Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method
Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method
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DOI：
10.1007/s00464-009-0347-0
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发表时间：
2009-05-01
影响因子：
3.1
通讯作者：
Stark, M.
中科院分区：
文献类型：
--
作者：
Benhidjeb, T.;Wilhelm, T.;Stark, M.
颈部外科是微创手术的最新应用领域之一。Miccoli[1]开发的微创视频辅助甲状腺切除术（MIVAT）是目前应用最广泛的方法。这种方法的限制因素包括令人烦恼的20毫米颈部切口，因此需要切除的标本大小。已经发表了几篇描述前颈部区域外通道的论文。这些入路包括胸部入路、腋窝入路、双侧腋窝联合入路或双侧腋窝入路[2-5]。宫颈无瘢痕甲状腺手术的发展是朝着更好的美容效果迈出的一大步。然而，这些技术只是将疤痕从前颈部移动到腋窝或胸部，在那里它们仍然可见。前面提到的微创入路和传统的甲状腺入路都不尊重解剖上给定的手术平面。这可能导致患者的抱怨，如疤痕的形成和吞咽障碍。此外，颈外入路不符合术语“微创”的使用，因为它们与胸部和颈部区域的广泛剥离有关，因此对患者来说是相当大的侵入性。本项目的主要目标是介绍一种满足以下标准的甲状腺切除术技术：(1)在甲状腺切除术中尊重手术平面并尽量减少手术创伤；手术通道本身应靠近甲状腺，以实现微创手术。只有通过无疤痕手术才能获得最佳美容效果，iv.无疤痕手术的最佳美容效果应该以最小的创伤来实现，v.这种方法的微创性和最佳美容效果可能不会以牺牲患者的安全为代价。)满足所有这些标准的技术是经口入路，因为舌下位置和甲状腺之间的距离很短，因此避免了广泛的剥离操作。此外，口腔黏膜可以毫无困难地缝合和自我修复，而不会留下任何明显的疤痕。我们小组的一名成员最近在猪模型中使用改良的腋镜[6]证明了经口通道的可行性。然而，所描述的技术是一种混合技术，因为通过套管针插入固定钳需要在喉下15mm处额外的内侧通道（3.5 mm切口）。oura项目的主要目标是研究和引进一种完全内窥镜甲状腺切除术的技术，这种技术对患者来说是微创和安全的，同时在美容上是最佳的（无疤痕）。为此，总共使用了五具人类尸体。在三具尸体中，根据确定的路线图评估了到达和切除甲状腺的安全性和可重复性。在手术结束时，解剖尸体以评估所有确定的关于可能损伤的解剖关键结构，并对所进行的手术进行评估。TOVAT本身在另外两具人类尸体上进行，借助一个5毫米和两个3毫米套管针，通过口底和口下平台前庭引入。通过在4-6毫米汞柱的压力下注入二氧化碳（“空气解剖”）来创建一个工作空间。用3mm双极剪刀实现进一步工作空间的手术解剖。该程序包括以下步骤：(i)患者仰卧位，鼻气管插管；5-mm小切口之间的钩骨下，iii。用钝器沿颈浅筋膜穿透口底，iv.插入5毫米套管针，v.通过二氧化碳注入（“空气分离”）钝性解剖颈阔下，vi.二氧化碳注入（4-6毫米汞柱）并创造一个工作空间，vii。在左、右前庭植入2个3-mm套管针；颈阔肌和肩带肌的分离大约在喉头的水平，一直延伸到胸骨上切迹。在外侧，这种剥离可以继续到胸锁乳突肌的内侧边界，9。白色大肠杆菌的分裂和带肌的暴露，x。带肌与甲状腺的分离，xi。峡部横断和从气管钝性剥离甲状腺，12。靠近腺体的上极动脉和甲状腺内侧静脉的分离和分裂，13。甲状腺下动脉分支靠近腺体的分支，14。如有必要，准备甲状腺后区，包括喉返神经的显像。甲状腺从颅部到尾部切除，经口经5毫米中线切口切除标本。如果腺体过大，可以纵向延长中线切口，xvi。所有三个切口都用可吸收缝合线缝合。)可以实现手术步骤的标志描述和明确解剖结构的解剖。短时间内可顺利到达阔侧下空间。解剖解剖显示完整的肌肉和血管结构。单侧甲状腺次全切除术可在60分钟内成功完成，无需再增加皮肤切口。TOVAT的微创性和无疤痕的特点构成了该方法在人类尸体上进行临床前研究的基本原理。我们可以成功地定义客观参数，详细描述手术过程，并对所进行的手术进行评估。论证了增值税的可及性和可行性。下一步将是在将其应用于人类之前将其应用于活猪。据我们所知，这是NOS在甲状腺手术中应用的第一篇报道，也是第一例完全无疤痕的视频辅助甲状腺切除术。
Neck surgery is one of the newest fields of application of minimally invasive surgery. The technique of minimally invasive video-assisted thyroidectomy (MIVAT) developed by Miccoli [1] is the method that has so far become most widespread. Limiting factors of this method include the bothersome 20-mm cervical incision and consequently the specimen size to remove. Several papers describing an access outside the front neck region have been published. Such approaches are via the chest, axillary, a combined axillary bilateral breast, or a bilateral axillary breast approach [2-5]. The development of cervical scarless thyroid surgery is a great step toward better cosmetic outcomes. However, these techniques just moved the scars from the front neck region to the axilla or the chest where they are still visible. And the mentioned minimally invasive accesses as well as the conventional approaches to the thyroid gland do not respect the anatomically given surgical planes. This may result in complaints by the patients, e.g., scar development and swallowing disorders. Furthermore, the extracervical approaches do not comply with the use of the term "minimally invasive," because they are associated with an extensive dissection of the chest and neck region, thus being rather maximally invasive for the patients. The main goal of this project was the introduction of a technique of thyroid resection that fulfills the following criteria: (i. Respecting surgical planes and minimizing surgical trauma in thyroidectomy, ii. The access itself should be close to the thyroid gland to achieve a minimally invasive procedure, iii. Achieving an optimal cosmetic result may only be obtained by performing a scarless operation, iv. This optimal cosmetic result with scarless surgery should be achieved with minimal trauma, v. The minimally invasive character of this approach and the optimal cosmetic result may not be reached at the expense of patient's safety.). The technique that meets all of these criteria is the transoral access because the distance between the sublingual place and the thyroid gland is short, thus avoiding extensive dissection maneuvers. Furthermore, the mouth mucosa can be sutured without difficulties and repairs itself without leaving any visible scars. Feasibility of the transoral access has been recently demonstrated by a member of our group in a porcine model by using a modified axilloscope [6]. However, the described technique is a hybrid one because an additional medial access (3.5-mm incision) 15-mm below the larynx was necessary for the insertion of a fixation forceps through a trocar. The main goal of oura project was the investigation and introduction of a technique of totally endoscopic thyroid resection that is minimally invasive and safe for the patient and at the same time cosmetically optimal (scarless).For this purpose, a total of five human cadavers were used. In three cadavers, safety and reproducibility to reach and resect the thyroid gland was assessed according to a defined road map. At the end of the procedure, the cadavers were dissected to evaluate all defined anatomical key structures regarding possible injuries and also allow an evaluation of the surgery performed. The TOVAT itself was performed on two more human cadavers with the help of one 5-mm and two 3-mm trocars that were introduced through the mouth floor and the vestibulum of the mouth subplatysmal. A working space was created by insufflating CO2 at a pressure of 4-6 mmHg ("air dissection"). Surgical dissection of the further working space was realized with 3-mm bipolar scissors. The procedure consists of the following steps: (i. Patient in supine position and nasotracheal intubation, ii. 5-mm small incision between the carunculae sublinguales, iii. Penetration through the mouth floor along the superficial fascia colli with a blunt instrument, iv. Insertion of a 5-mm trocar, v. Blunt dissection subplatysmal by CO2 insufflation ("air dissection"), vi. CO2 insufflation (4-6 mmHg) and creation of a working space, vii. Insertion of two 3-mm trocars in the vestibulum oris on the right and left side, viii. Separation of the platysma from the strap muscles approximately at level of the larynx, extending up to the suprasternal notch. Laterally, this dissection can be continued up to the medial border of the sternocleidomastoid muscles, ix. Division of the linea alba coli and exposure of the strap muscles, x. Separation of the strap muscles from the thyroid gland, xi. Isthmus transection and blunt dissection of the thyroid gland from the trachea, xii. Dissection and division of the upper pole arteries and medial thyroid vein closely to the gland, xiii. Division of branches of the inferior thyroid artery closely to the gland, xiv. If necessary, preparation of the retro-thyroidal area, including visualization of the recurrent laryngeal nerve, xv. Thyroid resection from cranial to caudal and transoral removal of the specimen through the 5-mm midline incision. If the gland is too large, the midline incision can be extended longitudinally, xvi. All three incisions are closed with absorbable sutures.)Description of landmarks of surgical steps and dissection of defined anatomic structures could be achieved. The subplatysmal space could be reached without any major problems within a short time. Anatomical dissection showed intact muscles and vascular structures. One-side subtotal thyroid resection could be successfully performed without any additional skin incision in 60 minutes.The minimally invasive aspect and the scarless character of TOVAT form the rationale for the preclinical investigation of this method in human cadavers. We could succeed in defining objective parameters, which describe the procedure in details and also allow an evaluation of the surgery performed. Access and feasibility of TOVAT could be demonstrated. The next step will be its application in living pigs before it may be applied in humans. To our knowledge of the literature, this is the first report on NOS application in thyroid surgery and also the first totally and scarless performed video-assisted thyroidectomy.