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terna
Pioniere
ANATOMIE
DER SCHILDDRÜSE
«PITFALLS AND PEARLS»
Martin Gerber, Spital Chur
Mai 2011
© by mg
made on a mac
Anatomie
Anatomie
Basisanatomie
Basisanatomie
R. colli n. facialis
V. jugularis
interna
Mandibula
A. laryngea sup.
N. hypoglossus
A. carotis comm.
Parotis
N. laryngeus sup.
M. thyrohyoideus
Platysma
Lamina superficialis
fasciae cervicalis
Lamina pretrachealis
fasciae cervicalis
V. jugularis externa
A. thyroidea sup.
M. sternocleidomastoideus
V. jugularis externa
M. sternothyroideus
M. sternohyoideus
Caput sternale
M. sternoclaidomastoideus
Arcus venosus jugularis
Plexus thyroideus impar
V. jugularis externa
Basisanatomie
Arterien
A. thyroidea sup.
N. laryngeus sup.
R. externus
A. carotis interna
A. carotis externa
A. thyroidea sup.
N. phrenicus
N. vagus
A. carotis comm.
Plexus brachialis
V. jugularis
interna
A. thyroidea inf.
Tr. thyrocervicalis
A. thyroidea inf.
A. subclavia
A. subclavia
V. subclavia
N. laryngeus inf.
Tr. brachiocephalicus
Plexus thyroideus impar
Aorta
Chirurgischer Zugang
Venen
V. facialis
V. jugularis int.
V. thyroidea sup.
V. thyroidea med.
Plexus thyroideus
impar
V. subclavia
V. brachiocephalica
V. thyroidea inf.
V. cava sup.
«Helferlein»
Ductus lymphaticus
Chirurgischer Zugang
Kocher‘scher Kragenschnitt
Chirurgischer Zugang
Chirurgischer Zugang
M. sternocleidomastoideus
Platysma
Mobilisierung
Haut- und Platysmalappen
Oberflächliche Halsfaszie
Mittlere Halsfaszie
OHF mit Venen
Subcutis
Platysma
M. sternohyoideus (MHF)
OHF mit Venen
Längsspalten der
OHF und der MHF
in der Medianen
M. sternothyreoideus (MHF)
Subplatysmale Lappenbildung, Längsspaltung
Quere Durchtrennung
Chirurgischer Zugang
«Pitfalls and Pearls»
Capsula Propria
der Schilddrüse
M. sternohyoideus (MHF)
M. sternothyreoideus (MHF)
V. jugularis int.
Capsula Propria der Schilddrüse
«Pitfalls and Pearls»
Resektionsausmass
Nervus laryngeus superior
Nervus laryngeus reccurens (inferior)
Tuberculum Zuckerkandl
Ligamentum Berry
Parathyroideae
Enukleation
Subtotale Resektion
Subtotal mit
Belassen des Oberpols
(Hemi) - Thyroidektomie
Resektionsausmass
Resektionsausmass
Universitätsklinik Halle 1995 - 2007 n=1555
OHF
OHF
«Kapseldissektion»
«Kapseldissektion»
OHF
MHF
Präparation
Capsula Propria SD
NLR
Grenzlamelle
Parathyroidea
A. thyroidea inf.
N. laryngeus superior
A. carotis ext.
A. thyroidea sup.
Obere Polgefässe
Ramus ext. N. laryngeus sup.
N. laryngeus inferior «Reccurens»
Reccurens
Verlauf der NLR im Bezug zur ITA
rechts
15%
37%
NLR hinter ATI
NLR vor ATI
links
26%
23%
9%
NLR ant ITA
NLR post ITA
NLR betw ITA
other
25%
14%
NLR zwischen ATI
Reccurens intraoperativ
Neuromonitoring
N. Vagus
Darstellen, Stimulieren
Stimulation NLR
OHF
Reccurens
«Nerves at risk» 120‘000
Recurrensparese ohne Darstellung 3.5%
Recurrensparese mit Darstellung 1.01%
«High volume surgeon» (50 Eingriffe / Jahr): deutlich < 1%
«Low volume surgeon»: 1-4%
«Zuckerkandl»
52%
OHF
OHF
«Zuckerkandl»
«Berry-Ligament»
Enge anatomische Beziehungen
ITTT;
i rn
ITTT;
i rn
'kTTTTT D"C
TD A FTTU.Sn1'TT
rtirntn
lln
A1JiLKf"T AU1IUJ.
In A TD A FTTU.Sn1'TT
'kTTTTT D"C
rtirntn lln
A1JiLKf"T AU1IUJ.
In A
493
493
illustrate two varieties of what may be called the first type.
of what
may bethecalled
illustrate
two varieties
the first
type.of
posterior
border
parathyroid
lies along
Here
the upper
posterior
liessomewhat
along the above
Here
the upper
of
the thyroid
the
lateral
lobe ofparathyroid
theborder
mid-point
the lower
thyroid" poles
somewhat
the lateral
mid-point
"; theabove
lowertheglandule
lies
between
the lobe
upperof and
OHF
" poles
the lower
and lower
lies
between
upper
pole.
It is glandule
not unlikely
thyroid
margin
or ";
near
the the
lower
It isoccurring
not unlikely
margin will
or pole.
nearthis
theparticular
lower thyroid
be found
most
arrangement
that
be
found
occurring
most
arrangement
will
that
this
particular
often in a large series of cases. In Fig. i, the lower paraoften in a large series of cases. In Fig. i, the lower para-
OHF
«Berry-Ligament»
Parathyroidea
W. S. HALSTED AND H. M. EVANS.
44 494tL.>tsrs.
-r-.
-tL.>tsrs.
the inferior thyroid, while the upper one happens to be a branch
of the uppermost cesophageal ramus.
Figs. 3 and 4 will illustrate a type but little removed
THE PARATHYROID GLANDULES.
'
495 are
from that just discussed,
but one in which
the parathyroids
of the thyroid. Here
unusual
it is notthe
find a relatively
rather symmetrically
disposed,
one toabove,
the otherlong
below
parathyroid
artery.the thyroid poles. The condition shown
the mid-point
between
..s'Al,
ANNALS OF SURGERY
VOL. XLVI
OCTOBER, I907
No. 4
ORIGINAL MEMOIRS.
BY WILLIAM S. HALSTED, M.D.,
AND
OF MODESTO, CAL.
THE BLOOD SUPPLY OF THE HUMAN PARATHYROID
GLANDULES. HERBERT M. EVANS. The vascular injections
and studies herein reported were made to determine accurately
the exact source and position of the blood supply to the parathyroid glands in man. Another aim, that of knowing more
of the angiology of the parathyroid gland itself, was also
served, but this subject will be reported separately at a later
date. I would here express my indebtedness to Professor Halsted at whose suggestion the problem was undertaken, to Professor Mall in whose laboratory the injections were made, to
Professor W. G. MacCallum, Dr. H. E. Helmholz and espe;.
cially Dr. Marshall Fabyan who have kindly given me many
opportunities to secure fresh human material, and to Mr.
Broedel whose advice I found invaluable in the execution of the
Plexus thyroideus
drawings.
I7
A. 14t.,
14t.,fkifki., .,
j.1 tLtizA...I-I-i.i.1.,Z..
t1.
.,Z..
......
OF BALTIMORE,
HERBERT M. EVANS, S.B.,
Arteria thyroidea inferior
'
Various other modifications in the exact plan of blood
supply were found, but, in general, the figures given illustrate
the chief conditions.
THE PARATHYROID GLANDULES. THEIR BLOOD
SUPPLY, AND THEIR PRESERVATION IN OPERATION UPON THE THYROID GLAND.
Nervus laryngeus reccurens
.
t,t,II
I
I
I
*a
*a
I
.sr
-
seen to
to arise
arise from
from the
thyroidartery
arteryisis seen
the prominent
lateralbranch
branch
prominentlateral
thyroid
inferior thyroid artery which supplies most ofofthe outer
theinferior
ofof
the
thyroid artery which supplies most the outer
surface of the lateral thyroid lobe. The upper parathyroid
of the
lateral
lobe.anastomosing
surface
The upper channel
parathyroid
fromthyroid
bearises
the strong
artery here
beanastomosing
channel
arisesandfrom
thethyroid
strongvessels
artery
the upper
along
lower
which courses
tween here
the upper
and lower
along
vesselsInwhich
tween
border
of thethyroid
Fig. courses
2, the lower
the posterior
lateral lobe.
borderfrom
of theonelateral
Fig. 2, the
the
posterior
of thelobe.
of
little
lateralInglandular
ramilower
artery comes
little artery comes from one of the lateral glandular rami of
489
;;.;E.
.I
O.W.
r1
la
A
lif '91.
F,- s-.
9
f''1. s-
It is without the purpose of this communication to follow
the behavior of the parathyroid artery after it enters the glandular hilus, but it may be said here that, in general, this vessel
a central course,
off obliquely
directedvessels
since giving
here both
branchescame
in Fig. pursues
4 is interesting
parathyroid
which
ramify
peripherally,
givingthyroid,
origin to which
capil- in
branch ofeventually
same
the inferior
from the
large
This picture
may
besuperior
seen beautifully in cleared
the
communicated
with
this caselaries.
thyroid
artery.
specimens of the glandule and, it may be pointed out, is in
In the third type, shown in the remaining two figures
and 6), is depicted the arrangement seen in those cases in
(5OHF
which the lower gland is appreciably below the lower margin
OHF
Parathyroidea
Gl. parathyroideae sup.
Gl. parathyroideae inf.
Realität
OHF
OHF
Realität
Realität
OHF
«Take Home»
Quellen
Lupenbrille
Neuromonitoring (N. vagus)
Darstellen Reccurens
Kapseldissektion, Grenzlamelle
Nervus laryngeus reccurens
Parathyroideae
Tuberculum Zuckerkandl
Ligamentum Berry
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