【摘要】： 背景 近年來(lái)隨著腹腔鏡手術(shù)的發(fā)展,腔鏡下解剖學(xué)研究成為了一門新興的學(xué)科。傳統(tǒng)的開(kāi)放手術(shù),其解剖學(xué)研究已經(jīng)非常深入和透徹,而腔鏡下解剖學(xué)的研究才剛剛開(kāi)始。內(nèi)鏡甲狀腺手術(shù)(endoscopic thyroidectomy, ET)開(kāi)展了將近20年,但是我們查閱了相關(guān)文獻(xiàn),了解到內(nèi)鏡甲狀腺手術(shù)的腔鏡下解剖學(xué)研究非常之少。我們通過(guò)一系列的尸體及臨床解剖學(xué)研究,找到了內(nèi)鏡甲狀腺手術(shù)的相關(guān)外科平面和解剖標(biāo)志,以期指導(dǎo)腔鏡外科醫(yī)生更安全地實(shí)施手術(shù)。 第一部分內(nèi)鏡甲狀腺手術(shù)的尸體解剖學(xué)研究 一、研究目的 我們?cè)诒狙芯恐?通過(guò)對(duì)尸體模擬經(jīng)胸前壁徑路的內(nèi)鏡甲狀腺手術(shù),找到了一系列組織層面和組織結(jié)構(gòu)間的相互位置關(guān)系。對(duì)內(nèi)鏡甲狀腺手術(shù)的解剖學(xué)研究進(jìn)行了初步探討,以指導(dǎo)下一步的研究工作。 二、研究方法 我們對(duì)3個(gè)尸體標(biāo)本進(jìn)行了內(nèi)鏡甲狀腺手術(shù)的解剖學(xué)研究,其中1個(gè)為新鮮標(biāo)本,2個(gè)為10%福爾馬林固定的標(biāo)本,均為廣州南方醫(yī)科大學(xué)解剖學(xué)教研室受捐贈(zèng)的標(biāo)本。3個(gè)標(biāo)本均無(wú)甲狀腺方面的病史體征。我們對(duì)標(biāo)本模擬施行了內(nèi)鏡甲狀腺手術(shù),由于實(shí)驗(yàn)室使用二氧化碳(C02)條件的限制,我們將胸前和頸前的操作空間分離開(kāi)后,將整個(gè)胸、頸的皮瓣向頭側(cè)翻起,使甲狀腺區(qū)域的操作空間完全暴露,在對(duì)甲狀腺區(qū)域進(jìn)行解剖時(shí),均遵循內(nèi)鏡手術(shù)下從尾側(cè)到頭側(cè)的操作方向。解剖過(guò)程當(dāng)中,我們對(duì)各解剖操作進(jìn)行了全程拍照。 三、結(jié)果 (一)層面 1、胸前壁淺筋膜與胸大肌筋膜之間有一疏松的筋膜間隙,胸前壁操作層面位于此筋膜間隙。 2、頸闊肌與頸前深筋膜淺層之間有一疏松的間隙,頸前操作層面位于此間隙；頸闊肌尾側(cè)起源于頸胸交界,位于皮下淺筋膜深面而緊貼皮下淺筋膜。 3、胸前壁的胸大肌筋膜與頸前的深筋膜淺層為一連續(xù)的筋膜層面。 4、內(nèi)鏡甲狀腺分離三角是尋找甲狀腺下動(dòng)脈和甲狀腺中靜脈的一個(gè)重要層面,位于帶狀肌與甲狀腺腺葉之間。 5、甲狀旁腺被甲狀腺外科被膜所包裹,甲狀旁腺與甲狀腺之間有一筋膜間隙。 6、在模擬內(nèi)鏡下頸中央?yún)^(qū)淋巴結(jié)清掃術(shù)中,我們發(fā)現(xiàn)有一層筋膜組織包裹著中央?yún)^(qū)淋巴結(jié)組,分離過(guò)程中完整保留此包膜,可以使淋巴結(jié)和其他組織(甲狀旁腺、喉返神經(jīng)以及胸腺組織等)安全地分離開(kāi)；胸腺組織也有其自身包膜,緊貼包膜外分離可避免在清掃淋巴結(jié)時(shí)切除部分胸腺組織,或者避免淋巴結(jié)清掃不干凈的情況。 (二)特殊的組織結(jié)構(gòu)位置關(guān)系 1、喉返神經(jīng)位于甲狀旁腺的深面。 2、有一血管與喉返神經(jīng)的走形平行,并位于喉返神經(jīng)的淺面。 3、上甲狀旁腺與甲狀腺中靜脈鄰近,同時(shí)上甲狀旁腺與喉返神經(jīng)入喉位置處于相同水平面。 4、喉上神經(jīng)的外支緊貼環(huán)甲肌于甲狀軟骨中下段入喉。 四、討論 內(nèi)鏡甲狀腺的外科平面在實(shí)際操作中是否正確,我們可以通過(guò)本研究發(fā)現(xiàn)的胸前和頸前組織層面來(lái)證實(shí),答案是肯定的。我們研究中發(fā)現(xiàn)的其他疏松層面可以指導(dǎo)外科醫(yī)生在實(shí)施內(nèi)鏡甲狀腺手術(shù)時(shí)如何保護(hù)重要的組織結(jié)構(gòu),如在頸中央?yún)^(qū)淋巴結(jié)清掃術(shù)中保護(hù)甲狀旁腺和喉返神經(jīng)。在我們研究中發(fā)現(xiàn)的組織結(jié)構(gòu)特殊的位置關(guān)系可以指導(dǎo)外科醫(yī)生安全地施行內(nèi)鏡甲狀腺手術(shù),避免損傷重要的結(jié)構(gòu),同時(shí)還可以指導(dǎo)我們?nèi)绾芜M(jìn)一步尋找相關(guān)的解剖標(biāo)志。 第二部分內(nèi)鏡甲狀腺手術(shù)的臨床解剖學(xué)研究 一、研究目的 在內(nèi)鏡甲狀腺手術(shù)中,由于使用器械使外科醫(yī)生缺乏手的觸覺(jué),以及操作方向的限制等缺點(diǎn),尋找合適的外科平面以及解剖標(biāo)志顯得非常重要,本研究的目的即在于此。 二、研究方法 通過(guò)采集83例經(jīng)胸前壁入路內(nèi)鏡甲狀腺手術(shù)病例的手術(shù)錄像及圖片,觀察并記錄相關(guān)外科平面和解剖標(biāo)志。其中女性74例,男性9例；手術(shù)在甲狀腺右葉者69例,左葉者30例。其中7例患者的單側(cè)手術(shù)標(biāo)本被冰凍病理切片檢查診斷為惡性腫瘤。 三、結(jié)果(一)外科平面 1、胸部的操作空間位于淺筋膜和胸大肌筋膜之間,頸前操作空間位于頸闊肌和頸深筋膜淺層之間,這兩個(gè)操作平面為相互連續(xù)的。 2、內(nèi)鏡甲狀腺分離三角位于帶狀肌和甲狀腺葉之間,在該外科平面中可尋找到甲狀腺下動(dòng)脈(100.0%)和甲狀腺中靜脈(100.0%)。 (二)解剖標(biāo)志 1、在甲狀腺下動(dòng)脈深面可發(fā)現(xiàn)下甲狀旁腺(90.0%),甲狀腺下動(dòng)脈可作為尋找下甲狀旁腺的解剖標(biāo)志。 2、在下甲狀旁腺深面可發(fā)現(xiàn)喉返神經(jīng)(85.7%),下甲狀旁腺可作為尋找喉返神經(jīng)的解剖標(biāo)志。 3、在甲狀腺葉背側(cè)、甲狀腺中靜脈附近可發(fā)現(xiàn)上甲狀旁腺(90.0%),甲狀腺中靜脈可作為尋找上甲狀旁腺的解剖標(biāo)志。 4、甲狀腺區(qū)域段的喉返神經(jīng)恒定從甲狀軟骨后下角入喉(100.0%)。通常,在喉返神經(jīng)入喉處淺面會(huì)發(fā)現(xiàn)一條與喉返神經(jīng)走形垂直的血管(V1)(100.0%)；有時(shí),在氣管食管溝會(huì)發(fā)現(xiàn)一條與喉返神經(jīng)走形平行的血管(V1),該血管深面可發(fā)現(xiàn)喉返神經(jīng)(40.0%)。V1和V2均可作為尋找喉返神經(jīng)的解剖標(biāo)志。 四、討論 由于內(nèi)鏡甲狀腺手術(shù)中狹小的操作空間以及從尾側(cè)到頭側(cè)限制性的操作方向,相關(guān)外科平面和解剖標(biāo)志的知識(shí)對(duì)于外科醫(yī)生來(lái)說(shuō)尤其重要。正確的外科平面和解剖標(biāo)志可以指導(dǎo)我們?cè)谑中g(shù)中如何保護(hù)重要的組織結(jié)構(gòu),如喉返神經(jīng)和甲狀旁腺。 結(jié)論 在甲狀腺手術(shù)中,內(nèi)鏡手術(shù)由于其術(shù)后較好的美容效果,已經(jīng)越來(lái)越多地應(yīng)用于臨床。不同個(gè)體甲狀腺腫瘤的位置變化多樣,內(nèi)鏡甲狀腺手術(shù)的系統(tǒng)解剖學(xué)知識(shí),可以為外科醫(yī)生在實(shí)施手術(shù)中提供一個(gè)清晰的手術(shù)思路,這一點(diǎn)對(duì)于初學(xué)者來(lái)說(shuō)尤為重要。腔鏡下解剖學(xué)今后應(yīng)該成為腔鏡外科醫(yī)生的一門基礎(chǔ)學(xué)科,相信隨著腔鏡手術(shù)應(yīng)用的越來(lái)越廣泛化,腔鏡下解剖學(xué)的研究領(lǐng)域?qū)⒅饾u擴(kuò)大及深入。
[Abstract]:Background In recent years, with the development of laparoscopic surgery, the anatomy of the cavity has become a new subject Subject. Traditional open surgery, its anatomical study has been very deep and thorough, and the anatomy of the cavity has just been studied. The endoscopic thyroidectomy (ET) has just begun for nearly 20 years, but we have consulted the literature to learn about the anatomy of endoscopic thyroidectomy. Often less, we have found the surgical planes and anatomical landmarks of endoscopic thyroidectomy through a series of bodies and clinical anatomical studies, with a view to guiding the surgeon to be safer and more secure Operation. First partial endoscopic thyroidectomy anatomy of the body For the purpose of this study, we have found a series of tissues by simulating the endoscopic thyroidectomy via the chest wall approach. The interpositional relationship between the level and the structure of the tissue. The anatomical study of endoscopic thyroidectomy was initially studied. Step through to refer to Next, we studied the anatomy of endoscopic thyroidectomy in three body specimens. 1 fresh specimen and 2 samples of 10% formalin fixed to the anatomy teaching and research section of Guangzhou Southern Medical University The donated specimens showed no signs of thyroid history in the 3 specimens. We performed endoscopic thyroidectomy for the specimen simulation. As a result of the laboratory use of carbon dioxide (C02) conditions, we left the entire chest, neck, The flap is turned over to the head so that the operation space of the thyroid area is completely exposed, and in the thyroid area During dissection, follow the operation direction of the endoscope procedure from the tail side to the head side. Dissect Of course, I The anatomy was photographed all the way. 3. Results (i) Level 1, chest wall There is a loose fascial space between the superficial fascia and the pectoral muscle fascia, which is located at the operation level of the chest wall. There is a loose gap between the fascia and the superficial fascia of the neck. It is located in this gap; the tail side of the latissimus latissimus originates from the junction of the neck and the chest, and is located in the deep subcutaneous superficial fascia. subcuticular superficial fascia. The superficial fascia of the chest wall and the superficial fascia of the anterior cervical fascia are a continuous fascia layer. Endoscopic thyroidectomy is an important aspect of the search for thyroid artery and thyroid veins. Between the band muscle and the thyroid gland lobe. 5. The parathyroid gland is surrounded by a membrane of thyroid surgery. There is a fascia gap between the parathyroid glands and the thyroid gland. During the scan, we found that there was a layer of fascial tissue wrapped in the lymph node group, the complete retention of the envelope during the separation, and the safe separation of lymph nodes and other tissues (parathyroid, recurrent laryngeal nerve, and thymus tissue, etc.) The thymus tissue also has its own envelope, It is possible to avoid the dissection of lymph nodes in close contact with the outside of the capsule. Partial thymus tissue should be cut off, or dissection of lymph nodes should be avoided. (2) Special structural positional relationship 1. The recurrent laryngeal nerve is located at the deep surface of the parathyroid gland. There is a blood vessel that is parallel to the shape of the recurrent laryngeal nerve and is located at the back of the recurrent laryngeal nerve. Face. 3. The upper parathyroid gland is adjacent to the thyroid gland, while the upper parathyroid gland and the recurrent laryngeal nerve enter the laryngeal position at the same level. To discuss whether the surgical plane of endoscopic thyroidectomy is correct in actual operation, we can adopt the anterior chest and anterior cervical group found in this study. To confirm that the answer is positive, the other loose aspects found in our study can direct the surgeon to protect important tissue structures during endoscopic thyroidectomy, such as protecting a nail in cervical lymph node dissection. Dorsal glands and recurrent laryngeal nerve. Groups found in our study woven with special structure The positional relationship can guide the surgeon to safely perform endoscopic thyroidectomy, avoid damaging important structures, and also refer to How do we further look for relevant anatomical landmarks? Second part endoscopic thyroidectomy Clinical anatomy of Study I. The purpose of this study was in endoscopic thyroidectomy due to the use of the device to give the surgeon a lack of hand tactile sense, as well as operation It is very important to find suitable surgical planes and anatomical landmarks in order to find suitable surgical planes and anatomical landmarks. the purpose of the study is that this. 2, the method of study is obtained by collecting 83 cases, Endoscopic thyroidectomy via chest wall The surgical video and pictures of the surgical cases were recorded and recorded. The related surgical plane and anatomical landmarks were observed and recorded. Among them, 74 were female, 9 in men, 69 in right lobe of thyroid, left lobe, One-sided surgical specimen of 7 patients was diagnosed as malignant tumor by frozen pathological section. Results (1) Surgical plane (1) and chest (1) were located in the surgical plane (1). superficial fascia and pectoralis major Between the fascia and the superficial fascia of the neck, the anterior operating space of the neck is continuous with each other. Hypothyroid artery (100. 0%) can be found in the surgical plane. Intrathyroid vein (100. 0%). (2) Anatomical sign 1. Hypoparathyroidism can be found in deep surface of thyroid artery (90. 0%) and the lower thyroid artery can be used as the anatomical marker for finding the hypoparathyroidism. The recurrent laryngeal nerve (85.7%), hypoparathyroidism could be used as the anatomical marker for the search for recurrent laryngeal nerve. 3. On the back side of the thyroid lobe, the upper parathyroid gland (90. 0%) can be found near the vein of the thyroid gland. the thyroid gland veins can be used as the anatomical marker for finding the upper parathyroid gland. 4. The recurrent laryngeal nerve in the thyroid area segment constant from nail In general, a blood vessel (1) (100. 0%) perpendicular to the recurrent laryngeal nerve was found on the superficial side of the laryngeal nerve entering the larynx (100. 0%); At the same time, a blood vessel (V1) parallel to the recurrent laryngeal nerve is found in the tracheoesophageal groove, which can find the recurrent laryngeal nerve (40. 0%). V1 and V2 can be used as anatomical landmarks for the search for recurrent laryngeal nerve. IV. Discussion is due to Knowledge of surgical planes and anatomical landmarks is particularly important for the surgeon in the narrow operating space in endoscopic thyroidectomy and the direction of operation that is restricted from the tail side to the head side. The correct surgical plane and anatomical landmarks may How to protect important tissue structures such as recurrent laryngeal nerve and parathyroid gland during surgery. Conclusion In thyroid surgery, endoscopic surgery is a good cosmetic effect after surgery
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2010
【分類號(hào)】：R653;R322
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本文編號(hào)：2306549