改良喉裂开术

【摘要】目的减少喉裂开术的损伤,减轻患者的痛苦,满足患者的美容要求。方法选择喉裂开手术适应证的患者16例,局麻后环甲膜处正中沿皮纹横切开至双侧胸锁乳突肌前缘,分离带状肌、暴露环甲膜、切开环甲膜置入气管插管行全麻,以后按裂开术式手术,手术结束后于环甲膜置入8 mm气管套管,不再行气管切开。观察术后2 d患者呼吸情况及术后6~12个月术区及环甲膜处的黏膜情况。结果16例手术患者于术后2 d拔除气管套管、缝合伤口、无呼吸困难。6个月至12个月行电子喉镜检查、术区及环甲膜光滑,外观颈部切开缝合处不明显。结论单一横切口行喉裂开术。减少了对患者的损伤和痛苦,有满足了患者的美容需求。

【关键词】

喉裂开术;改良

【Abstract】ObjectiveTo reduce the impairment and the pain of the patients after the laryngofission and make the outlook of the cervical part more concinnous through the modifid laryngofission.MethodsFirst,we selected 16 patients who had indications of laryngofission.Second,we made the transversal incision along the dermal ridge of cervical part from the center of the cricothyroid membrane to the anterior border of both sternocleidomastoids,divided strap muscles,exposed and incided cricothyroid membrane in local anesthesia,then performed the general anesthesia by tracheal intubation instead of tracheotomy.Third,we operated on the patient as the laryngofission,we inserted the trachea cannula with the diametre of 8 mm into the incision of cricothyroid membrane when the surgery was over.Fianally,we observed the state of respiration during two days and whether cricothyroid membrane was injured or not during 6 to 12 months postoperationally.ResultsThe dyspnea wasn’t occurred in 16 patients during 2 days and we observed that the mucous membrane of the operative region and cricothyroid membrane was smooth through electronic-laryngoscope and the incision didn’t attract more attention during 6 to 12 months postoperationally.ConclusionThe modifid laryngofission maybe reduce the impairment and the pain of patients and make the operative incision more concinnous.

【Key words】

Laryngofission;Modified

目前由于激光外科的发展,在大型医院行喉裂开术的患者已减少,但由于器械设备的要求以及其局限性和风险性[1],许多医院尚不能开展喉激光外科手术,喉裂开术也不能完全由激光外科所代替,目前仍是一些医院治疗喉部疾病的重要术式。但是经典的喉裂开术由于需行气管切开、造成患者的创伤及痛苦增大,我们应用改良的手术横切口行喉裂开术,不再行气管切开术,改用必需切开的环甲膜置管,减少了一个手术,达到了同样治疗的目的,又满足了患者的美容要求。现报告如下。

1资料与方法

1.1一般资料声门型喉癌12例(T1a-T2CNOMO),声带内翻性状瘤癌变3例,声带内翻性状瘤上皮内病变Ⅲ级1例(复发性),年龄48~78岁,平均63岁。男14例,女2例。

1.2方法患者肩下垫枕平卧位于手术台,常规消毒、铺巾、局麻下于环甲膜处沿皮纹横切口,至胸锁乳突肌前缘,于颈阔肌深面游离皮瓣,沿正中线分离带状肌,暴露环甲膜横行切开,置入气管插管,行全麻,牵引颈阔肌皮瓣,向上沿中线分离带状肌,暴露喉前部软骨支架,按照术前电子喉镜及CT检查正中或偏向健侧裂开甲状软骨板,于距病变0.5 cm处切除病变,游离术区上下喉腔内黏膜、室带,缝合修复术区缺损,关闭喉腔,缝合伤口,患者清醒后拔除气管插管,置入8 mm金属套管,术后第1天试堵管。第2天拔出套管,缝合伤口。

2结果

全部患者术后6个月~12个月随访,行电子喉镜检查,术区光滑、声门下伤口愈合较好,无瘢痕增生及复发,无环状软骨损伤及喉狭窄,颈部切口由于和皮纹一致不明显。

3讨论

喉裂开术是治疗喉部疾病的一个经典术式,随着喉激光外科手术的开展,喉裂开手术的患者已减少。但是很大一部分医院还没有耦合到显微镜上的激光设备。因此,喉激光外科手术尚不能在各级医院广泛开展,另外由于喉激光外科手术的局限性、危险性、以及喉裂开术有激光外科不可替代的术野宽畅、清晰的优点。喉裂开术尚不能废弃、经典的喉裂开术需行气管切开[2],较患者多了一个手术,加大了患者的创伤,气管切开的目的主要是全麻和预防术后喉阻塞。我们采用环甲膜切开置管全麻和术后环甲膜置入8 mm气管套管。其通气面积达50 mm2,明显大于引起呼吸困难通气面积38 mm2[3],足可保证术后患者的正常呼吸,不会出现喉阻塞,由于套管直径小,置管时间短小于48 h[4],对环状软骨基本无影响,术后患者术区外观无明显瘢痕,又有美容作用,同时由于减少了一个手术,又节约了手术时间,减少了患者的治疗费用,实是一个良好的改良方法。

参考文献

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[3]黄益灯,郑宏良,周水淼,等.双侧声带麻痹不同术式治疗前后声门测量及噪音评价.中华耳鼻咽喉头颈外科杂志,2009,41:652.

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