甲状腺外科手术图谱.doc

甲状腺切除术手术图谱

The patient is placed in semi-Fowler's position with the neck slightly extended and supported with a wadded towel on each side. A collar incision is made from one posterior edge of sternocleidomastoid to the other one fingerbreadth above the clavicle on either side. The line of incision is impressed on the skin using a silk ligature to ensure symmetry

图片附件: 1.jpg (2005-7-8 18:20, 8.15 K)

Beginning laterally, the upper flap is bluntly dissected up to the notch of the thyroid cartilage with a moist gauze over the thumb

The inferior flap is dissected downward over the sternal notch using mostly careful sharp dissection. The lower flap may be sutured temporarily to the skin of the chest and the upper flap is held with a retractor. The strap muscles and anterior jugular veins are exposed anteriorly and the sternocleidomastoids laterally

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The fascia of the strap muscles is carefully incised in the midline avoiding entry into the thyroid capsule. Crossing veins between anterior jugulars are divided

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Two fingers are used to elevate both strap muscles on each side to the level of the thyroid lobes. It is important to not push too deeply posteriorly before direct visualization is achieved to avoid tearing the middle thyroid veins. Mobilization of the straps is usually more than sufficient for safe exposure of even a moderately enlarged gland. For a massive goiter, division of the straps is prudent.

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Lateral retraction of the straps exposes the thyroid lobes and middle thyroid veins on either side

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Lateral retraction of the straps exposes the thyroid lobes and middle thyroid veins on either side (2).

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The center of the thyroid lobe is transfixed with a heavy (2-0) figure of eight suture and retracted medially. Retraction of the lobe by penetrating clamps is often bloody, tears the tissue and the bulk of the instrument gets in the way. The middle thyroid veins are carefully isolated from the areolar carotid sheaths, ligated and divided. Mobilization of the posterior surfaces is then completed again using two fingers. If thorough exploration of the opposite lobe is indicated, that middle thyroid vein is also divided.
图片附件: 8.jpg (2005-7-8 18:25, 20.26 K)

A thyroid pole retractor is used to elevate the straps above while downward traction is applied to the suture. The apex of the thyroid lobe is tethered by the superior pole vessels above.

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The superior pole vessels must now be carefully separated from the peritracheal fascia containing the superior laryngeal nerve. The nerve usually lies posteromedial to the vessels.

While delicately retracting the superior pole laterally, a small hemostat is insinuated just medial to the fascia containing the vessels, hugging the contour of the top of the lobe. Opening the clamps separates the vessels from the nerve.
图片附件: 10.jpg (2005-7-8 18:26, 18.77 K)

Once the upper pole is free, the traction suture is used to gently pull the lobe medially. The posterior surface of the upper pole is examined for the delicate brown upper parathyroid gland. The upper glands are more variable in position than the lower. If the gland is identified, it is carefully dissected out of the thyroid capsule and left on the carotid sheath posteriorly. It is usually not possible to identify a discrete feeding vessel with the upper gland. If the gland turns dark in color it is devascularized and may need to be implanted in muscle (see below).
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The inferior thyroid artery is now dissected and elevated and the recurrent laryngeal nerve is identified, usually posterior to the vessel and within or anterior to the tracheo-eosphageal groove (see discussion of nerve location under thyroid anatomy).
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The lower parathyroid is usually found in close association with the inferior thyroid artery and below it. It is often possible to preserve its blood supply as it is dissected off the thyroid capsule, ligating the inferior thyroid vessel distal to the takeoff of the parathyroid branch. In the case of an isolated gland, the safest survival strategy is to cut the gland into thin slices and implant it into the adjacent sternocleidomastoid muscle. The site of implantation should be marked with a metal clip in the event of future problems, especially when operating for parathyroid disease. In the latter case, it is best to implant the questionable gland into a forearm muscle so that it is easily accessible without reopening the neck.

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The lobe is then retracted to the right, exposing the suspensory ligament (of Berry) attaching it to the trachea. The ligament is sharply divided close to the gland to avoid entering the pretracheal fascia which can cause significant postoperative pain. The isthmus is then easily mobilized from the trachea and divided at its junction with the opposite lobe.
图片附件: 14.jpg (2005-7-8 18:33, 19.74 K)