Minimally invasive thyroidectomy using the Sofferman technique

Surgical outcomes of minimally invasive thyroidectomy in thyroid cancer: comparison with conventional open thyroidectomy

Background

Minimally invasive thyroidectomy (MIT) is a safe method of performing thyroidectomy with notable benefits, such as improved cosmesis and reduced postoperative pain. The objective of this retrospective study was to report our experience with the technical feasibility of MIT, and compare its early surgical outcomes with those of conventional open thyroidectomy (COT) in patients with differentiated thyroid carcinoma (DTC).

Methods

A total of 617 patients who underwent MIT and 2,674 patients who underwent COT were reviewed between March 2006 and November 2017 at Yonsei University (Seoul, Korea). The mean follow-up duration was 41.2±19.7 months.

Results

The mean age of patients with DTC was 46.1±11.2 years. The mean operation time in the MIT group was significantly shorter than that of the COT group (63.5±26.2 vs. 85.3±36.8 minutes, P<0.001). The mean hospital stay was significantly shorter in the MIT group than it was in the COT group as well (2.7±0.6 vs. 3.1±0.8 days, P<0.001). There were significantly fewer painkillers used after surgery in the MIT group than in the COT group (1.2±0.5 vs. 2.7±1.6, P<0.001). The mean number of harvested LNs in the MIT group was significantly lower than that of the COT group (3.1±2.6 vs. 5.5±4.0, P<0.001).

Conclusions

This study demonstrated that MIT is technically feasible in patients with DTC. MIT is a valuable alternative operative technique to COT with good surgical outcomes and outstanding cosmetic results.

Application of minimal invasive technique for thyroidectomy without remote access in locally advanced thyroid carcinoma with gross extra-thyroidal extension

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Minimally invasive thyroidectomy (MIT) is useful and famous technique that is being applied to thyroid carcinoma.

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MIT without remote access is useful and applicable in thyroid disease and carcinoma in terms of cost effect and cosmetic outcome.

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MIT without remote access can be feasible method for thyroid carcinoma with gross extra-thyroidal extension, especially, upper pole carcinoma.

Introduction

Minimally invasive thyroidectomy (MIT) is technically less damaging tissue and is better cosmetic results with small neck scar, decreasing postoperative pain and neck discomfort. We present the experience of MIT without remote access with case of grossly extra-thyroidal extension positive papillary thyroid carcinoma.

Presentation of case

A 44-year-old, female presented 1.6 cm irregular hypoechoic nodule at upper pole in Right thyroid gland and diagnosed to papillary thyroid carcinoma. The tumor was suspicious to have extra-thyroidal extension. We performed MIT without remote access for this patient with 2 cm cervical incision. Postoperative course was uneventful and patient was discharged on the 3th postoperative day. At present, she is taking 100mcg levothyroxine and is free of disease 3 years post-surgery.

Conclusion

If experienced surgeons can get sufficient resection margin and control bleeding of superior thyroid artery, MIT without remote access can be feasible method for thyroid carcinoma with gross extra-thyroidal extension, especially, upper pole carcinoma.

The advantages of extended subplatysmal dissection in thyroid surgery-the "mobile window" technique

PURPOSE

Minimal access thyroidectomy, using various techniques, is widely known, but respective data on thyroidectomy for thyroid cancer with lymphadenectomy is scarce. The present study aims to evaluate the feasability of extended subplatysmal dissection in combination with a small incision ("mobile window" technique).

METHODS

A retrospective study was performed analysing data from 93 patients. All patients suffered from thyroid carcinoma and underwent (total) thyroidectomy, bilateral cervico-central (levels VI and VII) and functional lateral neck dissection (levels II to V) on the side of the malignancy. In group A, consisting of 47 patients, the operation was performed by a traditional Kocher incision (minimal range 6-7 cm), in 46 patients (group B) a mini-incision (≤4 cm) was made. Intra- and postoperative morbidity as well as oncological accuracy were assessed.

RESULTS

There was no significant difference between the two groups comparing postoperative pathological diagnosis, intra- and postoperative complications and the number of removed lymph nodes. However, operating time was slightly longer in group A and thyroid weight was heavier in group B.

CONCLUSIONS

Extended subplatymsal dissection allows thyroidectomy and even lateral lymphadenectomy for thyroid carcinoma via "mobile" mini-incision. The procedure is safe, of equivalent oncological accuracy compared to traditional incision and the cosmetic results are excellent.

Outpatient thyroid surgery is safe and desirable

Background

Thyroid surgery has traditionally been done on an inpatient basis. With the advent of minimal access techniques, drains are frequently not required and ambulatory thyroidectomy is possible.

Design

Prospective, nonrandomized analysis of consecutive series of patients.

Methods And Materials

Patients undergoing thyroid surgery between 12/1/04 and 10/31/05 were stratified based on admission status. Demographic data were collected and outcome measures were considered.

Results

Ninety-one patients underwent thyroid surgery. Fifty-two were done on an outpatient basis, 26 patients were observed under a 23-hour status, and 13 were admitted. There were two complications in the outpatient group and one in the inpatient group ( P = 1.0). Costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288; P < 0.0001).

Significance

In carefully selected patients who prefer convalescence at home, outpatient thyroidectomy can be performed safely and cost-effectively, particularly when prophylactic calcium supplementation is utilized after total thyroidectomy to prevent transient postoperative hypocalcemia.

Minimal incision for open thyroidectomy

Objectives

To establish the incision length for thyroid surgery that optimizes access and cosmesis.

Study Design and Setting

Prospective study from January 2003 to June 2004. All thyroidectomies were included. Exclusion criteria were concomitant neck dissections, previous surgery, and those performed endoscopically. The first 40 cases were attempted through a 5 cm incision and the second 40 through a 4 cm incision.

Methods

In both groups, the size of the incision was compared with the thyroid's weight and histology.

Results

Two subtotal, 22 total, and 56 hemithyroidectomies were performed. In the first group, median gland weight was 39.5 gm and 62.5% of these were removed through a 5 cm incision. In the second group, median gland weight was 34 gm and 75% were removed through a 4 cm incision.

Conclusion

A 4 cm incision provides adequate access for the majority of thyroidectomies in our cohort.

Significance

The minimal incision thyroidectomy is a useful addition to the thyroid surgeon's armamentarium. EBM rating: B-3b

Minimally invasive nonendoscopic thyroidectomy

OBJECTIVES: Minimal-access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach (MIT).

STUDY DESIGN: Between October 2002 and December 2004, a prospective nonrandomized study of patients undergoing thyroid surgery was performed to evaluate the variables that might condition the indications to minimally invasive nonendoscopic approach.

RESULTS: 296 patients underwent thyroid surgery; 46 of these were eligible for MIT through a 2.5- to 3-cm incision. There was one case of transient inferior laryngeal nerve palsy and no postoperative definitive hypoparathyroidism. MIT was converted to conventional thyroidectomy only in two cases. Cosmetic results were considered excellent by all patients.

CONCLUSIONS: Minimal-access thyroid surgery is a safe and feasible alternative to conventional thyroid surgery in selected cases. The advantage that this technique offers, in addition to low morbidity, is an improved cosmetic result.

A Review on the History of 'Thyroid Surgery'

The history of thyroid surgery is both interesting and illustrative. The ambitions of a thyroid surgeon have evolved along the length of time. The objective of this article is to give an idea about the evolution of thyroid surgery thus giving inspiration to future surgeons in their quest for a perfect technique, which would take into consideration disease elimination and maintenance of physiology and cosmesis. The history of thyroid surgery back to as early as 952 AD, when Albucasis first performed the surgery. Thereafter, the course of this surgery had its crests and troughs. At one point of time, surgeons refused to perform this surgery because of the complications. But later on, surgeons like Billroth and Kocher gave this procedure a new leash of life, after which this surgery became popular and underwent numerous modifications to where now it stands. History reveals that thyroid surgery has travelled a long path in time. From an operation which once was considered dreadful to the present times when techniques are being tried to make the incision as small as possible. The quest is still on to develop the perfect technique.

Minimally invasive compared with conventional thyroidectomy for nodular goitre

Since minimally invasive thyroidectomy was introduced in 1997, different surgical approaches to the thyroid have been described: the minimal neck incision and the anterior chest, areolar breast or axillary access. Whereas conventional open thyroidectomy is suitable for any thyroid disease, minimal neck incision thyroidectomy or extracervical scarless neck thyroidectomy are limited to small-volume disease. In 11 prospective randomized studies and six systematic reviews, minimally invasive video-assisted thyroidectomy via a central or lateral neck approach afforded better cosmesis in the first 3 months than conventional open thyroidectomy, with less postoperative pain for the first 48 h. Surgical morbidity did not differ in these limited studies. No head-to-head comparison is available for extracervical scarless neck thyroidectomy and conventional open thyroidectomy. Extracervical scarless neck thyroidectomy caused more postoperative pain and gave rise to complications not seen with minimal neck incision thyroidectomy or conventional open thyroidectomy. In the absence of evidence to the contrary, conventional open thyroidectomy continues to remain the gold standard for any nodular goitre.

Stretch of the Minimally Invasive Incision during Thyroid and Parathyroid Surgery

Objective

Identify and quantify changes in length of the skin incision following minimally invasive thyroid and parathyroid surgery and determine whether these changes persist postoperatively.

Study Design

Cohort study.

Setting

Tertiary care teaching hospital.

Subjects and Methods

Between July 2012 and June 2013, a prospective, nonrandomized study was performed on 44 consecutive patients undergoing open cervical minimally invasive thyroidectomy (incision approximately 6 cm or less) or minimally invasive parathyroidectomy (incision approximately 3 cm or less). Incision length was measured following initial incision, immediately after wound closure, and on postoperative follow-up at 2-week and 14-week visits.

Results

Thirty-one patients underwent minimally invasive thyroidectomy or parathyroidectomy with initial incision lengths ranging from 20 mm to 60 mm. Seven patients (21%) underwent total thyroidectomy with a mean length of 45 ± 8 mm, 15 patients (44%) underwent unilateral thyroid lobectomy with a mean length of 37 ± 5 mm, and 9 patients (26%) underwent parathyroidectomy with a mean length of 28 ± 2 mm. On average, the skin incision lengthened by 3.0 ± 0.9 mm during surgery representing an intraoperative stretch of 8.0% ( P < .0001). Incision lengths decreased by an average of 0.3 mm at 2-week postoperative follow-up ( ns) and 6.3 mm at 14-week postoperative follow-up ( P < .0001).

Conclusion

Significant intraoperative incision stretch is likely to occur during minimally invasive thyroid and parathyroid surgery. Postoperative follow-up data suggest that the increase in incision length is not permanent and resolves upon postoperative follow-up.

Factors influencing the length of the incision and the operating time for total thyroidectomy

BACKGROUND

The incision used for thyroid surgery has become shorter over time, from the classical 10 cm long Kocher incision to the shortest 15 mm access achieved with Minimally Invasive Video-Assisted Thyroidectomy. This rather large interval encompasses many different possible technical choices, even if we just consider open surgery.The aim of the study was to assess the correlation between incision length and operation duration with a set of biometric and clinical factors and establish a rationale for the decision on the length of incision in open surgery.

METHODS

Ninety-seven consecutive patients scheduled for total thyroidectomy were prospectively evaluated. All operations were performed by the same team and the surgeon decided the length of the incision according to his personal judgement. Patients who had previously undergone neck surgery were excluded.

RESULTS

The length of the incision was strongly correlated with gender, thyroid volume, neck circumference and clinical diagnosis and weakly correlated with the body mass index. Operation duration was only weakly correlated with gender and neck circumference. Multiple linear regression revealed that the set of factors assessed explained almost 60 % of the variance in incision length but only 20 % of the variance in operation duration. When patients were classified according to the distribution of their thyroid volume, cases within one standard deviation of the mean did not show a significant difference in terms of operation duration with incisions of various lengths.

CONCLUSIONS

Although thyroid volume was a major factor in driving the decision with respect to the length of the incision, our study shows that it had only minor effect on the duration of the operation. Many more open thyroidectomies could therefore be safely performed with shorter incisions, especially in women. Duration of the operation is probably more closely linked to the inherent technical difficulty of each case.

Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: A single-blinded, randomized controlled clinical trial

We aimed to test the hypothesis that Minimally Invasive Video-assisted Thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery, when dealing with patients with unilateral thyroid nodules or follicular lesions, in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain and hospital stay.

MATERIALS AND METHODS

This was a single-blinded randomised controlled trial comparing the MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain after 24 and 48 hours from operation and self-rated patient satisfaction with cosmetic outcome three months postoperatively. The secondary outcome measures were operative time, incidence of temporary and permanent recurrent laryngeal nerve injury, postoperative haematoma formation, length of incision, and duration of hospital stay.

RESULTS

Operative time was significantly less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Blood loss did not reach significance between procedures. Comparisons between the two procedures with regard to pain scores after 24 and 48 hours, respectively, depicted statistically significant differences in favour of the MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfactory cosmetic results. There were statistically no significant differences between both procedures for the presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism.

CONCLUSIONS

MIVAT is a safe procedure that produces outcomes, in view of short-term adverse events, similar to those of open thyroidectomy, and is superior in terms of immediate postoperative pain and cosmetic results.

Flapless conventional thyroidectomy: a prospective, randomized study

PURPOSE

Conventional thyroid surgery is one of the most common operations performed worldwide. The conventional technique involves placement of small or large cutaneous flaps. However, the published data regarding flap use for thyroidectomy are contradictory. This study presents the results using a flapless conventional thyroidectomy and the efficacy of this approach in a thyroidectomy. In addition, the study determined whether there are any advantages associated with the use of this approach in comparison to conventional thyroid surgery.

METHODS

One hundred and forty-two patients underwent a thyroidectomy. The patients were randomly assigned to surgical procedures. Patients in Group 1 (n = 70) underwent a conventional thyroidectomy, and patients in Group 2 (n = 70) underwent a conventional thyroidectomy without a cutaneous flap.

RESULTS

There was no significant difference between the two groups in terms of age, sex, body mass index, length of incision, gland volume, and length of hospital stay. Postoperative pain was significantly less in Group 2 than in Group 1 (P = 0.006). Patients in Group 2 showed significantly lower requirement for postoperative intravenous analgesic (P = 0.001), and postoperative peroral analgesic (P = 0.023) in comparison to those in Group 1. Incidences of transient vocal cord paralysis and hypocalcemia were 1.4% and 1.4%, respectively. Of 140 patients, 5 (3.6%) developed postoperative wound complications.

CONCLUSIONS

These results indicate that a flapless thyroidectomy is safe and technically feasible, and therefore could be an alternative to a conventional thyroidectomy.

Minimally invasive, video-assisted thyroidectomy: first experience from the United Kingdom

INTRODUCTION

Minimally-invasive, video-assisted thyroidectomy (MIVAT) was developed to reduce scarring/trauma associated with cervical incisions used in open thyroidectomy. Results from various centres have been published internationally but none from the UK. This study reports the first results from the UK and compares them with other centres. We also aim to compare the results of a single-surgeon experience in a small/moderately-sized hospital to those of larger tertiary centres.

PATIENTS AND METHODS

Retrospective analysis of a single surgeon experience in a district general hospital

RESULTS

The cohort was 55 patients (52 female, 3 male), mean age 48 years (range, 21-77 years) who had 64 MIVAT procedures. There were 49 hemithyroidectomies (HTs), 2 isthmusectomy, 4 total thyroidectomies (TTs) and 9 completion thyroidectomies (CTs) with median operating time of 86 min (IQR 66-110 min). Individual operating times were HT 85 min (IQR 60-110 min); TT 130 min (IQR 100-140 min) and CT 77 min (IQR 70-98 min). Median operating time was shorter in the second half of this series (76 min vs 92 min; P < 0.001). Length of stay was < 1 day in 92%. Conversions occurred in 6.3% with no haematoma or re-operation. Transient voice change was present in 7 (11%), permanent unilateral recurrent laryngeal nerve palsy in 2 (3%), and transient hypocalcaemia in 2 (3%).

CONCLUSIONS

The first results from the UK are similar to those of other international centres. A single-surgeon practice can obtain results comparable to larger tertiary centres provided there is sufficient case-load. MIVAT is safe and effective, but has a steep learning curve with rapid improvement observed within first 30 cases. Future studies should focus on objective assessment of scar/cosmesis and cost-effectiveness. MIVAT is an acceptable alternative to open surgery in highly selected patients.

Minimally invasive video-assisted thyroidectomy: A retrospective study over two years of experience

Objective: The minimally invasive video-assisted thyroidectomy technique has slowly gained acceptance. Previous studies have reported advantages of better cosmetic results and faster postoperative recovery. We report preliminary results from our single assistant technique over the initial two years of inception at an academic training center.

Methods: This study consists of a retrospective chart review of 172 cases between May 2005 and September 2007. All cases started as video-assisted thyroidectomy were included. Demographic, pre- and postoperative clinical data, imaging results, and hospital stay were collected.

Results: Acceptable data were available for 24 male and 148 female patients who underwent the video-assisted procedure. Five cases were converted to the conventional thyroidectomy. Of the 172 cases, 60 total thyroidectomies and 112 hemithyroidectomies were performed, with 37 cases of malignancy. The average hospitalization was 1.43 days with mean incision length was 3.51 cm, mean surgical time of 91.37 minutes, and mean blood loss of 31 cc. Transient voice problems were noted in 10 patients.

Conclusion: We found statistically improved operative times, hospital stay, and blood loss the first 2 years with a low rate of temporary complications. It appears that minimally invasive video-assisted thyroidectomy is a safe and feasible option to standard thyroidectomy in selected patients.

Minimally invasive thyroid surgery for single nodules: an evidence-based review of the lateral mini-incision technique

BACKGROUND

Minimally invasive thyroidectomy techniques are being developed in an effort to minimize pain, shorten the length of hospital stay, and improve cosmesis. Various minimally invasive thyroid surgery (MITS) techniques have been shown to be safe and feasible with some benefits in terms of cosmesis and pain outcomes; however, no single technique has been broadly accepted. This study was designed to review the evidence in relation to MITS and our experience with the direct lateral mini-incision technique.

METHODS

A review of literature published until December 2007 on minimally invasive thyroidectomy techniques was undertaken. Three issues were addressed: 1) Does MITS provide any benefit compared with conventional open thyroidectomy? 2) Is there any advantage to the use of endoscopic or video-assisted techniques compared with the direct mini-incision technique? 3) Is the lateral mini-incision technique safe and efficacious? Additional data in relation to the above issues was derived from a retrospective cohort study of patients undergoing mini-incision thyroid surgery within our unit.

RESULTS

Issue 1: Five prospective randomized studies and eight studies at a lower level of evidence have demonstrated consistent advantages of MITS compared with open thyroid surgery in terms of reduced pain and improved cosmesis with equivalent operative safety. Issue 2: In compiling four level III and IV studies that compared open and video-assisted minimally invasive surgery, there do not seem to be significant differences in patient satisfaction with the incision. The video-assisted approaches require significantly longer operative times but also seem to be less painful. Issue 3: Three cohort studies (level IV) have demonstrated that the lateral mini-incision technique is both safe and efficacious compared with open surgery for hemi-thyroidectomy. Data from our cohort study of 1281 patients (open hemi-thyroidectomy 1054 vs. MITS 227) confirmed MITS to be a safe and effective procedure. The rate of postoperative hematoma formation and wound infection was equivalent between groups. The rate of permanent recurrent laryngeal nerve injury was 0.4% for MITS and 0.3% for CHT and not significantly different (p = 0.7).

CONCLUSIONS

MITS has demonstrated advantages over conventional open approaches for both hemi- and total thyroidectomy and the benefits do not depend on the open or video-assisted approach. For thyroid lobectomies, the lateral mini-incision approach can be performed with an operative time and postoperative complication profile equivalent to conventional hemi-thyroidectomy while providing excellent cosmesis with a 2-3 cm scar.

Minimally invasive video-assisted thyroidectomy for benign thyroid disease: an evidence-based review

BACKGROUND

A decade after nearly all surgical disciplines developed minimally invasive techniques, the first report of a single case of minimally invasive thyroidectomy was published. Minimally invasive video-assisted thyroidectomy (MIVAT) is now considered the most widely practiced and most easily reproducible minimally invasive procedure for thyroidectomy. The aim of this review was to analyze the treatment of benign thyroid diseases by MIVAT.

METHODS

A systematic evidence-based literature review focusing on three questions was carried out. Additional data were obtained on the basis of our personal experience. (1) Are minimally invasive procedures indicated in the treatment of thyroid diseases? (2) Is MIVAT a safe technique and what are the demonstrated advantages? (3) Since different thyroid diseases may be treated by MIVAT, is it of any value in the treatment of benign thyroid diseases?

RESULTS

MIVAT can be considered an appropriate treatment of some thyroid diseases; it represents a safe procedure with the same incidence of complications as traditional surgery, and also has advantages in terms of both cosmetic result and postoperative distress.

CONCLUSIONS

In spite of an increasing trend toward performing more extensive procedures other than thyroidectomy alone during videoscopic procedures, the current literature seems to reaffirm that the main and safest indication for MIVAT is benign disease.

Minimally invasive video-assisted thyroidectomy for small follicular thyroid nodules

Minimal access surgery in the thyroid compartment has evolved considerably over the past 10 years and now takes many forms. This study examined the feasibility and reliability of minimally invasive thyroid surgery for the management of small benign thyroid lesions. A total of 68 patients with small thyroid nodules admitted to the Oncology Center of Mansoura University, Egypt, were enrolled in this prospective randomized trial. Patients were allotted to one of two procedures: minimally invasive video-assisted thyroidectomy (MIVAT) or minimally invasive open thyroidectomy using the Sofferman technique of strap muscle transection. Exclusion criteria were nodules > 4 cm, presence of thyroiditis, and thyroid gland volume > 20 ml. Preoperative diagnosis, operating time, blood loss, postoperative pain, complications, and cosmetic outcome were all evaluated. The MIVAT group included 35 patients, and the Sofferman group included 33 patients. The main preoperative pathology was a benign follicular lesion (70.5%), and the main postoperative final pathology was follicular adenoma (54.4%). The two groups were comparable regarding age, sex, and extent of thyroid surgery. Operating time was significantly longer in the MIVAT group (115.4 +/- 33.5 minutes) compared to the Sofferman group (65.6 +/- 23.7 minutes). The postoperative course was significantly less painful in the MIVAT group (p < 0.05). Although patients in the MIVAT group had smaller incisions (p < 0.05), the cosmetic outcome in the two groups was comparable. No long-term complication was encountered in either group. Two distinct approaches of minimally invasive thyroidectomy are now available and can be performed safely in selected patients. Despite some MIVAT advantages of less postoperative pain and slightly better cosmesis, minimally invasive open thyroidectomy offers an advantage of less operating time with comparable cosmetic results.

Cosmetic thyroid surgery: defining the essential principles

OBJECTIVES

Minimally invasive thyroid surgery is rapidly becoming a common approach in busy endocrine surgery practices. The surgical concepts necessarily include a number of principles found within the realm of plastic surgery.

DESIGN

The study was a prospective, nonrandomized analysis of a consecutive series of thyroid surgical patients.

METHODS AND MATERIALS

All patients who underwent thyroid surgery at the Medical College of Georgia in the Department of Otolaryngology were prospectively evaluated. Recommendations for endoscopic thyroidectomy, minimally invasive nonendoscopic thyroidectomy (MINET), or conventional thyroid surgery were based on patient and disease parameters as previously described. Specific factors contributing to improved cosmetic outcomes were sought.

RESULTS

Two hundred forty-eight patients underwent thyroidectomy between September 2003 and June 2006. There were 50 males and 198 females, with a mean age of 44.9 +/- 14.6 years. Seventy-seven (31.0%) patients underwent conventional thyroidectomy (group A), 120 (48.4%) patients had MINET (group B), and the remaining 51 (20.6%) patients underwent thyroidectomy with an endoscopic technique (Group C). Incision lengths were 92.4 +/- 22.3 mm in Group A, 46.4 +/- 9.9 mm in Group B, and 24.3 +/- 5.9 mm in Group C. The factors that contributed most to an optimal cosmetic result were marking the patient while he or she was sitting up prior to surgery, resecting skin edges during closure, avoidance of subplatysmal flap elevation and drains, and use of Dermabond.

CONCLUSIONS

Achieving an optimal cosmetic result when performing thyroid surgery is easiest when oneapplies a number of principles, including elements normally associated with plastic surgery.

Ultrasonic Technology Facilitates Minimal Access Thyroid Surgery

OBJECTIVES

Options for controlling the vasculature during thyroid surgery include suture ligatures, vessel clips, and bipolar cautery. Ultrasonic technology represents an alternative to conventional techniques in which the vessels are simultaneously sealed and divided. We sought to determine the safety and efficacy of thyroidectomy with ultrasonic technology.

DESIGN

Nonrandomized, prospective analysis of a series of patients undergoing thyroidectomy at the Medical College of Georgia.

METHODS AND MATERIALS

The records of 51 consecutive patients who underwent thyroid surgery between December 2004 and June 2005 were reviewed. Patients in whom ultrasonic technology (Harmonic-ACE, Ethicon Endo-Surgery, Cincinnati, OH) was used comprised the study population.

RESULTS

Forty-four of 51 patients underwent thyroidectomy with the assistance of ultrasonic technology. There were 4 males and 40 females with a mean age of 43.5 +/- 15.8 years. Twenty-two patients had a total thyroidectomy, 18 underwent unilateral lobectomy, and 4 underwent completion thyroidectomy. The overall mean incision length was 5.0 +/- 2.6 (range 2-12) cm. A subgroup of patients underwent minimally invasive video-assisted thyroidectomy (n = 13) and had a mean incision length of 29.3 +/- 0.8 mm. There were no cases of permanent injury to the recurrent laryngeal nerve and no cases of persistent hypoparathyroidism. Blood loss ranged from 5 mL to 100 mL, with a mean of 26.7 +/- 21.8 mL.

CONCLUSIONS

Ultrasonic technology facilitates thyroid surgery, particularly when a minimally invasive approach is undertaken. It reliably seals and divides the thyroid vasculature and will likely replace other methods of managing the thyroid blood supply.

Minimally Invasive Thyroidectomy: Basic and Advanced Techniques

OBJECTIVE

Minimal access surgery in the thyroid compartment has evolved considerably over the past 10 years and now takes many forms. We advocate at least two distinct approaches, depending on the disease process and multiple patient factors. The technical aspects are explored in depth with liberal use of videographic demonstration.

METHODS

The authors conducted a comparison of two distinct surgical techniques with photographic and videographic documentation of two distinct minimal access approaches to the thyroid compartment termed minimally invasive thyroidectomy (MITh) and minimally invasive video-assisted thyroidectomy (MIVAT). Both historic and previously unpublished data (age, gender, pathology, incision length, and complications) are systematically analyzed.

RESULTS

Patients who underwent minimally invasive thyroidectomy (n = 31) had a mean age of 39.4 +/- 10.7 years; seven were male and 24 were female. The most common diagnosis was follicular or Hürthle cell adenoma (29%), followed by papillary or follicular cancer (26%). The mean incision length was 4.9 +/- 1.0 cm. One patient developed a hypertrophic scar and one patient developed thrombophlebitis of the anterior jugular vein. There were 14 patients in the MIVAT group with a mean age of 43.7 +/- 11.4 years; one was male and 13 were female. The majority of patients had follicular adenoma (42.9%) or papillary carcinoma (21.4%) as their primary diagnosis. The mean incision length was 25 +/- 4.3 mm (range, 20-30 mm), and there were no complications.

CONCLUSIONS

Two distinct approaches to minimal access thyroid surgery are now available. The choice of approach depends on a number of patient and disease factors. Careful patient selection will result in continued safe and satisfactory performance of minimally invasive thyroid surgery.