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双侧腋窝乳晕入路机器人辅助甲状腺乳头状癌颈侧区淋巴结清扫中神经功能保护策略
赵文新, 颜守义, 张立永, 蔡少俊, 唐子涵, 王波, 田文
中国实用外科杂志 ›› 2026, Vol. 46 ›› Issue (6) : 784-788.
PDF(4185 KB)
PDF(4185 KB)
双侧腋窝乳晕入路机器人辅助甲状腺乳头状癌颈侧区淋巴结清扫中神经功能保护策略
Strategies for neural function preservation in robot-assisted lateral neck dissection via the bilateral axillo-breast approach for papillary thyroid carcinoma
机器人辅助颈侧区淋巴结清扫因手术范围广、解剖关系复杂，仍属甲状腺外科高难度操作。双侧腋窝乳晕入路（BABA）在清扫范围和根治性方面可满足分化型甲状腺癌颈侧区淋巴结清扫要求，适用于接受治疗性清扫的N1b期甲状腺乳头状癌（PTC）病人；在根治基础上兼顾神经功能保护，是该术式的重要价值。围绕颈丛神经、副神经、迷走神经和膈神经的保护，手术需合理建立皮瓣与胸锁乳突肌深面间隙，采用精细器械组合和稳定牵拉，借助机器人高清放大视野辨认筋膜层面、神经走行及关键解剖标志。颈丛神经保护应从建腔阶段开始，以颈横神经、耳大神经及C2~C4神经根为重点，必要时舍弃颈丛神经细小交通支以保证清扫连续性；副神经保护依赖颌下腺、二腹肌后腹、C2神经根及胸锁乳突肌深面血管等标志，尤其需重视Ⅱb区清扫中的视野维护、器械裸露段避让和牵拉安全；迷走神经在颈内静脉后方清扫时可能随静脉移位而暴露，分离和止血均应保持安全距离；膈神经保护关键在于不误入椎前筋膜深面，Ⅳ区清扫时可借颈横动脉定位其所在层面。基于操作空间、肿瘤生物学特点和术后分区病理需求，以C3神经根和肩胛舌骨肌为界分区清扫，较整块切除更有利于降低难度、保证彻底性并提升神经功能保护质量。
Robot-assisted lateral neck lymph node dissection remains a highly challenging procedure in thyroid surgery due to its extensive surgical field and complex anatomical relationships. The bilateral axillo-breast approach (BABA) meets the requirements for lateral neck lymph node dissection in differentiated thyroid cancer regarding both extent of resection and radicality, making it suitable for patients with N1b papillary thyroid carcinoma (PTC) undergoing therapeutic dissection; preserving nerve function while ensuring radical resection represents a core value of this procedure. To protect the cervical plexus, spinal accessory nerve, vagus nerve, and phrenic nerve, appropriate development of the skin flap and dissection of the deep plane of the sternocleidomastoid muscle are required. Fine instrument combinations with stable retraction should be employed, and the high-definition magnified view of the robotic system was utilized to identify fascial planes, nerve courses, and key anatomical landmarks. Protection of the cervical plexus should begin during working space establishment, focusing on the transverse cervical nerve, great auricular nerve, and C2 to C4 nerve roots; fine communicating branches may be sacrificed when necessary to maintain dissection continuity. Preservation of the spinal accessory nerve depends on anatomical landmarks including the submandibular gland, posterior belly of the digastric muscle, C2 nerve root, and vessels deep to the sternocleidomastoid muscle; special emphasis should be placed on maintaining clear visualization, avoiding exposed instrument shafts, and ensuring safe retraction during level IIb dissection. The vagus nerve may become exposed due to venous displacement during dissection posterior to the internal jugular vein; a safe distance must be maintained during separation and hemostasis. The key to phrenic nerve protection lies in avoiding inadvertent entry into the deep plane of the prevertebral fascia; during level Ⅳ dissection, the transverse cervical artery can be used to locate its anatomical plane. Based on working space constraints, tumor biological characteristics, and postoperative compartmental pathological requirements, compartmental dissection using the C3 nerve root and omohyoid muscle as boundaries is more advantageous than en bloc resection for reducing surgical difficulty, ensuring thoroughness, and improving nerve function preservation.
机器人甲状腺手术 / 甲状腺乳头状癌 / 颈侧区淋巴结清扫 / 神经功能保护 / 双侧腋窝乳晕入路
robotic thyroid surgery / papillary thyroid carcinoma / lateral neck dissection / neural function preservation / bilateral axillo-breast approach
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王猛, 田文, 贺青卿, 等. 车载5G远程移动机器人手术系统在甲状腺外科中的应用探索[J]. 国际外科学杂志, 2025, 52(1):28-32. DOI: 10.3760/cma.j.cn115396-20241120-00356.
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Robotic total thyroidectomy (TT) with modified radical neck dissection (MRND) using a gasless transaxillary approach has been reported safe and effective in patients with N1b papillary thyroid carcinoma (PTC), with notable cosmetic benefits when compared with conventional open TT. We have compared oncological outcomes and quality of life (QoL) in PTC patients undergoing robotic TT and MRND and those undergoing conventional open procedures.Between March 2010 and July 2011, 128 patients with PTC and lateral neck node metastases underwent TT with MRND, including 62 who underwent robotic and 66 who underwent open TT. We compared oncologic outcomes and safety as well as functional outcomes such as postoperative subjective voice and swallowing difficulties. We also evaluated neck pain, sensory changes, and cosmetic satisfaction after surgery using various QoL symptom scales. Neck and shoulder disability was assessed using arm abduction tests (AAT) and questions from the neck dissection impairment index (NDII).Although the mean operating time was significantly longer in the robotic (mean, 271.8 ± 50.2 min) than in the open group (mean, 208.9 ± 56.3 min) (P <.0001), postoperative complication rates and oncologic outcomes, including the results of radioactive iodine scans and postoperative serum Tg concentrations, did not differ significantly. Subjective voice outcomes and postoperative AAT and neck dissection impairment index were also similar, but postoperative swallowing difficulties (P =.0041) and sensory changes (P <.0001) were significantly more frequent in the open than in the robotic group. In particular, mean cosmetic satisfaction score was significantly higher in the robotic than in the open group (P <.0001).Robotic TT with MRND yielded similar oncologic outcomes and safety as conventional open procedures, with similar recovery of neck and shoulder disability. However, the robot technique resulted in better QoL outcomes, including better cosmetic results and reductions in neck sensory changes and swallowing discomfort.
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There is ongoing debate about whether or not robot-assisted thyroidectomy is appropriate for modified radical neck dissection (MRND). The purpose of this study was to compare the surgical outcomes of robot-assisted MRND with those of a conventional open procedure.One hundred and forty-five patients who underwent total thyroidectomy, bilateral central neck dissection, and MRND (robotic, n = 28; open, n = 117) at our institution from June 2011 to June 2015 were enrolled in the study. The surgical completeness and complication rates in the robotic and open groups were retrospectively compared after 1:3 propensity score matching for age, sex, body mass index, tumor size, and extrathyroidal extension.The complication rates, including transient or permanent hypoparathyroidism and recurrent laryngeal nerve palsy, were comparable between the study groups (p > 0.05). The operating time was significantly longer in the robotic group than in the open group (p < 0.001). There was no significant difference in the number of retrieved lymph nodes, metastatic lymph nodes, or stimulated serum thyroglobulin level between the two groups (p = 0.733, p = 0.663, and p = 0.285, respectively).The surgical outcomes, including complication and completeness rates, were comparable between robot-assisted MRND using a bilateral axillary breast approach and conventional open surgery. Robot-assisted MRND can be recommended as an alternative to a conventional open procedure for thyroidectomy.
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To evaluate the feasibility and safety of robotic lateral cervical lymph node dissection via BABA, 260 thyroid cancer patients with suspected level II, III, IV, and V lymph node metastasis were selected. The lateral cervical compartment was exposed by splitting the sternocleidomastoid muscle longitudinally, and separating between the strap muscles and the anterior margin of the sternocleidomastoid muscle. The procedure was completed in 260 patients. Mean time for robotic lateral node dissection took 80 ± 21 min. The wound catheter was removed 6.3 days. Postoperative transient symptomatic hypocalcemia was observed in 51 patients, transient hoarseness in three, seroma in three, chyle leakage in two, and tracheal injury in one. 124 patients were confirmed to have lymph node metastasis on final pathological report. Average postoperative hospital stay was 6.5 days. Robotic lateral neck dissection by BABA is the acceptable operative alternative for thyroid cancer patients who wished to keep their surgical history private.
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李小磊, 贺青卿, 庄大勇, 等. 双侧腋窝乳晕入路机器人甲状腺手术单中心1 000例报告[J]. 中华外科杂志, 2021, 59(11):918-922.DOI:10.3760/cma.j.cn112139-20201218-00866.
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中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会. 分化型甲状腺癌颈侧区淋巴结清扫专家共识(2017版)[J]. 中国实用外科杂志, 2017, 37(9):985-991.DOI:10.19538/j.cjps.issn1005-2208.2017.09.13.
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中国医师协会外科医师分会甲状腺外科专家工作组, 中国研究型医院学会甲状腺疾病专业委员会, 中国医疗保健国际交流促进会普通外科学分会. 机器人手术系统辅助甲状腺癌颈侧区淋巴结清扫实践指南(2025版)[J]. 中华内分泌外科杂志, 2025, 19(5):625-632. DOI:10.3760/cma.j.cn115807-20250910-00267.
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中国医师协会外科医师分会甲状腺外科专家工作组, 中国研究型医院学会甲状腺疾病专业委员会, 中国医疗保健国际交流促进会普通外科学分会. 机器人手术系统辅助甲状腺和甲状旁腺手术临床实践指南(2024版)[J]. 中华外科杂志, 2024, 62(9):805-817.DOI:10.3760/cma.j.cn112139-20240608-00285.
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中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会. 甲状腺外科能量器械应用专家共识(2017版)[J]. 中国实用外科杂志, 2017, 37(9):992-997.DOI:10.19538/j.cjps.issn1005-2208.2017.09.14.
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田文, 费阳, 郗洪庆. 甲状腺手术中新技术的合理应用及展望[J]. 中国实用外科杂志, 2018, 38(6):600-604.DOI:10.19538/j.cjps.issn1005-2208.2018.06.03.
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The marginal mandibular branch of the facial nerve is vulnerable to iatrogenic injuries during surgeries involving the submandibular region. This leads to significant post-operative morbidity. Studies assessing accurate anatomical landmarks of the marginal mandibular branch are sparse in South Asian countries. Present study was conducted to assess the relationship between the marginal mandibular branch and the inferior border of the body of mandible.Twenty-two preserved cadavers of Sri Lankan nationality were selected. Cadavers were positioned dorsal decubitus with necks in extension. The maximum perpendicular distance between the inferior/caudal most ramus of the marginal mandibular branch and the inferior border of the body of the mandible was recorded on both hemi faces.Recorded maximum distance was 17.65 mm on left side and 10.80 mm on right side. Mean maximum distance, was 7.12 ± 2.97 mm. There was no statistically significant difference in the maximum deviation on left (7.84 ± 3.41 mm) and right sides (6.44 ± 2.37 mm).Course of the marginal mandibular nerve is complex. If the distance of the incision in the posterior submandibular approach is less than 2 cm from the inferior border of the mandible, there is a high probability of damaging the inferior ramus of the marginal mandibular branch of the facial nerve.
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杨方玖, 薛黔, 李季容, 等. 胸锁乳突肌亚部肌构筑、肌梭和神经入肌点定位[J]. 解剖学杂志, 2005, 28(4):465-467. DOI:10.3969/j.issn.1001-1633.2005.04.033.
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Neck dissection is a commonly performed procedure for oncologic control of head and neck malignancy. With contemporary modified radical and selective neck dissections, haematoma, wound infection, tissue necrosis, chyle leak and injury involving the marginal mandibular, hypoglossal, vagus or accessory nerves are commonly described complications. Although the phrenic nerve courses within the surgical planes explored during a neck dissection and has a vital function in innervating the diaphragm, few studies have been performed to investigate the exact incidence of post-operative phrenic nerve paresis. This study aims to review the literature as to the rate of phrenic nerve injury following neck dissection.A systematic literature review was conducted from 2000 to 2022 including studies reporting on phrenic nerve paresis following neck dissection.In total, 11 studies were included. The reported rate of immediate post-operative phrenic nerve paresis ranged from 0% to 5.3%, with an average rate of 0.613% (12/1959). The reported rate of phrenic nerve paresis at follow-up (1 month-127 months) ranged from 0% to 4.7%, with an average rate of 1.035% (5/483). There were no cases of bilateral phrenic nerve paresis reported in this period.Phrenic nerve paresis is an uncommon complication following neck dissection, often asymptomatic and potentially underreported. Bilateral phrenic nerve paresis is exceedingly rare. Injury can be avoided by staying superficial to the prevertebral fascia when dissecting around the anterior scalene muscle. Routine phrenic nerve integrity monitoring is not commonly utilized but may aid intra-operative phrenic nerve identification or confirmation of function.© 2023 Royal Australasian College of Surgeons.
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The brachial plexus is an important anatomical structure that is regularly encountered by head and neck surgeons and radiation oncologists. Surgical or radiation-induced brachial plexus injury have great impact on arm function and quality of life. Anatomical variations and management of the brachial plexus in head and neck cancer treatment are discussed.The brachial plexus consists of spinal roots from C5-C8 and T1. The most prevalent anatomical variations in brachial plexus anatomy include the prefixed brachial plexus (additional contribution from C4) in 11%, the roots of C5 and C6 piercing the belly of the anterior scalene muscle in 6.8%, and presence of the scalenus minimus muscle in 4.1-46%. Due to its location, the brachial plexus is at risk of inadvertent division or neuropraxia during surgical procedures such as neck dissection or robot-assisted transaxillary thyroid surgery (RATS). In case of inadvertent division, nerve reconstruction surgery is warranted and may lead to improved function. The risk of radiation-induced brachial plexus injury is dose-dependent and occurs in approximately 12-22%. Currently, no successful treatment options exist for radiation-induced injury.Knowledge of anatomical variations is important for head and neck surgeons to minimize the risk of brachial plexus injury. Limiting radiation therapy dose to the brachial plexus is desirable to decrease the risk of brachial plexus injury.Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
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