首次侧喉返神经损伤或信号丢失后的分期甲状腺切除术：基于证据的手术框架

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中文摘要

背景： 甲状腺切除术后双侧喉返神经（RLN）损伤虽不常见但后果灾难性，可导致气道受损、气管造口依赖和永久性残疾。2025年美国甲状腺协会指南和国际神经监测研究组指南均建议，当识别到首次侧RLN损伤或持续性信号丢失时，应推迟对侧切除，前瞻性监测系列研究显示，在这种情况下终止双侧手术可减少双侧声带麻痹，而不影响患者满意度。现有建议未提供的是手术路径：什么应触发暂停、如何排查信号丢失、什么恢复阈值允许同期完成、何时应进行喉镜检查，以及应如何重新考虑完成性甲状腺切除术。本综述综合了当代指南语言、前瞻性监测数据以及从Westlaw检索到的已发表甲状腺切除术医疗事故判决，形成实用的双轨术中框架。A轨处理肉眼可见的横断或明显无活力的神经；B轨处理无肉眼可见损伤的持续性信号丢失，其中经迷走神经刺激确认的振幅恢复至基线至少一半，支持同期完成。已发表的判例法用于说明而非流行病学目的，显示被裁决的手术批评集中在切除范围和完成第二侧的决定上，而非神经损伤的发生，而辩护结果更常反映可接受风险的解剖、具体的知情同意文件以及充分的专家证明。支持选择性立即完成的证据与支持分期的理由一并呈现。该框架是对现有指南的操作化而非替代，并提供了具体的排查、知情同意和手术记录要素。

英文摘要

Bilateral recurrent laryngeal nerve (RLN) injury after thyroidectomy is uncommon but catastrophic, producing airway compromise, tracheostomy dependence, and permanent disability. The 2025 American Thyroid Association guideline and the International Neural Monitoring Study Group guidelines both recommend deferring contralateral resection when first-side RLN injury or persistent loss of signal is recognized, and prospective monitoring series show that terminating bilateral surgery in this setting reduces bilateral vocal cord paralysis without compromising patient satisfaction. What existing recommendations do not supply is an operative pathway: what should trigger the pause, how loss of signal should be troubleshot, what recovery threshold permits same-session completion, when laryngoscopy should occur, and how completion thyroidectomy should be reconsidered. This review synthesizes contemporary guideline language, prospective monitoring data, and published thyroidectomy malpractice decisions retrieved from Westlaw into a practical two-track intraoperative framework. Track A addresses visualized transection or a clearly nonviable nerve; Track B addresses persistent loss of signal without visualized injury, where amplitude recovery to at least half of baseline, confirmed by vagal stimulation, supports same-session completion. Published case law is used illustratively rather than epidemiologically and shows that adjudicated operative criticism has clustered around extent of resection and the decision to complete the second side rather than around the occurrence of nerve injury, while defense outcomes more often reflected accepted-risk anatomy, specific consent documentation, and adequate expert proof. Evidence favoring selective immediate completion is presented alongside the case for staging. The framework operationalizes rather than replaces existing guidance and supplies concrete troubleshooting, consent, and operative-note elements.