Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M....
Transcript of Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M....
![Page 1: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/1.jpg)
Endokrine Chirurgie
Seminar
Blockpraktikum Chirurgie
Dr. M. Jäger
Allgemein-, Viszeral- und Transplantationschirurgie
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Endokrine Drüsen in VCH
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
Schilddrüse
Nebenschilddrüse
Nebenniere
Pankreas
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![Page 3: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/3.jpg)
Schilddrüse
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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„Kraftwerk des Körpers”
15 – 20 g schwer
Produktion von
Thyroxin (T4)
Trijodthyronin (T3) biologisch aktiv
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Hyperthyreose ?
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Ursachen ?
Immunthyreopathie
Autonomie
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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M. Basedow ?
Merseburger Trias
• Exophthalmus
• Tachykardie
• Struma
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
![Page 8: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/8.jpg)
Diagnostik ?
Anamnese
Klinische Untersuchung
Labor (fT3, fT4, TSH)
Sonographie
Szintigraphie
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Feinnadel-Aspirationszytologie
Schichtbildgebung
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Anamnese ?
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SD-Vergrößerung ?
Vegetative Symptome ?
Augen, Stimme ?
Familie ?
Medikamente ?
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Labor
TSH fT3, fT4
normal
normal normal
normal
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Hyperthyreose
manifest
latent / kompensiert
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Klinische Untersuchung
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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WHO Klassifikation der Struma
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0 Keine Struma
Ia Palpabel, nicht sichtbar
Ib Palpabel und sichtbar bei
Reklination
II Sichtbar ohne Reklination
III Sehr groß, sichtbar aus der
Distanz,
mit Kompressionserscheinungen
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
![Page 13: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/13.jpg)
Sonographie
Basisdiagnostik, prä-op unverzichtbar
Ausdehnung (Volumetrie)
Struktur
Intra- UND extra-thyreoidale
Veränderungen (≥ 3mm erfassbar)
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Sonographie
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Szintigraphie
detektiert Jod-Speicherung
„kalt“ Jod-Speicher-Defekt
Zyste, Malignom ?
„heiß“ vermehrte Anreicherung
Adenom
Nachweisgrenze 8 – 10 mm
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Indikationen zur SD-Resektion
Hormonüberschuss ?
Struma ?
Knoten ?
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Thyreotoxische Krise
M. Basedow mit endokr. Orbitopathie
Therapierefraktäre Autonomie
Grad II unzureichende kons. Tx
kosmetische Gründe
Grad III
„kalter Knoten“
V.a. / Nachweis Malignom
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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prä-op „must haves“
Anamnese + Befund
Labor (SD + NSD)
Sono
Szinti
Stimmbandfunktion
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Kocher´scher Kragenschnitt
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Theodor Kocher (Nobelpreis 1909)
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Bern 1912
> 7000 SD-Resektionen
Mortalität < 1 %
Samuel Gross (1866):
„If a surgeon should be so foolhardy as to undertake a thyroid removal, every step of the way will be environed with difficulty, every stroke of his knife will be followed by a torrent of blood, and lucky will it be for him if his victim lives long enough to enable him to finish his horrid butchery. No honest and sensible surgeon would ever engage it.“
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Topographische Anatomie: Faszien
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Eposition durch Haltenähte
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Luxierte Schilddrüse
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Topographische Anatomie: Leitungen
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Schilddrüsenbett
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Schilddrüse A. thyroidea inf.
NSD rechts oben
NSD rechts unten
N. laryngeus recurrens
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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N. laryngeus recurrens
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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N. laryngeus non-recurrens ?
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N. laryngeus
non-recurrens
A. carotis com.
A. thyroidea inf.
Parathyroid
(lower right)
Parathyroid
(upper right)
N. vagus
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
![Page 27: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/27.jpg)
Situs nach Resektion
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Wunde nach Verschluss
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Thyreoidektomie-Präparat
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Komplikationen
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Blutung < 1%
Recurrens-Parese < 1%
Hypoparathyreoidismus < 1%
Infekt < 1%
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
![Page 31: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/31.jpg)
Schilddrüsen-Karzinom
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1 – 3 % aller Karzinome des Menschen
Risikofaktoren für differenziertes Karzinom
externe Bestrahlung
höheres Alter
weibliches Geschlecht
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Formen des SD-Karzinom
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Form Abk. Ursprung Metastasierung (überwiegend)
Papillär PTC Follikelepithel lymphogen
Follikulär FTC Follikelepithel hämatogen
Undifferenziert UTC Epithel / BG lymphogen / hämatogen, infiltrierend
Medullär MTC C-Zelle lymphogen / hämatogen
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Papilläres SD-CA (PTC)
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70 - 80 % der SD-CA
Metastasierung überwiegend lymphogen
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
![Page 34: Seminar Blockpraktikum Chirurgie - mh- · PDF fileSeminar Blockpraktikum Chirurgie Dr. M. Jäger . Topographische Anatomie: ... Parathyroid (lower right) Parathyroid (upper right)](https://reader031.fdocuments.in/reader031/viewer/2022020411/5ab0c6767f8b9a6b468baf83/html5/thumbnails/34.jpg)
Follikuläres SD-CA (FTC)
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10 - 15 % der SD-CA
Metastasierung überwiegend hämatogen
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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FTC Tumorthrombus
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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FTC Präparat
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Undifferenziertes SD-CA (UTC)
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3 – 5 % der SD-CA
rapider Progress, infiltrierend
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Adjuvante Therapie bei SD-CA
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Form TU-Marker Therapie
PTC Thyreoglobulin OP
FTC Thyreoglobulin OP
UTC ? Thyreoglobulin Bestrahlung OP
MTC Calcitonin OP
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Nebenschilddrüse
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Regulation d. Ca2+ -Homöostase
NSD - Ca2+ Regulator
Darm - Ca2+ Aufnehmer
Knochen - Ca2+ Speicher
Niere - Ca2+ Ausscheider
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Hyperkalziämie ?
Hyperparathyreoidismus
Tumorhyperkalziämie
PTH ↑ primärer HPT
NSD-CA
PTHrP ↑ Lungen-CA
Mamma-CA
Urogenital-CA
Kopf- / Hals-CA
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Differenzierung der Hyper-Ca2+
Calcium
PTH
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Primärer HPT Symptome ?
„Bein – Stein – Magenpein“
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Ziele der PT
Korrektur von HPT / Hyperkalziämie
Übertherapie vermeiden
Rezidiv vorbeugen
Einschätzung des Ausmaß der NSD-Pathologie
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Herausforderung intra-op
Auffinden der NSD
Einschätzung der NSD-Pathologika
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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NSD Lagevariabilität
Obere NSD Untere NSD
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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NSD Anlage untere NSD untere NSD
Thymus Thymus
dorsal
dorsal
ventral
ventral
Schlundtasche 3
Schlundtasche 4
Schilddrüsenanlage
obere NSD obere NSD
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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PT bei pHPT
1,8 g
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Hilfsmittel intra-op
NSD-Schnellschnitt
PTH-Schnelltest
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Sekundärer HPT renalen Ursprungs
Calcium
Phosphat
Vit D
PTH
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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sHPT Symptome
„Knochenschwund“ (Osteopenie)
Schmerz
erhöhte Frakturneigung
Arteriosklerose
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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sHPT
276 mg
934 mg 1172 mg
395 mg
+ NSD-Auto-Tx
(sub-) totale PT
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Nebenniere
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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CT normaler NN
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Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Hormone der NN
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Mark
Adrenalin / Noradrenalin
„Kampf / Flucht“
Hypertonie bis 300 mmHg
Rinde
Mineralokortikoide
Glukokortikoide
Androgene, Östrogene
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Phäochromozytom Diagnostik
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„swiss cheese“
Katecholamine im Serum / Urin
„10 % - Tumor“
• bilateral
• maligne Entartung
• extraadrenale Lokalisation
• multiples Vorkommen
• familiäre Häufung
• bei Kindern
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Syndrome der NN-Rinde
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Syndrom Conn Cushing
Hormon Aldosteron Cortisol
Leit-Symptome RR ↑
Na+ ↑
K+ ↓
Adenom 80 % 80%
Hyperplasie 20 % 20%
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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OP bei Phäochromozytom
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Vorbereitung α – Blockade in steigender Dosierung (Dibenzyran)
ggf. zusätzlich β-Blockade
anästhesiologisch sehr anspruchsvoll
Nachsorge RR-Monitoring
Flüssigkeitsmanagement
nach 6 Wochen Katecholaminbestimmung -> Rezidiv ?
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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OP bei M. Conn
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Vorbereitung Spironolacton + Kalium-Substitution
OP erst bei ausgeglichenem E´lyt- und Flüssigkeitshaushalt
Vorgehen Adenom einseitige Resektion
Hyperplasie konservative Therapie
ggf. subtotale NN-Resektion
Nachsorge ggf. K+-Substitution + Diuretika-Gabe
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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OP bei Cushing-Syndrom
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Vorbereitung Antibiotika-Prophylaxe
ggf. Hemmung der Kortisol-Synthese (Metyparon)
OP-Vorgehen Adenom einseitig
Hyperplasie zweiseitig
Nachsorge Hydrocortison-Gabe
bei zweiseitiger Adrenalektomie lebenslang Astonin H
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Zugänge zur Adrenalektomie
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Adenom nachweis
80 %
Hyperplasie verdacht
20 %
laparoskopisch
offen
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger
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Auf Wiedersehen !
Endokrine Chirurgie
Seminar Blockpraktikum Chirurgie
Dr. M. Jäger