小切口经口腔前庭入路腔镜甲状腺手术中单隧道向壁穿刺建腔技术的临床评价

Clinical evaluation of the single-tunnel transmural puncture method in small-incision transoral endoscopic thyroidectomy vestibular approach

摘要:

背景与目的 经口腔前庭入路腔镜甲状腺手术（TOETVA）因其体表无瘢痕及中央区淋巴结清扫便利等优势得到快速推广，但传统10 mm腔镜及较大口腔切口常导致口唇与颏部组织牵拉损伤。为减少颌面部组织创伤，临床开始尝试采用5 mm内镜开展小切口经口腔前庭入路腔镜甲状腺手术（SITOETVA）。然而，5 mm穿刺器建腔空间更小，常出现导管不易汇聚、初始出血率上升等困难。本研究比较单隧道向壁穿刺法与多隧道向腔穿刺法在SITOETVA中的建腔效果，以优化手术流程。方法 回顾性分析2024年5月—9月接受SITOETVA的60例患者，均由同一术者完成，其中30例患者使用单隧道向壁穿刺法建腔（观察组），另30例患者使用多隧道向腔穿刺法建腔（对照组）。比较两组建腔时间、手术时间、第一空间出血发生率、术中出血量、术后引流量、中央区淋巴结清扫数目及术后住院时间等指标。结果 两组一般资料无明显差异（均P>0.05）。观察组建腔时间［（14.5±2.3）min vs.（24.9±5.7）min］、手术时间［（81.5±17.6）min vs.（96.8±15.6）min］、术中出血量［（2.5±1.4）mL vs.（4.8±3.5）mL］及第一空间出血发生率（3.33% vs. 33.33%）均明显低于对照组（均P<0.05）。两组术后引流量、清扫淋巴结数目与住院时间差异均无统计学意义（均P>0.05）。两组均未出现呼吸困难、声音嘶哑或下唇活动受限等并发症。两组患者在随访期间均未出现复发或远处转移，术后口唇及颏下感觉功能均在2~4周内恢复，无长期功能障碍发生。结论 单隧道向壁穿刺法能够在SITOETVA狭小的初始空间中有效降低建腔难度与出血风险，加快建腔速度并缩短总体手术时间，是一种更为精简、安全且具有临床实用性的建腔流程改良方案。

Abstract:

Background and Aims Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has gained increasing popularity due to its scarless appearance and convenience in central compartment lymph node dissection. However, the conventional approach using a 10-mm endoscope and relatively large vestibular incisions often leads to traction-related injuries of the lips and chin. To minimize maxillofacial trauma, a 5-mm endoscope-based small-incision TOETVA (SITOETVA) has been introduced. Yet the smaller trocar limits the initial working space, making trocar convergence difficult and increasing bleeding risk. This study compares the single-tunnel transmural puncture method with the multi-tunnel transcavity puncture method to determine an optimized cavity-creation strategy for SITOETVA.Methods A retrospective analysis was conducted on 60 patients who underwent SITOETVA between May and September 2024, all operated on by the same surgeon. Among them, 30 patients underwent cavity creation using the single-tunnel transmural puncture method (observation group), and the remaining 30 patients underwent cavity creation using the multi-tunnel transcavity puncture method (control group). The two groups were compared in terms of cavity-creation time, operative time, initial-space bleeding rate, intraoperative blood loss, postoperative drainage volume, number of central compartment lymph nodes dissected, and postoperative length of hospital stay.Results Baseline characteristics were comparable between the two groups (all P>0.05). The observation group demonstrated significantly shorter cavity-creation time [(14.5±2.3) min vs. (24.9±5.7) min], shorter operative time [(81.5±17.6) min vs. (96.8±15.6) min], lower intraoperative blood loss [(2.5±1.4) mL vs. (4.8±3.5) mL], and markedly reduced initial space bleeding rate (3.33% vs. 33.33%) compared with the control group (all P<0.05). No significant differences were observed in postoperative drainage volume, lymph node yield, or hospital stay (all P>0.05). No cases of dyspnea, hoarseness, or limitation of lower-lip movement were observed in either group. During follow-up, no cases of recurrence or distant metastasis were detected in either group, and sensory function of the lips and chin recovered within 2-4 weeks without long-term functional impairment.Conclusion The single-tunnel transmural puncture technique effectively reduces bleeding risk, simplifies trocar convergence, and shortens operative time in SITOETVA. It represents a practical and streamlined modification of the cavity-creation procedure and has strong clinical applicability.