甲状腺手术时喉返神经损伤及其防治幻灯片1.pptVIP

甲状腺手术时喉返神经损伤及其防治;前 言;Large goiters are prevalent in areas of iodine deficiency. (A). A woman from Switzerland operated upon by Dr. Theodor Kocher (From Kocher T: Zur pathologie und therapie deKropfes (parts I and 2). Dtsch Z Chir 4, 1874 ) (B). One hundred years later, large goiters still occur in many parts of the world, as demonstrated in this woman from a mountainous region of Viet Nam, 1970. ;;;喉返神经损伤发生率 （1）;喉返神经损伤发生率（2）; 一. 喉返神经临床解剖;;;The normal anatomy of the neck in the region of the thyroid gland. (With permission from Halsted WS: The operative story of goiter. Johns Hopkins Hosp Rep 19:71, 1920).;1. 喉返神经的行程 （1）;1. 喉返神经的行程（2）;1. 喉返神经的行程（3）; 喉返神经的行径 ;2. 喉返神经的分支（1）;2. 喉返神经的分支（2）;2. 喉返神经的分支 （3）;2. 喉返神经在喉外分支的高度;3. 喉返神经的变异;非折返性喉??部神经;A) Normal anatomy of the recurrent laryngeal nerve. Note that on the right side the recurrent laryngeal nerve hooks around behind the subclavian artery, while on the left side this nerve passes around behind the aortic arch before ascending in the neck. B) When there is a vascular anomaly of the right subclavian artery, the recurrent laryngeal nerve no longer recurs around this artery but proceeds from the vagus nerve in a more transverse direction to the larynx. In such a situation, the nerve is much more likely to be damaged during operation unless care is taken to visualize its course in the neck.;右侧非返性喉返神经;4. 喉返神经与甲状腺下动脉的关系（1）;1、甲状旁腺2、甲状腺下动脉 分支3、喉返神经 ;4. 喉返神经与甲状腺下动脉的关系（3）;4. 喉返神经与甲状腺下动脉的关系（4）;;;;;二. 甲状腺手术时喉返神经损伤的常见原因;1. 病理分型;2. 手术术式和次数 ;3. 手术医师年资高低;4. 是否显露喉返神经（1）;甲状腺手术中显露喉返神经对预防喉返神经损伤价值的Meta分析;4. 是否显露喉返神经（2）; 三. 如何寻找喉返神经？（1）;三. 如何寻找喉返神经？（2）;1. 在甲状腺下动脉下方寻找 ;2. 在喉返神经入喉处寻找 ;于甲状软骨下角下方1cm，即喉返神经入喉处寻找;双侧喉返神经都经过环甲关节后方。术中掀起甲状腺侧叶后切开后鞘即可见气管食管沟内的喉返神经，多与甲状腺下动脉分支交叉，左侧多在血管后，右侧多在血管前。;3. 在甲状腺侧后方寻找;4.右侧喉返神经还可在颈动脉鞘内侧缘寻找;5.以肿大淋巴结作为寻找喉返神经的标志;;;甲状腺癌病人行气管食管沟内淋巴结清扫。因转移性淋巴结呈串珠状肿大，且互相粘连成团，将喉返神经完全包绕其中，不得已剔除大部分癌组织，而与神经相连的少量癌组织残留。; 喉 咽; ;甲状软骨thyroid cartilage：; 环状软骨 cricoid cartilage ：;喉肌;开关声门， 张弛声带， 活动会厌。;喉上面观;