Endoscopic neck surgery by the axillary approach

Asian perspective on endoscopic thyroidectomy -- a review of 193 cases

Endoscopic surgery has become widely used, so much so that recent technical and mechanical advances have led to "endoscopic surgery" being synonymous with "minimally invasive surgery". In particular, endoscopic thyroid surgery has developed rapidly and been increasingly refined in recent years. The incidence of thyroid diseases is markedly higher in women than in men, and operations for these diseases result in a scar on the anterior neck that is exposed when open-necked clothing is worn. Therefore, a technique for endoscopic endocrine neck surgery that results in a better cosmetic appearance is desirable. We have developed a totally gasless endoscopic surgical technique using an anterior neck-skin lifting method for thyroid and parathyroid diseases. This technique is called the video-assisted neck surgery (VANS) method. Since our original report, we have treated more than 200 cases of thyroid and parathyroid disease using this technique. In cases of benign thyroid tumours, near total lobectomy was the most common procedure followed by total lobectomy. The maximum resected tumour size was 7.4 cm in diameter. For malignant tumours, the indication for the VANS method was limited to thyroid papillary microcarcinomas measuring less than 1 cm in diameter. Total lobectomy and prophylactic neck dissection were performed in all 10 of these cases. A subtotal thyroidectomy was performed for only a few cases of Graves' disease. The operating time and the amount of bleeding were statistically significantly reduced, as the surgeon gained experience with the technique. In conclusion, the VANS method is a feasible, practical and safe procedure, with excellent cosmetic benefits.

Clinical benefits in endoscopic thyroidectomy by the axillary approach

BACKGROUND

Surgical treatments for thyroid diseases require skin incisions that can result in prominent scars, complaints resulting from adhesions, hypesthesia, and paresthesia in the neck. We have developed an endoscopic thyroidectomy using an axillary approach. In this article, we compare our original technique with conventional open surgery from the aspects of surgical invasiveness and patients' complaints after surgery.

STUDY DESIGN

Each procedure was performed in 20 patients with follicular tumors. The two groups were similar for age, gender, and the mean diameter of the thyroid tumor. No statistically significant difference in the final pathological diagnosis was found between the two groups. Surgical invasiveness and patients' complaints after surgery were compared using results of the operation and a questionnaire.

RESULTS

The operating time for open surgery was significantly shorter than that for endoscopic surgery (p < 0.01). In the endoscopic surgery group, the patient questionnaires revealed that 4 patients had severe anterior chest pain on the first postoperative day. The postoperative pain decreased after, and we could not find any difference between the two groups with regard to postoperative pain. Three months after surgery, one patient who had received an endoscopic procedure complained of slight hypesthesia, and none of the patients complained of discomfort while swallowing. Among the patients who underwent open surgery, 13 patients (65%; p < 0.01) complained of hypesthesia or paresthesia and 6 patients (30%; p < 0.05) complained of discomfort while swallowing. All of the patients treated using the endoscopic procedure were satisfied with the cosmetic results, but 15 patients who underwent open surgery complained of unsatisfactory cosmetic results (p < 0.01).

CONCLUSIONS

The incidence of postoperative complaints after endoscopic surgery is considerably lower than that after open surgery.

Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness

BACKGROUND

The effectiveness of minimally invasive video-assisted thyroidectomy (MIVAT) in papillary thyroid carcinoma is still debated. Some are concerned about this procedure in patients with thyroid cancer. This prospective study aimed to demonstrate that near-total thyroidectomy can be performed by MIVAT with similar results compared with open thyroidectomy.

METHODS

A total of 33 patients with a thyroid nodule proven to be a papillary thyroid carcinoma underwent a near-total thyroidectomy. They were randomly assigned to group A (n = 16) or group B (n = 17) who were treated either by MIVAT or conventional near-total thyroidectomy, respectively. Iodine-131 thyroid bed uptake and serum thyroglobulin were measured 1 month after operation. Data were analyzed by unpaired t test and Mann-Whitney statistic methods.

RESULTS

. Mean iodine-131 uptake was 5.1 +/- 4.9% in group A and 4.6 +/- 6.7% in group B. Mean thyroglobulin serum levels were 5.3 +/- 5.8 ng/mL in group A and 7.6 +/- 21.7 ng/mL in group B. The differences were not statistically significant.

CONCLUSIONS

The results of this study showed that the completeness obtained with MIVAT is similar to that obtained with open thyroidectomy, with the great advantage of a minimal neck wound. No conclusions can be drawn in terms of influence of MIVAT on the outcome of the patients with small papillary thyroid carcinoma.

Minimally invasive thyroidectomy

BACKGROUND

Conventional thyroidectomies by a direct approach through the neck require long incisions in the neck that can result in prominent scars, hypesthesia, and paresthesia. Minimally invasive procedures have recently been adopted for the surgical treatment of thyroid disease as a means of preventing such problems.

METHODS

In the present paper, the anterior chest approach and axillary approach to endoscopic thyroidectomy are described.

RESULTS

Twenty-two patients were treated by the anterior chest approach to endoscopic thyroidectomy and 28 patients by the axillary approach. The only complication was one case of postoperative emphysema. The patients were satisfied with the cosmetic results of the procedures and with the minimal degree of postoperative hypesthesia, paresthesia and discomfort.

CONCLUSION

Endoscopic thyroidectomy may become the procedure of choice for the surgical treatment of carefully selected patients with thyroid disease.

Minimal access thyroid surgery: is it feasible, is it appropriate?

BACKGROUND

Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral 'focused' or endoscopically assisted approach.

METHODS

The study group comprised all patients undergoing minimally invasive parathyroidectomy (MIP) during the period May 1998 to April 2002 in whom a concomitant thyroid procedure was undertaken. All procedures were performed either through a 2-cm lateral cervical incision (n = 19) or endoscopically (n = 7).

RESULTS

Twenty-six patients underwent thyroid surgery, consisting of either local excision of a thyroid nodule (n = 25) or hemi-thyroidectomy (n = 1). In 13 patients the nodule was incidentally discovered, in four patients removal of the parathyroid necessitated partial thyroidectomy, and in nine patients the lesion identified by preoperative parathyroid localization proved to be a thyroid nodule. There were no permanent complications in the study group. Two patients required drainage of a haematoma. The final pathology of all 26 cases revealed benign nodular thyroid disease.

CONCLUSION

Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible option for selected patients. The question remains to be answered as to whether this surgical approach is appropriate treatment for nodular thyroid disease.

Video-assisted thyroidectomy

OBJECTIVE

In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained.

METHODS

Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules </=35 mm in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; no previous neck surgery or irradiation and no thyroiditis. The VAT procedure was totally gasless. It was performed under endoscopic vision through a single 1.5 to 2.0-cm skin incision, using a technique very similar to conventional surgery.

RESULTS

Eighty-one VATs were attempted on 73 patients. Forty-five lobectomies, 24 total thyroidectomies and eight completion thyroidectomies were successfully performed. Mean operative time was 82 minutes for lobectomy, 100 minutes for total thyroidectomy and 77 minutes for completion thyroidectomy. The conversion rate was 4.9%. Postoperative complications included two transient recurrent nerve palsies, five transient symptomatic postoperative hypocalcaemias and one wound infection. The cosmetic result was considered excellent by most of the patients.

CONCLUSION

VAT is a feasible and and safe procedure that allows for excellent cosmetic results. In selected cases, it can be a valid option for the surgical treatment of thyroid diseases.

Endoscopic thyroid surgery today: a diversity of surgical strategies

The advancement of video-assisted minimally invasive surgery in this decade fostered the successful attempt at endoscopic thyroidectomy in 1997. This technically demanding surgery is now being evaluated in a small number of specialized centers. The procedure earned the most attention in Japan and is performed in more than 20 centers; a conference dedicated to the technique was held in Japan in 2001. By retrieving information from published or presented articles and direct personal communications, we report on the multitude of surgical strategies designed by different experts to enable relocalization of the surgical wounds to optimize cosmesis to the patient while complying with the gold standard of thyroid surgery.

Central neck lymph node removal during minimally invasive video-assisted thyroidectomy for thyroid carcinoma: a feasible and safe procedure

BACKGROUND AND PURPOSE

In 1998, we developed a technique for video-assisted thyroidectomy (VAT) which we proposed using also in patients with small low-risk papillary thyroid carcinomas (PTC). In some cases, enlarged lymph nodes are incidentally found at surgery for PTC. These nodes should be removed because of the risk of metastases. In this paper, we report on the patients in whom we removed enlarged central neck lymph nodes during VAT for PTC and discuss the feasibility and safety of video-assisted central neck lymph node dissection (VALD).

PATIENTS AND METHODS

The procedure is performed by a totally gasless video-assisted technique through a single 1.5-to 2.0-cm skin incision above the sternal notch. Dissection is performed under endoscopic vision using a technique very similar to that of conventional surgery. Only enlarged lymph nodes were removed and sent for frozen section examination (FS). No other dissection was performed in case of negative FS. Five patients underwent VALD during VAT for PTC.

RESULTS

The mean number of lymph nodes removed was 2.4. No metastases were found at FS or final histology examination. Postoperative complications included two transient postoperative hypocalcemias. No evidence of residual or recurrent disease was observed at postoperative follow-up. The cosmetic result was excellent.

CONCLUSION

Our experience demonstrates that removal of central compartment lymph nodes is feasible and safe. Perhaps also complete central neck lymph node dissection can be performed. Some doubts persist about the oncologic validity of this approach. For definitive conclusions, larger series and comparative studies are necessary.

Video-assisted thyroidectomy

BACKGROUND

In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this article we report on the entire series of patients who underwent VAT and discuss the results obtained.

STUDY DESIGN

Forty-seven patients were selected for VAT. Eligibility criteria were: thyroid nodules of 35 mm or less in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; neither previous neck surgery nor irradiation; and no thyroiditis. After a learning period, VAT was proposed also for completion thyroidectomy (of previous video-assisted lobectomy) and nodules with maximum diameter up to 45 mm. The procedure is performed by a totally gasless video-assisted technique through a single 1.5- to 2.0-cm skin incision. Dissection is performed under endoscopic vision using a technique very similar to conventional operation.

RESULTS

Fifty-three VATs were attempted on 47 patients. Thirty-three lobectomies, 10 total thyroidectomies, and 6 completion thyroidectomies were successfully performed. Six patients with papillary carcinoma underwent central neck lymph node removal by the same access. Mean operative time was 86.8 minutes for lobectomy, 116.0 minutes for total thyroidectomy, and 77.5 minutes for completion thyroidectomy. Conversion rate was 7.5%. Postoperative complications included one transient recurrent nerve palsy, three transient symptomatic postoperative hypocalcemias, and one wound infection. The cosmetic result was considered excellent by most of the patients who successfully underwent VAT.

CONCLUSIONS

VAT is feasible and safe and allows for an excellent cosmetic result. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.

Impact of harmonic scalpel on operative time during video-assisted thyroidectomy

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) has been practiced in our department since 1998. It has some advantages over conventional surgery in terms of postoperative pain and cosmetic result. The aim of this study was to evaluate the use of the Harmonic scalpel (HS) on the performance of this procedure.

METHODS

Between October 1998 and January 2001, 116 patients underwent MIVAT. The HS was used for the last 26 operations. We compared this group of patients (HS-G) with a control group (C-G) of 26 patients who had undergone MIVAT before the introduction of the HS. The following parameters were considered: age, gender, preoperative diagnosis, size of the lesion, type of operation (lobectomy or total thyroidectomy), operative time, complication rate, and postoperative hospital stay.

RESULTS

The two groups were well matched for age, gender, preoperative diagnosis, lesion size, and type of operation. The mean operative time was significantly reduced in the HS-G for both lobectomy (37.3 +/- 8.4 vs 49.4 +/- 18.0 min) and total thyroidectomy (53.8 +/- 16.3 vs 90.6 +/- 22.1 min). No differences were found for postoperative stay. One patient in the C-G experienced a transient recurrent nerve palsy. There were no other complications.

CONCLUSIONS

This study showed that the utilization of the HS for MIVAT is safe and associated with a shorter operative time. A reduction of the rates for such complications such as hypoparathyroidism and recurrent nerve injuries was not possible to demonstrate in the present study. Much larger series are needed for further evaluation of this instrument.

Thoracoscopic esophagectomy combined with mediastinoscopy via the neck

Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.

New operative strategies in primary hyperparathyroidism

More than 95% of patients with primary hyperparathyroidism have been treated with bilateral neck exploration by experienced surgeons. This procedure has been performed without employing preoperative localization tests or specialized techniques of intraoperative measurement. A renewed interest in unilateral neck exploration for primary hyperparathyroidism emerged (in three developments), in an attempt to maintain the excellent cure rate and to minimize the invasiveness of the procedure. The first development was the introduction of sestamibi scintigrams as a new preoperative localization technique and intraoperative nuclear mapping with a hand-held gamma probe. The localization of adenomas using this technique was much more accurate than that of previous localization studies, allowing unilateral procedures to become feasible. Sestamibi guidance enables parathyroidectomies to be performed much more rapidly through a significantly less invasive dissection. Secondly, the intraoperative quick parathyroid hormone assay allows the confirmation of removal of the parathyroid mass. The third development was endoscopic parathyroidectomy. Various approaches have been shown to be technically feasible, including endoscopic procedures that rely on CO2 insufflation to create a working space or video-assisted procedures in which the working space is maintained through conventional external retraction. Given the safety and high success rate of the standard exploration, the potential advantages of these new strategies include decreased operating time, local or regional anaesthesia rather then general anaesthesia, and smaller incisions.

Video-assisted thyroid lobectomy through a small wound in the submandibular area

BACKGROUND

Endoscopic thyroidectomy has not gained wide acceptance because of the expertise required, the long operation time, the wide dissection, and the extra cost of specialized instruments. We developed a video-assisted hemithyroidectomy procedure that requires only one small incision at the upper neck.

METHODS

Hemithyroidectomy was performed through a 25 to 30 mm transverse incision made in the upper lateral neck for the treatment of benign thyroid nodule. No gas or external lift dissection was needed.

RESULTS

The mean age of 39 patients was 33.8 years. The tumor size ranged from 1.9 to 5.5 cm (mean 3.1 cm). All patients underwent total lobectomy without conversion to traditional cervicotomy. The mean operation time was 56 minutes (range 36 to 90). Follicular adenoma was the final pathologic diagnosis in 25 patients and adenomatous goiter in 14. Transient recurrent laryngeal nerve palsy was seen in 1 patient.

CONCLUSIONS

Our technique is safe, minimally invasive, less time consuming, and cosmetically excellent.

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study

BACKGROUND

Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated.

METHODS

Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated.

RESULTS

MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 +/- 24 minutes for MIVAT and 45 +/- 15 minutes for CT (P = .001). Postoperative course was significantly less painful in the patients who underwent MIVAT (P = .003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT (P = .003 and P = .01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies.

CONCLUSIONS

Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages.

Minimally invasive thyroid surgery

Endoscopic surgery is often considered to be 'minimally invasive surgery' in the light of recent technical developments. Endoscopic neck surgery, including thyroid and parathyroid surgery, has developed rapidly over the past 2 years. The various techniques of thyroid surgery, including sites of incision and procedures for creating adequate working space, are described here. The cosmetic benefits of endoscopic versus conventional open surgery were evaluated by questionnaires sent to two groups of patients. The lower invasiveness of endoscopic surgery in terms of operating time and amount of bleeding is also discussed. Endoscopic surgery with a new, totally gasless anterior neck skin lifting method, with which we have now had much experience, will be described and its advantages discussed.

Minimally invasive parathyroid surgery

Several minimally invasive procedures have been described over the past 3 years for the treatment of sporadic primary hyperparathyroidism (PHPT). These techniques (totally endoscopic, video assisted and radio guided) have been demonstrated to be feasible and safe, but the surgeon should be well trained to obtain the best results with these approaches. Not all patients are eligible for minimally invasive procedures. The results are comparable to those of conventional surgery with advantages in terms of cosmetic result and reduced post-operative pain. These procedures should be considered to be a valid option by surgeons dealing with patients with primary hyperparathyroidism.