Serpell Jonathan W, Grodski Simon, Yeung Meei, Swann John, Kemp Sarah, Johnson William
Monash University, Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.
ANZ J Surg. 2008 Dec;78(12):1122-7. doi: 10.1111/j.1445-2197.2008.04764.x.
Heuristics describe the multiple small steps required for successful surgery, which are often taken for granted, enabling key manoeuvres, their correct order and their timely performance. Successful hemithyroidectomy is dependent on correct siting of the incision; tension to allow elevation of sub-platysmal flaps without damaging anterior jugular veins; strap muscle division with preservation of the ansa cervicalis; recognition of the importance of the sub-sternothyroid plane; superior mobility of the thyroid lobe, involving freeing the superior strap muscle layer and dissection of the pyramidal lobe; division of the isthmus to assist anteromedial mobility; dissection of the lateral thyroid space to free the posterior 'v' lip of the superior pole; medial to lateral dissection of the avascular cricothyroid space with preservation of the external laryngeal nerve, prior to ligation of the superior thyroid vessels; anteromedial rotation of the thyroid lobe with elevation of any retrosternal component; capsular dissection of the inferior pole with preservation of vascularity of the inferior parathyroid gland; dissection of the thyroid lobe off the recurrent laryngeal nerve, especially above the inferior thyroid artery in the region of greatest risk to the nerve, the region of the ligament of Berry; preservation of a vascularized superior parathyroid gland; capsular dissection, creating windows between vessels enabling their precise control, thereby minimizing haemorrhage. This paper aims to emphasize these heuristic components of thyroidectomy.
启发法描述了成功手术所需的多个小步骤，这些步骤常常被视为理所当然，它们促成了关键操作、正确的操作顺序以及适时的执行。成功的甲状腺半切术取决于切口的正确定位；施加张力以使颈阔肌下皮瓣能够提起而不损伤颈前静脉；在保留颈袢的情况下切断带状肌；认识到胸骨甲状肌平面的重要性；甲状腺叶的上移，包括松解上带状肌层和切除锥状叶；切断峡部以协助甲状腺叶向内侧移动；解剖甲状腺外侧间隙以游离上极的后侧“V”形边缘；在结扎甲状腺上血管之前，从内侧向外侧解剖无血管的环甲膜间隙并保留喉外神经；将甲状腺叶向内侧旋转并抬起任何胸骨后部分；在下极进行包膜下解剖并保留甲状旁腺下极的血供；将甲状腺叶从喉返神经上分离，尤其是在神经最易受损的区域，即贝里韧带区域，在甲状腺下动脉上方；保留带血管蒂的甲状旁腺上极；进行包膜下解剖，在血管之间形成窗口以便精确控制，从而将出血降至最低。本文旨在强调甲状腺切除术的这些启发式要素。
