1000例神經監測甲狀腺手術之神經受傷機轉－傳統綁線與無綁線LigaSure技術之比較研究

Mechanism of Neural Injury in 1,000 Monitored Thyroidectomies-Comparison between Clamp-and-tie and Sutureless LigaSure Technique

劉承信(Cheng-Hsin Liu) ； 江豐裕(Feng-Yu Chiang) ； 陳慧君(Hui-Chun Chen) ； 吳哲維(Che-Wei Wu) ； 黃子晏(Tzu-Yen Huang)

《台灣耳鼻喉頭頸外科雜誌》 55卷3期 (2020/09) Pp. 160-165

https://doi.org/10.6286/jtohns.202009_55(3).160

摘要

背景：在甲狀腺手術中，能量器械（energy-based device）之使用如LigaSure Small Jaw（LSJ）已被廣泛使用多年。相較於傳統之綁線止血法，能量器械更能降低術後出血及術後低血鈣等併發症的產生，然而有關於能量器械潛在的熱傷害風險之相關研究討論有限。本研究聚焦於無綁線LSJ手術與綁線止血法對於喉返神經損傷發生率的差異，以及受傷機轉的比較。方法：本研究於2013至2019年間共收案1000名接受甲狀腺手術的病人，500名使用LSJ的病人歸於分組L，500名使用傳統綁線止血法的病人歸於分組C。每名病人都經過一致的手術步驟及標準化術中神經監測技術，並於術前術後記錄詳盡的影像紀錄，比較兩組別當中對喉返神經的傷害與機轉。結果：在分組L中喉返神經受傷的比例為1.38%（12/870條神經），而分組C為2.08%（18/867條神經），兩組並沒有顯著差異（p = 0.4819）。然而使用LSJ之分組L傾向於較低的壓迫性與牽扯性傷害，但有增加熱傷害（thermal injury）的趨勢。結論：比較LSJ與傳統綁線止血法在喉返神經的受傷機率上雖無顯著差異，然而術者在使用能量器械LSJ需要謹慎小心可能因側邊熱散播而造成嚴重神經熱傷害，而組織在加熱過程中的攣縮更可能升高這樣的風險性。

關鍵字

clamp-and-tie ； intraoperative neuromonitoring ； LigaSure ； recurrent laryngeal nerve injury ； thyroid surgery（clamp-and-tie ； 術中神經監測 ； LigaSure ； 喉返神經損傷 ； 甲狀腺手術）

並列摘要

BACKGROUND: LigaSure Small Jaw (LSJ) is widely used in thyroid surgery with less postoperative hematoma rate than conventional techniques, but whether LSJ can provide neural safety in sutureless thyroidectomy has not been well determined. This study aimed to investigate and compare the mechanism of recurrent laryngeal nerve (RLN) injury between LSJ and conventional clamp-and-tie hemostatic technique. METHODS: One thousand consecutive standardized intraoperative neuromonitoring assisted thyroidectomy patients were enrolled in this study. Five hundred patients received sutureless thyroidectomy performed with LSJ (Group L), and 500 patients received surgery performed with conventional clamp-and-tie technique (Group C). Incidence of RLN palsy and the mechanism were compared between groups. RESULTS: In nerves at risk, the incidence of RLN palsy did not significantly (p = 0.4819) differ between Group L (1.38%; 12/870 nerves) and Group C (2.08%; 18/867 nerves). All four nerves with thermal injury were in the Group L. CONCLUSIONS: Comparing LSJ with conventional clamp-and-tie technique, there is no significant difference in the RLN palsy rate. However, the surgeons must be cautious when using LSJ near the RLN. The potential risk of lateral thermal spread can cause irreversible thermal injury, and the tissue contraction during LSJ activation increases the risk.

並列關鍵字

clamp-and-tie ； intraoperative neuromonitoring ； LigaSure ； recurrent laryngeal nerve injury ； thyroid surgery