Die totalendoskopische Schilddrüsenresektion in der ABBA-Technik: Anmerkungen zur Integrierung des intraoperativen Neuromonitorings in die Operationsmethode

 

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Zusammenfassung

Einleitung: Totalendoskopische Resektionen der Schilddrüse, die auf eine Schnittführung am Hals vollständig verzichten, stellen für den Chirurgen eine besondere Herausforderung dar. Klinische Erfahrungen in der Anwendung des intraoperativen Neuromonitorings (IONM) in der ABBA-Technik (axillo-bilateral-breast-approach) liegen bisher nicht vor.

Methodik: 29 weibliche Patienten (~ 40 Jahre) wurden wegen eines einseitigen Schilddrüsenbefundes in der ABBA-Technik operiert (20 subtotale Resektionen, 9 Hemithyreoidektomien). Befunde mit Malignomverdacht, einem Volumen > 35 ml, einer doppelseitigen Thyreoiditis, doppelseitige Knotenbefunde und Rezidive wurden ausgeschlossen. Die Stimulation erfolgte mit einer 30 cm langen bipolaren Handsonde, die Ableitung über eine auf Höhe des Stimmbands platzierte Tubusklebeelektrode (ISIS; Fa. Inomed, Emmendingen, Deutschland).

Ergebnisse: Die durchschnittliche Operationszeit betrug 132 Minuten. Eine Konversion war notwendig wegen einer venösen Blutung. Die direkte Stimulation des N. laryngeus recurrens war in allen Fällen möglich. Bei einer Tubuselektrodendislokation wurde perkutan die bipolare Nadelelektrode angewendet. Ein Signalausfall während des Eingriffs bestätigte sich postoperativ als passagere Stimmbandparese, die sich innerhalb von 6 Monaten zurückbildete. Eine passagere, lagerungsbedingte Armplexusirritation erholte sich innerhalb von 2 Tagen nach der Operation.

Schlussfolgerung: Das direkte Neuromonitoring zur Identifikation des N. laryngeus recurrens lässt sich in der totalendoskopischen ABBA-Technik methodisch in den Ablauf der Präparation und die Operationstaktik integrieren. Die in der offenen Schilddrüsenchirurgie geforderte Vagusstimulation lässt sich (noch) nicht konsequent umsetzen. Die Risiken einer unbemerkten Dislokation der Tubuselektrode oder einer doppelseitigen Parese bei beidseitigen Eingriffen bestehen.

Abstract

Background: Total endoscopic thyroid resections without any scars on the neck are a special challenge for the surgeon. Clinical results of intraoperative neuromonitoring (IONM) in the axillo-bilateral-breast-approach (ABBA) have not been described so far.

Methods: 29 female patients (~ 40 years) were operated for one-sided thyroid pathology using the ABBA technique (20 subtotal resections, 9 hemithyroidectomies). Suspected malignoma, size > 35 mL, known thyroiditis and recurrencies were excluded. For stimulation a 30-cm handprobe and for signal deviation a tube adhesive electrode (ISIS; Fa. Inomed, Emmendingen, Germany) were used.

Results: The average operation time was 132 minutes. Intraoperative blood loss necessitated conversion to the open procedure in 1 case. A single tube electrode dislocation occurred. In the alternative a bipolar needle electrode was inserted percutaneously through the cricothyroid ligament. One intraoperative signal loss was confirmed by the laryngoscopic finding of vocal cord paresis, which recovered within 6 months. An additional case of incomplete brachial plexus paralysis was observed with a 2-day recovery time.

Conclusion: Direct neuromonitoring of the recurrent laryngeal nerve can be easily applied in the total endoscopic ABBA technique for thyroid resection. Vagal stimulation, which is obligatory in open thyroid surgery, cannot consequently be included in this endoscopic operation method. Unexpected tube electrode dislocation may cause IONM misinterpretation. A risk of double-sided vocal cord palsy is theoretically present.

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