Monash University Endocrine Surgery Unit, The Alfred Hospital, Commercial Road, Melbourne, Vic., Australia.
Ann Surg Oncol. 2010 Jun;17(6):1628-36. doi: 10.1245/s10434-010-0928-0. Epub 2010 Feb 9.
Avoiding recurrent laryngeal nerve (RLN) injury is aided by a precise anatomical understanding of the RLN before entry into the larynx where it is at greatest risk.
A literature review and study of 977 RLNs at operation have been used to describe the last 2 cm of the anatomical course of the extralaryngeal RLN.
The tertiary branches of the inferior thyroid artery pass in a superficial vascular fascial layer anterolateral to the RLN. The tubercle of Zuckerkandl and the superior parathyroid glands lie within this superficial vascular fascial covering layer. The RLN lies on a deeper layer of more fibrous tissue, the ligament of Berry. In all 977 RLNs, the RLN was sandwiched between an anterolateral vascular layer and a medial layer, the ligament of Berry.
The site of greatest risk during thyroidectomy to the RLN is in the 2-cm course of the extralaryngeal nerve above the trunk of the inferior thyroid artery where tension forms an artificial genu of the nerve. Once the superficial vascular fascial and Berry's ligament layers are released, the nerve falls back into the tracheoesophageal groove and adopts a serpiginous appearance, indicating completeness of the dissection of the lobe from the lateral trachea and division of the ligament of Berry.
在进入喉时，准确了解喉返神经（RLN）的解剖结构可以帮助避免 RLN 损伤，因为此时它处于最危险的位置。
通过文献复习和 977 例手术 RLN 的研究，描述了 RLN 进入喉外的最后 2cm 的解剖路径。
甲状腺下动脉的三级分支在 RLN 的前外侧走行于浅层血管筋膜层中。Zuckerkandl 结节和上甲状旁腺位于该浅层血管筋膜覆盖层内。RLN 位于更深层的纤维组织——Berry 韧带之上。在所有 977 例 RLN 中，RLN 位于前外侧血管层和内侧的 Berry 韧带之间。
甲状腺切除术时 RLN 最危险的部位是在甲状腺下动脉干上方的 RLN 喉外 2cm 段，此处张力形成神经的人工膝状部。一旦松解了浅层血管筋膜和 Berry 韧带层，神经就会回落至气管食管沟，呈现出蜿蜒状，表明已完成从气管外侧对叶的解剖和 Berry 韧带的分离。
