[Lateral endoscopic approach for thyroid and parathyroid surgery]

Modern internet search analytics and thyroidectomy: What are patients asking?

Objectives

Thyroidectomy is among the most commonly performed head and neck surgeries, however, limited existing information is available on topics of interest and concern to patients.

Study Design

Observational.

Setting

Online.

Methods

A search engine optimization tool was utilized to extract metadata on Google-suggested questions that "People Also Ask" (PAA) pertaining to "thyroidectomy" and "thyroid surgery." These questions were categorized by Rothwell criteria and topics of interest. The Journal of the American Medical Association (JAMA) benchmark criteria enabled quality assessment.

Results

A total of 250 PAA questions were analyzed. Future-oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management, risks or complications of surgery, and technical details were significantly less popular among the "thyroid surgery" group (P < 0.001, P = 0.005, and P < 0.001, respectively). PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain (335 and 319 vs. 113 combined search engine response page count, respectively). The overall JAMA quality score remained low (2.50 ± 1.07), despite an increasing number of patients searching for "thyroidectomy" (r(77) = 0.30, P = 0.007).

Conclusions

Patients searching for the nonspecific term "thyroid surgery" received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery, as compared to patients with higher health literacy who search with the term "thyroidectomy." This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.

Endoscopically-Assisted Scar-Free Midline Neck Mass Excision

Traditional open surgery is indicated for the treatment of selected tumor subsites in the head and neck. However, it can cause major cosmetic problems and functional pathologies. The endoscopically-assisted transoral approach is increasingly preferred in some surgical fields due to its superior cosmetic and functional outcomes. Nonetheless, endoscopically-assisted transoral approach is not yet standard in the head and neck due to their anatomical complexity. The transoral surgical approach has been used for head and neck masses since the 1960s, and its application continues to evolve with changing disease conditions and recent innovations in surgical instruments. The potential for wide application of transoral surgery continues to be investigated, with a focus on minimizing occurrence of the complications. This review presents details of the surgical procedure and postoperative clinical outcomes, as well as endoscopically-assisted scar-free techniques for the resection of midline neck masses.

Proposal of New Key Step in Lateral Approach Thyroidectomy in Light of Comparison of Surgical Outcomes of Medial versus Lateral Approach Thyroidectomy: A Randomised Controlled Study

Objective

Thyroid surgery has travelled a long path, from a surgery which once was considered deemed to fail and even led to death, to the current time when newer techniques are being tested to make the incision smaller and smaller. The aim of our study is to give a precise detailed stepwise description of medial and lateral surgical approach with the anatomical basis and to compare their feasibility and safety.

Methods

104 cases presenting with thyroid swelling in the Department of Otorhinolaryngology, Assam Medical College Dibrugarh from January 1, 2019, to December 31, 2019, were selected and randomisation was done based on day of admission from OPD. Basic demographic data, preoperative diagnosis, operative time, blood loss, need for transection of strap muscles, and complications were recorded.

Result

The distribution of thyroid cases according to age ranged from 17 to 81 years. The prevalence of thyroid disorders was the highest (37.5%) in the age group of 31-40 yrs. Of a total of 104 thyroid cases, 49 were colloid goitre, 24 were multinodular goitre, 9 were follicular neoplasm category 4, 4 were papillary thyroid carcinoma, 2 were follicular neoplasm category 3, and 3 were follicular neoplasm category 5.

Conclusion

Out of the two approaches, lateral approach thyroidectomy showed better results with fewer complications. A single structure (superior belly of omohyoid) can be used as a guide to preserving all vital structures related to the thyroid gland.

Transoral endoscopic thyroidectomy via vestibular approach: First case in Saudi Arabia

INTRODUCTION

There has been increased interest in applying the principles of minimally invasive surgery in thyroid surgery which was promoted by Miccoli and his colleagues in 1999. Different surgical techniques since then were introduced, transcervical and extracervical approaches.

PRESENTATION OF CASE

A 33-year-old Saudi female presented with a swelling over the left side of her neck and dysphagia for three years. The patient underwent transoral endoscopic left thyroid lobectomy, isthmusectomy and sampling of the central compartment via vestibular approach (TOETVA). To the best of our knowledge, this is the first case underwent TOETVA successfully in Saudi Arabia and gulf cooperation council countries.

DISCUSSION

TOETVA is a novel promising procedure, an adaptation of the concept of natural orifice transluminal endoscopic surgery (NOTES) with advantages of scar-less result in excellent cosmesis while retaining the advantages of minimally invasive surgery and the potential value of the procedure outside the enhanced cosmesis continuous to be defined. The cosmetic superiority in avoiding visible scarring must be balanced against operative time, post-operative hospital stays, increased expense, surgical training, and steep learning curve required. The technique is novel, some thyroid surgeons opted for longer postoperative observation to exclude complications. As experience and confidence in the procedure increase, the length of stay should decrease dramatically.

CONCLUSION

This procedure is feasible and safe with excellent cosmetic result. It is in its initial stage in Saudi Arabia, gulf cooperation council countries and it has a potential to be performed more frequently in near future.

Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature

INTRODUCTION

The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature.

METHODS

Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4).

RESULTS

All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high.

CONCLUSION

Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Endoscopic Thyroid Surgery Through Trans-oral Vestibular Approach (TOVA): A Case Series and Review of Literature

Endoscopic surgery is now standard of care for different Endocrine Disorders; the endoscopic thyroid surgery is becoming more popular and different approaches has been practice by many thyroid surgeon worldwide. Trans-orovestibular approach, based on the principle of natural orifice transluminal surgery is truly scar free thyroid surgery and has minimal dissection. We are presenting here three cases of benign solitary thyroid nodule operated endoscopically through trans-oro-vestibular approach in one male and two female patients. Described about the approach, challenges during surgery and outcome. These surgeries documented very few in literatures in live human patients. Transoral endoscopic thyroid surgery through vestibular approach is shortest and direct remote access approach. The need of limited dissection in this approach provides less complication and excellent cosmetic outcome in strictly selected patients.

Transoral endoscopic total thyroidectomy vestibular approach: A case series and literature review

Conventional open thyroidectomy is often associated with post-operative complications including nerve damage, voice disturbances, paraesthesias, adhesions and prominent scarring. Several endoscopic surgical techniques have been reported as alternatives to conventional thyroidectomy. Natural orifice transluminal endoscopic surgery is a promising approach which leaves no scar, produces few complications and affords faster discharge from care. Several studies have explored its utility in total thyroidectomy in patients with benign or malignant thyroid disease. Herein, we present a case series on the successful application of transoral endoscopic total thyroidectomy vestibular approach (TOETVA) in benign and malignant diseases of the thyroid. We performed TOETVA in 11 patients presenting with benign or malignant thyroid nodules in our hospital, between 1^st January 2015 and 30^th June 2016. The surgery was completed successfully in all patients with a pre-operative diagnosis of multinodular goitre. The surgery was performed under general anaesthesia and the mean operative time was 130 min. The mean blood loss was 2–3 cc. No incidence of recurrent laryngeal nerve injury, damage to mental nerve, parathyroid damage or peri-incisional adhesion occurred in the study participants. No visible scarring occurred in the patients following surgery. The patients had an uneventful recovery after the surgery and were discharged after 4 days. TOETVA is safe and effective in the surgical management of multinodular goitre and offers a scar-free alternative to conventional surgery.

The lateral "backdoor" approach to open thyroid surgery: A comparative study

INTRODUCTION

The traditionally taught technique for conventional open thyroidectomy is via a midline splitting of the strap muscles following a skin crease neck incision - midline approach (MA). The lateral "backdoor" approach (LA) uses the same central neck incision but approaches the thyroid gland between the anterior border of sternocleidomastoid (SCM) and strap muscles. This technique is usually reserved for re-do thyroid surgery. We compared the results of the two approaches in patients undergoing conventional thyroidectomy for the first time.

METHODS

A case-control study was performed on 90 patients undergoing conventional open thyroidectomy from 2012 to 2014. The first 45 patients underwent MA and subsequent 45 patients underwent LA. All patients were given 10 ml of 1% Marcaine infiltration into the neck incision before closure. Basic demographic data, operative time, incision length, weight of gland, need for transection of strap muscles and complications were recorded. Revision thyroid surgery and minimally invasive thyroid operations were excluded.

RESULTS

The demographics, operative timing, gland weight and incisional length showed no significant difference. Post-operative pain was significantly lower in the LA group. 5 patients (11%) in MA group needed horizontal transection of strap muscles to extract large goitres compared to 1 patient (2.2%) in the LA group. No major complications occurred in either group.

CONCLUSION

The LA method is as safe as the midline technique with comparable operative time and significantly lower pain scores. It avoids midline separation and suturing of strap muscles and reduces the need for strap muscle transection to removal large goitres.

The operation experience of endoscopic thyroidectomy by areola and axilla approach

To explore the feasibility of endoscopic thyroidectomy via breast areola and axilla approach. The clinical data of 36 cases that underwent endoscopic thyroidectomy via breast areola and axilla approach from February 2012 to December 2013 were reviewed. All cases were completed, the mean operation time was 136.3 min (95-183 min), intraoperative blood loss was 15.8 ml (5-60 ml). The average hospitalization time was 5 days (4-6 days). There were no conversions to open surgery, no permanent nerve injuries, and no cases of hypoparathyroidism. Three patients had postoperative subcutaneous ecchymosis who were cured spontaneously after 1 month. Endoscopic thyroidectomy is safe and feasible for patients with thyroid diseases with good cosmetic results, and is worthy of being widely applied for patients who have cosmetic demand.

Relationship between the ansa cervicalis and the omohyoid muscle: clinical consequences in parathyroid surgery

PURPOSE

To determine the position of the lower loop of the ansa cervicalis (AC) compared to the inferior edge of the omohyoid muscle to guide minimally invasive surgery for the lateral oblique approach of parathyroid glands.

METHODS

Authors performed 36 anatomical dissections in the laboratory of anatomy (Laboratoire d'Anatomie Des Alpes Françaises) of the Grenoble medical school in 2012 on human cadavers. They independently measured the distance between the caudal extremity of the AC and the lower edge of the superior belly of the omohyoid muscle. Then, they controlled this measure on pictures.

RESULTS

The study shows a majority of long AC (under the omohyoid muscle) in 66.7 % of cases. In addition, the AC was located on an average value of 0.1 cm below the lower edge of the omohyoid muscle (median -0.5 cm). Thus, two-thirds of AC are between 0 and -2 cm under the omohyoid muscle. Furthermore, the AC is generally non-symmetrical: there is a mean difference of 1.3 cm between the left and right AC. In this series, there are as many long AC on the right side as on the left side.

CONCLUSIONS

These results are in contradiction with literature data. To preserve the ansa cervicalis and its phonatory functions, it is necessary for the surgeon to perform a systematic per operative identification of the AC because the position of the AC is mainly under the omohyoid muscle and because of an asymmetry. Per operative neurostimulation and/or magnified lenses might be helpful during the surgical approach.

Salient anatomical landmarks of thyroid and their practical significance in thyroid surgery: a pictorial review of thyroid surgical anatomy (revisited)

Thyroid surgery is a prototype of operations requiring thorough knowledge of surgical anatomy. There are many vital and delicate anatomical structures such as recurrent laryngeal nerve, superior laryngeal nerve, parathyroid glands, and distinct fascial planes surrounding the thyroid gland. A protean range of pathologies such as goiter, nodules, thyroiditis, and malignancy distort or alter the location and course of these structures and planes. The distinct vascular supply and high vascularity of thyroid region challenges the surgeon's expertise. Several pathologies like malignancy, multinodularity, toxicity, and retrosternal extension further compounds this vascular aspect of surgery. Several structures of embryological importance such as pyramidal lobe, tubercle of Zuckerkandl, and ligament of Berry have decisive clinical implications in the surgical management of thyroid disorders. Surgeons attempting thyroidectomy need to have thorough knowledge of embryology and surgical anatomy of the thyroid gland. In this context, we highlight through a pictorial assay the embryological and anatomical aspects of the thyroid gland emphasizing on their clinical and surgical importance.

Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach

Background

Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique.

Methods

Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO₂ insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely.

Results

Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days.

Conclusions

We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.

Single-port access transaxillary totally endoscopic thyroidectomy: a new approach for minimally invasive thyroid operation

PURPOSE

Various techniques for minimally invasive thyroid surgery have been described over the last decade. As interest in single-port access laparoscopic surgery (SPA™) continues to grow, the authors present their technique and short-term outcomes for single-port access transaxillary totally endoscopic thyroidectomy in the management of benign thyroid tumors in a series of 4 patients.

PATIENTS AND METHODS

Four consecutive patients from a prospectively maintained endoscopic thyroidectomy database were analyzed under an institutional review board-approved protocol. Clinical characteristics and short-term outcomes were reviewed.

RESULTS

All the patients were young women with no prior neck surgery. A single-port totally endoscopic thyroidectomy was performed for thyroid adenoma in 2 cases and for nodular goiter in 2 cases. Retraction, exposure, and extraction were possible in all cases. The average operating room time was 92.5 minutes. Postoperative pain scores on postoperative day 1 were all 1/10. No patient experienced complications. The median hospital stay was 1.75 days. The mean specimen size was 2.7 cm × 2.375 cm × 2.625 cm. The patients were uniformly pleased with the cosmetic results of the operation.

CONCLUSIONS

Single-port access transaxillary totally endoscopic partial thyroidectomy appears to be safe and feasible. This technique may provide both an attractive way to reduce injury to the anterior neck tissue and a method for ideal cosmetic effect.

Minimal access surgery - thyroid and parathyroid

The concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, MIT or MIP should properly be defined as operations through a short and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection.Parathyroid glands are particularly suitable for minimally invasive surgery as most parathyroid tumors are small and benign. MIP are performed through a limited or discrete incision when compared to classic open transverse cervical incision and are targeted on one specific parathyroid gland. The concept of these limited explorations is based on the fact that 85% of patients will have single-gland disease. MIP must be proposed only for patients with sporadic hyperparathyroidism in whom a single adenoma has been clearly localized by preoperative imaging studies.The minimal access approaches to the thyroid gland may be broadly classified into three groups: the mini-open lateral approach via a small incision, minimally invasive video-assisted thyroidectomy via the midline and various endoscopic techniques. Endoscopic extracervical approaches have the main advantage of leaving no scar in the neck but cannot reasonably be described as minimally invasive as they require more dissection than conventional open surgery.Initially the indications for MIT were a solitary thyroid nodule of less than 3 cm in diameter in an otherwise normal gland. Today, MIT are also proposed in patients with small nodular goiters, Graves's diseases and low risk papillary thyroid cancers. Some concern remains about the radicality of MIT in this latter group but preliminary results are comparable to those of conventional surgery both in terms of I-131 uptake and serum thyroglobuline levels.Demonstrating the advantages of MIT and MIP over conventional surgery is not easy. Main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in conventional surgery. Several studies comparing conventional surgery with minimally invasive techniques using a cervical access have shown a diminution of postoperative pain, and better cosmetic results with minimally invasive techniques. MIP and MIT seem overall to be an advance but only randomized studies will demonstrate the real benefit.

Extracervical approaches to endoscopic thyroid surgery

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).

Evaluation of postoperative pain after minimally invasive video-assisted and conventional thyroidectomy: results of a prospective study. ESES Vienna presentation

BACKGROUND

One of the advocated benefits of minimally invasive video-assisted thyroidectomy (MIVAT) is reduction of postoperative pain. We compared in a prospective study pain after video-assisted and conventional thyroidectomy (CT).

METHODS

One hundred sixty-nine patients (56 men, 113 women, mean age: 50 ± 14 years) operated between November 2007 and February 2008 were included. MIVAT was performed if thyroid volume was <30 ml or the nodule diameter < 35 mm. Postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 100 = unbearable pain) at 8, 24, 36, and 48 h after surgery. Additionally, postoperative analgesic consumption was registered.

RESULTS

Seventy-five patients (17 men, 58 women, mean age: 45 ± 15 years) underwent MIVAT and 94 (39 men, 55 women, mean age: 54 ± 15 years) CT. The mean overall VAS score at 8, 24, 36 and 48 h did not significantly differ between the groups (26 ± 21 vs. 26 ± 19 at 8 h, 17 ± 15 vs. 21 ± 18 at 24 h, 11 ± 13 vs. 10 ± 11 at 36 h and 7 ± 12 vs. 6 ± 8 at 48 h in MIVAT and CT group, respectively) [p = ns]. Twelve vs. 13 patients (16% vs. 14%) required opioid administration on the day of the operation [p = ns].

CONCLUSIONS

The length of the skin incision seems not to influence the perception of pain after thyroid surgery.

Minimally invasive thyroid and parathyroid operations: surgical techniques and pearls

With advances in technology and greater demand for minimally invasive procedures, novel minimally invasive approaches to thyroid and parathyroid glands increasingly have been described and practiced worldwide. For the MIT approaches, the direct/cervical approaches truly can be considered minimally invasive, as they require less surgical dissection than the conventional thyroidectomy. The indirect/extracervical approaches, however, only can be considered endoscopic, however, because they generally do require greater surgical dissection. Still, among the indirect/extracervical approaches, the axillary approach appears the preferred choice, as it requires the least amount of dissection while offering the advantage of being scarless in the neck. The addition of the robot such as the de Vinci surgical system could make some of the extracervical approaches technically less challenging and improve patient outcomes. Unlike MIT, MIP has become the standard approach for surgical management of primary hyperparathyroidism caused by localized solitary parathyroid adenoma.

What is the evidence for endoscopic thyroidectomy in the management of benign thyroid disease?

Background

Endoscopic thyroidectomy (ET) is a demanding surgical technique in which dissection of the gland is entirely performed with an endoscope, in a closed area maintained by insufflation or mechanical retraction. ET by direct cervical approach (anterior or lateral) is minimally invasive, but ET using an extracervical access (chest wall, breast, or axillary) is not. No technique seems to be universally accepted yet. This review was designed to clarify the existing evidence for performing endoscopic thyroid resections in the management of benign thyroid nodules.

Methods

A database search was conducted in PubMed and Embase from which summaries and abstracts were screened for relevant data, matching our definition. Publications were further assessed and assigned their respective levels of evidence. Additional data derived from our own unit’s experience with endoscopic thyroidectomy were included.

Results

Thirty mainly retrospective cohort studies have been published in which morbidity, such as unilateral vocal cord palsy, is poorly evaluated. ET takes from 90 to 280 minutes for lobectomy by cervical access and total thyroidectomy by chest wall approach, respectively. Cosmetic outcome in extracervical approach is less troubled by size of the resected specimen compared with direct cervical approach. Extracervical approach avoids a neck scar but implies invasiveness in terms of dissection and postoperative discomfort. Long-term cosmetic outcome comparisons with conventional thyroidectomy have not been published.

Conclusions

Currently it is not possible to recommend the application of ET based on evidence. Reported complications stress the importance of advanced endoscopic skills. ET should only be offered to carefully selected patients and, therefore, a high volume of patients requiring thyroid surgery is needed. Superiority of endoscopic to conventional thyroidectomy has yet to be demonstrated. Possible advantages of endoscopic thyroid techniques and our patient’s desire for the highest cosmetic outcome possible justify further development of ET in expert hands of endocrine surgeons.