Joint Hospital Grand Round

1. Joint Hospital Grand Round 21st, May 2005 NDH Hon Sok Fei

2. Minimally invasive thyroid surgery

3. Conventional thyroidectomy • GA • Lower cervical incision, 4-6cm • Creation of myocutaneous flap • Scar cosmetically unfavorable location • Hyperesthesia • Paresthesia

4. Minimally invasive thyroid surgery • Rapid development of laparoscopic surgery in the 1990s • 1st endoscopic neck surgery in 1996 • Gagner M et al., Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 196; 83:875 • Proposed advantage • Better cosmetics • Better visualization of RLN and parathyroid • Improvement endoscopic technique of neck surgery • Miniscopes • Miniature instruments • Understanding of CO2 insufflation of the neck

5. Minimally invasive thyroid surgery • Minimal invasive video-assisted thyroidectomy • Endoscopic thyroidectomy • Constant CO2 insufflation required • Gasless • Cervical lifting method

6. Minimally invasive video-assisted thyroidectomy • Method • Preparation of operative space • GA, neck not extended • Small incision above sternal notch • Elevation of skin and platysma by external traction • Blunt dissection between strap muscles and thyroid capsule • Insertion of endoscopic instrument • Dissection of thyro-tracheal groove

7. Minimally invasive video-assisted thyroidectomy 2. Ligature of main thyroid vessels • Clips and ultrasonic scalpel 3. Visualization and dissection of RLN and parathyroid 4. Extraction of the lobe and resection under direct vision

8. Minimally invasive video-assisted thyroidectomy • Indication • Single nodule, </= 3cm • Thyroid volume <20ml • Benign • Contra-indication • Absolute • Previous neck surgery • Large goiter • Locally advanced cancer • Relative • Previous neck irradiation • Hyperthyroidism (Graves’ disease or toxic adenoma) • Thyroiditis

9. Minimally invasive video-assisted thyroidectomy • Video-assisted vs conventional thyroid lobectomy – A Randomized Trial • Bellantone R et al, Arch Surg. 2002 137:301-304 • 62 patient, 31 patient in each arm • Excluding multiple nodule, >/=3cm, previous operation and irradiation • Cx: blood loss, RLN palsy, hypocalcaemia • No difference • Better cosmetic outcome • Less post-op wound pain • Shorter hospital stay • Longer operation time( 81+/- 3 vs 62+/-4mins)

10. The largest series • Miccoli P et al., Minimally invasive video-assissted thyroidectomy: five years of experience • 579 patients • 312 total thyroidectomy, 267 lobectomy • Mean operative time • 51.6+/-18.8 min for total; 41+/-19.5 min for lobectomy • Conversion in 7 patients • Post-op bleeding 0.1%; RLN palsy 1.3%, hypoparathyroidism 0.2%

11. Endoscopic Thyroidectomy • CO2 insufflation required • Supraclavicular approach • Anterior chest approach • Breast approach • Transaxillary approach • Gasless • Cervical lifting method

12. Endoscopic Thyroidectomy • GA • Creation and maintenance of operative space • External traction (cervical lifting) • CO2 insufflation(8-12mmHg) • Operative ports away from the anterior neck • Dissection of thyroid lobe • Use of vascular clips and ultrasonic scalpels for haemostasis • Dissection of RLN, SLN and parathyroids • Convert to open if difficulty in identifying anatomy

13. Endoscopic Thyroidectomy • Indications • Solitary nodule <3cm • Small MNG • Contra-indications • Suspicious/malignant cytology • Large MNG • Graves disease • Thyroiditis • Morbid obesity • Elderly patient

14. Supra-clavicular approach • Small scars over neck • Bilateral neck exposure • Rapid access to thyroid basin if bleeding occurs • Shortest route • Avoid division of strap muscles • Gagner M et al. Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 2001;11:161-3

15. Ant chest approach • Unilateral exposure • Small scars over ant chest wall and neck • Need division of strap muscle for large lesions • Yamaota M et al. Endoscopic suntotal thyroidectomy for patients with Graves’ disease. Surgery Today 2001, 31:1-4

16. Breast approach • Avoid scar at the neck • Bilateral neck exposure • Deformity of nipple-areola complex • Dissection over breast and sternum • Division of strap muscles • Ishii S et al. Endoscopic thyroidectomy with anterior wall approach. Surg Endosc 1998; 12:611

17. Transaxillary approach • Unilateral exposure • Scars coved by clothing • Division of strap muscles • Extensive dissection • Prolonged operation(3hrs) • Ikeda Y et al. Endoscopic resection of thyroid tumors by the axillary approach. J Cardiovasc Surg 2000; 41:791-2

18. Cervical lifting • Bilateral exposure • Small wounds at ant chest wall • Dissection limited to cervical region • Avoid division of strap muscles • Avoid problem of CO2 insufflation to the neck • Huscher CSG et al. Endoscopic right thyroid lobectomy. Surg Endosc 1997; 11:877

19. Results of endoscopic thyroidectomy • Mainly case series • Laurent B et al. Endoscopic thyroid surgery. Endoscopic surgery. 2004: 201-7 • Total, subtotal, lobectomy (>130 cases) • Mostly performed for benign disease • Conversion rate: 7.6% • Carcinoma in frozen section • Insufficient working space • Haemorrhage • Difficulty in recognizing anatomy • Adhesion

20. Results of endoscopic thyroidectomy • Mortality: zero • Morbidity: 3.8% • Transient hypocalcaemia • RLN palsy (transient and permanent)

21. Potential advantage • Better cosmetic outcome • esp. in young lady • Reduce post-op pain • Reduction of RLN and parathyroid gland damage??

22. Potential problems of minimally invasive thyroid surgery • Related to CO2 insufflation • Pneumomediastimum • Surgical emphysema of head and neck region • Raised ICP • Hypercapnia • Difficulty in control of bleeding intra-operatively and post-operatively • Pre-op Ix cannot totally r/o malignancy

23. Summary

24. Conclusion • Feasible and safe • Better cosmetic result • Technically more complex • Strict selection criteria • Increased operating time • Large prospective studies are required to define the indication and confirm its safety and efficacy

25. The End Thank you!

26. Comparison of endoscopic approaches