Method for extrafascial hemithyroidectomy

FIELD: medicine, surgery.

SUBSTANCE: extrafascially one should isolate thyroid portion, successively perform visualization of the lower parathyroid, reciprocating nerve, the upper parathyroid and complete mobilization of thyroid portion, isolate and cross the upper thyroid artery after visualization. The suggested method enables to decrease the number of post-operational complications caused by intra-operational damage of reciprocating and the upper laryngeal nerves and prevent disease relapses.

EFFECT: higher efficiency of therapy.

6 dwg

 

The invention relates to medicine, in particular to surgery, and can be used in the treatment of diseases of the thyroid gland.

Surgery for nodal goiter is the most common form of surgical treatment of thyroid cancer. However, any surgery on the thyroid gland can cause serious specific complications. In the postoperative period there is a probability of development of paresis of the vocal cords (0.1 to 26%), hypoparathyroidism (5-26%). In 10-15%, there is a likelihood of recurrence of the disease. The majority of domestic specialists in nodular goiter various methods are used by resection of the lobe of the gland with the node, or enucleation site (Iceblade "Surgical treatment of diseases of the thyroid gland", publishing house "Hippocrates", 1998, , St. Petersburg). The disadvantage of these methods is that a large percentage of relapse. In addition, the detection of cancer of the nature of a nodule, this operation is non-radical, which leads to the need for re-intervention.

The known method Subtotal resection of the thyroid gland by flashing both lobes of the gland, crossing the isthmus, serial, release, and delete sections of the gland (A.S. USSR № 488585, publ. 25.10.1975 year).

And the use of the known method subfascial removal of the thyroid is non-radical in the case of cancer of the thyroid gland.

Known resection of the thyroid gland by the method of Kocher, widely used in many countries. The peculiarity of it is that the excision of the gland is made after ligation of the upper and inferior thyroid arteries throughout the outside of the capsule, which is a complex manipulation and is associated with an increased risk of traumatic recurrent and superior laryngeal nerves.

Known also adopted for the prototype, the way the extrafascial hemithyroidectomy by crossing thyroid artery visualization recurrent nerve mobilization of the parathyroid glands and the mobilization of the affected lobe of the gland ("Surgery of the endocrine system" edited by professors Mpfservice and Oppositive, 2002, , Perm - Moscow, p.53).

Holding in the known methods of intersection of the thyroid arteries in the beginning of the operation may lead to injury to the recurrent and superior laryngeal nerves, in addition, at high location of the upper pole of the thyroid lobe after crossing the superior thyroid artery is the probability of abandonment fabric upper pole of the proportion of cancer that can cause a relapse.

The task to be solved by the invention, is to reduce the number of specific complications of surgery on the thyroid gland associated with intra erational damage return, the superior laryngeal nerves, and preventing relapses.

The solution is achieved by the fact that in the known method the extrafascial hemithyroidectomy by extrafascial allocation of shares of a thyroid gland, visualization recurrent nerve, parathyroid glands, selection and crossing of the superior thyroid artery, according to the invention when extrafascial the allocation of shares of a thyroid gland consistently produce a visualization of the lower parathyroid glands, recurrent nerve, upper parathyroid gland, full mobilization of the thyroid lobe, and then allocate and cross over after visualization of the superior thyroid artery.

The difference of the proposed method against known is the sequence of actions taken when conducting operations on the thyroid gland, selection and crossing the upper thyroid artery at the final stage, after full mobilization of the lobe of the thyroid gland, helps to avoid injury and the superior laryngeal nerve, and by the complete removal of the tissue of the lobe of the gland to prevent the relapse of the disease.

The proposed method is as follows.

Produce voronkoobraznyy incision of skin and subcutaneous tissue, superficial fascia on the Kocher 2.5-3.0 cm above the jugular notch. RA is scout in the longitudinal direction of the fascial sheets neck and preteenie muscles with subsequent lead them outwards. Visualized thyroid gland.

Crossed and Perevoznaya unpaired thyroid vein. Then will be cut off of the isthmus from the unaffected share gland with partial seizure. After that, the fabric of the isthmus by acute clipped from the trachea. Then in the wound pywikipedia the lower pole of the affected lobe of the thyroid gland and is captured by the left hand (figure 1). Is the intersection between the two clamps and the subsequent ligation of the inferior thyroid veins (figure 2). After this share is becoming more mobile, allowing you to take her in the medial direction to explore the posterolateral surface. Next visualized the lower parathyroid gland (figure 3). She carefully so as not to disturb the blood circulation, is separated from the lobe of the thyroid gland. After this blunt by using probe Kocher top-side surface of the shares shall be released from the fiber so that it became visible to the lateral surface of the trachea. In tracheal-esophageal crease visualized recurrent nerve (figure 4). The progress can be traced to the point of penetration into the larynx. Under visual control recurrent nerve branches of the inferior thyroid artery sequentially from the bottom up are clamped by the clamps of the type "Mosquito" or "Billroth, then crossed and tied interrupted sutures. Ligation of vessels is extrafascial the but. The clamps must be placed as close as possible to the tissue of the gland, avoiding contact with the selected recurrent nerve, but in any case not capturing the capsule gland. Then outstanding upper parathyroid gland (figure 5). When all this manipulation produced similarly as in the selection of the lower parathyroid gland. The portion that gradually becomes more mobile, the left hand of the operator is removed from the wound up to full mobilization, until then, until it becomes apparent to the superior thyroid artery, which flows into the upper pole of the proportion of cancer (6). You stupid way (probe Kocher) to free it from the surrounding tissue, carefully examined, and after the operator will have full conviction that there aren't other tyazhistye structures (which may be the superior laryngeal nerve), on the upper thyroid artery superimposed clip at some distance from the upper pole of the removed lobe of the gland, after which the artery is crossed between the clamp and the upper pole of the deleted share and Perevoznaya a ligature.

The wound is washed with a solution of novocaine, aasiaat and perform hemostasis. In the bed of the share injected rubber graduate. The wound is sutured in layers.

According to this method operated on 110 patients with nodular thyroid cancer. 3 (2,7%) observations were noted temporary hypocalcemia who I am. In 1 (0.9%) observation of recurrent nodular goiter marked cut vocal fold on the side of the operation. The fate of this sick traced. 3 months after monotherapie the mobility of the vocal fold fully recovered.

The way the extrafascial hemithyroidectomy by extrafascial allocation of shares of a thyroid gland, visualization recurrent nerve, parathyroid glands, selection and crossing of the superior thyroid artery, characterized in that when extrafascial the allocation of shares of a thyroid gland consistently produce a visualization of the lower parathyroid glands, recurrent nerve, upper parathyroid gland, full mobilization of the thyroid lobe, and then allocate and cross after visualization of the superior thyroid artery.



 

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