甲狀腺再次手術中喉返神經危險之解剖學變異

背景：甲狀腺再次手術常伴有較高喉返神經麻痺的發生率，尤其是永久性麻痺。本研究的目的在探討喉返神經解剖學的變異對甲狀腺再次手術發生較高聲帶麻痺的關聯性，並找出可靠的策略以降低喉返神經麻痺的發生率。方法：56名病人接受甲狀腺再次手術。49例施行第二次手術，7例施行第三次手術；單側手術36例、雙側手術20例。所有病人手術都為同一術者執行，術中常規使用神經偵測器定位喉返神經，並利用高解析度相機記錄神經各種解剖學的變異。結果：56名病人中，共76條喉返神經。36例良性腫瘤中（49條神經），24條神經沾粘於包膜的後側或外側、2條神經位於復發腫瘤上方，1條夾在兩顆復發結節中間，所有的神經都可完全解離，然而2條神經解剖後訊號減弱。20例惡性腫瘤中（27條神經），4條神經被甲狀腺癌侵犯，其中2條神經雖有微小腫瘤殘留但神經功能得以完全保存；另2條神經無法完全解離而截斷，其中1例對側聲帶在術前已麻痺，術後因呼吸困難而需氣管切開。結論：喉返神經危險的解剖變異是甲狀腺再次手術神經受傷的重要因素，喉返神經可位移至任何位置或被惡性腫瘤侵犯。術中及早確認喉返神經是必須且重要的步驟。初次手術全葉切除術是避免腫瘤復發及降低再次手術時喉返神經高風險的最佳策略。

關鍵字

甲狀腺再次手術；喉返神經之解剖位置；術中神經偵測

並列摘要

BACKGROUND: Operation for recurrent goiter has been reported to be associated with higher rates of recurrent laryngeal nerve (RLN) palsy, but the actual cause has seldom been discussed in the literature. This study aimed to investigate the possible anatomical variations of RLN position in re-operative thyroidectomy with the added intention of providing surgeons with useful information to prevent RLN injury. METHODS: Fifty-six patients underwent re-operative thyroidectomy. Among these patients, 49 patients received the second operation, and another 7 patients received the third operation. Thirty-six unilateral and 20 bilateral resections were performed, while 36 of these cases were benign lesion and 20 cases were malignant lesion. Intraoperative neuromonitoring (IONM) was routinely applied for RLN localization and identification. All exposed RLNs were photographed with high-resolution camera. RESULTS: All 76 RLNs were well localized and identified with IONM during the operation. Among 49 RLNs in thirty-six patients with benign recurrent goiter, 24 nerves (49%) were adherent to the thyroid capsule at posterior or lateral position, while 2 nerves ran above the goiter and 1 ran between two recurrent nodules. These 49 nerves were well dissected from the tumor, but 2 nerves encountered severely weakened EMG signal after RLN dissection and developed temporary cord palsy. However, among 27 RLNs in twenty patients with malignant recurrent tumor, 4 nerves were invaded by cancer. Of these 4 nerves, 2 nerves were dissected and preserved with residual tumor, and another 2 nerves were relentlessly encased by the cancer and were sacrificed. One patient with pre-operative contralateral vocal palsy needed tracheostomy due to bilateral cord palsy after operation. CONCLUSIONS: Risky anatomical variations of RLN play an important role in the occurrence of nerve injury in re-operative thyroidectomy. The RLN can be displaced to any position or invaded by malignant tumor. Definite identification of RLN before dissection is an important initial step to prevent inadvertent transection injury. IONM is a useful tool to help identify the nerve. Our previous study and the literature suggested that initial total lobectomy is the best strategy to decrease the risk of RLN injury in re-operative thyroidectomy.

並列關鍵字

re-operative thyroidectomy ； recurrent laryngeal nerve anatomy ； intraoperative neuromonitoring

國際替代計量

甲狀腺再次手術中喉返神經危險之解剖學變異

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