经腋窝无充气后入路腔镜甲状腺手术的“场景化”辅助操作
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南方医科大学南方医院 普通外科,广东 广州 510515

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孙百慧,南方医科大学南方医院主治医师,主要从事甲状腺良、恶性肿瘤外科诊疗方面的研究。

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"Scene-based" approach for gasless transaxillary posterior endoscopic thyroidectomy
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Department of General Surgery, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China

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    摘要:

    随着腔镜甲状腺手术的发展及推广,经腋窝腔镜甲状腺手术无疑被证实是一种安全、可行的手术方式。其中,经腋窝无充气后入路腔镜甲状腺手术(GTPET)因无充气干扰的清晰视野,已被广泛接纳并采用。但因其侧面观视角、镜头与器械共用手术空间的特点,使手术操作存在固有难点。为解决腔镜操作中视角配合问题,有团队应用扶镜机器人,但对于GTPET这种操作范围较小的手术方式,手术视角及操作仍依赖于术者及扶镜手的配合。为克服GTPET操作中的难点,笔者引入“场景化”操作理念,从扶镜手的角度出发,通过三部分规范GTPET手术过程中扶镜手的操作流程。一为手术前准备:规范患者体位摆放及扶镜手位置;二为扶镜手操作要点:概括为“一支点”“二入路”“三平行”;三为“四宫格”法镜下视野场景化辅助操作:将手术区域划分为I~Ⅳ区,据此引导手术操作。

    Abstract:

    With the development and promotion of endoscopic thyroid surgery, transaxillary endoscopic thyroid surgery has been proven to be a safe and feasible surgical method. Among them, gasless transaxillary posterior endoscopic thyroid surgery (GTPET) has been widely accepted and adopted due to its clear field of vision without gas interference. However, due to the characteristics of the lateral viewing angle, shared surgical space of the lens and instruments, inherent difficulties exist in the surgical operation. To solve the problem of visual angle coordination in endoscopic operations, some teams have applied an assistant robot. However, for GTPET, which has a small operating range, the surgical view and operation still depend on the coordination of the surgeon and the camera-holding assistant. To overcome the difficulties in GTPET procedures, the author introduces the concept of "scene-based" operations, focusing on the perspective of the camera-holding assistant. This involves standardizing the assistant's operational procedures during the GTPET surgery into three parts. Firstly, preoperative preparation: standardizing patient positioning and the location of the camera-holding assistant. Secondly, key points for the assistant's operation: summarized as "one pivot," "two approaches," and "three planes." Thirdly, the "four-quadrant" method was used to assist the operation by visualizing the field of endoscopic view, dividing the surgical area into zones I to Ⅳ and guiding the surgical procedures accordingly.

    图1 术前照片 A:患者体位摆放;B:扶镜手位置Fig.1 Preoperative photos A: Patient positioning; B: Position of the camera-holding assistant
    图2 一支点(胸大肌表面)Fig.2 One pivot (surface of the pectoralis major muscle)
    图3 二入路 A:镜头置于术区头侧;B:镜头置于术区正中位Fig.3 Two approaches A: Camera on the head side of the surgical area; B: Camera in the middle of the surgical area
    图4 三平行 A:胸大肌平面;B:胸锁乳突肌锁骨头平面;C:气管水平(头侧高30°)Fig.4 Three planes A: Pectoralis major muscle plane; B: Clavicular head of the sternocleidomastoid muscle plane; C: Tracheal plane (30° higher on the head side)
    图5 “四宫格”场景划分(上界为颈前带状肌,下界为颈鞘内侧缘,头侧界为甲状软骨,足侧界为胸骨上缘,以气管水平为横轴、肩胛舌骨肌为纵轴)Fig.5 Four-quadrant scene division (upper boundary is the strap muscle of the neck, lower boundary is the inner edge of the neck sheath, cranial boundary is the thyroid cartilage, foot side boundary is the upper border of the sternum, using the tracheal level as the horizontal axis and the scapular hyoid muscle as the vertical axis)
    图6 “四宫格”场景操作 A:Ⅳ区操作,扩展椎前筋膜前间隙、甲状腺系膜后界解剖;B:Ⅲ区操作,扩展椎前筋膜前间隙、甲状腺上极背侧处理;C:Ⅱ区操作,甲状腺上极处理;D:I区操作,甲状腺及中央区充分游离、完成中央区清扫、离断甲状腺峡部Fig.6 Four-quadrant scene-based operation A: Zone Ⅳ operation, expanding the prevertebral fascia interspace, and dissecting the posterior border of the thyroid fascial plane; B: Zone Ⅲ operation, expanding the prevertebral fascia interspace and handling the dorsal aspect of the superior pole of the thyroid; C: Zone Ⅱ operation, handling the superior pole of the thyroid; D: Zone I operation, thorough dissociation of the thyroid and central compartment, completing the central dissection, and division of the isthmus of the thyroid
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孙百慧,余诗桐,葛军娜,魏志刚,雷尚通.经腋窝无充气后入路腔镜甲状腺手术的“场景化”辅助操作[J].中国普通外科杂志,2023,32(5):724-730.
DOI:10.7659/j. issn.1005-6947.2023.05.012

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  • 收稿日期:2022-12-29
  • 最后修改日期:2023-01-19
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  • 在线发布日期: 2023-06-03