah, and L Delbridge。"Scarless" (in the neck) endoscopic thyroidectomy (SET):an evidence-based review of published techniques.World J Surgo 2008;32(7):1349-57.
2. Miccoli P, Berti P, Raffaelli M, et al. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy:A prospective randomized study. Surgery,2001,130(6):1039-1043.
3. Ohgami M,Ishii S,Arisawa Y.et al.Scarless endoscopic thyroidectomy, breast approach for better cosmesis[J]. Surg Laparosc Endosc Percutan Tech,2000,10(1):1-4.
4. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy by the axillary approach[J]. Surg Endosc,2001,15(11):1362-1364.
5. Shimazu K, Shiba E, amaki Y, et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach[J]. Surg Laparosc Endosc Percutan Tech,2003,13(3):196-201.
6. Biirlehner E, Benhidjeb T. Cervical scarless endoscopic thyroidectomy: axillo-bilateral-breast approach(ABBA)[J]. Surg Endosc,2008,22(l): 154-157.
7. Choe JH, Kim SW, Chung KW. etal. Endoscopic thyroidectomy using a new bilateral axillo-breast approach[J]. World J Surg,2007,31(3):601-606.
8. Koh YW,Kim JW, Lee SW, et al. Endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insuf-flation for unilateral benign thyroid lesions[J]. Surg Endosc,2009,23(9):2053-2060.
9. K. Jeryong, L. Jinsun, K. Hyegyong,C. et al. Total Endoscopic Thyroidectomy with Bilateral Breast Areola and Ipsilateral Axillary (BBIA) Approach. World J Surg,2008,32:2488-2493
10. Youben F, Bomin G, Bo W, et al. Trans-areola single-incision endoscopic hyroidectomy[J]. Surg Laparosc Endose Percutan Tech,2011,21(4): e192-194.
11. Schardey HM, Barone M, Portl S, et al. Invisible scar endoscopic dorsal approach thyroidectomy:a clinical feasibility study. World J Surg,2010, 34:2997-3006
12. J. Y. Choi, K. E. Lee, K. W. Chung, et al.Endoscopic thyroidectomy via bilateral axillo-breast approach(BABA):review of 512 cases in a single institute. Surg Endosc,2012,26:948-955.
13. Choe JH, Kim SW, Chung KW, et al.Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg,2007,31:601-606.
1. Gagner M (1996) Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 83:875
2. Huscher CS, Chiodini S, Napolitano C, Recher A (1997) Endoscopic right thyroid lobectomy. Surg Endosc 11:877
3. Yeung GH (1998) Endoscopic surgery of the neck:a new frontier. Surg Laparosc Endosc 8:227-232
4. Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, et al. (2001)Endoscopic thyroidectomy by the axillary approach. Surg Endosc 15:1362-1364
5. Chantawibul S, Lokechareonlarp S, Pokawatana C (2003) Total video endoscopic thyroidectomy by an axillary approach.J Laparoendosc Adv Surg Tech A 13:295-299
6. Udomsawaengsup S, Navicharern P, Tharavej C, et al(2004) Endoscopic transaxillary thyroid lobectomy:flexible vs rigid laparoscope. J Med Assoc Thai 87(suppl 2):10-14
7. Yoon JH, Park CH, Chung WY (2006) Gasless endoscopic thy-roidectomy via an axillary approach:experience of 30 cases. Surg Laparosc Endosc Percutan Tech 16:226-231
8. Jung EJ, Park ST, Ha WS, et al (2007) Endoscopic thyroidectomy using a gasless axillary approach. J Laparoendosc Adv Surg Tech A 17:21-25
9. Witzel K (2007) The axillary access in unilateral thyroid resec-tion. Langenbecks Arch Surg 392:617-621
10.Duncan TD, Rashid Q, Speights F, Ejeh I (2007) Endoscopic transaxillary approach to the thyroid gland:our early experience.Surg Endosc 21:2166-2171
11.Ohgami M, Ishii S, Arisawa Y, et al (2000) Scarless endoscopic thyroidectomy:breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 10:1-4
12.Yamamoto M, Sasaki A, Asahi H, et al(2001).Endoscopic subtotal thyroidectomyfor patients with Graves'disease. Surg Today 31:1-4
13.Takami H, Ikeda Y (2002) Minimally invasive thyroidectomy.ANZ J Surg 72:841-842
14.Park YL, Han WK, Bae WG (2003).100 cases of endoscopic thyroidectomy:breast approach. Surg Laparosc Endosc Percutan Tech 13:20-25
15.Shimazu K, Shiba E, Tamaki Y, et al. (2003) Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13:196-201
16.Barlehner E, Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy:Axillo-bilateral-breast approach (ABBA). Surg Endosc 22: 154-157
17.Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions. Surg Endosc 23:2053-2060
18.Choe JH, Kim SW, Chung KW, Park KS, Han W, et al. (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601-606
19.Schardey HM, Barone M, Portl S, et al. (2010) Invisible scar endoscopic dorsal approach thyroidectomy:a clinical feasibility study. World J Surg 34:2997-3006
20.an Youben. Wu Bo. Zhong Chunlin.et al(2012).Trans-areola single-site endoscopic thyroidectomy:pilot study of 35 cases. Surg Endosc 26:939-947
21.YingFan,MD,Shuo-DongWu,MD,JingKong,MD(2011).Single-PortAccess TransaxillaryTotally EndoscopicThyroidectomy:A New Approach for MinimallyInvasiveThyroidOperation.J Laparoendosc Adv Surg Tech A, 21:243-247
22.Youben F, Bomin G, Bo W, Jie K, Fan Y, et al. (2011) Trans-areola single-incision endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech 21:e192-196
1. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg,1996,83:875.
2. Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J(2001) Endoscopic thyroidectomy by the axillary approach. Surg Endosc 15:1362-1364
3. Chantawibul S, Lokechareonlarp S, Pokawatana C (2003)Total video endoscopic thyroidectomy by an axillary approach.J Laparoendosc Adv Surg Tech A 13:295-299
4. Udomsawaengsup S, Navicharern P, Tharavej C, Pungpapong SU(2004) Endoscopic transaxillary thyroid lobectomy:flexible vsrigid laparoscope. J Med Assoc Thai 87(suppl 2):10-14
5. Yoon JH, Park CH, Chung WY (2006) Gasless endoscopic thy-roidectomy via an axillary approach:experience of 30 cases. Surg Laparosc Endosc Percutan Tech 16:226-231
6. Jung EJ, Park ST, Ha WS, Choi SK, Hong SC, Lee YJ, Jeong CYJoo YT, Moon HG (2007) Endoscopic thyroidectomy using agasless axillary approach. J Laparoendosc Adv Surg Tech A 17:21-25
7. Witzel K (2007) The axillary access in unilateral thyroid resec-tion. Langenbecks Arch Surg 392:617-621
8. Duncan TD, Rashid Q, Speights F, Ejeh I (2007) Endoscopic transaxillary approach to the thyroid gland:our early experience. Surg Endosc 21:2166-2171
9. Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T,Kitajima M (2000) Scarless endoscopic thyroidectomy:breast approach for better cosmesis. Surg Laparosc Endosc PercutanTech 10:1-4
10.Yamamoto M, Sasaki A, Asahi H, Shimada Y, Sato N, NakajimaJ, Mashima R, Saito K (2001) Endoscopic subtotal thyroidectomyfor patients with Graves'disease. Surg Today 31:1-4
11.Takami H, Ikeda Y (2002) Minimally invasive thyroidectomy.ANZ J Surg 72:841-842
12.Park YL, Han WK, Bae WG (2003) 100 cases of endoscopic thyroidectomy:breast approach. Surg Laparosc Endosc Percutan Tech 13:20-25
13.Cho YU, Park IJ, Choi KH, Kim SJ, Choi SK, Hur YS, Lee KY, Ahn SI, Hong KC, Shin SH, Kim KR, Woo ZH (2007) Gasless endoscopic thyroidectomy via an anterior chest wall approach using a flap-lifting system. Yonsei Med J 48:480-487
14.Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E,Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13:196-201
15.Baurlehner E,Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy:axillo-bilateral-breast approach (ABBA). Surg Endosc 22:154-157
16.Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, OhSK, Youn YK (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601-606
17.Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thy-roidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions. Surg Endosc 23:2053-2060
18.Lee KE, Kim HY, Park WS, Choe JH, Kwon MR, Oh SK, Youn YK (2009) Postauricular and axillary approach endoscopic neck surgery:a new technique. World J Surg 33:767-772
19.Thomas Wilhelm, Andreas Metzig.Endoscopic minimally invasive thyroidectomy:first clinicalexperience.Surg Endosc,2010,24:1757-1758
20.Fan Youben, MD, Guo Bomin, MD, Wu Bo, Kang Jie, MD, et al.Trans-areola Single-incision Endoscopic Thyroidectomy. Surg Laparosc Endosc Percutan Tech,2011,21 (4):192-195.
21.ZHANG j,HAN GS,WANG CC.Clinical study of trauma induced from endoscopic thyroidectomy with breast areola approach. China Journal of Endoscopy,2006,12(1):28-30.
22.Kim JS, Kim KH, Ahn CH, et al. A clinical analysis of gasless endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech,2001,11:268-72.
23.Miccoli P, Berti P, Raffaelli M, et al. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy:A prospective randomized study. Surgery,2001,130:1039-43.
24.Gauger PG, Reeve TS, Delbridge LW. Endoscopically assisted, minimally invasive parathyroidectomy. Br J Surg,1999,86:1563-6.
25.Miccoli P, Berti P, Raffaelli M. Minimally invasive video-assisted thyroidectomy. Am J Surg,2001,181:567-70.
26.Miccoli P, Rocco Bellantone, Michel Mourad,et al. Minimally Invasive Video-assisted Thyroidectomy:Multiinstitutional Experience, World J. Surg,2002,26:972-975.
1. Gagner M (1996) Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 83:875
2. Dulguerov P, Leuchter I, Szalay-Quinodoz I, Allal AS, Marchal F, Lehmann W, Fasel JH (2001) Endoscopic neck dissection in human cadavers. Laryngoscope 111:2135-2139
3. Carreno OJ, Wilson WR, Nootheti PK (1999) Exploring endoscopic neck surgery in a porcine model. Laryngoscope 109:236-240
4. Rubino F, Deutsch H, Pamoukian V, Zhu JF, King WA, Gagner M (2000) Minimally invasive spine surgery:an animal model for endoscopic approach to the anterior cervical and upper thoracic spine. J Laparoendosc Adv Surg Tech A 10:309-313
5. Hu'scher CS, Chiodini S, Napolitano C, Recher A (1997) Endo-scopic right thyroid lobectomy. Surg Endosc 11:877
6. Terris DJ, Haus BM, Gourin CG, Lilagan PE (2005)Endorobotic resection of the submandibular gland in a cadaver model. Head Neck 27:946-951
7. Malloy KM, Cognetti DM, Wildemore BM, Cunnane MF, Keane WM, Pribitkin EA, Rosen D (2007) Feasibility of endoscopic sentinel node biopsy in the porcine neck. Otolaryngol Head Neck Surg 136:806-810
8. Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, De CreaC, Traini E (2002) Video-assisted thyroidectomy. J Am Coll Surg 194:610-614
9. Guerrissi JO (2002) Innovation and surgical techniques:endo-scopic resection of cervical branchiogenic cysts. J Craniofac Surg 13:478-482
10.华泸玮,芩均华,范慧光,等.颈部无疤痕内镜甲状腺切除手术要点.现代临床医学生物工程学杂志.2000；8：350—352.
11.Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J(2001) Endoscopic thyroidectomy by the axillary approach. Surg Endosc 15:1362-1364
12.Chantawibul S, Lokechareonlarp S, Pokawatana C (2003)Total video endoscopic thyroidectomy by an axillary approach.J Laparoendosc Adv Surg Tech A 13:295-299
13.Udomsawaengsup S, Navicharern P, Tharavej C, Pungpapong SU(2004) Endoscopic transaxillary thyroid lobectomy:flexible vs rigid laparoscope. J Med Assoc Thai 87(suppl 2):10-14
14.Yoon JH, Park CH, Chung WY (2006) Gasless endoscopic thy-roidectomy via an axillary approach:experience of 30 cases. Surg Laparosc Endosc Percutan Tech 16:226-231
15.Jung EJ, Park ST, Ha WS, Choi SK, Hong SC, Lee YJ, Jeong CYJoo YT, Moon HG (2007) Endoscopic thyroidectomy using a gasless axillary approach. J Laparoendosc Adv Surg Tech A17:21-25
16.Witzel K (2007) The axillary access in unilateral thyroid resec-tion. Langenbecks Arch Surg 392:617-621
17.Duncan TD, Rashid Q, Speights F, Ejeh I (2007) Endoscopic transaxillary approach to the thyroid gland:our early experience. Surg Endosc 21:2166-2171
18.Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T,Kitajima M (2000) Scarless endoscopic thyroidectomy:breastapproach for better cosmesis. Surg Laparosc Endosc PercutanTech 10:1-4
19.Yamamoto M, Sasaki A, Asahi H, Shimada Y, Sato N, NakajimaJ, Mashima R, Saito K (2001) Endoscopic subtotal thyroidectomy for patients with Graves'disease. Surg Today 31:1-4
20.Takami H, Ikeda Y (2002) Minimally invasive thyroidectomy.ANZ J Surg 72:841-842
21.Park YL, Han WK, Bae WG (2003) 100 cases of endoscopic thyroidectomy:breast approach. Surg Laparosc Endosc PercutanTech 13:20-25
22.Cho YU, Park IJ, Choi KH5 Kim SJ, Choi SK, Hur YS, Lee KY,Ahn SI, Hong KC, Shin SH, Kim KR, Woo ZH (2007) Gasless endoscopic thyroidectomy via an anterior chest wall approach using a flap-lifting system. Yonsei Med J 48:480-487
23.Henry JF, Sebag F (2006) Lateral endoscopic approach for thy-roid and parathyroid surgery. Ann Chir 131:51-56 (in French)
24.Palazzo FF, Sebag F, Henry JF (2006) Endocrine surgical tech-nique: endoscopic thyroidectomy via the lateral approach. Surg Endosc 20:339-342
25.Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E,Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13:196-201
26.Barlehner E, Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy:axillo-bilateral-breast approach (ABBA). Surg Endosc 22:154-157
27.Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601-606
28.Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thy-roidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions. Surg Endosc 23:2053-2060
29.Lee KE, Kim HY, Park WS, Choe JH, Kwon MR, Oh SK, YounYK (2009) Postauricular and axillary approach endoscopic neck surgery:a new technique. World J Surg 33:767-772
30.Thomas Wilhelm, Andreas Metzig.Endoscopic minimally invasive thyroidectomy:first clinicalexperience.Surg Endosc,2010,24:1757-1758
31.Fan Youben, MD, Guo Bomin, MD, Wu Bo, Kang Jie, MD, et al.Trans-areola Single-incision Endoscopic Thyroidectomy. Surg Laparosc Endosc Percutan Tech,2011,21(4):192-195.
32.Su-jin Kim, MD,Kyu Eun Lee, MD, Jun-Ho Choe, MD, et al.Endoscopic Completion Thyroidectomy by the Bilateral Axillo-Breast Approach.Surg Laparosc Endosc Percutan Tech,2010,20(5):312-316.
33.姚宏伟,修典荣,王立新,等。经腋窝途径的单孔内镜下甲状腺切除术.中国微创外科杂志,2011,11(8)：687-690.
34.Shimizul K, Kitagawa W, Akasu H, et al. Indications for and limitations of endoscopic thyroid surgry.Nippon Geka Gakkai Zasshi.2002;103: 708.712.
35.华泸玮,芩均华,范慧光,等.颈部无疤痕腔镜甲状腺切除手术要点.现代 临床医学生物工程学杂志.2000；8：35—352.
36.池畔,林惠铭.免气体锁骨下径路腔镜甲状腺切除术探讨.腹腔镜外科,2005；10(2)：16-17.
37.William B, Gagner M,et al.Endoscopic thyroidectomy. The Journal of Otolaryngology,2001,30(1):41-42.
38.王存川,吴东波,陈鏊,等.150例经乳晕入路的腔镜甲状腺切除术临床研究.中国腔镜杂志.2003,9(11)：50-52.
39.Miccoli P,Rafaelli M,et al. Minimally invasive video-assisted thyroidectomy.Am J Surg,2001,181(6):567-570.
40.Yeh IS,Jan YY,Hsu BIL et a 1.Vidco-assisted endoscopies thyroidectomy. Am J Surg.2000,180(2):82-85
41.ZhiYu Li, Ping Wang, Yong Wang, et al. Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma:a preliminary report.Surg Endosc,2011,25:890-896
42.JS Bae, WC Park, BJ Song,et al. Endoscopic thyroidectomy and sentinel lymph node biopsy via an anterior chest approach for papillary thyroid cancer.Surg Today, January 1,2009; 39(2):178-81.
43.Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc,2000, 10(1):1-4.
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