Roberts John R, Wadsworth James
The Surgical Clinic, The Sarah Cannon Cancer Center, Nashville, Tennessee, USA.
Ann Thorac Surg. 2007 Feb;83(2):388-91; discussion 391-2. doi: 10.1016/j.athoracsur.2006.03.124.
Recurrent nerve injuries occur during mediastinoscopy despite assiduous technique. We evaluated mediastinoscopy by monitoring laryngeal nerve stimulation during the surgery. These techniques utilize sensing electrodes on laryngeal masks to evaluate stimulus of the larynx, and are used to identify recurrent nerves during redo neck surgery.
Fifteen patients were monitored during the entire mediastinoscopy. The laryngeal sensor was placed just before intubation. All patients had a suprasternal incision, digital dissection along the anterior wall of the trachea, and harvest of the nodes in the left paratracheal (4L), right paratracheal (4R), and subcarinal (7) positions. Cautery was used when needed in the subcarinal space and the right paratracheal groove.
Surprisingly, 14 of 15 patients demonstrated intense recurrent nerve stimulation during digital dissection along the anterior wall of the trachea. This dissection activated the right and left recurrent nerves. Though the use of cautery on the left caused significant laryngeal nerve activity, cautery in the subcarinal space and on the right caused very little activity. One patient was found to have a (transient) recurrent nerve injury after surgery. She demonstrated intense activity both during dissection along the anterior wall of the trachea, and during removal of a left paratracheal node.
Our data demonstrate that traction in the anterior mediastinum causes the greatest stimulation to the nerves, even greater than direct stimulation with current. Thus, these data suggest that injuries could result only from traction. Traction on both recurrent nerves can occur with dissection along the trachea. Laryngeal nerve monitoring can be used to direct biopsies in the left paratracheal groove.
尽管技术娴熟，但纵隔镜检查过程中仍会发生喉返神经损伤。我们通过在手术过程中监测喉返神经刺激来评估纵隔镜检查。这些技术利用喉罩上的传感电极来评估喉部刺激，并用于在再次颈部手术中识别喉返神经。
在整个纵隔镜检查过程中对15例患者进行监测。喉传感器在插管前放置。所有患者均行胸骨上切迹切口，沿气管前壁进行手指分离，并获取左气管旁（4L）、右气管旁（4R）和隆突下（7）部位的淋巴结。在隆突下间隙和右气管旁沟必要时使用电灼。
令人惊讶的是，15例患者中有14例在沿气管前壁进行手指分离时出现强烈的喉返神经刺激。这种分离激活了左右喉返神经。虽然在左侧使用电灼会引起明显的喉神经活动，但在隆突下间隙和右侧使用电灼引起的活动很少。1例患者术后发现有（短暂性）喉返神经损伤。她在沿气管前壁分离以及切除左气管旁淋巴结时均表现出强烈的活动。
我们的数据表明，前纵隔的牵拉对神经的刺激最大，甚至大于电流直接刺激。因此，这些数据表明损伤可能仅由牵拉引起。沿气管分离时双侧喉返神经均可受到牵拉。喉神经监测可用于指导左气管旁沟的活检。
