内镜甲状腺手术的外科平面和解剖标志
摘要
背景
近年来随着腹腔镜手术的发展,腔镜下解剖学研究成为了一门新兴的学科。传统的开放手术,其解剖学研究已经非常深入和透彻,而腔镜下解剖学的研究才刚刚开始。内镜甲状腺手术(endoscopic thyroidectomy, ET)开展了将近20年,但是我们查阅了相关文献,了解到内镜甲状腺手术的腔镜下解剖学研究非常之少。我们通过一系列的尸体及临床解剖学研究,找到了内镜甲状腺手术的相关外科平面和解剖标志,以期指导腔镜外科医生更安全地实施手术。
第一部分内镜甲状腺手术的尸体解剖学研究
一、研究目的
我们在本研究中,通过对尸体模拟经胸前壁径路的内镜甲状腺手术,找到了一系列组织层面和组织结构间的相互位置关系。对内镜甲状腺手术的解剖学研究进行了初步探讨,以指导下一步的研究工作。
二、研究方法
我们对3个尸体标本进行了内镜甲状腺手术的解剖学研究,其中1个为新鲜标本,2个为10%福尔马林固定的标本,均为广州南方医科大学解剖学教研室受捐赠的标本。3个标本均无甲状腺方面的病史体征。我们对标本模拟施行了内镜甲状腺手术,由于实验室使用二氧化碳(C02)条件的限制,我们将胸前和颈前的操作空间分离开后,将整个胸、颈的皮瓣向头侧翻起,使甲状腺区域的操作空间完全暴露,在对甲状腺区域进行解剖时,均遵循内镜手术下从尾侧到头侧的操作方向。解剖过程当中,我们对各解剖操作进行了全程拍照。
三、结果
(一)层面
1、胸前壁浅筋膜与胸大肌筋膜之间有一疏松的筋膜间隙,胸前壁操作层面位于此筋膜间隙。
2、颈阔肌与颈前深筋膜浅层之间有一疏松的间隙,颈前操作层面位于此间隙；颈阔肌尾侧起源于颈胸交界,位于皮下浅筋膜深面而紧贴皮下浅筋膜。
3、胸前壁的胸大肌筋膜与颈前的深筋膜浅层为一连续的筋膜层面。
4、内镜甲状腺分离三角是寻找甲状腺下动脉和甲状腺中静脉的一个重要层面,位于带状肌与甲状腺腺叶之间。
5、甲状旁腺被甲状腺外科被膜所包裹,甲状旁腺与甲状腺之间有一筋膜间隙。
6、在模拟内镜下颈中央区淋巴结清扫术中,我们发现有一层筋膜组织包裹着中央区淋巴结组,分离过程中完整保留此包膜,可以使淋巴结和其他组织(甲状旁腺、喉返神经以及胸腺组织等)安全地分离开；胸腺组织也有其自身包膜,紧贴包膜外分离可避免在清扫淋巴结时切除部分胸腺组织,或者避免淋巴结清扫不干净的情况。
(二)特殊的组织结构位置关系
1、喉返神经位于甲状旁腺的深面。
2、有一血管与喉返神经的走形平行,并位于喉返神经的浅面。
3、上甲状旁腺与甲状腺中静脉邻近,同时上甲状旁腺与喉返神经入喉位置处于相同水平面。
4、喉上神经的外支紧贴环甲肌于甲状软骨中下段入喉。
四、讨论
内镜甲状腺的外科平面在实际操作中是否正确,我们可以通过本研究发现的胸前和颈前组织层面来证实,答案是肯定的。我们研究中发现的其他疏松层面可以指导外科医生在实施内镜甲状腺手术时如何保护重要的组织结构,如在颈中央区淋巴结清扫术中保护甲状旁腺和喉返神经。在我们研究中发现的组织结构特殊的位置关系可以指导外科医生安全地施行内镜甲状腺手术,避免损伤重要的结构,同时还可以指导我们如何进一步寻找相关的解剖标志。
第二部分内镜甲状腺手术的临床解剖学研究
一、研究目的
在内镜甲状腺手术中,由于使用器械使外科医生缺乏手的触觉,以及操作方向的限制等缺点,寻找合适的外科平面以及解剖标志显得非常重要,本研究的目的即在于此。
二、研究方法
通过采集83例经胸前壁入路内镜甲状腺手术病例的手术录像及图片,观察并记录相关外科平面和解剖标志。其中女性74例,男性9例；手术在甲状腺右叶者69例,左叶者30例。其中7例患者的单侧手术标本被冰冻病理切片检查诊断为恶性肿瘤。
三、结果(一)外科平面
1、胸部的操作空间位于浅筋膜和胸大肌筋膜之间,颈前操作空间位于颈阔肌和颈深筋膜浅层之间,这两个操作平面为相互连续的。
2、内镜甲状腺分离三角位于带状肌和甲状腺叶之间,在该外科平面中可寻找到甲状腺下动脉(100.0%)和甲状腺中静脉(100.0%)。
(二)解剖标志
1、在甲状腺下动脉深面可发现下甲状旁腺(90.0%),甲状腺下动脉可作为寻找下甲状旁腺的解剖标志。
2、在下甲状旁腺深面可发现喉返神经(85.7%),下甲状旁腺可作为寻找喉返神经的解剖标志。
3、在甲状腺叶背侧、甲状腺中静脉附近可发现上甲状旁腺(90.0%),甲状腺中静脉可作为寻找上甲状旁腺的解剖标志。
4、甲状腺区域段的喉返神经恒定从甲状软骨后下角入喉(100.0%)。通常,在喉返神经入喉处浅面会发现一条与喉返神经走形垂直的血管(V1)(100.0%)；有时,在气管食管沟会发现一条与喉返神经走形平行的血管(V1),该血管深面可发现喉返神经(40.0%)。V1和V2均可作为寻找喉返神经的解剖标志。
四、讨论
由于内镜甲状腺手术中狭小的操作空间以及从尾侧到头侧限制性的操作方向,相关外科平面和解剖标志的知识对于外科医生来说尤其重要。正确的外科平面和解剖标志可以指导我们在手术中如何保护重要的组织结构,如喉返神经和甲状旁腺。
结论
在甲状腺手术中,内镜手术由于其术后较好的美容效果,已经越来越多地应用于临床。不同个体甲状腺肿瘤的位置变化多样,内镜甲状腺手术的系统解剖学知识,可以为外科医生在实施手术中提供一个清晰的手术思路,这一点对于初学者来说尤为重要。腔镜下解剖学今后应该成为腔镜外科医生的一门基础学科,相信随着腔镜手术应用的越来越广泛化,腔镜下解剖学的研究领域将逐渐扩大及深入。
Background
The development of laparoscopic surgery has spawned the new field of study, laparoscopic anatomy. In the field of abdominal surgery, the traditional approach of open surgery and related surgical anatomy are well established, while laparoscopic surgery and correlative laparoscopic anatomy are still under study. Endoscopic thyroidectomy (ET) was carried out since nearly 20 years ago. But few study on anatomy research of ET was found from information retrieval. The following studies were research work done by us in order to find out the surgical planes and anatomic landmarks in ET, which could guide surgeons to take ET operation safely. We did the work both by autopsy and clinical research.
Part 1 Autopsy Rearch of Endoscopic Thyroidectomy Anatomy
Aim
In this study, we imitated the breast approach of live ET procedure on cadavers, in order to find out the structure layer of procedure and position relationships of structures. The aim is to do some initial research about anatomy in ET.
Methods
Three cadavers, of which one was fresh and two were fixed with 10% formalin, donated to department of anatomy of the Southern Medical University of Guangzhou were studied. None had signs or history of thyroid diseases. ET procedures were taken on them imitating the approach of live procedure without using carbon dioxide, instead of procedure space unwrapped. Photos were taken when dissecting.
Results
1. Structure layers
1.1 The procedure space of ET on the anterior chest was between the superficial fascia and the deep fascia.
1.2 The procedure space of ET on the neck was between the platysma muscle and the superficial layer of deep fascia. The platysma on neck adhered tightly to superficial fascia, which was continuous from superior breast to neck.
1.3 The pectoralis major fascia on breast and superficial layer of deep fascia on neck were continuous.
1.4 The ET dissecting triangle, which was between the muscle strip and thyroid gland, was an important layer to search the inferior thyroid vessels and middle thyroid vein.
1.5 The parathyroid gland was wrapped within fibrous capsule of thyroid gland. A loose space could be found between thyroid gland and parathyroid gland.
1.6 During the procedure of the central lymph node dissection, lymph nodes group had its own fascia wrapped, and the spaces between thymus gland and lymph nodes of level VI could be found.
2. Structure position relationships
2.1 The recurrent laryngeal nerve could be found beneath inferior parathyroid gland.
2.2 A vessel could be found above and parallel with RLN.
2.3 The superior parathyroid gland could be found adjacent to middle thyroid vein and on the same horizontal level with that of recurrent laryngeal nerve going in to larynx.
2.4 The the external branch of superior laryngeal nerve was stick to cricothyroid muscle, and went into larynx during the middle and inferior part of thyroid cartilage.
Discussion
The surgical plane during live ET procedure could be proofed appropriate by the research of the structure layers of the anterior chest and neck in this study. The loose spaces found in our study could guide surgeons how to protect important structures, such as parathyroid glands and recurrent laryngeal nerves, during the central lymph node dissection of ET. These specific structure position relationships found in our study could guide surgeons to operate safely during ET without injury of the important strutures, as well as lead us to find the anatomic landmarks in live ET procedure.
Part 2 Clinical Anatomy Rearch of Endoscopic Thyroidectomy
Aim
Because of lacking of tactile sensation and limitation of procedure direction, how to find appropriate surgical planes and anatomic landmarks in ET is of importance to surgeons. This study is aim to find these in live ET procedure.
Methods
The surgical plane and anatomic landmark were observed on endoscopic eyesight in 83 consecutive cases (74 females and 9 males,69 right lobes and 30 left lobes) of living endoscopic thyroidectomy by anterior breast approach.7 cases were diagnosed as malignant tumour of single lobe by frozen.
Results
1. Surgical planes
1.1 The appropriate procedure spaces were between the superficial fascia and pectoralis major fascia on beast, and between platysma and superficial layer of deep fascia on neck, which of the two layers were continuous.
1.2 The ET dissecting triangle was the space between the muscle strip and thyroid lobe, which could be the surgical plane for finding the inferior thyroid vascular (100.0%) and the middle thyroid vein (100.0%).
2. Landmarks
2.1 The inferior parathyroid gland could be found under the inferior thyroid artery (92.5%). Therefore, the inferior thyroid artery could be landmark for finding the inferior parathyroid gland.
2.2 The recurrent laryngeal nerve could be found under the inferior parathyroid gland (85.7%). Therefore, the inferior parathyroid gland could be landmark for finding the recurrent laryngeal nerve.
2.3 The superior parathyroid gland could be found adjacent to the middle thyroid vein (90.0%). Therefore, the middle thyroid vein could be landmark for finding the superior parethyroid gland.
2.4 The thyroid region segment of exposed recurrent laryngeal nerves went into larynx posterior inferior the thyroid cartilage, above which a vessel (V1) perpendicular to recurrent laryngeal nerve, as a landmark to find laryngeal nerve, went from the thyroid lobe to larynx (100.0%). Sometimes a vascular (V2) above and parallel with the recurrent laryngeal nerve could be found in tracheoesophageal groove (40.0%), which could be another landmark to found the recurrent laryngeal nerve.
Discussion
Due to small space and single procedure direction (from caudal side to head side) during ET operation, the surgical planes and anatomic landmarks are particularly important for the surgeons. The recurrent laryngeal nerve and the parathyroid gland would be protected during ET following the surgical planes and anatomic landmarks we observed.
Conclusion
In the field of thyroidectomy, endoscopic surgery has become increasingly popular because of its excellent cosmetic result post operation. Systematic anatomy on ET can provide surgeons with a clear idea to design their operations of different tumor position during ET, which is particularly important for practicing novice surgeons. Laparoscopic anatomy is a basic curriculum for laparoscopic surgeons, and will certainly become an important new subject as the use of laparoscopic procedures increases.
近年来随着腹腔镜手术的发展,腔镜下解剖学研究成为了一门新兴的学科。传统的开放手术,其解剖学研究已经非常深入和透彻,而腔镜下解剖学的研究才刚刚开始。内镜甲状腺手术(endoscopic thyroidectomy, ET)开展了将近20年,但是我们查阅了相关文献,了解到内镜甲状腺手术的腔镜下解剖学研究非常之少。我们通过一系列的尸体及临床解剖学研究,找到了内镜甲状腺手术的相关外科平面和解剖标志,以期指导腔镜外科医生更安全地实施手术。
第一部分内镜甲状腺手术的尸体解剖学研究
一、研究目的
我们在本研究中,通过对尸体模拟经胸前壁径路的内镜甲状腺手术,找到了一系列组织层面和组织结构间的相互位置关系。对内镜甲状腺手术的解剖学研究进行了初步探讨,以指导下一步的研究工作。
二、研究方法
我们对3个尸体标本进行了内镜甲状腺手术的解剖学研究,其中1个为新鲜标本,2个为10%福尔马林固定的标本,均为广州南方医科大学解剖学教研室受捐赠的标本。3个标本均无甲状腺方面的病史体征。我们对标本模拟施行了内镜甲状腺手术,由于实验室使用二氧化碳(C02)条件的限制,我们将胸前和颈前的操作空间分离开后,将整个胸、颈的皮瓣向头侧翻起,使甲状腺区域的操作空间完全暴露,在对甲状腺区域进行解剖时,均遵循内镜手术下从尾侧到头侧的操作方向。解剖过程当中,我们对各解剖操作进行了全程拍照。
三、结果
(一)层面
1、胸前壁浅筋膜与胸大肌筋膜之间有一疏松的筋膜间隙,胸前壁操作层面位于此筋膜间隙。
2、颈阔肌与颈前深筋膜浅层之间有一疏松的间隙,颈前操作层面位于此间隙；颈阔肌尾侧起源于颈胸交界,位于皮下浅筋膜深面而紧贴皮下浅筋膜。
3、胸前壁的胸大肌筋膜与颈前的深筋膜浅层为一连续的筋膜层面。
4、内镜甲状腺分离三角是寻找甲状腺下动脉和甲状腺中静脉的一个重要层面,位于带状肌与甲状腺腺叶之间。
5、甲状旁腺被甲状腺外科被膜所包裹,甲状旁腺与甲状腺之间有一筋膜间隙。
6、在模拟内镜下颈中央区淋巴结清扫术中,我们发现有一层筋膜组织包裹着中央区淋巴结组,分离过程中完整保留此包膜,可以使淋巴结和其他组织(甲状旁腺、喉返神经以及胸腺组织等)安全地分离开；胸腺组织也有其自身包膜,紧贴包膜外分离可避免在清扫淋巴结时切除部分胸腺组织,或者避免淋巴结清扫不干净的情况。
(二)特殊的组织结构位置关系
1、喉返神经位于甲状旁腺的深面。
2、有一血管与喉返神经的走形平行,并位于喉返神经的浅面。
3、上甲状旁腺与甲状腺中静脉邻近,同时上甲状旁腺与喉返神经入喉位置处于相同水平面。
4、喉上神经的外支紧贴环甲肌于甲状软骨中下段入喉。
四、讨论
内镜甲状腺的外科平面在实际操作中是否正确,我们可以通过本研究发现的胸前和颈前组织层面来证实,答案是肯定的。我们研究中发现的其他疏松层面可以指导外科医生在实施内镜甲状腺手术时如何保护重要的组织结构,如在颈中央区淋巴结清扫术中保护甲状旁腺和喉返神经。在我们研究中发现的组织结构特殊的位置关系可以指导外科医生安全地施行内镜甲状腺手术,避免损伤重要的结构,同时还可以指导我们如何进一步寻找相关的解剖标志。
第二部分内镜甲状腺手术的临床解剖学研究
一、研究目的
在内镜甲状腺手术中,由于使用器械使外科医生缺乏手的触觉,以及操作方向的限制等缺点,寻找合适的外科平面以及解剖标志显得非常重要,本研究的目的即在于此。
二、研究方法
通过采集83例经胸前壁入路内镜甲状腺手术病例的手术录像及图片,观察并记录相关外科平面和解剖标志。其中女性74例,男性9例；手术在甲状腺右叶者69例,左叶者30例。其中7例患者的单侧手术标本被冰冻病理切片检查诊断为恶性肿瘤。
三、结果(一)外科平面
1、胸部的操作空间位于浅筋膜和胸大肌筋膜之间,颈前操作空间位于颈阔肌和颈深筋膜浅层之间,这两个操作平面为相互连续的。
2、内镜甲状腺分离三角位于带状肌和甲状腺叶之间,在该外科平面中可寻找到甲状腺下动脉(100.0%)和甲状腺中静脉(100.0%)。
(二)解剖标志
1、在甲状腺下动脉深面可发现下甲状旁腺(90.0%),甲状腺下动脉可作为寻找下甲状旁腺的解剖标志。
2、在下甲状旁腺深面可发现喉返神经(85.7%),下甲状旁腺可作为寻找喉返神经的解剖标志。
3、在甲状腺叶背侧、甲状腺中静脉附近可发现上甲状旁腺(90.0%),甲状腺中静脉可作为寻找上甲状旁腺的解剖标志。
4、甲状腺区域段的喉返神经恒定从甲状软骨后下角入喉(100.0%)。通常,在喉返神经入喉处浅面会发现一条与喉返神经走形垂直的血管(V1)(100.0%)；有时,在气管食管沟会发现一条与喉返神经走形平行的血管(V1),该血管深面可发现喉返神经(40.0%)。V1和V2均可作为寻找喉返神经的解剖标志。
四、讨论
由于内镜甲状腺手术中狭小的操作空间以及从尾侧到头侧限制性的操作方向,相关外科平面和解剖标志的知识对于外科医生来说尤其重要。正确的外科平面和解剖标志可以指导我们在手术中如何保护重要的组织结构,如喉返神经和甲状旁腺。
结论
在甲状腺手术中,内镜手术由于其术后较好的美容效果,已经越来越多地应用于临床。不同个体甲状腺肿瘤的位置变化多样,内镜甲状腺手术的系统解剖学知识,可以为外科医生在实施手术中提供一个清晰的手术思路,这一点对于初学者来说尤为重要。腔镜下解剖学今后应该成为腔镜外科医生的一门基础学科,相信随着腔镜手术应用的越来越广泛化,腔镜下解剖学的研究领域将逐渐扩大及深入。
Background
The development of laparoscopic surgery has spawned the new field of study, laparoscopic anatomy. In the field of abdominal surgery, the traditional approach of open surgery and related surgical anatomy are well established, while laparoscopic surgery and correlative laparoscopic anatomy are still under study. Endoscopic thyroidectomy (ET) was carried out since nearly 20 years ago. But few study on anatomy research of ET was found from information retrieval. The following studies were research work done by us in order to find out the surgical planes and anatomic landmarks in ET, which could guide surgeons to take ET operation safely. We did the work both by autopsy and clinical research.
Part 1 Autopsy Rearch of Endoscopic Thyroidectomy Anatomy
Aim
In this study, we imitated the breast approach of live ET procedure on cadavers, in order to find out the structure layer of procedure and position relationships of structures. The aim is to do some initial research about anatomy in ET.
Methods
Three cadavers, of which one was fresh and two were fixed with 10% formalin, donated to department of anatomy of the Southern Medical University of Guangzhou were studied. None had signs or history of thyroid diseases. ET procedures were taken on them imitating the approach of live procedure without using carbon dioxide, instead of procedure space unwrapped. Photos were taken when dissecting.
Results
1. Structure layers
1.1 The procedure space of ET on the anterior chest was between the superficial fascia and the deep fascia.
1.2 The procedure space of ET on the neck was between the platysma muscle and the superficial layer of deep fascia. The platysma on neck adhered tightly to superficial fascia, which was continuous from superior breast to neck.
1.3 The pectoralis major fascia on breast and superficial layer of deep fascia on neck were continuous.
1.4 The ET dissecting triangle, which was between the muscle strip and thyroid gland, was an important layer to search the inferior thyroid vessels and middle thyroid vein.
1.5 The parathyroid gland was wrapped within fibrous capsule of thyroid gland. A loose space could be found between thyroid gland and parathyroid gland.
1.6 During the procedure of the central lymph node dissection, lymph nodes group had its own fascia wrapped, and the spaces between thymus gland and lymph nodes of level VI could be found.
2. Structure position relationships
2.1 The recurrent laryngeal nerve could be found beneath inferior parathyroid gland.
2.2 A vessel could be found above and parallel with RLN.
2.3 The superior parathyroid gland could be found adjacent to middle thyroid vein and on the same horizontal level with that of recurrent laryngeal nerve going in to larynx.
2.4 The the external branch of superior laryngeal nerve was stick to cricothyroid muscle, and went into larynx during the middle and inferior part of thyroid cartilage.
Discussion
The surgical plane during live ET procedure could be proofed appropriate by the research of the structure layers of the anterior chest and neck in this study. The loose spaces found in our study could guide surgeons how to protect important structures, such as parathyroid glands and recurrent laryngeal nerves, during the central lymph node dissection of ET. These specific structure position relationships found in our study could guide surgeons to operate safely during ET without injury of the important strutures, as well as lead us to find the anatomic landmarks in live ET procedure.
Part 2 Clinical Anatomy Rearch of Endoscopic Thyroidectomy
Aim
Because of lacking of tactile sensation and limitation of procedure direction, how to find appropriate surgical planes and anatomic landmarks in ET is of importance to surgeons. This study is aim to find these in live ET procedure.
Methods
The surgical plane and anatomic landmark were observed on endoscopic eyesight in 83 consecutive cases (74 females and 9 males,69 right lobes and 30 left lobes) of living endoscopic thyroidectomy by anterior breast approach.7 cases were diagnosed as malignant tumour of single lobe by frozen.
Results
1. Surgical planes
1.1 The appropriate procedure spaces were between the superficial fascia and pectoralis major fascia on beast, and between platysma and superficial layer of deep fascia on neck, which of the two layers were continuous.
1.2 The ET dissecting triangle was the space between the muscle strip and thyroid lobe, which could be the surgical plane for finding the inferior thyroid vascular (100.0%) and the middle thyroid vein (100.0%).
2. Landmarks
2.1 The inferior parathyroid gland could be found under the inferior thyroid artery (92.5%). Therefore, the inferior thyroid artery could be landmark for finding the inferior parathyroid gland.
2.2 The recurrent laryngeal nerve could be found under the inferior parathyroid gland (85.7%). Therefore, the inferior parathyroid gland could be landmark for finding the recurrent laryngeal nerve.
2.3 The superior parathyroid gland could be found adjacent to the middle thyroid vein (90.0%). Therefore, the middle thyroid vein could be landmark for finding the superior parethyroid gland.
2.4 The thyroid region segment of exposed recurrent laryngeal nerves went into larynx posterior inferior the thyroid cartilage, above which a vessel (V1) perpendicular to recurrent laryngeal nerve, as a landmark to find laryngeal nerve, went from the thyroid lobe to larynx (100.0%). Sometimes a vascular (V2) above and parallel with the recurrent laryngeal nerve could be found in tracheoesophageal groove (40.0%), which could be another landmark to found the recurrent laryngeal nerve.
Discussion
Due to small space and single procedure direction (from caudal side to head side) during ET operation, the surgical planes and anatomic landmarks are particularly important for the surgeons. The recurrent laryngeal nerve and the parathyroid gland would be protected during ET following the surgical planes and anatomic landmarks we observed.
Conclusion
In the field of thyroidectomy, endoscopic surgery has become increasingly popular because of its excellent cosmetic result post operation. Systematic anatomy on ET can provide surgeons with a clear idea to design their operations of different tumor position during ET, which is particularly important for practicing novice surgeons. Laparoscopic anatomy is a basic curriculum for laparoscopic surgeons, and will certainly become an important new subject as the use of laparoscopic procedures increases.
引文
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