Objective To understand anatomy of parathyroid gland and explore its application value in protection of parathyroid gland function during thyroidectomy. Methods The literatures, which were associated with the parathyroid anatomy and hypoparathyroidism were collected. The origin, function, anatomical location, number, blood supply, lymphatic system of the parathyroid gland and its relationship with surrounding tissues of parathyroid gland and its clinical significance in the thyroidectomy, were reviewed. Results The position of the superior parathyroid gland was relatively constant, and the inferior parathyroid gland was more likely to be ectopic. The number of the parathyroid gland was uncertain. The mainstream view was that the arterial supply of the parathyroid glands was mainly ensured by the inferior thyroid artery, a few by anastomosis of the superior and inferior thyroid arteries, or by the superior thyroid artery. However, the alternative view was that the blood supply of the parathyroid gland was not mainly derived from the inferior thyroid artery. The parathyroid gland was not easily distinguished from the adipose tissue and lymph node. Whether there was an independent lymphatic system in the parathyroid gland was still controversial. In the thyroidectomy, the parathyroid gland and its blood supply were reserved or protected by distinguishing from the Zuckerkandl tubercle, recurrent laryngeal nerve, and parathyroid specific attachment fat, which were identified by utilizing of the nanocarbon, loupe magnification, etc.. Especially in the central lymph neck dissection, the main thyroid artery trunk and its important branches should be carefully dissected or retained through the gentle capsular dissection and the correct use of energy devices for vessel sealing. The parathyroid gland in situ was reserved according to the parathyroid type. If it was not possible to be preserved, the parathyroid autotransplantation was necessary during the thyroidectomy. Conclusions Understanding origin and location of parathyroid gland, it could provide a direction for searching parathyroid gland during thyroidectomy. Being familiar with blood supply of parathyroid gland makes it possible to protect blood vessel and preserve parathyroid gland. Gentle capsular dissection, rational use of energy device, and indocyanine green angiography seem to be more important. Number of parathyroid gland allows us to treat each parathyroid gland as the last one, if it is not preserved in situ , parathyroid gland need to be autografted to avoid hypoparathyroidism.
目的 探讨甲状腺手术方式和喉返神经损伤（RLN）的关系。 方法 回顾性分析2009年1月至2012年6月期间于笔者所在医院科室接受开放性甲状腺手术的985例患者的临床资料，探讨甲状腺手术方式和RLN损伤的关系。 结果 本组患者术后发生RLN损伤26例（2.6%），未发生RLN损伤959例（97.4%）。logistic回归分析结果显示，年龄、性别、超声刀应用、麻醉方式及肿块良恶性与RLN损伤均无关（P＞0.05），而手术范围（OR=3.726，P=0.007）和显露RLN（OR=0.302，P=0.006）则是RLN损伤的影响因素，行扩大性手术及未显露RLN者的RLN损伤率较高。 结论 在开放性甲状腺手术中，手术范围以及显露RLN是RLN损伤的独立影响因素，术中显露并注意保护RLN，对避免RLN损伤具有重要意义。
Objective To evaluate whether the classification of parathyroid can be used to evaluate how difficult it is that the parathyroid glands get preserved in situ during thyroid surgery. Methods Clinical date were retrospectively collected from the patients with thyroid nodules, who had undergone the initial thyroidectomy in the Department of Thyroid Surgery, West China Hospital of Sichuan University between January 2014 and June 2016. The number of parathyroid glands was counted according to the classification of parathyroid. It got comparative analysis that the rates of parathyroid glands in situ among the different types. Results A total of 996 patients were included in the study, and 3 269 pieces of parathyroid glands were identified. The mean number of parathyroid identification was 3.3 pieces. These parathyroid glands consisted of 77.5% (2 532/3 269) type A and 22.5% (737/3 269) type B. The rate of parathyroid glands in situ was 77.1% (1 951/2 532) in type A, and 80.7% (595/737) in type B, the difference was significant (P=0.03). And the rate of parathyroid glands in situ in type A1 was significantly higher than that in type A2 (80.5%vs 21.4%,P<0.001). The parathyroid of type A3 couldn’t get preserved in situ. The rate of superior parathyroid glands in situ in type B1 was higher than that in type A1 (97.5%vs 93.7,P<0.01). But the rate of inferior parathyroid glands in type B1 was closed to that in type A1 (62.2%vs 65.7%,P=0.23), and both the rates were significant less than that in type B2 (86.0%) and in type B3 (90.2%),PA1vs B2=0.001,PA1vs B3<0.001,PB1vs B2=0.004,PB1vs B3=0.001. Conclusion The classification of parathyroid can be used to evaluate effectively how difficult it is that the parathyroid glands get preserved in situ during thyroid surgery.
Objective To compare the therapeutic effects between endoscopic thyroidectomy by anterior chest approach and modified Miccoli thyroidectomy. Methods Sixty patients with thyroid goiter were performed endoscopic thyroidectomy by anterior chest approach (endoscopic thyroidectomy by anterior chest approach group, n=30) and modified Miccoli thyroidectomy (modified Miccoli group, n=30) respectively. The operative time, the drainage volume, cosmetic benefit, the postoperative hospitalization time, the expenses of hospitalization and postoperative complications of two groups were compared. Results The operative time and the drainage volume after operation of endoscopic thyoidectomy by anterior chest approach group were significantly more than modified Miccoli group 〔(99.9±23.4) min vs. (74.0±29.6) min; (68.6±8.7) ml vs. (40.9±6.1) ml, respectively〕, Plt;0.05. The cosmetic benefit score of endoscopic thyoidectomy by anterior chest approach group was higher than that of modified Miccoli group 〔(4.7±0.2) points vs. (3.7±0.1) points〕, Plt;0.05. The postoperative hospitalization time and expenses of hospitalization were no significant differences between the two groups 〔(6.5±1.7) d vs. (5.5±0.9) d; (9 328.3±1 107.1) yuan vs. (8 568.2±1 032.3) yuan, respectively〕, Pgt;0.05. One case had transient hoarseness in 2 groups respectively, no other complications happened. Conclusions Modified Miccoli operation is both minimally invasive and cosmetic, but endoscopic thyroidectomy by anterior chest approach has better cosmetic benefit, which can release patients’ psychological trauma. The patients with specific cosmetic demand may choose endoscopic thyroidectomy by anterior chest approach.
ObjectiveTo explore optimal current intensity for neural monitoring of vagus nerve and recurrent laryngeal nerve during the thyroid and parathyroid surgery, so that we can judge function, location, identify, and protect the nerve more effectively and more quickly. MethodA total of 100 patients who underwent thyroid or parathyroid operations by the same surgeon in West China Hospital, meanwhile accepted intraoperative neuromonitoring (IONM), and 186 nerves at risk were enrolled in this study. According to the standardized process of nerve monitoring, we stimulated the vagus nerve with the current strength of 1-5 mA, and respectively stimulated laryngeal recurrent nerve with 1-3 mA indirectly and directly, and recorded the amplitude of electromyographic signal, and changes of heart rate and blood pressure during the process. The purpose was seeking the optimum current strength for each stage of IONM. ResultsIn 186 vagus nerves being tested, when monitoring the vagus nerve outside the carotid sheath, 109 vagus nerves (58.6%) sent out signals and got stable electromyography and warning tone with 1 mA, 164 (88.2%) vagus nerves had signals with 2 mA, 177 (95.2%) vagus nerves had signals with 3 mA, 182 (97.8%) vagus nerves had signals with 5 mA. Before and after the vagus nerve stimulation, heart rate and blood pressure of patients had no significant change. When directly monitoring the vagus nerve with 1 mA, V1 signals had no response in 2 vagus nerves (1.1%), V2 signals had no response in 9 vagus nerves (4.8%). But if the current intensity of stimulation was 2 mA or 3 mA, all patients got stable electromyographic signals. When searching for the laryngeal recurrent nerve, 92 (49.5%) got signals with 1 mA, 171 (91.9%) got signals with 2 mA, 184 (98.9%) got signals with 3 mA. When identifying laryngeal recurrent nerve and others, if the intensity of current was more than 2 mA, the current might conduct around and produce illusion. However, if the intensity of stimulation current was 1 mA, there's no electromyographic signal when we put the probe onto the tissue close to the laryngeal recurrent nerve. During identification of branches of laryngeal recurrent nerve with current strength of 1 mA, each electromyographic signal could be obtained. The chief branch into the throat produced the highest amplitude. The esophagus and trachea branch emg amplitude value was similar, equalling to 1/3-1/4 of the amplitude value in chief branch. ConclusionsWe suggest using current intensity of 5 mA on the surface of the carotid sheath to monitor the vagus nerve indirectly and obtain V1 signal, as an alternative to opening the carotid sheath. If fail, dissecting the carotid sheath, and using current intensity of 3 mA to monitor the vagus nerve directly; 3 mA is the optimal current intensity to search for the laryngeal recurrent nerve, and 1 mA is the optimal current intensity to identify the laryngeal recurrent nerve and its branches of esophagus and trachea, blood vessels, and so on.
ObjectiveTo compare the effect of robotic thyroidectomy and endoscopic thyroidectomy on the voice function. MethodsThe clinical data of 181 patients with differentiated thyroid cancer admitted to Panzhihua Central Hospital of Sichuan Province from March 2022 to June 2023 were analyzed retrospectively. According to the operative mode, this patients were divided into two groups: the endoscope group (n=91) and the robot group (n=90). The subjective and objective acoustic indicators were compared between the two groups at 1 day before operation and 1 week, 1 month and 3 months after operation. ResultsThere were no significant difference in voice handicap index (VHI)-10 scores between the two groups at different time points before and after operation (P>0.05). There were no significant difference of VHI-10 scores between preoperative and different postoperative phases in the robot group (P>0.05). The score of VHI-10 at different postoperative phases in the endoscopic group was higher than that at 1 d before operation (P<0.05). The incidence of voice dysfunction (VHI-10 score ≥8) was 1.1% (1/90), 1.1% (1/90) and 0.0% (0/90) in the robot group, 1.1% (1/91) , 2.2% (2/91) and 0.0% (0/91) in the endoscope group at 1 week, 1 month and 3 months after operation respectively, there were no significant difference between the two groups (P>0.05). The fundamental frequency of patients in the endoscopic group was lower than that at 1 d before operation (P<0.05), and there was no significant difference between each phase after operation and at 1 d before operation of fundamental frequency in the robot group (P>0.05). The fundamental frequency of patients in the endoscopic group was lower than that in the robot group at 1 week after operation (P<0.05). The maximum phonation time of each phase after operation in the robot group was not significantly different from that at 1 d before operation (P>0.05). The maximum phonation time of 1 week after operation in the endoscopic group was shorter than that at 1 d before operation (P<0.05) and also shorter than that in the robot group (P<0.05). There were no significant difference in fundamental frequency perturbation, amplitude perturbation, harmonic noise ratio and voice disorder severity index between the two groups at different phases before and after operation (P>0.05). ConclusionCompared with endoscopic thyroidectomy, the voice function of robotic thyroidectomy via bilateral axillary breast approach is better.
ObjectiveTo discuss clinical significance of total endoscopic thyroidectomy (TET) via chest-breast approach. MethodsThe clinical data of 890 patients with thyroid diseases from September 2008 to September 2015 in this hospital were analyzed retrospectively. These patients were divided into TET group (received TET, n=420) and traditional group (received traditional thyroidectomy, n=470). The data of operation and postoperative recovery were compared between these two groups. ResultsThere was no significant difference between the TET group and the traditional group in the operation time [(73.571 4±28.533 9) min versus (70.212 8±27.199 8) min, t=1.80, P=0.072 7], bleeding volume [(30.714 3±14.225 1) mL versus (29.106 4±13.559 1) mL, t=1.73, P=0.084 8], postoperative drainage [(60.000 0±27.287 9) mL versus (56.595 7±27.803 5) mL, t=1.84, P=0.066 2], postoperative hospitalization time [(5.333 3±1.085 1) d versus (5.446 8± 1.089 0) d, t=1.55, P=0.120 4], postoperative 24 h pain score [(5.333 3±2.308 7) points versus (5.404 3±2.182 1) points, t=0.47, P=0.637 8] and postoperative injury rate of recurrent laryngeal nerve [0.714 2% (3/420) versus 0.851 1% (4/470), x2=0.053 2, P=0.817 6] and hypoparathyroidism rate [0.476 2% (2/420) versus 0.851 1% (4/470), x2=0.465 5, P=0.495 1]. The score of aesthetic effect of incision on day 7 after operation in the TET group was significantly higher than that in the traditional group [(7.809 5±1.296 9) points versus (3.361 7±1.391 8) points, t=49.14, P < 0.000 1]. ConclusionTET is safe and effective, and could improve cosmetic effect for patients with thyroid diseases.
ObjectiveTo investigate the voice function before and after surgery in patients undergoing axillary thyroidectomy with da Vinci robotic Xi system. MethodsSeventy female patients who underwent robotic thyroid cancer radical resection in Panzhihua Central Hospital from March 2022 to March 2023 were selected. The voice dysfunction index scale VHI-10, auditory perception evaluation scale GRBAS and voice analysis software were used to evaluate the voice function of patients subjectively and objectively at 1 day before operation, 1 week and 3 months after surgery. ResultsThe operative time was (128.13±48.36) min, the amount of blood loss was (16.36±8.23) mL. There were no significant differences in the points of function, physiology and emotion evaluated by VHI-10 scale at 1 week and 3 months after operation compared with those before operation (P>0.05). There were no significant differences in the three characteristics points of voice roughness, breathiness, and strain evaluated by GRBAS scale at 1 week and 3 months after operation (P>0.05). At 1 week after operation, the total hoarseness grade and asthenia evaluated by GRBAS scale were increased in different degrees as compared with those before operation and the difference was statistically significant (P<0.05), while the total hoarseness grade and asthenia points were decreased at 3 months after operation and there was no significant difference as compared with that before operation (P>0.05). Voice acoustic analysis results showed that there were no significant differences in fundamental frequency, jitter, shimmer and harmonic to noise ratio of the patients between at 1 week or 3 months after operation and before operation (P>0.05). The maximum phonation time (MPT) of patients was decreased at 1 week after operation as compared with that before operation, and the difference was statistically significant (P<0.05). The MPT of the patients recovered at 3 months after operation, and there was no significant difference as compared with that before operation (P>0.05). The dysphonia severity index (DSI) of patients at 1 week after surgery was decreased as compared with that before surgery, and the difference was statistically significant (P<0.05). The DSI was increased at 3 months after operation and there was no significant difference as compared with that before operation (P>0.05). ConclusionRobot radical thyroidectomy via axillary breast is safe and can protect the voice function.
ObjectiveTo establish a stable laboratory model of temporary hypoparathyroidism following thyroid operation in rabbits. MethodsTwenty New Zealand white rabbits were randomized into 2 groups (the four parathyroid glands injured group and the two inferior parathyroid glands injured group, n=10 for each group). In the two inferior parathyroid glands injured group, blood supply vessels of the two inferior parathyroid glands were injured with ligation. In the four parathyroid glands injured group, total thyroidectomy (including two superior parathyroid glands) were performed and blood supply vessels of the two inferior parathyroid glands were injured with ligation. The number of the identified parathyroid glands were counted during operation. Serum calcium and parathyroid hormone (PTH) were evaluated preoperatively and postoperatively on 1 d, 2 d, 3 d, 5 d and in 1 week, 2 weeks, 3 weeks, and 4 weeks. Model achievement rate were calculated. ResultsFour parathyroid glands were identified in rabbits. The two superior parathyroid glands were in thyroid tissue which were identified with histology, and the two inferior parathyroid glands located in the fascia plane between the sternohyoid, sternothyroid muscles and the carotid artery which can easily be identified with naked eye. There were no significant difference in preoperative calcium and PTH between the two groups (P > 0.05). In the two inferior parathyroid glands injured group, significantly decreased in serum calcium were observed on 1 d, 2 d and 3 d after operation (P < 0.05). In the four parathyroid glands injured group, significantly decreased in blood calcium were observed on 1 d, 2 d, 3 d and 5 d after operation (P < 0.05). The lowest level of serum calcium was observed on 1 d in two groups. Postoperative serum PTH were significantly declined in two groups on 1 d, 2 d, 3 d, 5 d, and in 1 week, 2 weeks and 3 weeks (P < 0.05). The lowest serum PTH was also observed on 1 d in two groups. Significantly lower serum PTH were found in the four parathyroid glands injured group on 1 d, 2 d and 3 d than in the two inferior parathyroid glands injured group (P < 0.05). Lower PTH level were found in the four parathyroid glands injured group on 5 d, and in 1 week, 2 weeks, 3 weeks and 4 weeks, but no significance (P > 0.05). Positive correlation between serum calcium and PTH were noticed (r=0.771, P=0.000). Model achievement rate were higher on 3 d and 5 d in the four parathyroid glands injured group than that of the two inferior parathyroid glands injured group (P < 0.05). ConclusionsStable animal model of temporary hypoparathyroidism following thyroidectomy can be established by total-thyroidectomy plus ligation the blood vessels of the two inferior parathyroid glands. This model can be used for further study.