甲状腺手术时喉返神经损伤及其防治课件.pptVIP

Operative technique of thyroid lobectomy. The neck is extended and a symmetrical, gently curved incision is made 1 to 2 cm above the clavicle. Upper and lower subplatysmal flaps are developed. The deep cervical fascia is divided in the midline and the strap muscles are retracted laterally, exposing the anterior surface of the thyroid lobe. Occasionally, in cases of large goiters, better exposure can be obtained by dividing the strap muscles transversely. The thyroid lobe is retracted medially and is bluntly dissected from the surrounding fascia. The middle thyroid vein is encountered and is ligated close to the thyroid. The superior thyroid vessels are then individually ligated and divided at the level of the superior pole, rather than cephalad to it, in order to protect the external branch of the superior laryngeal nerve from damage. This nerve can be seen in many patients. The thyroid lobe is retracted medially again and, by careful blunt dissection, the recurrent laryngeal nerve, the inferior thyroid artery, and the parathyroid glands are identified. The inferior thyroid artery is not ligated laterally as a single trunk. Rather, each small branch is ligated and divided at a point distal to the parathyroid glands in order to preserve their blood supply. The thyroid lobe can then be removed from its tracheal attachments if a lobectomy is to be performed.Another representation of removing the thyroid lobe without devascularizing the parathyroid glands. 四. 医源性喉返神经损伤特点（1） 主要原因 过度牵拉 缝线结扎 电灼 钳夹 瘢痕粘连压迫 离断 术后水肿 血肿压迫 四. 医源性喉返神经损伤特点（2） 损伤部位 以近环甲关节处 甲状软骨下角前方，咽下缩肌下方的喉返神经入喉平面。此处的损伤约占 80%以上。 甲状腺中下部 而真正在神经跨过甲状腺下动脉平面附近的损伤约占16%。 五. 预 防 （1） 采用颈从神经阻滞麻醉，不仅麻醉效果良好，且可随时了解声带发音功能，对监测喉返神经损伤具有重要意义。 熟悉正常解剖及变异。 手术操作精细。 在腺体背面内侧向下分离时，不得超 过甲状软骨下角平面。 五. 预 防 （2） 分离甲状腺下极和结扎甲状腺下动脉时，采用膜内结扎法，即切除腺体的同时，在其背侧固有膜内分别结扎甲状腺下动脉各分支 。 分离腺体背面及解剖甲状腺下动脉主干时，切勿将腺体过于内翻，以免损伤位于腺体背面的喉返神经 。 五. 预 防 （3） 甲状腺峡部切断后，分离腺体内侧或钳夹切除腺体时，不得过度深入腺体背面，必须保留腺体背面内侧被膜的完整，楔形切除大部分腺体，使其背面留有约0.5cm厚的组织 。 腺体切面止血或