甲状腺切除术手术图谱

甲状腺切除术手术图谱Thepatientisplacedinsemi-Fowler'spositionwiththeneckslightlyextendedandsupportedwithawaddedtoweloneachside.Acollarincisionismadefromoneposterioredgeofsternocleidomastoidtotheotheronefingerbreadthabovetheclavicleoneitherside.Thelineofincisionisimpressedontheskinusingasilkligaturetoensuresymmetry图片附件:1.jpg(2005-7-818:20,8.15K)Beginninglaterally,theupperflapisbluntlydissecteduptothenotchofthethyroidcartilagewithamoistgauzeoverthethumb图片附件:2.jpg(2005-7-818:21,13.29K)Theinferiorflapisdissecteddownwardoverthesternalnotchusingmostlycarefulsharpdissection.Thelowerflapmaybesuturedtemporarilytotheskinofthechestandtheupperflapisheldwitharetractor.Thestrapmusclesandanteriorjugularveinsareexposedanteriorlyandthesternocleidomastoidslaterally图片附件:3.jpg(2005-7-818:22,18.38K)Thefasciaofthestrapmusclesiscarefullyincisedinthemidlineavoidingentryintothethyroidcapsule.Crossingveinsbetweenanteriorjugularsaredivided图片附件:4.jpg(2005-7-818:23,20.12K)Twofingersareusedtoelevatebothstrapmusclesoneachsidetothelevelofthethyroidlobes.Itisimportanttonotpushtoodeeplyposteriorlybeforedirectvisualizationisachievedtoavoidtearingthemiddlethyroidveins.Mobilizationofthestrapsisusuallymorethansufficientforsafeexposureofevenamoderatelyenlargedgland.Foramassivegoiter,divisionofthestrapsisprudent.图片附件:5.jpg(2005-7-818:23,17.07K)Lateralretractionofthestrapsexposesthethyroidlobesandmiddlethyroidveinsoneitherside图片附件:6.jpg(2005-7-818:24,20.25K)Lateralretractionofthestrapsexposesthethyroidlobesandmiddlethyroidveinsoneitherside(2).图片附件:7.jpg(2005-7-818:24,20.3K)Thecenterofthethyroidlobeistransfixedwithaheavy(2-0)figureofeightsutureandretractedmedially.Retractionofthelobebypenetratingclampsisoftenbloody,tearsthetissueandthebulkoftheinstrumentgetsintheway.Themiddlethyroidveinsarecarefullyisolatedfromtheareolarcarotidsheaths,ligatedanddivided.Mobilizationoftheposteriorsurfacesisthencompletedagainusingtwofingers.Ifthoroughexplorationoftheoppositelobeisindicated,thatmiddlethyroidveinisalsodivided.图片附件:8.jpg(2005-7-818:25,20.26K)Athyroidpoleretractorisusedtoelevatethestrapsabovewhiledownwardtractionisappliedtothesuture.Theapexofthethyroidlobeistetheredbythesuperiorpolevesselsabove.图片附件:9.jpg(2005-7-818:26,20.54K)Thesuperiorpolevesselsmustnowbecarefullyseparatedfromtheperitrachealfasciacontainingthesuperiorlaryngealnerve.Thenerveusuallyliesposteromedialtothevessels.Whiledelicatelyretractingthesuperiorpolelaterally,asmallhemostatisinsinuatedjustmedialtothefasciacontainingthevessels,huggingthecontourofthetopofthelobe.Openingtheclampsseparatesthevesselsfromthenerve.图片附件:10.jpg(2005-7-818:26,18.77K)Oncetheupperpoleisfree,thetractionsutureisusedtogentlypullthelobemedially.Theposteriorsurfaceoftheupperpoleisexaminedforthedelicatebrownupperparathyroidgland.Theupperglandsaremorevariableinpositionthanthelower.Iftheglandisidentified,itiscarefullydissectedoutofthethyroidcapsuleandleftonthecarotidsheathposteriorly.Itisusuallynotpossibletoidentifyadiscretefeedingvesselwiththeuppergland.Iftheglandturnsdarkincoloritisdevascularizedandmayneedtobeimplantedinmuscle(seebelow).图片附件:11.jpg(2005-7-818:27,19.37K)Theinferiorthyroidarteryisnowdissectedandelevatedandtherecurrentlaryngealnerveisidentified,usuallyposteriortothevesselandwithinoranteriortothetracheo-eosphagealgroove(seediscussionofnervelocationunderthyroidanatomy).图片附件:12.jpg(2005-7-818:28,12.1K)Thelowerparathyroidisusuallyfoundincloseassociationwiththeinferiorthyroidarteryandbelowit.Itisoftenpossibletopreserveitsbloodsupplyasitisdissectedoffthethyroidcapsule,ligatingtheinferiorthyroidvesseldistaltothetakeoffoftheparathyroidbranch.Inthecaseofanisolatedgland,thesafestsurvivalstrategyistocuttheglandintothinslicesandimplantitintotheadjacentsternocleidomastoidmuscle.Thesiteofimplantationshouldbemarkedwithametalclipintheeventoffutureproblems,especiallywhenoperatingforparathyroiddisease.Inthelattercase,itisbesttoimplantthequestionableglandintoaforearmmusclesothatitiseasilyaccessiblewithoutreopeningtheneck.图片附件:13.jpg(2005-7-818:28,9.47K)Thelobeisthenretractedtotheright,exposingthesuspensoryligament(ofBerry)attachingittothetrachea.Theligamentissharplydividedclosetotheglandtoavoidenteringthepretrachealfasciawhichcancausesignificantpostoperativepain.Theisthmusistheneasilymobilizedfromthetracheaanddividedatitsjunctionwiththeoppositelobe.图片附件:14.jpg(2005-7-818:33,19.74K)