甲状腺手术喉返神经损伤危险因素及应对策略

目的探讨甲状腺手术出现喉返神经损伤的危险因素及避免损伤的方法。方法回顾性分析1902例甲状腺患者,按手术科别、性别、麻醉方法、病变性质、术中是否常规解剖喉返神经、手术次数及手术范围分组,观察喉返神经损伤率,进行单因素分析及多因素回归分析。结果喉返神经总损伤率为1.84%。单因素分析显示,在甲状腺恶性病变患者、多次手术及甲状腺广泛性手术中喉返神经损伤率升高有统计学意义(χ2分别为1.096、1.893、1.467,P<0.05)。在甲状腺广泛性手术中,术中显露喉返神经可有效降低喉返神经损伤率(χ2=1.758,P<0.05);而在保守性手术中,术中是否显露喉返神经,喉返神经损伤率的差异无统计学意义(χ2=0.638,P>0.05)。Logistic回归分析显示,多次手术及甲状腺广泛性手术是喉返神经损伤的重要危险因素。结论对于病变范围较小的甲状腺良性肿瘤,术中不显露喉返神经、保留部分甲状腺背侧组织是安全可靠的。而对于广泛性甲状腺切除手术,术中应常规解剖喉返神经。

Analysis of the risk factors and strategies for recurrent laryngeal nerve paralysis in patients with thyroidectomy

OBJECTIVE To investigate the incidence and risk factors of recurrent laryngeal nerve paralysis in patients after thyroidectomy.METHODS The clinical data of 1902 patients who had consecutively undergone a thyroid operation from 2003 to 2010 were retrospectively analyzed.The potential correlation of the incidence of recurrent laryngeal nerve palsy with division,gender,anesthesiology,thyroid pathology,whether the nerve was identified or not,the number of surgery times and the extent of surgery were evaluated.RESULTS The overall rate of nerve palsy postoperatively was 1.84%.The incidence of recurrent laryngeal nerve palsy were significantly higher in the patients with thyroid malignancy,repeat surgery and who had an extended thyroidectomy comparing with the control groups on univariate analysis（χ 2 =1.096,1.893,1.467,P〈0.05）.In extended thyrodiectomy,exposure of recurrent laryngeal nerve during operation may reduce the risk of nerve injury（χ 2 =1.758,P〈 0.05）.In conservative surgery,the rates of nerve injury were not significantly different in patients with and without identification of the nerve during thyroidectomy（χ 2 =0.638,P〉0.05）.Multivariate analysis showed that repeat surgery and extended thyroidectomy were the independent predictors of recurrent laryngeal nerve injury.CONCLUSION It is safe for smaller benign goiter to leave some remnant tissue without exposure of recurrent laryngeal nerve during the thyroid surgery.Routine exposure of recurrent laryngeal nerve during thyroid surgery is beneficial for extended thyroidectomy.