【作者】 高超；

【导师】 曾庆东；

【作者基本信息】 山东大学 ， 外科学（普通外科）（专业学位）， 2016， 硕士

【摘要】 目的：甲状腺结节是临床上一种很常见的疾病,有调查显示人群中甲状腺结节发病率大约为20-76%,其中甲状腺癌占到5%-15%,并以青年女性居多。而甲状腺结节患者中,怀疑为恶性的以及相当一部分良性肿瘤均需要手术治疗。传统常规开放甲状腺手术(CT, Conventional thyroidectomy)的安全性及有效性已得到公认,但其需在颈部作长约6-8cm长切口,术后常在颈部遗留较大瘢痕,瘢痕体质者尤为明显。且因甲状腺疾病患者中青年女性居多,常规开放手术美容效果差,可能会对患者造成心理负担。随着医学技术的不断完善、科学仪器的不断发展,“微创外科”的概念逐渐深入人心,腔镜甲状腺手术已成为一种治疗有效,安全可靠的手术方式。腔镜甲状腺手术的手术方式可分为完全腔镜甲状腺手术(TET, total endoscopic thyroidectomy)和颈前小切口腔镜辅助下甲状腺手术,即改良Miccoli术。颈前小切口腔镜辅助下甲状腺手术经颈前作一2cm小切口,使用拉钩建立操作空间,游离较少的皮下组织,创伤小,术后恢复快,是一种兼顾微创和美容效果的手术。本文将通过对传统开放术式及颈前小切口腔镜辅助下甲状腺手术的安全性、创伤性及美容性等方面做出对比,以评价两种术式的优势与不足。方法：研究包含了山东大学齐鲁医院自2013年至2016年收治的,术后病理结果为甲状腺微小乳头状癌的病例82例。其中行颈前小切口腔镜辅助下甲状腺手术的患者共36例,传统常规开放甲状腺手术患者取中位时间区间内的46例。统计患者的性别、年龄、切口长度、术中出血量、术中及术后并发症、术后病理检查结果、引流量、引流天数、住院时间、患者主观感受、美容效果满意度等方面数据并做出分析,以评价两种术式在各个方面的差异。资料收集通过查询病历、调查问卷及电话随访等方式实现。结果：(1)手术情况：两组患者肿瘤大小均无显著差异。所有手术术中喉返神经均连续性完好或术中神经监测信号均完好。术中出血有明显差异(26.6± 4.99ml vs 47.6±9.88ml,P<0.05).手术切口长度有明显差异(2.5±0.36cm vs 7.1±0.85cm P<0.05)(2)术后情况：术后6h、12h及24h疼痛评分VAS(Visual analogue scales,视觉模糊评分)两组无显著差异；术后3天RSI评分(The Reflux Symptom Index,反流症状指数量表)无显著差异(23.2±7.21vs 26.1±6.80,P>0.05)；术后引流量小切口组明显小于传统术式组(20.2±8.76m1 vs 46.8±18.5m1 P<0.05);引流天数有明显差异(2.5±0.91 vs 2.8±0.88d P<0.05)；患者住院天数(5.0±1.26天vs 4.9±1.28天,P>0.05)无显著差异；术后3个月随访VHI(Voice Handicap Index,嗓音障碍指数)无显著差异(21.6±4.39 vs 22.7±3.42,P>0.05)；术后病理结果显示淋巴结清扫数量未见明显差异(2.5±1.63枚vs 3.5±2.91枚,p=0.076>0.05),其中转移淋巴结数目也无明显差异(0.8±0.89枚vs 1.0±1.32枚,p=0.12>0.05)。术后长期随访感觉和外观量表,两组患者的颈部疼痛及不适的结果中,均在术后1-3个月内相对于术前有明显差异,两组之间在长期随访中组间并无明显差异；患者满意度评分两组有明显差异(4.2±0.56 vs 3.5±0.86,P<0.05)。结论：小切口腔镜辅助下甲状腺手术与传统开放术式相比,在安全性方面类似,均为安全可靠的手术方式,但创伤性、术后恢复及美容效果有统计学意义,结果显示小切口腔镜辅助下甲状腺手术的创伤小,术后不适较轻,且术后恢复较快。故小切口腔镜辅助下甲状腺手术在微创、恢复、美容效果方面要优于传统开放性术式。更多还原

【Abstract】 Objective:Thyroid nodule is a common clinical disease. A survey shows incidence of thyroid nodule is about 20-76%, with thyroid carcinoma accounted for 5%-15%. Most of them are young women. The malignant nodule and a part of benign tumors need surgery.The efficacy and safety of Conventional thyroidectomy (CT) has been recognized. It needs incision in the neck about 5-10cm. Big scar is left after surgery, especially apparent on body with scar constitution. With the continuous development of medical technology and scientific instruments, the endoscopic thyroid surgery has become an effective and safe surgery. Endoscopic thyroid surgery can be divided into completely cavity mirror and modified Miccoli surgery. This article will contrast CT and modified Miccoli on safety, traumatic and beauty to evaluate modified Miccoli surgery.Methods:The study include 82 patients undergoing thyroidectomy at Qilu Hospital of Shandong University in 2013 to 2016. There are 36 patients undergoing modified Miccoli surgery, and 46 patients undergoing the CT. Information about gender, age, operation data, intraoperative and postoperative complications, length of stay, feelings of patients and satisfaction about comesis is collected and analysised. Data were collected from patient medical records, survey, follow-up of outpatient and telephone.Results:Statistic analysis showed no significant difference (P>0.05) between two groups in tumor factors. All the recurrent laryngeal nerves(RLN) of 66 patients were intact and all signals of then showed no injury. There showed a significant difference between two groups in the intraoperative blood loss (26.6±4.99ml vs 47.6±9.88ml, P<0.05). There was significant difference in incision length (2.5±0.36cm vs 7.1±0.85cm P<0.05). Postoperative pain was similar (2.3±0.92 vs 2.0±0.91, P >0.05). The two groups have similar Voice Handicap Index(VHI) (21.6 ±4.39 vs 22.7±3.42, P>0.05). The Reflux Symptom Index (RSI) (23.2 ±7.21 vs 26.1±6.80).There was significant difference in postoperative bleeding(20.2±8.76ml vs 46.8±18.5ml P<0.05). There was no significant difference in postoperative length of stay in hospital (5.0±1.26天vs 4.9±1.28天,P>0.05). Difference was noted in patient satisfaction index about cosmesis (4.2±0.56 vs 3.5±0.86, P<0.05) after 3 month. Conclusion:Compared with conventional thyroidectomy, modified Miccoli in thyroid surgery has some features:(1) It is safe, reliable and effective operation; (2) It has some advantages such as incision is small, quick recovery of activity of neck, minimally invasive, and cosmetology. So the modified Miccoli operation in minimally invasive, restore, cosmetic effect is superior to the conventional thyroidectomy.更多还原