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Médecine

经口内窥镜甲状腺切除术甲状腺叶切除术前庭入路甲状腺叶切除术

Published: May 12, 2023
doi:
10.3791/64437
, , ,
1West China School of Medicine,Sichuan University, 2Sichuan University West China Hospital

Summary

在这里，我们提出了一个协议来详细描述经口内窥镜甲状腺切除术前庭入路的方法。

Abstract

手稿描述了用于甲状腺叶切除术的经口内窥镜甲状腺切除术前庭入路 （TOETVA）。将患者置于仰卧位，伸展并固定颈部。在对皮肤和口腔进行消毒后，通过口腔前庭的粘膜做一个20毫米的横向切口和两个5毫米的切口，用于放置相机和仪器。工作区由皮肤悬浮装置建立和维护，该装置由不可吸收的绳子（3-0）和橡皮筋以及CO2 吹气压力制成。使用内侧到外侧技术和预防性同侧中央颈清扫术同时对甲状腺状癌 （PTC） 患者进行肺叶切除术。通过20毫米切口提取标本。立即在标本中寻找甲状旁腺并自动移植到左臂桡骨。引流管通过牵开器孔插入甲状腺床，并使用可吸收缝合线关闭口腔前庭和白线宫颈的粘膜切口。建议在术后前 24 小时内静脉注射预防性药物，术后 7 天使用口服抗生素。

Introduction

传统的开放性甲状腺切除术已经使用宫颈切口安全进行了 100 多年1。尽管大多数患者具有有效的疤痕愈合，并且美容效果通常可以接受，但颈部的永久性疤痕总是引起普通观察者的立即注意2。近20%的甲状腺切除术后患者有自我意识，超过10%的患者考虑进一步治疗以去除疤痕3。此外，据报道，宫颈切口对健康相关生活质量（HRQOL）也有负面影响4。已经开发了各种用于甲状腺手术的远程访问方法，例如腋窝乳房、经腋窝、耳后和锁骨下方法，通过将皮肤切口移动到不太显眼的位置来避免可见的颈部疤痕5，6，7，8。9然而，这些方法需要宽瓣解剖才能进入甲状腺，并且仍然在切口部位留下皮肤疤痕10。

自2008年以来，已经开发了用于经口甲状腺手术的自然孔腔内镜手术技术。这些可以通过口腔前庭入路或舌下入路 进行 。前者更受欢迎，因为它与较少的并发症相关。2016年，Anuwong发表了第一个病例系列，纳入了60名接受经口内窥镜甲状腺切除术前庭入路术（TOETVA）的患者，并确定了良好的预后11。与远程访问方法相比，TOETVA被认为是真正的微创，因为皮瓣夹层的区域类似于传统的开放性甲状腺切除术，并且不会在身体上留下任何疤痕10。

TOETVA是一种革命性的内窥镜方法，可满足女性的美容需求，并可轻松进入双侧甲状腺和中央间室12。它的特点是中央淋巴结完全暴露和解剖，有利于用cN1a10，13，14，15治疗分化型甲状腺癌。然而，由于手术空间有限，处理甲状腺上极的大肿瘤相对具有挑战性。目前的研究描述了TOETVA的分步程序。

Protocol

该研究经四川大学华西医院医学伦理委员会批准（2018[457]），并取得所有受试者的书面知情同意。 1.术前准备 患者资格选择对美容有严格要求并符合以下标准的患者：（1）良性结节直径<4cm;（2）分化型甲状腺癌（DTC）直径<2cm，临床无侧淋巴结转移或远处转移;（3）无中央淋巴结转移或转移性淋巴结直径<2cm且无融合和固定的影像学指征。 排?…

Representative Results

我们在中心为TOETVA患者建立了常规临床路径。手术前对每位患者进行喉镜检查和甲状腺超声检查。甲状旁腺激素（PTH）、甲状腺功能、25-二羟基维生素D（25-OH-VD）和血清钙在术前常规检测，除甲状腺功能外，所有甲状腺功能均在术后1天重新测定。在我们医院，Foley导管通常用于将进行TOETVA手术超过3小时的患者。Foley导管也在手术后1天移除。手术后，每位患者通过静脉滴注给予4g葡萄糖酸钙，并在?…

Discussion

TOETVA的特征是中央淋巴结完全暴露和解剖，这在cN1a10，13，14，15治疗分化型甲状腺癌方面具有显着优势。但是，需要注意的是，由于手术空间有限，处理位于甲状腺上极的大肿瘤相对困难。应严格遵守手术适应症和禁忌症，确保手术安全开展。甲状腺上极完全脱位后，在手术过程中通过IONM监测直接可…

Divulgations

The authors have nothing to disclose.

Acknowledgements

我们感谢所有参与这项研究的患者的合作。本研究得到了四川省科技厅项目基金的支持。（批准号：2021YFS0103）。

Materials

Allis Grasping Forceps,310 mm x 5 mm AESCULAP PO111R
Button Electrode Tip AESCULAP GK385R
Ceramic Electrode AESCULAP GK384R
Complete Trocar AESCULAP EJ751R
Endoscope Olympus WA53005A
IONM Medtronic NIM-3.0
Light Transmitting Bundle Olympus WA03310A
Maryland Dissecting Forceps, 310 mm x 5 mm AESCULAP PO102R
Monopolar Handle (5 mm diameter, 33 cm working length) AESCULAP GK372R
Pneumoperitoneum tube,4 m STRYKE 620-240-223
Pyramidal Tip Obturator AESCULAP EJ755R
Reusable Monopolar Cable AESCULAP GK245
Scissors AESCULAP P0004R
Suction irrigation tube AESCULAP PG027R
Super Righting Needle Holder, 5 mm AESCULAP PL414R
Veress TianSong E2014.6
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Tags

Keywords: TOETVATransoral Endoscopic Thyroidectomy Vestibular ApproachThyroid LobectomyUltrasonic ScalpelStrap MuscleCommon Carotid ArteryVagus NerveIsthmusTracheaCricothyroid SpaceSternothyroid MuscleSuperior Thyroid Artery And VeinRecurrent Laryngeal NerveBerry’s LigamentInferior Parathyroid GlandPretracheal And Prelaryngeal Lymph NodesCentral Lymph Nodes
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Wu, Z., Tian, Y., Chen, Z., Su, A. Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy. J. Vis. Exp. (195), e64437, doi:10.3791/64437 (2023).
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