Thyroid. Although the risk of these complications cannot be eliminated entirely, they can be minimized in the hands of an experienced thyroid surgeon. 2). It is uncommon, but when it occurs after thyroidectomy, it is usually associated with Grave's disease. Fifty-one patients (42 PTC patients and 9 thyroid adenoma patients) were included in this study. A tube may be left in place to drain fluid and blood. The patients were placed in a supine position while the lesion side limb was extended 90 degrees after general anesthesia. In certain cases, the surgeon may choose to perform a near-total thyroidectomy in which a small piece of thyroid tissue is left behind usually in the area of the parathyroid glands and recurrent laryngeal nerve in order to avoid damaging these structures. Symptoms of hypocalcemia include numbness and tingling in your hands, soles of your feet and around your lips. These symptoms appear between 24 and 48 hours after surgery. This technique can be performed on incisions as small as 2.0 cm (0.8 inches), and generally has excellent healing and cosmetic result. In this study, we reported our initial experiences with 51 patients who underwent gasless endoscopic trans-axillary thyroid surgery performed by a single experienced surgeon. The median hospital stay was 1.67 0.74 (range 13) days. Surg Endosc. . Fifty-one patients (49 females and 2 males) received operations by gasless, endoscopic trans-axillary approaches with one patient whose operation was converted to open surgery because of internal jugular vein injury. All cases of this complication reported to date have been temporarily, and is related to compression of the brachial plexus from arm positioning during surgery. This procedure may also be appropriate for small, non-aggressive thyroid carcinomas less than 1cm. Minimally Invasive Thyroid Surgery The typical incision made for thyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collar bone. A, An extended low cervical collar incision is used when a lateral neck dissection is indicated. Opening of the chest in the surgical management of substernal goiter is rarely required. Huang Z, Qin H, Liao J, Meng L, Qin Y, Li B, et al. The majority of people will likely be candidates for this procedure. Patients who spend the night in the hospital are typically discharged by 10AM the next morning. By contrast, a television commentator with an 11-inch neck (Figure 42-3, A) and a 2-cm follicular neoplasm (Figure 42-3, B) is an ideal candidate for an endoscopic thyroidectomy. Springer Nature. 1999-2022. Excellent long-term cosmetic outcomes can be expected with minimally invasive endoscopic thyroid surgery (B). Moreno Llorente P, E AGL, Alberich Prats M, Francos Martnez JM, Garca Barrasa A. Surgical approaches to thyroid. A number of technological advances such as advanced energy devices for hemostasis, 1 high-resolution endoscopes for improved visualization, 2 and laryngeal nerve monitoring 3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions. Standard incisions that are placed too low, spanning this indented suprasternal notch region, may appear asymmetrical and tend to be hypertrophic in their midsegment as opposed to incisions higher, in a more uniform, cylindrical region of the neck. The Thyroid Center recommends taking Tylenol, Motrin, or Advil as the bottle directs around the clock for the first few days (as long as their overall health allows it). With the transformation of thyroid and parathyroid surgery since the late 1990s, there are now a variety of methods for accessing the thyroid and central neck. This approach accesses the thyroid through an incision inside the mouth. The length of the incision will vary depending on the thickness of the neck and the size of the gland or nodule, although it should be noted that virtually always the benign gland or nodule can be bigger than the incision itself, as these structures are compressible and can be manipulated through an incision smaller than the gland. Part of This approach involves making an incision in the center of your neck to directly access your thyroid gland. Prior to the operation, patients will need certain pre-operative testing to make sure that they are healthy enough and properly prepared for an operation. In cases of indeterminate lesions, some surgeons refer to a thyroid lobectomy as a diagnostic lobectomy because the main purpose of the operation is to make a diagnosis cancer or benign thyroid disease. Background Since Theodor Kocher reduced the mortality rate of thyroidectomy from the 40% reported by Billroth to 0.2% in 1895, a collar incision with open removal of the thyroid gland is the standard procedure [1, 2]. Have certain genes or a family member with goiters. Remote access is focused by many surgeons in the decade to be a feasible technique in thyroidectomy avoiding the neck scar caused by conventional surgery, which includes endoscopic or robotic approaches [16, 17]. n7z0#L1gV>>Z1>~G|s1OG3(dzmJ ')6bF1]/Bpp During the 1850s, operations on the thyroid gland were undertaken via longitudinal, oblique, or vertical neck incisions. Patients now expect a more measured approach to their care, which sometimes includes quite small incisions (Figure 42-5). It seems no consensus has been reached on the clinical application of this technique considering the discrepant complications rate. A The retractors were used to maintain the working space during the operation. Temporary or sometimes permanent hypoparathyroidism (low blood calcium levels). Fortunately, in the hands of Columbia Thyroid Center surgeons, the risk of bleeding is less than 1%. When the goiter is caused by a noncancerous. Surg Oncol Clin N Am. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. This chapter contains additional online-only content, available on expertconsult.com. California Privacy Statement, Patients who are asked to stay overnight generally have very large goiters, advanced cancer, bleeding disorders, a history of taking anticoagulation, or have a personal preference to spend the night. There are two nerves called the recurrent laryngeal nerves that run just behind the thyroid. In conclusion, these results revealed that gasless, endoscopic trans-axillary thyroidectomy is a feasible surgery type with an acceptable safety profile and cosmetic outcomes in strictly selected patients. It is no longer sufficient to remove a thyroid, preserve the laryngeal nerves, and preserve the parathyroid glands (Figure 42-4). This percent decreases in older women, patients with a personal or family history of Hashimoto's thyroiditis or hypothyroidism, and patients with a family history of autoimmune disease. Johri G, Chand G, Mishra A, Mayilvaganan S, Agarwal G, Agarwal A, et al. low collar incision 3). This will disappear over the next 3 to 6 months. The dissected area is marked in red. Substernal Goiter Surgery. 2012;42:83541. In general, there are three types of thyroid resections: A total thyroidectomy may be done for a variety of diseases including thyroid cancer, Graves' disease (See Hyperthyroidism ), multinodular goiter, and substernal goiter, among others. However, the rate of complications is higher in individuals older than 60 years of age. Skin flaps were created deep to the platysma up to the hyoid bone and down to the suprastemal notch. The safety of gasless endoscopic trans-axillary thyroid surgery is still undetermined. Eur Arch Otorhinolaryngol. As the sternal head of the SCM was elevated by the retractor during the procedure, the decreased VRSs may be partly due to the shorter surgical time and improved surgical techniques. Based on this procedure, Kang et al. Classically 8-12 cm (3-5 inch) incisions were performed. Because there is no more gland to produce thyroid hormone after a total thyroidectomy, patients are dependent on long-term thyroid hormone supplementation after surgery. The thyroidectomy (near or total), as we know it today, began in the 1860s with the help of Billroth [ 5 ]. This study was reviewed and approved by the Ethics Committee of Xiangya Hospital, Central South University (No. . The optimal position in which to mark the anticipated thyroid incision is with the patient seated upright in the holding area. 14,17,18 Indications for OMIT are defined as thyroid volume >30ml but <70-80ml and a dominant nodule . Figure 42-7 When a large thyroid lobe is delivered through small incisions, it is not uncommon to observe evidence of an ischemic or traumatized skin edge (A). After a completion thyroidectomy, patients will need to take thyroid hormone replacement pills (one pill a day for the rest of their lives). Please see the Expert Consult website for more discussion of this topic, including Figure 42-1. J Laparoendosc Adv Surg Tech A. The stiffness and paraesthesia of the SCM resulting from the division of the SCM are also relieved over time. AN INCISION (CUT) THAT WILL REQUIRE SPECIAL CARE. Thyroid cancer often spreads to lymph nodes in the neck. 2021;99:26775. In each patient, the indication for surgery was a small nodule of unclear malignant potential. Provided by the Springer Nature SharedIt content-sharing initiative. With the transformation of thyroid and parathyroid surgery since the late 1990s, there are now a variety of methods for accessing the thyroid and central neck. The mean age was 34 years old, ranging from 19 to 45 years. Prophylactic unilateral lymphadenectomy was also routinely performed among patients with thyroid cancer including the prelaryngeal, pretracheal, and ipsilateral paratracheal areas (Fig. None of the patients developed hypoparathyroidism, esophageal injury, or surgical site infection after the surgery. Figure 42-5 Delivery of a thyroid lobe through a minimal access incision (A), which is just big enough to admit the gland. The VRSs in a short time (1 week) were significantly higher in the first 25 cases than in the last 25 cases (the patient whose operation was converted to open surgery was excluded). They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement. This test is used in patients with hoarseness, a previous neck operation, or cases of advanced cancer. We have been using this approach since 1999. A seroma is a collection of fluid under the incision. Meanwhile, prospective clinical studies are needed to investigate and validate surgical and oncological outcomes. In the absence of contraindications, substernal goiter should be treated with early surgery rather than having it run the risk of acute airway distress, especially in younger patients. Thus, gasless endoscopic thyroidectomy without the assistance of robots might be more suitable. In addition to classifying the extent of surgical resection, a number of surgical approaches have been described. The best way to identify the proper crease and overall location is with the patient sitting upright in the preoperative holding area rather than waiting until the patient is lying supine on an operating table (Figure 42-6). See additional information. A 5- to 7-cm arc incision was made along the dermatoglyphic direction, 1-2 cm above the sternal notch. It is not common to need these additional tests, but they may include: Fiberoptic laryngoscopy: This test allows the surgeon to look at how well the vocal cords are moving by passing a thin flexible camera through the nose into the airway. It is critical to work with a team of thyroid specialists to choose the right operation for each individual patient. The internal jugular vein was injured in two of the patients during the making of working space, one patients operation was converted to open surgery. Gasless, endoscopic trans-axillary thyroid surgery is a feasible procedure with acceptable safety and better cosmetic results in strictly selected patients. This can also happen after parathyroid surgery. Only two patients developed temporary vocal cord paralysis and no patients developed other severe complications. While the conventional collar incision is widely used, endoscopic thyroidectomy is gradually becoming accepted for thyroid nodule patients with cosmetic needs [2,3,4]. Seromas happen rarely and usually disappear within a few weeks. Popular incisions included the Lahey incision (Figure 42-1. 1). Written informed consent for publication of their clinical details and clinical images was obtained from all patients. All rights reserved. A number of technological advances such as advanced energy devices for hemostasis,1 high-resolution endoscopes for improved visualization,2 and laryngeal nerve monitoring3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions.4 Also emerging are techniques for remote access thyroid and parathyroid surgery.5,6 Conventional surgery remains necessary in many circumstances, such as for large substernal goiters or advanced malignancy, and will remain in the endocrine surgeons armamentarium. Terms of Use. FDX conceived of the design of the study. Call (212) 305-0444 or request an appointment online. 2020;44:411826. WBX and ZYZ drafted the Result, Discussion, and Conclusion sections. It is important to minimize the amount of trauma to the skin edge, either from retraction or from inadvertent instrument trauma (for example, electrocautery and ultrasonic energy burns or gauze abrasion). Most people will not be able to notice the incision once the redness fades away. Furthermore, the sensory change and paralysis results from this technique and patients satisfaction with the cosmesis were also studied. The length of the incision will vary depending on the thickness of the neck and the size of the gland or nodule, although it should be noted that virtually always the benign gland or nodule can be bigger than the incision itself, as these structures are compressible and can be manipulated through an incision smaller than the gland. Next, a vertical cut will be made through the strap-like muscles located just below the skin, and these muscles . Our data indicated that sensory changes around the anterior chest are relieved over time in most cases. The procedure is not indicated for aggressive thyroid cancers, for very large tumors, or tumors with significant inflammation such as severe Hashimotos thyroiditis, Graves disease, or in patients who are significantly obese or have abnormalities of shoulder function. Bilateral axillary approach for total thyroidectomy ensures better identification of recurrent laryngeal nerve (RLN) and PTG on both sides. The retractors (Kangji, Hangzhou, China) were used to maintain the working space during the operation. By using this website, you agree to our Kang JB, Kim EY, Park YL, Park CH, Yun JS. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be as small as possible, as big as necessary, therefore perhaps qualifying him as the first minimally invasive surgeon. If the seroma is large, the surgeon may drain it with a small needle. Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve or fix the voice. The primary advantage of this surgical procedure is avoidance of an incision on the neck. XYL and HOY drafted the Methods sections. The surgical procedure was similar to the methods described by other surgeon groups [11, 12]. A comparison of postoperative pain after conventional open thyroidectomy and single-incision, gasless, endoscopic transaxillary thyroidectomy: a single institute prospective study. 2013;9:11621. With careful preoperative testing and thoughtful consideration of the type of anesthesia, including the type of intubation, preparation for surgery can be optimized. Temporarily lowered calcium levels occur in approximately 15-40% of patients, and is treatable with calcium and vitamin D supplementation post-operatively. The average drainage volume was 48.0 24.4 ml (20100 ml) on day one and 13.7 5.6 ml (1030 ml) on day two. After the seventh day, reduce the calcium to one Tums Ultra 1000 tablet three times a day until your follow-up appointment. A number of surgical procedures and surgical approaches have been developed and the terminology can be confusing. Yan HC, Xiang C, Wang Y, Wang P. Scarless endoscopic thyroidectomy (SET) lateral neck dissection for papillary thyroid carcinoma through breast approach: 10 years of experience. In this operation, an incision is made in the axilla (armpit) and dissection is carried superiorly across the collar bone into the neck. The system also has tremor filtration and scaling of movements to eliminate tremor and allow very fine microsurgical movements if needed. Only gold members can continue reading. %PDF-1.6 % However, the da Vinci system is blamed for a prolonged surgery duration and a significantly higher economic cost. 4 Also emerging are techniques for remote access thyroid and 2011;25:161723. Jsls. Injury of internal jugular vein (IJV) in two cases. Single-incision, gasless, endoscopic trans-axillary total thyroidectomy: a feasible and oncologic safe surgery in patients with papillary thyroid carcinoma. In general, patients may resume taking their normal medications the day after the operation. The final pathology is ready approximately1 week after the operation. To date, conventional open thyroidectomy through a collar incision is the standard approach to thyroidectomy (4). MedicineNet does not provide medical advice, diagnosis or treatment. Typically, patients will be given prescriptions for the following medications after the operation: Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. 2 ). If you are dealing with a thyroid issue, our team at the Columbia Thyroid Center is here to help. World J Surg Onc 20, 9 (2022). Verbal response scores (VRSs) for sensory changes around the anterior chest and paralysis of the SCM (1-week, 1- and 3- month visits) were as follows: 0 = Never, 1 = Sometimes, 2 = Most of the time, 3 = All the time [14]. https://doi.org/10.1186/s12957-021-02484-z, DOI: https://doi.org/10.1186/s12957-021-02484-z. Ann Surg Oncol. Feeling that something is stuck in the throat. After surgery, the patient will stay in the recovery room for several hours. Introduction The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. Several reports with large case cohorts were regarding robotically assisted thyroidectomy [8,9,10]. 2017;24:R1326. The best suits have snaps in the areas of the penis or vulva and the anus so you don't have to take the suit off when . Rarely, a patient may have temporary changes in the voice such as fluctuations in volume and clarity (hoarseness). https://emedicine.medscape.com/article/2051665-overview. Thyroid cancer can also spread to the lateral neck. Some patients experience a "crawling" sensation in the skin, muscle cramps or headaches. Second, we divided the area between the sternal and clavicular head of the SCM, up to the annular cartilage and down to the clavicle. 32 0 obj <> endobj Despite the additional trauma resulting from the flap formation, the application of the trans-axillary approach is of some value in suitable circumstances. For example, a gentleman with a 26-inch neck (Figure 42-2. The patient may then be placed on thyroid hormone pills. Although researchers made some efforts to achieve it by sectioning the sternohyoid muscle, the long operation duration, pain in the neck, and swallowing discomfort should also be taken into consideration. If all 4 glands are injured or removed during the operation, the blood calcium levels can become lower than normal called hypocalcemia. Approximately 70% of patients who have half of a normal thyroid gland left in place will not require thyroid hormone replacement pills. Columbia University Irving Medical Center, Department of Surgery, New York, NY. The size of the incision is dictated by surgeon preference and need for adequate exposure to remove the tumor. Surg Endosc. Some people experience a dull ache, while others feel a sharp pain. The supraclavicular lateral collar incision is a feasible and safe approach for thyroidectomy. Retractor was placed beneath the strap muscles to finish creating the working space (Fig. Consideration should be given to breast size, especially in younger women, as over time the incision will be pulled downward if the breasts are large and pendulous. Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. A thyroidectomy is the surgical removal of all (total thyroidectomy) or part (partial thyroidectomy) of your thyroid gland the butterfly-shaped organ in your neck. It is often possible for your surgeon to place the incision in an existing skin crease. 2009;56:3619. This helps to ensure proper wound healing in the postoperative period. It is nearly always preferable to identify and utilize a preexisting skin crease (if present), as this will result in the most optimally camouflaged scar. Kim EY, Lee KH, Park YL, Park CH, Lee CR, Jeong JJ, et al. When present, surgical removal is generally indicated. In addition to the complications of standard thyroid surgeries listed below, there are several complications specific to this operation. MedicineNet does not provide medical advice, diagnosis or treatment. Classically 8-12 cm (3-5 inch) incisions were performed. Patient concern about cosmetic appearance has led surgeons to explore performing surgery through smaller incisions to extract tumors. Trans-axillary robotically assisted approaches were first reported by Lobe et al. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days. They have a higher death rate due to postoperative complications. Hoarseness generally improves within the first 3 to 4 weeks after the operation but it may take up to 6 months. From July 2020 to March 2021, 51 patients (49 females and 2 males) underwent operations by gasless, endoscopic trans-axillary approaches, with one patient whose operation was converted to open surgery because of internal jugular vein injury. Poor cosmetic result from scarring of the neck or axillary incision may occur and require secondary scar management. A 4-cm length incision was made just behind the anterior axillary fold for the laparoscope (a rigid 30-degree videoscope) and one operating instrument. Moreover, the patients arm is raised during the entire operation time which might cause pain in the axilla [20, 21]. The trans-axillary approach (TA) can hardly locate the contralateral thyroid lobe, causing the limitation of TA in bilateral thyroidectomy. Duncan TD, Ejeh IA, Speights F, Rashid QN, Ideis M. Endoscopic transaxillary near total thyroidectomy. 4 Technologic Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. All authors made substantive intellectual contributions to this study to qualify as authors. In the past, piecemeal or berry picking operations have been advocated, but currently, removal of all lymph nodes in all levels or compartments containing metastatic nodes is performed. Most thyroid nodules are small, and performing a full collar incision is not necessary to provide needed surgical exposure to safely remove the thyroid lobe. Another variation of the minimally invasive thyroidectomy is the minimally invasive video-assisted thyroid surgery (MIVAT). The mean size of the benign tumors was 39 mm (range 3149 mm), and the mean size of malignant tumors was 10,0 mm (range 526 mm) (Table 1). Traditionally, parathyroidectomy involved a collar incision, bilateral exploration of the neck, identification of all four glands, and removal of the diseased gland or glands. If the patient was taking thyroid hormone before the operation, they should continue taking the same dose unless it was changed by the surgeon. Surg Endosc. The contribution of the incision to the cosmetic outcome does not end with the making of the incision itself. All authors have no conflicts of interest or financial ties to disclose. E, F Step three, the strap muscles were dissected laterally and the retractor was placed beneath the straps muscle to expose the thyroid lobe. As the working space is crucial to the surgery and time-consuming, the time of working space makes and thyroidectomy were calculated separately. Medscape. Chen GZ, Zhang X, Shi WL, Zhuang ZR, Chen X, Han H. Systematic comparison of cervical and extra-cervical surgical approaches for endoscopic thyroidectomy. After the seventh day, reduce the calcium to one Tums Ultra 1000 tablet three times a day until your follow-up appointment. Duncan et al. As the working space is crucial to the surgery, we have summarized this process in three standard steps. We also recommend a multivitamin for most patients. The cosmetic effect and the self-healing of the discomfort in the anterior neck area and SCM suggest that the application of gasless endoscopic trans-axillary thyroidectomy is feasible. Jules Boeckel of Strasbourg introduced the collar incision to thyroid. The complications, including hypoparathyroidism, tracheal injury, esophageal injury, or surgical site infection did not occur. The midline fascia was divided and strap muscles separated from the thyroid gland. Figure 42-4 Examples of the so-called necklace neck incision associated with a classical thyroidectomy through an open approach (A and B). There are a number of factors that affect suitability for this procedure. Thyroid Nodules Diagnosis and Treatment , Follicular Thyroid Cancer/ Hurthle Cell Carcinoma. Nabhan F, Ringel MD. + )&`30^2{[b#nuwUhSr e4vMHCH qOmo.S2:uZN|/L.J. During the procedure: Goiters are noncancerous enlargement of the thyroid gland. Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis. Total thyroidectomy (sometimes called near-total thyroidectomy) is the surgical removal of the entire thyroid gland. 2010;24:18897. Medication to normalize abnormal thyroid hormone levels may help decrease the size of goiters. In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. This study kept the confidentiality of patient data and strictly complied with the Declaration of Helsinki and its later amendments or comparable ethical standards. Medical records were reviewed retrospectively. Last, the strap muscles were dissected laterally, the omohyoid muscle and internal jugular vein (IJV) were also exposed.