微创外科在狗颈廓清术中的应用
【摘要】目的于动物实验中探讨微创外科在狗的颈廓清手术中应用的可行性。方法选取6只条件基本相同的杂狗，以3%戊巴比妥钠(300mg/kg体重)施行静脉麻醉，取侧颈中部30mm长的横型切口，游离颈皮肌皮瓣后，置入两把常规小拉钩拉开皮瓣，置入0°4mm鼻窦内镜为照明光源，在直视或电视介导下用常规外科器械实施颈廓清联合颌下腺、甲状腺和半喉软骨切除手术。 结果 分别对6只狗的左或右侧颈实施了改良性颈廓清加颌下腺、甲状腺和半喉软骨切除手术，术中耗时(2±0.5)h，出血量为(50±30)ml，术中无伤口感染、皮下积血、积气、死亡等并发症发生。2～3天后所有狗进食、活动恢复正常，1周后伤口完全愈合。 结论 在电视介导的鼻窦内镜下以常规外科器械通过一小切口对狗实施颈廓清术而达到了微创外科目的，此技术值得进一步在临床头颈外科的颈廓清手术中试运用。
关键词 微创外科 颈廓清 狗
Radical neck dissection in dogs with minimally invasive surgery
Yi Huiming，Kuang Guangyi，Bai Dianqing，et al.
Department of Otolaryngology-Head and Neck Surgery，Hainan ProvincialPeople's Hospital，Haikou570311.
【Abstract】 Objective To investigate the possibility of minimally invasive surgery applied in the neck dissection by animal experiment of dogs.Methods Six immunized health adult mongrel dogs were chooses.Anesthesia was main-tained with3%thiopental sodium by i.v.A30mm horizontal skin incision was performed in the middle area of lateral neck.After the musculus cutaneus colli(MCC)were divided，two small conventional retractors were inserted to retract the strap muscles and a0°4mm sinus endoscope was inserted as light source.Modified radical neck dissection was per-formed with conventional instruments on direct visual or by video-assisted.Results Left or right modified radical neck dissection plus excision of submandibular salivary，thyroid lobe and half-thyroid cartilage were performed with conven-tional instruments on six dogs separately.The operating time was2±0.5hours.The operative bleeding volume was50±30ml.No complication such as wound infected，subcutaneous edema，wizened，death etc.occurred.All dogs take food and activity as usual2～3days later.The wound was recovered completely one week later.Conclusion Under video-assisted sinus endoscope，we can perform dog's neck dissection just by using conventional instrumentation through a small incision for the goal of minimally invasive surgery.It's worth to be applied in the neck dissection of clinical head and neck surgery.
Key words minimally invasive surgery radical neck dissection dogs
Kelling play a vanguard role in minimally invasive surgery since he examed the dog's abdominal cavity with an endoscope in1902.The development of video-assist-ed endoscopy improved the minimally invasive surgery to a new grade in1986.The success of endoscopic parathy-roidectomy by Gagner [1] in1996and endoscopic thyroid lobectomy by Hüscher [2] in1997make the gradually de-velopment of minimally invasive surgery in head and neck area.However there was still no report of minimally inv- asive surgery applied in radical neck dissection.So we would like to prove the possibility of this kind of operation in animal experiment.
1 Material
1.1 Animal Six immunized health adult mongrel dogs.1.2 Instruments (1)Type BDJ-E4mm0°sinus en-doscope(Hangzhou，China).(2)Type4210.001WOLF light source.(3)Type8061.453WOLF optic fibric cable.(4)Conventional instruments for head and neck surgery. 2 The anatomy of dog
2.1 Muscles The subcutaneous muscle of dog's neck anterior is musculus cutaneus colli(MCC)，this strap muscle is very easy to divided.The main muscle of dog's neck anterior are musculus sterno-cephalicus(MSC)，musculus sterno-hyoideus(MSH)，musculus sterno-thyroideus(MST)etc.
2.2 Arteries the main arteries are common carotid art-ery(CCA)and it's branches such as posterior thyroid artery，pharynx artery，anterior thyroid artery，larynx artery，muscle artery，trachea artery and submaxillary artery etc.
2.3 Vein The main vein of the dog's neck is external jugular vein(EJV)which combined by internal and exter-nal maxillary vein behind the submandibular gland.There is a horizontal transfer branch connect the left and right EJV below the thyroid cartilage.The EJV is just cover by MCC and go down along the superficial of MSC and dig in the depth of clavicle and connect with internal jugular vein(IJV)to be the common jugular vein.IJV is com-bined by cerebral ventrolateral vein，occipital vein，pha-ryngeal vein and thyroid vein etc.and in company withCCA.
2.4 Lymph nodes Most dogs only have2submandibu-lar lymph nodes.There is no lymph node in the anterior and middle part of neck.The lymph trunk is in company with IJV.
2.5 Nerves The important nerves are vagus，sympa-thetic nerve(SN)，and recurrent nerve(RN).Vagus combined with SV go down in company with CCA.RN isbeside the trachea.
3 Operative procedure
All dogs，under anesthesia by3%thiopental sodi-um，were placed in a side sleep position，regular poodle，sterilized，draped of the operative region of neck.A30mm horizontal skin incision was performed in the mid-dle-lateral part of neck，just around the across point of MSC with MSH.After cleft the MCC，two small conven-tional retractors were inserted to elevate the strap muscles and a0°4mm sinus endoscope was inserted as light source.On direct visual or by video-assisted，we per-formed the operations with conventional instruments.Dis-section under the MCC from the mandible inferior to the clavicle superior and from the midline anterior to the post bound of MSC posterior.EJV was exposed and preserved whole way.Dissect and remove the muscle membrane of MSC and MSH below the mandible and downward till the clavicle superior with the fat tissue around the CCA.In the way above dissect and take out the submandibular gland with the lymph nodes below it，half thyroid cartilage and a thyroid lobe etc.Exposed and preserved the impor-tant organs CCV，IJV，Vagus，SN and RN etc.After clean the wound cavity and stop bleeding by diathermy or ligature，suture the MCC with the MSC and MSH to de-crease dead cavity for avoid the subcutaneous fluidify postoperative.Close the skin by discontinuous suture.Fluid5%G.N.S500ml with antibiotics PG-Na4.5million unit and Gentamycin160thousand unit was given in the operation and no more antibiotics needed postopera-tive.
4 Results
Left or right modified radical neck dissection was performed plus resection of one side of the submandibular gland with the lymph nodes below it，half thyroid cartilage and a thyroid lobe(all specimens were certified by pathology check)on six dogs from Nov.15，2002to Dec.18，2002.The operating time was2±0.5hours.The operative bleeding volume was50±30ml.No complica-tion such as wound infected，subcutaneous edema，wiz-ened，death etc.occurred.All dogs took food and activi-ty as usual2～3days later.The wound was recovered
completely one week later.
5 Discussion
The specialist of head and neck surgery are gradually interesting in the application of the technique of minimally invasive surgery in the operation of head and neck to avoid the big ugly scar postoperative.But there are still exist some question need to be solved:(1)Surgeons relat-ed to the minimally invasive surgery have to accept the strictly training preoperative.Ordinary surgeon can not hand this skills flexible [3] .(2)Special and expensive min-imally invasive instrumentation was needed in the opera-tion so the operative charge is very high.(3)Carbon diox-ide neck insufflation was needed for the enough space to perform the operation and may cause hypercapnia，respi-ratory acidosis，supraventricular tachycardia，venous gas embolism，and massive subcutaneous emphysema [4] .(4)Conversion to an extension of incision may be required and the possibility of recurrent laryngeal nerve hurt is high [5] .(5)Four scar in the neck and upper chest is also ugly and not only its whole length is near30mm but also the sm all incision is very difficulty to take out the big tis-sue such as tumor or thyroid [1] etc.(6)The operating times are longer than usual which increased the rate of “Surgical fatigue syndrome” [3] .
Therefore，for the goal of“minimally invasive”，we try to reform partial skills of minimally invasive surgery technique in the experiments and receive some experience below:(1)We only take one small30mm incision in the middle-lateral part of dog's neck and most operating field can directly exposing in visual through this small in-cision cause the dog's neck skin is loosely.This30mm incision is big enough to take out most specimens such as thyroid gland，submandibular gland and neck dissection specimen.The technique is feasible and safe，no compli-cation occurred.(2)Using the small conventional retractor to elevate the strap muscles can make enough space for the performance，it's totally avoid the series syndromes of carbon dioxide neck insufflation.(3)There are all conven-tional instrumentations except the sinus endoscope and the bleeding be stop by diathermy or ligature，so the operat-ing charge is lower.(4)Ordinary head and neck surgeons can perform this kind of operations if only have the expe-riences of sin us endoscopy and neck dissection，and do not need special minimally invasive technique training preoperative.(5)This operation is some how like conven-tional radical neck dissection and less time consuming.It not only be propitious to the operative acceptor，but also may decrease the possibility of“Surgical fatigue syn-drome”.
In conclusion，the animal research of“minimally in-vasive surgery applied in the dog's modified radical neck dissection”has achieved the satisfactory effects of small incision，clearly operating field，few bleeding，less time-consuming，feasible and safe，less complication，lower medical charge，fast recover and cosmetic result etc.The success of this research proved that for the goal of mini-mally invasive surgery the ordinary head and neck surgeon could perform dog's radical neck dissection just by using both video-assisted sinus endoscope and conventional in-strumentation through a small incision in the middle-lat-eral part of dog's neck.It's worth to be applied in the radical neck dissection of clinical head and neck surgery.
参考文献
1 GagnerM.Endoscopic subtotal parathyroidectomy in patients with primaryhyperparathyroidism.Br J Surg，1996，83:875.
2 Hüscher CSG，Chiodini S，Napolitano C，et al.Endoscopic right thyroid lobectomy.Surg Endosc，1997，11:877.
3 Gallagher AG，Richie K，McClure N，et al.Objective psychomotor skills assessment of experienced，junior，and novice laparoscopists with virtual reality.World J Surg，2001，25:1478.
4 Gottlieb A，Sprung J，Zhang XM，et al.Massive subcutaneous emphyse-ma and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation.Anesth Analg，1997，84:1154.
5 Gauger PG，Reeve TS，Delbridge LW.Endoscopically assisted，mini-mally invasive parathyroidectomy.Br J Surg，1999，86:1563.
作者单位:570311海口海南省人民医院耳鼻咽喉-头颈外科
(编辑克 俭), http://www.100md.com(易慧明 况光仪 白殿卿 许晨耘 赵质斌 魏 欣 龚选举 符志龙)
关键词 微创外科 颈廓清 狗
Radical neck dissection in dogs with minimally invasive surgery
Yi Huiming，Kuang Guangyi，Bai Dianqing，et al.
Department of Otolaryngology-Head and Neck Surgery，Hainan ProvincialPeople's Hospital，Haikou570311.
【Abstract】 Objective To investigate the possibility of minimally invasive surgery applied in the neck dissection by animal experiment of dogs.Methods Six immunized health adult mongrel dogs were chooses.Anesthesia was main-tained with3%thiopental sodium by i.v.A30mm horizontal skin incision was performed in the middle area of lateral neck.After the musculus cutaneus colli(MCC)were divided，two small conventional retractors were inserted to retract the strap muscles and a0°4mm sinus endoscope was inserted as light source.Modified radical neck dissection was per-formed with conventional instruments on direct visual or by video-assisted.Results Left or right modified radical neck dissection plus excision of submandibular salivary，thyroid lobe and half-thyroid cartilage were performed with conven-tional instruments on six dogs separately.The operating time was2±0.5hours.The operative bleeding volume was50±30ml.No complication such as wound infected，subcutaneous edema，wizened，death etc.occurred.All dogs take food and activity as usual2～3days later.The wound was recovered completely one week later.Conclusion Under video-assisted sinus endoscope，we can perform dog's neck dissection just by using conventional instrumentation through a small incision for the goal of minimally invasive surgery.It's worth to be applied in the neck dissection of clinical head and neck surgery.
Key words minimally invasive surgery radical neck dissection dogs
Kelling play a vanguard role in minimally invasive surgery since he examed the dog's abdominal cavity with an endoscope in1902.The development of video-assist-ed endoscopy improved the minimally invasive surgery to a new grade in1986.The success of endoscopic parathy-roidectomy by Gagner [1] in1996and endoscopic thyroid lobectomy by Hüscher [2] in1997make the gradually de-velopment of minimally invasive surgery in head and neck area.However there was still no report of minimally inv- asive surgery applied in radical neck dissection.So we would like to prove the possibility of this kind of operation in animal experiment.
1 Material
1.1 Animal Six immunized health adult mongrel dogs.1.2 Instruments (1)Type BDJ-E4mm0°sinus en-doscope(Hangzhou，China).(2)Type4210.001WOLF light source.(3)Type8061.453WOLF optic fibric cable.(4)Conventional instruments for head and neck surgery. 2 The anatomy of dog
2.1 Muscles The subcutaneous muscle of dog's neck anterior is musculus cutaneus colli(MCC)，this strap muscle is very easy to divided.The main muscle of dog's neck anterior are musculus sterno-cephalicus(MSC)，musculus sterno-hyoideus(MSH)，musculus sterno-thyroideus(MST)etc.
2.2 Arteries the main arteries are common carotid art-ery(CCA)and it's branches such as posterior thyroid artery，pharynx artery，anterior thyroid artery，larynx artery，muscle artery，trachea artery and submaxillary artery etc.
2.3 Vein The main vein of the dog's neck is external jugular vein(EJV)which combined by internal and exter-nal maxillary vein behind the submandibular gland.There is a horizontal transfer branch connect the left and right EJV below the thyroid cartilage.The EJV is just cover by MCC and go down along the superficial of MSC and dig in the depth of clavicle and connect with internal jugular vein(IJV)to be the common jugular vein.IJV is com-bined by cerebral ventrolateral vein，occipital vein，pha-ryngeal vein and thyroid vein etc.and in company withCCA.
2.4 Lymph nodes Most dogs only have2submandibu-lar lymph nodes.There is no lymph node in the anterior and middle part of neck.The lymph trunk is in company with IJV.
2.5 Nerves The important nerves are vagus，sympa-thetic nerve(SN)，and recurrent nerve(RN).Vagus combined with SV go down in company with CCA.RN isbeside the trachea.
3 Operative procedure
All dogs，under anesthesia by3%thiopental sodi-um，were placed in a side sleep position，regular poodle，sterilized，draped of the operative region of neck.A30mm horizontal skin incision was performed in the mid-dle-lateral part of neck，just around the across point of MSC with MSH.After cleft the MCC，two small conven-tional retractors were inserted to elevate the strap muscles and a0°4mm sinus endoscope was inserted as light source.On direct visual or by video-assisted，we per-formed the operations with conventional instruments.Dis-section under the MCC from the mandible inferior to the clavicle superior and from the midline anterior to the post bound of MSC posterior.EJV was exposed and preserved whole way.Dissect and remove the muscle membrane of MSC and MSH below the mandible and downward till the clavicle superior with the fat tissue around the CCA.In the way above dissect and take out the submandibular gland with the lymph nodes below it，half thyroid cartilage and a thyroid lobe etc.Exposed and preserved the impor-tant organs CCV，IJV，Vagus，SN and RN etc.After clean the wound cavity and stop bleeding by diathermy or ligature，suture the MCC with the MSC and MSH to de-crease dead cavity for avoid the subcutaneous fluidify postoperative.Close the skin by discontinuous suture.Fluid5%G.N.S500ml with antibiotics PG-Na4.5million unit and Gentamycin160thousand unit was given in the operation and no more antibiotics needed postopera-tive.
4 Results
Left or right modified radical neck dissection was performed plus resection of one side of the submandibular gland with the lymph nodes below it，half thyroid cartilage and a thyroid lobe(all specimens were certified by pathology check)on six dogs from Nov.15，2002to Dec.18，2002.The operating time was2±0.5hours.The operative bleeding volume was50±30ml.No complica-tion such as wound infected，subcutaneous edema，wiz-ened，death etc.occurred.All dogs took food and activi-ty as usual2～3days later.The wound was recovered
completely one week later.
5 Discussion
The specialist of head and neck surgery are gradually interesting in the application of the technique of minimally invasive surgery in the operation of head and neck to avoid the big ugly scar postoperative.But there are still exist some question need to be solved:(1)Surgeons relat-ed to the minimally invasive surgery have to accept the strictly training preoperative.Ordinary surgeon can not hand this skills flexible [3] .(2)Special and expensive min-imally invasive instrumentation was needed in the opera-tion so the operative charge is very high.(3)Carbon diox-ide neck insufflation was needed for the enough space to perform the operation and may cause hypercapnia，respi-ratory acidosis，supraventricular tachycardia，venous gas embolism，and massive subcutaneous emphysema [4] .(4)Conversion to an extension of incision may be required and the possibility of recurrent laryngeal nerve hurt is high [5] .(5)Four scar in the neck and upper chest is also ugly and not only its whole length is near30mm but also the sm all incision is very difficulty to take out the big tis-sue such as tumor or thyroid [1] etc.(6)The operating times are longer than usual which increased the rate of “Surgical fatigue syndrome” [3] .
Therefore，for the goal of“minimally invasive”，we try to reform partial skills of minimally invasive surgery technique in the experiments and receive some experience below:(1)We only take one small30mm incision in the middle-lateral part of dog's neck and most operating field can directly exposing in visual through this small in-cision cause the dog's neck skin is loosely.This30mm incision is big enough to take out most specimens such as thyroid gland，submandibular gland and neck dissection specimen.The technique is feasible and safe，no compli-cation occurred.(2)Using the small conventional retractor to elevate the strap muscles can make enough space for the performance，it's totally avoid the series syndromes of carbon dioxide neck insufflation.(3)There are all conven-tional instrumentations except the sinus endoscope and the bleeding be stop by diathermy or ligature，so the operat-ing charge is lower.(4)Ordinary head and neck surgeons can perform this kind of operations if only have the expe-riences of sin us endoscopy and neck dissection，and do not need special minimally invasive technique training preoperative.(5)This operation is some how like conven-tional radical neck dissection and less time consuming.It not only be propitious to the operative acceptor，but also may decrease the possibility of“Surgical fatigue syn-drome”.
In conclusion，the animal research of“minimally in-vasive surgery applied in the dog's modified radical neck dissection”has achieved the satisfactory effects of small incision，clearly operating field，few bleeding，less time-consuming，feasible and safe，less complication，lower medical charge，fast recover and cosmetic result etc.The success of this research proved that for the goal of mini-mally invasive surgery the ordinary head and neck surgeon could perform dog's radical neck dissection just by using both video-assisted sinus endoscope and conventional in-strumentation through a small incision in the middle-lat-eral part of dog's neck.It's worth to be applied in the radical neck dissection of clinical head and neck surgery.
参考文献
1 GagnerM.Endoscopic subtotal parathyroidectomy in patients with primaryhyperparathyroidism.Br J Surg，1996，83:875.
2 Hüscher CSG，Chiodini S，Napolitano C，et al.Endoscopic right thyroid lobectomy.Surg Endosc，1997，11:877.
3 Gallagher AG，Richie K，McClure N，et al.Objective psychomotor skills assessment of experienced，junior，and novice laparoscopists with virtual reality.World J Surg，2001，25:1478.
4 Gottlieb A，Sprung J，Zhang XM，et al.Massive subcutaneous emphyse-ma and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation.Anesth Analg，1997，84:1154.
5 Gauger PG，Reeve TS，Delbridge LW.Endoscopically assisted，mini-mally invasive parathyroidectomy.Br J Surg，1999，86:1563.
作者单位:570311海口海南省人民医院耳鼻咽喉-头颈外科
(编辑克 俭), http://www.100md.com(易慧明 况光仪 白殿卿 许晨耘 赵质斌 魏 欣 龚选举 符志龙)