腔镜甲状腺手术出血的预防与处理

Prevention and management of bleeding in endoscopic thyroid surgery

摘要:

腔镜甲状腺手术（ET）经过30余年的发展，已成为满足美容需求患者的重要治疗方式。大量研究表明，ET在安全性、疗效及肿瘤根治性方面与开放手术相当，但因操作空间受限，对术者的腔镜技巧、空间定位能力及出血控制技术提出更高要求。尽管ET的出血总体发生率与开放术式接近，但其“狭窄工作腔”特点使术中止血和视野重建更具挑战；术后若形成颈部血肿，则可能迅速压迫气道，需及时识别与处理。因此，建立系统化的出血防控策略，是保证ET安全的关键。术前应充分评估患者的出血风险并优化甲状腺功能与凝血状态；术中需遵循精细解剖原则，合理使用能量器械，重点保护上、下甲状腺血管及喉返神经周围细小血管；术后需严密监测引流量与颈部形态变化，警惕早期血肿征象，必要时快速解除压迫并再次探查止血。本文基于本中心的丰富临床经验，并结合国内外最新证据，对ET术中出血的类型、特点、预防与处理策略进行系统阐述，旨在为临床外科医师提供可操作、可推广的技术路径，为推动ET的规范化、高质量发展提供参考。

Abstract:

Endoscopic thyroidectomy (ET) has rapidly evolved over the past three decades and has become a preferred option for patients with cosmetic concerns. Evidence shows that ET offers safety, efficacy, and oncologic completeness comparable to conventional open surgery; however, its confined operative space imposes higher demands on the surgeon's endoscopic skills, spatial perception, and hemorrhage control techniques. Although the overall incidence of bleeding is similar between ET and open thyroidectomy, achieving hemostasis and restoring visualization during ET are more challenging. Postoperative cervical hematoma, though infrequent, may rapidly lead to airway compromise, requiring prompt recognition and intervention. Systematic prevention and management of hemorrhage is therefore essential for ensuring ET safety. Preoperative optimization-including evaluation of bleeding risks and adjustment of thyroid and coagulation status-is fundamental. Intraoperatively, meticulous dissection, judicious use of energy devices, and careful protection of the superior and inferior thyroid vessels as well as microvasculature around the recurrent laryngeal nerve are key. Postoperatively, close monitoring of drainage and cervical contour is required to detect early signs of hematoma formation, enabling timely decompression and re-exploration when needed. Drawing on extensive institutional experience and current literature, this review summarizes the characteristics, risk factors, preventive measures, and management strategies for bleeding in ET. We aim to provide practical and standardized recommendations that enhance surgical safety, reduce severe complications, and support the standardized and high-quality development of endoscopic thyroid surgery.