ANATOMIE DER SCHILDDRÜSE

Transcription

1 terna Pioniere ANATOME DER SCHLDDRÜSE «PTFALLS 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 M. sternocleidomastoideus V. jugularis externa M. sternothyroideus M. sternohyoideus Caput sternale M. sternoclaidomastoideus Arcus venosus jugularis Plexus thyroideus impar V. jugularis externa

2 Basisanatomie Arterien N. laryngeus sup. R. externus A. carotis interna A. carotis externa 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 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 Kocher scher Kragenschnitt

3 M. sternocleidomastoideus Platysma Mobilisierung Haut- und Platysmalappen Oberflächliche Halsfaszie Mittlere Halsfaszie mit Venen Subcutis Platysma M. sternohyoideus (MHF) mit Venen Längsspalten der und der MHF in der Medianen M. sternothyreoideus (MHF) Subplatysmale Lappenbildung, Längsspaltung Quere Durchtrennung «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

4 Resektionsausmass Resektionsausmass Universitätsklinik Halle n=1555 «Kapseldissektion» «Kapseldissektion» MHF Präparation Capsula Propria SD NLR Grenzlamelle Parathyroidea A. thyroidea inf. N. laryngeus superior A. carotis ext. Obere Polgefässe Ramus ext. N. laryngeus sup. N. laryngeus inferior «Reccurens»

5 Reccurens Verlauf der NLR im Bezug zur TA rechts 15% 37% NLR hinter AT NLR vor AT links 26% 23% 9% NLR ant TA NLR post TA NLR betw TA or 25% 14% NLR zwischen AT Reccurens intraoperativ Neuromonitoring N. Vagus Darstellen, Stimulieren Stimulation NLR Reccurens «Nerves at risk» 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%

6 «Zuckerkandl» «Berry-Ligament» Enge anatomische Beziehungen TTT; i rn TTT; i rn 'kttttt D"C TD A FTTU.Sn1'TT rtirntn lln A1JiLKf"T AU1UJ. n A TD A FTTU.Sn1'TT 'kttttt D"C rtirntn lln A1JiLKf"T AU1UJ. n A illustrate two varieties of what may be called first type. of what may becalled illustrate two varieties first type.of posterior border lies along Here upper posterior liessomewhat along above Here upper of thyroid lateral lobe of border mid-point lower thyroid" poles somewhat lateral mid-point "; above lowerglandule lies between lobe upperof and " poles lower and lower lies between upper pole. t is glandule not unlikely thyroid margin or "; near lower t isoccurring not unlikely margin will or pole. nearthis particular lower thyroid be found most arrangement that be found occurring most arrangement will that this particular often in a large series of cases. n Fig. i, lower paraoften in a large series of cases. n Fig. i, lower para- «Berry-Ligament» Parathyroidea W. S. HALSTED AND H. M. EVANS tL.>tsrs. -r-. -tl.>tsrs. inferior thyroid, while upper one happens to be a branch of uppermost cesophageal ramus. Figs. 3 and 4 will illustrate a type but little removed THE PARATHYROD GLANDULES. ' 495 are from that just discussed, but one in which s of thyroid. Here unusual it is not find a relatively rar symmetrically disposed, one toabove, orlong below artery. thyroid poles. The condition shown mid-point between..s'al, ANNALS OF SURGERY VOL. XLV OCTOBER, 907 No. 4 ORGNAL MEMORS. BY WLLAM S. HALSTED, M.D., AND OF MODESTO, CAL. THE BLOOD SUPPLY OF THE HUMAN PARATHYROD GLANDULES. HERBERT M. EVANS. The vascular injections and studies herein reported were made to determine accurately exact source and position of blood supply to glands in man. Anor aim, that of knowing more of angiology of gland itself, was also served, but this subject will be reported separately at a later date. would here express my indebtedness to Professor Halsted at whose suggestion problem was undertaken, to Professor Mall in whose laboratory 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 found invaluable in execution of Plexus thyroideus drawings. 7 A. 14t., 14t.,fkifki.,., j.1 tltiza...--i.i.1.,z.. t1..,z..... OF BALTMORE, HERBERT M. EVANS, S.B., Arteria thyroidea inferior ' Various or modifications in exact plan of blood supply were found, but, in general, figures given illustrate chief conditions. THE PARATHYROD GLANDULES. THER BLOOD SUPPLY, AND THER PRESERVATON N OPERATON UPON THE THYROD GLAND. Nervus laryngeus reccurens. t,t, *a *a.sr - seen to to arise arise from from thyroidartery arteryisis seen prominent lateralbranch branch prominentlateral thyroid inferior thyroid artery which supplies most ofof outer inferior ofof thyroid artery which supplies most outer surface of lateral thyroid lobe. The upper of lateral lobe.anastomosing surface The upper channel fromthyroid bearises strong artery here beanastomosing channel arisesandfrom thyroid strongvessels artery upper along lower which courses tween here upper and lower along vesselsnwhich tween border of thyroid Fig. courses 2, lower posterior lateral lobe. borderfrom of onelateral Fig. 2, posterior of lobe. of little lateralnglandular ramilower artery comes little artery comes from one of lateral glandular rami of 489 ;;.;E.. O.W. r1 la A lif '91. F,- s-. 9 f''1. s- t is without purpose of this communication to follow behavior of artery after it enters 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 which ramify peripherally, givingthyroid, origin to which capil- in branch ofeventually same inferior from large This picture may besuperior seen beautifully in cleared communicated with this caselaries. thyroid artery. specimens of glandule and, it may be pointed out, is in n third type, shown in remaining two figures and 6), is depicted arrangement seen in those cases in (5 which lower gland is appreciably below lower margin Parathyroidea Gl. eae sup. Gl. eae inf. Realität

7 Realität Realität «Take Home» Quellen Lupenbrille Neuromonitoring (N. vagus) Darstellen Reccurens Kapseldissektion, Grenzlamelle Nervus laryngeus reccurens Parathyroideae Tuberculum Zuckerkandl Ligamentum Berry med-education.ch by mg