Picardi N, Di Rienzo M, Annunziata A, Bartolacci M, Relmi F
Università degli Studi G. D'Annunzio di Chieti Facoltà di Medicina e Chirurgia, Dipartimento di Scienze Chirurgiche Sperimentali e Cliniche Chirurgia Generale III.
Ann Ital Chir. 1999 Sep-Oct;70(5):741-8.
To remove the immerse portion of a cervical goitre it is necessary to treat preventively the cervical thyroid arteries. In most cases it is afterwards it is easy the blunt finger dissection of the mediastinal bulk following the correct cleavage plane and its dislodging in the cervical area. But in very rare instances, according also to the personal experience, remains some difficulty for the passage of a too bulky and hard mediastinal mass through the rigid limits of the upper thoracic outlet, or the immerse struma is too fragile for pulling it by transfixion threads. Therefore, traditionally arises the opportunity of an additional surgical access, through the breastbone or through the thoracic wall, according to the circumstances. Our experience, completely occasional but extremely positive of two of such cases, induces us to advance a proved alternative surgical proposal. When the difficulty of the removal of the immerse portion of the goitre comes only from the incongruence of the immerse volume and the rigid limits of the upper thoracic outlet, our proposal is that to obtain an amplification of the narrow passage breaking the continuity of the clavicle, by its section beneath the periostium near the breastbone and removing this sternal stump from the joint. The result is that of an widening of the upper thoracic outlet, no more rigid, and making easy the transit of the immerse portion from anterior mediastinum so dislodged in the neck. The rationale of this choice is that all is requested in such cases is only to overcome the obstacle of the incongruence among volume and bulk of the immerse portion and the bone limits fixed from the narrow upper thoracic outlet. Both the traditional sternotomy and the thoracotomy seems disproportional for this purpose, moreover with additional problems during the operation. The true advantage of these classical solutions is in treating under direct vision the anomalous arteries of the mediastinal goitre in cases of ectopic localization. But this is not the case of an immerse cervical goitre. It is therefore essential to note that this proposal applies only to the migrated goitre and not to the ectopic ones. The recovery is extremely simple, and both the aesthetics and the static of the scapular joint are not substantially compromised.
为了切除颈部甲状腺肿的纵隔部分，有必要对颈部甲状腺动脉进行预防性处理。在大多数情况下，之后沿着正确的解剖平面用手指钝性分离纵隔肿物并将其移至颈部区域很容易。但根据个人经验，在极少数情况下，过于巨大且坚硬的纵隔肿物穿过胸廓上口的坚硬界限仍有困难，或者纵隔甲状腺肿过于脆弱，无法通过贯穿缝线牵拉。因此，传统上根据具体情况会有通过胸骨或胸壁进行额外手术入路的机会。我们在两例此类病例中的经验完全是偶然的，但非常积极，这促使我们提出一个经过验证的替代手术方案。当切除甲状腺肿纵隔部分的困难仅源于纵隔部分的体积与胸廓上口坚硬界限不匹配时，我们的建议是通过在靠近胸骨的骨膜下切断锁骨并将该胸骨残端从关节处移除来扩大狭窄通道，以打破锁骨的连续性。结果是胸廓上口变宽，不再坚硬，便于已移位至颈部的前纵隔部分通过。这种选择的基本原理是，在这种情况下所需要的只是克服纵隔部分的体积与胸廓上口狭窄的骨骼界限不匹配这一障碍。为此，传统的胸骨切开术和开胸术似乎都不成比例，而且手术过程中还会有其他问题。这些经典解决方案的真正优势在于在直视下处理纵隔甲状腺肿异位定位情况下的异常动脉。但对于颈部纵隔甲状腺肿并非如此。因此必须注意，此建议仅适用于移位性甲状腺肿，不适用于异位性甲状腺肿。恢复极其简单，肩胛骨的美观和稳定性基本不受影响。
