Ultrasonic Technology Facilitates Minimal Access Thyroid Surgery

Radiofrequency dissection versus 'knot tying' in conventional total thyroidectomy

OBJECTIVE

To evaluate the safety and effectiveness of radiofrequency dissection in conventional 'open' total thyroidectomy.

METHODS

Thirty-nine patients scheduled for conventional total thyroidectomy were included in a prospective randomised study. Patients were randomly assigned to one of two groups: a radiofrequency dissection method was used in one group, and a knot tying technique was used in the other.

RESULTS

Significantly fewer surgical instruments and materials were required for the radiofrequency dissection group than the knot tying group (p < 0.01). There were no significant differences between the two groups in mean operative time, blood loss, post-operative drainage and pain, recurrent palsy, and hypocalcaemia (p > 0.05).

CONCLUSION

Radiofrequency dissection is a safe alternative to the knot tying technique, and enables a significant reduction in the number of surgical instruments required for the operation.

Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: a cost-effective analysis

OBJECTIVE

To compare the cost of minimally invasive video-assisted thyroidectomy (MIVAT) with conventional thyroidectomy.

STUDY DESIGN

A cost-effectiveness study and chart review.

SETTING

Academic university hospital.

SUBJECTS AND METHODS

Pediatric and adult patients referred to the Department of Otolaryngology-Head and Neck Surgery for suspicious thyroid nodules, goiters, or known carcinomas. A tertiary care hospital's billing department was queried for all hemithyroidectomies and total thyroidectomies completed by the Department of Otolaryngology-Head and Neck Surgery between January 5, 2006, and November 1, 2007. The charges, including surgery, hospital, pathology, and anesthesia, for minimally invasive video-assisted thyroidectomy (MIVAT) and traditional or minimally invasive open thyroidectomies meeting MIVAT inclusion criteria were then reviewed retrospectively and compared statistically.

RESULTS

A total of 185 thyroidectomies were performed, 50.3 percent of which met criteria for MIVAT. Length of stay (days) was significantly shorter for patients undergoing MIVAT hemithyroidectomy (mean difference -0.8; 95% confidence interval [95% CI] -1.08 to -0.52) and not significantly different between groups for total thyroidectomy (mean difference 0.1; 95% CI -0.36 to 0.56). Mean anesthesia cost (U.S.$) was similar between groups for hemi- and total thyroidectomies. MIVAT mean pathology cost was significantly less than open thyroidectomy for hemithyroidectomy (mean difference -89.9; 95% CI -179.01 to -0.79) and approached significance for total thyroidectomy. There was no significant difference in hospital cost and total cost for hemithyroidectomy and total thyroidectomy.

CONCLUSION

In a group of matched cohorts, the cost of MIVAT appears to be equal to that of open thyroidectomy.

Endoscope-assisted partial-superficial parotidectomy through two small skin incisions

CONCLUSION

Endoscope-assisted partial-superficial parotidectomy is a feasible method for treatment of benign parotid superficial lobe tumors located at the anterior or the inferior of the auricular lobule. The main advantage of this procedure is that the small operative scar resulted in improved cosmetic results.

OBJECTIVES

This study evaluated the feasibility of endoscope-assisted partial parotidectomy through two small skin incisions.

PATIENTS AND METHODS

Thirty cases with benign parotid superficial lobe tumors with a diameter < 30 mm located at the anterior or the inferior of the auricular lobule underwent endoscope-assisted partial-superficial parotidectomy via retrograde approach through two small skin incisions.

RESULTS

All 30 operations were successfully performed endoscopically. All the patients were satisfied with the cosmetic results. Only three patients had transient facial paresis and recovered in 1-2 months. The endoscopic surgery lasted for 106.48+/-12.62 min. There was no tumor recurrence during the follow-up after 26-50 months.

Outpatient thyroid surgery and the advances making it possible

PURPOSE OF REVIEW

To review the literature regarding the safety and feasibility of outpatient thyroid surgery.

RECENT FINDINGS

Outpatient thyroidectomy is increasingly reported especially for hemithyroidectomy. Meta-analysis of 11 randomized trials comparing routine drain with no drains found no significant difference in respiratory distress or wound reexploration but found an increased length of stay with drain usage. In addition to risk from delayed hematoma formation, risk of hypocalcemia developing from hypoparathyroidism has traditionally challenged outpatient total or completion thyroidectomy. Routine calcium and vitamin D supplementation has been shown to reduce the risk of hypocalcemia. A meta-analysis of rapid postoperative parathyroid hormone (PTH) measurement confirmed a significantly increased risk of hypocalcemia for PTH less than 15 pg/ml.

SUMMARY

Outpatient thyroidectomy is increasingly performed and reported. The senior author currently offers outpatient thyroidectomy for patients not requiring drain placement (smaller goiters without significant blood loss) and with postanesthesia care unit PTH levels of at least 30 pg/ml or with postanesthesia care unit PTH levels of at least 20 pg/ml with oral calcium supplementation.

Ultrasonic technology: a new treatment option for anal condylomata acuminata

PURPOSE

Treatment options for anal and perianal warts caused by human papillomavirus include topical application of cytotoxic substances or immunomodulators and ablative procedures. The objective of this prospective study was the evaluation of the ultrasound-driven Harmonic Scalpel (Ethicon Endo-Surgery, Norderstedt, Germany) for resection of anal and perianal condylomata acuminata.

METHODS

Eight men and three women (age range, 26-72 years) with anal and perianal condylomata acuminata were treated by a Harmonic Scalpel blade operating at a vibration frequency of 55.5 kHz and within a temperature range of 65 degrees C to 120 degrees C. Nine patients were treatment naïve, and two patients had recurrent disease. Follow-up ranged from 4 to 26 months.

RESULTS

Seven patients had perianal condylomata, two patients had exclusively intra-anal, and two patients had perianal and intra-anal warts. All condylomata were excised in a single-step procedure with complete clearing without injury of subepidermal layers. We observed no intraoperative or postoperative complications. No recurrences occurred during follow-up.

CONCLUSIONS

The Harmonic Scalpel has been an effective and safe method for the treatment of anal perianal human papillomavirus condylomata without recurrent warts. Subepidermal skin levels remained uninjured; thus, no complications or unsatisfactory cosmesis occurred.

Ultrasonic harmonic scalpel in total thyroidectomies

INTRODUCTION

Haemostasis is very important in thyroid surgery. In conventional surgery, electrocoagulation and suture ligation are used for haemostasis; newer techniques include vessel clips, ultrasonic instruments and lasers. The aim of this prospective study was to compare the usage of the ultrasonic harmonic scalpel (UHS) with conventional procedures, in total thyroidectomies, for operation time, blood loss, usage of drain, cost, length of hospitalisation and complications.

METHODS

We examined 104 patients who underwent bilateral total thyroidectomy. They were divided randomly into two groups. Patients in Group I (n=54) underwent operations using conventional techniques (electrocautery and suture ligation) while patients in Group II (n=50) underwent operations using the UHS. Operation time, number of ligatures used, blood loss, intra-operative complications, weight of the specimen, necessity of drain, postoperative seroma, bleeding, infection, transient or permanent hypocalcaemia, permanent recurrent laryngeal nerve palsy and length of hospitalisation were recorded.

RESULTS

The operation time was significantly longer in Group I (conventional) (105+/-16 minutes; mean+/-standard deviation) than Group II (UHS) (77.9+/-12.5 minutes; P<0.001). The mean blood loss was less in patients who were operated on with the UHS (25.3+/-10.2 g) than in patients operated on with conventional methods (59.5+/-33.9 g; P<0.001). The mean number of ligatures used in the UHS group was 5.3, which was significantly fewer than the mean of 51.6 ligatures used in the conventional methods group (P<0.001). Drains were also used less in the UHS operations (12%-59%; P<0.001).

CONCLUSION

Use of the UHS in thyroid surgery results in decreased operation time, drain usage and amount of bleeding and does not increase postoperative complications. The UHS is an effective, reliable and less expensive technique for thyroid surgery.

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.

Clinical Implementation of Endoscopic Thyroidectomy in Selected Patients

OBJECTIVES

Systematic investigation of minimal access thyroid compartment surgery combined with the advent of several key new technologies has culminated in the implementation of endoscopic thyroidectomy in specific clinical situations.

STUDY DESIGN

: The authors conducted a prospective, nonrandomized analysis of a consecutive cohort of surgical patients from the Medical College of Georgia Thyroid Center.

METHODS AND MATERIALS

A series of patients meeting specific criteria underwent thyroid surgery with the intention of performing endoscopic thyroidectomy. Demographic and clinical data were prospectively collected and included age, gender, indications for surgery, length of incision, need for conversion, and pathology.

RESULTS

Thirty-five patients successfully underwent 36 endoscopic thyroidectomies between February 2005 and March 2006 (representing 28.8% of the 125 thyroidectomies done during that period of time). There were 32 females and three males with a mean age of 45.3 +/- 13.9 years. There were five total thyroidectomies and 31 hemithyroidectomies. The mean incision length was 24.2 +/- 0.5 mm. There were no cases of permanent hypocalcemia or recurrent laryngeal nerve paralysis. Factors that increased the difficulty of endoscopic surgery included obesity, the presence of thyroiditis, and nodules >2.5 cm.

CONCLUSIONS

The combination of new technology and careful experimental investigation has spawned a new era of thyroidectomy in which definitive management of thyroid pathology may be accomplished through an incision of <1 inch. This approach is feasible in the hands of surgeons with high-volume thyroidectomy practices who are comfortable with endoscopic principles. The cosmetic advantages are self-evident.