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Anatomie şi tehnici chirurgicale Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341] Imposibilitatea identificării nervului din partea dreaptă folosind criteriile menţionate mai sus atrage atenţia asupra unui eventual nerv nerecurent. Disecţia în imediata vecinătate a capsulei tiroidiene şi aplicarea ligaturilor numai pe elementele vasculare care intră în parenchimul tiroidian (inclusiv în cazul vaselor din pediculul tiroidian superior) previn lezarea nervului. Nervul nerecurent poate avea un traiect descendent, în vecinătatea pediculului tiroidian superior, un traiect transversal sau chiar un traiect ascendent, în vecinătatea arterei tiroidiene inferioare. Toniato relatează un caz în care nervul laringeu inferior nerecurent era asociat cu o modificare a poziţiei vagului. Nervul vag (situat în mod obişnuit între artera carotidă internă şi vena jugulară internă) era la un pacient cu nerv laringeu inferior nerecurent cel mai medial element al mănunchiului vasculo-nervos cervical[5]. Nervul vag situat medial de artera carotidă internă ar putea deci sugera existenţa unui nerv cu traiect nerecurent. Din păcate observaţia este singulară. CONCLUZIE Pentru o chirurgie sigură a glandei tiroide chirurgul trebuie să ţină seama de reperele anatomice consacrate şi de existenţa variantelor anatomice. BIBLIOGRAFIE 1. Stewart WB, Rizzolo LJ. Embryology and surgical anatomy of the thyroid and parathyroid glands. In Oertli D, Udelsman R, eds. Surgery of the thyroid and parathyroid glands. Berlin Heidelberg NewYork, Springer; 2007; p. 13-20. 2. Pelizzo MR., Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg 1998; 187(3): 333-336. 3. Yun JS, Lee YS, Jung JJ, Nam KH, Chung WY, Chang HS et al. The Zuckerkandl's tubercle: a useful anatomical landmark for detecting both the recurrent laryngeal nerve and the superior parathyroid during thyroid surgery. Endocr J 2008; 55(5): 925-930. 4. Sadler TW. Lagman's Medical Embryology. 11 ed. Philadelphia, Lippincott Williams & Wilkins, 2009. 5. Toniato A, Merante Boschin I, Pagetta C, Casalide E, Pelizzo MR. A "pilot light" of the right non-recurrent laryngeal nerve. Acta Otorhinolaryngol Ital 2010; 30: 107-109. 6. Delbridge L. Total thyroidectomy: the evolution of surgical technique. ANZ J Surg 2003; 73(9): 761-768. 7. Carrizo GJ, Marjani MA. Dysphagia lusoria caused by an aberrant right subclavian artery. Tex Heart Inst J 2009; 31(2): 168-171. 8. Asherson N. David Bayford. His syndrome and sign of dysphagia lusoria. Ann R Coll Surg Engl 1979; 61(1): 63-67. 9. Friedman M, LaSavio P, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg 2002; 128(3): 296-303. 10. Ozlugedik S, Acar HI, Apaydin N, Tekdemir I, Elhan A, Comert A. Surgical anatomy of the external branch of the superior laryngeal nerve. Clin Anat 2007; 20(4): 387-391. 11. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 1995; 16(5): 307-311. 12. Kierner AC, Aigner M, Burian M. The external branch of the superior laryngeal nerve: its topographical anatomy as related to surgery of the neck. Arch Otolaryngol Head Neck Surg 1998; 124(3): 301-303. 13. Aina EN, Hisham AN. External laryngeal nerve in thyroid surgery: recognition and surgical implications. ANZ J Surg 2001; 71(4): 212-214. 14. Hurtado-Lopez LM, Zaldivar-Ramírez FR. Risk of injury to the external branch of the superior laryngeal nerve in thyroidectomy. Laryngoscope 2002; 112(4): 626-629. 15. Bellantone R, Boscherini M, Lombardi CP, Bossola M, Rubino F, De Crea C et al. Is the identification of the external branch of the superior laryngeal nerve mandatory in thyroid operation? Results of a prospective randomized study. Surgery 2001; 130(6): 1055-1059. 473
Anatomie şi tehnici chirurgicale Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341] 16. Furlan JC, Cordeiro AC, Brandão LG. Study of some "intrinsic risk factors" that can enhance an iatrogenic injury of the external branch of the superior laryngeal nerve. Otolaryngol Head Neck Surg 2003; 128(3): 396-400. 17. Meyer T, Hamelmann WH, Schramm C, Hoppe F, Thiede A, Timmermann W. Is there a high risk of damaging the external branch of the superior laryngeal nerve during thyroid surgery? Eur Surg 2003; 35(4): 202-205. 18. Mishra AK, Temadari H, Singh N, Mishra SK, Agarwal A. The external laryngeal nerve in thyroid surgery: the 'no more neglected' nerve. Indian J Med Sci 2007; 61(1): 3-8. 19. Pagedar NA, Freeman JL. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Arch Otolaryngol Head Neck Surg 2009; 135(4): 360-362. 20. Chuang FJ, Chen JY, Shyu JF, Su CH, Shyr YM, Wu CW et al. Surgical anatomy of the external branch of the superior laryngeal nerve in Chinese adults and its clinical applications. Head Neck 2010; 32(1): 53-57. 21. Whitfield P, Morton RP, Al-Ali S. Surgical anatomy of the external branch of the superior laryngeal nerve. ANZ J Surg 2010; 80(11): 813-816. 22. Ardito G, Revelli L, D'Alatri, Lerro V, Guidi ML, Ardito F. Revisited anatomy of the recurrent laryngeal nerves. Am J Surg 2004; 187(2): 249-253. 23. Chiricuţă I, Gavrilescu TH. Cancerele tiroidiene. In Milcu S, Arseni C, Juvara I, Proca E, Setlacec D, Gozariu L eds. Cancerul si alte tumori ale sistemului endocrin. Cluj-Napoca, Ed. Oncologică, 1984; p. 140-231. 24. Shindo ML, Wu JC, Park EE. Surgical anatomy of the recurrent laryngeal nerve revisited. Otolaryngol Head Neck Surg 2005; 133(4): 514-519. 25. Weeks C, Hinton JW. Extralaryngeal division of the recurrent laryngeal nerve. Ann Surg 1942; 116(2): 251-258. 26. Steinberg JL, Khane GJ, Fernandes CM, Nel JP. Anatomy of the recurrent laryngeal nerve: a redescription. J Laryngol Otol 1986; 100(8): 919-927. 27. Schweizer V, Dörfl J. The anatomy of the inferior laryngeal nerve. Clin Otolaryngol Allied Sci 1997; 22(4): 362-369. 28. Hisham AN, Lukman MR. Recurrent laryngeal nerve in thyroid surgery: a critical appraisal. ANZ J Surg 2002; 72(12): 887-889. 29. Page C, Foulon P, Strunski V. The inferior laryngeal nerve: surgical and anatomic considerations. Report of 251 thyroidectomies. Surg Radiol Anat 2003; 25(3-4): 188-191. 30. Beneragama T, Serpell JW. Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation. ANZ J Surg 2006; 76(10): 928-931. 31. Yalçin B, Tugcu H, Cantürk N, Ozan H. Laryngeal branching pattern of the inferior laryngeal nerve, before entering the larynx. Surg Radiol Anat 2006; 28(4): 339-342. 32. Casella C, Pata G, Nascimbeni R, Mittempergher F, Salerni B. Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy? World J Surg 2009; 33(2): 261-265. 33. Cernea CR, Hojaij FC, De Carlucci D Jr, Gotoda R, Plopper C, Vanderlei F et al. Recurrent laryngeal nerve: a plexus rather than a nerve? Arch Otolaryngol Head Neck Surg 2009; 135(11): 1098-1102. 34. Serpell JW, Yeung MJ, Grodski S. The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg 2009; 249(4): 648-652. 35. Serpell JW. New operative surgical concept of two fascial layers enveloping the recurrent laryngeal nerve. Ann Surg Oncol 2010; 17(6): 1628-1636. 36. Sasou S, Nakamura S, Kurihara H. Suspensory ligament of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head Neck 1998; 20(8): 695-698. 37. Yalçin B, Tugcu H, Cantürk N, Kurt B, Ozan H. Critical course of the anterior laryngeal branch of the inferior laryngeal nerve. ANZ J Surg 2006; 76(6): 481-483. 38. Yalçin B, Ozan H. Detailed investigation of the relationship between the inferior laryngeal nerve including laryngeal branches and ligament of Berry. J Am Coll Surg 2006; 202(2): 291-296. 39. Sun SQ, Zhao J, Lu H, He GQ, Ran JH, Peng XH. An anatomical study of the recurrent laryngeal nerve: its branching patterns and relationship to the inferior thyroid artery. Surg Radiol Anat 2001; 23(6): 363-369. 40. Yalçin B. Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery. Surgery 2006; 139(2): 181-187. 474
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