Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4437_Библиотеки_им_академика_М_И_Перельмана
.pdf
14 Thyroidectomy Procedures
Fig. 14.5 Division of the middle thyroid vein to free the
thyroid gland laterally
Fig. 14.6 The STA is individually divided low on the
thyroid gland to prevent injury of the EB-SLN
thyroid [65]. The middle thyroid veins should be
cleaned of adjacent tissues to prevent any injury
to the RLN when these veins are ligated and
divided. It is always safest to mobilize tissues
parallel to the RLN [66].
14.5.1.3 Mobilization ofThyroid Gland
andIdentication
ofUpperPTGs
Dissection is performed superiorly, laterally, and
posteriorly with a small peanut sponge on a
clamp. The STA and veins are identied by
retracting the thyroid inferiorly and medially.
They are individually identied and divided low
on the thyroid gland to prevent injury of the
EB-SLN (Fig. 14.6). The tissues lateral to the
upper lobe of the thyroid and medial to the carotid
sheath can be mobilized caudally to the cricothyroid muscle (Fig.14.7); the RLN enters the crico-
415
Fig. 14.7 Mobilizing the upper part of the thyroid lobe
caudally to the cricothyroid muscle
thyroid muscle at the level of the cricoid cartilage,
rst passing through Berry’s ligament [67, 68].
The upper PTG is often identied at the level of
the cricoid cartilage [69].
To prevent injury to the EB-SLN, the vessels
are divided and ligated on the thyroid surface, the
thyroid is retracted laterally and caudally, and
dissection is carried out on the medial edge of the
thyroid gland and lateral to the cricothyroid muscle. As alternatives to sutures, devices such as the
harmonic scalpel (Ethicon Endo-Surgery, Inc.)
and the LigaSure Precise (Valleylab) may be used
to control vessels [70, 71].
It is essential to avoid injury of the EB-SLN,
the motor branch of SLN responsible for tensing
the vocal cords. The EB-SLN runs on the surface
of the cricothyroid muscle in about 80% of
patients, with the superior pole vessels in about
10%, and within the cricothyroid muscle in the
remaining 10%. Injury to the EB-SLN occurs in
as many as 10% of patients undergoing thyroidectomy [72]. The best ways of preventing such
injury are (1) providing gentle traction on the
thyroid gland in a caudal and lateral direction and
(2) ligating the superior pole vessels directly on
the capsule of the upper pole individually and
low on the thyroid gland rather than to crossclamp the entire superior pole pedicle [69, 72].
14.5.1.4 Identication ofRLNs
andLower PTGs
When the thyroid lobe is further mobilized, the
lower PTG is usually seen anterior to the RLN,
t.me/Dr_Mouayyad_AlbtousH
416
Fig. 14.8 Identication and dissection of the recurrent
laryngeal nerve (RLN)
usually inferior to where the ITA crosses the
RLN [73]. The carotid sheath is retracted laterally, and the thyroid gland is retracted anteriorly
and medially to facilitate the identication of the
RLN [74] (Fig.14.8). The nerve is situated more
medially on the left (running in the tracheoesophageal groove) and more obliquely on the
right. Dissection should proceed cephalic along
the lateral edge of the thyroid.
With the thyroid retracted anteriorly, these
short peri-tracheal vessels running through the
suspensory ligament of Berry are successively
clamped with curved mosquito clamps on the tracheal surface from posterior to anterior and
sharply divided. The minute arterial branches
must be ligated or suture-ligated; they may be the
source of a severe, rapidly developing bleeding
with compression. When a short bleeding stump
retracts beneath the RLN, bleeding must be controlled with ne stick tie ligatures, with the nerve
being carefully protected [75]. In some patients
(about 15%), the peduncle of Zuckerkandl, a
small protuberance of thyroid tissue on the right,
tends to obscure the RLN at the level of Berry’s
ligament [76]. Fatty and lymphatic tissues immediately adjacent to the thyroid gland are swept
from it with a peanut sponge on a clamp, and
small vessels are ligated. No tissue should be transected until one is sure that it is not the RLN [77].
The upper PTGs are usually situated on each
side of the thyroid gland at the level where the
RLN enters the cricothyroid muscle at the level of
the cricoid cartilage [74]. Thus, the area cephalic
to the cricoid cartilage is relatively safe [77].
M. Sakr
Fig. 14.9 Mobilization of the pyramidal lobe
14.5.1.5 Mobilization
ofPyramidalLobe
The pyramidal lobe is found in about 80% of
patients. It extends in a cephalic direction, often
through the notch in the thyroid cartilage to the
hyoid bone. One or more LNs are frequently
found just cephalic to the isthmus of the thyroid
gland over the cricothyroid membrane (Delphian
LNs) [60]. The pyramidal lobe is mobilized by
retracting it caudally and by dissecting immediately adjacent to it in a cephalic direction. Small
vessels are coagulated or ligated (Fig.14.9).
14.5.1.6 Thyroid Resection
Once the PTGs have been carefully swept or dissected from the thyroid gland and the RLN has
been identied, the thyroid lobe can be quickly
resected (Fig.14.10). For TT, the same operation
is done again on the other side [76, 78].
14.5.1.7 Drainage
The fear of a hematoma enlarging and obstructing the airway prompts many surgeons to use
drains routinely after thyroid surgery [79, 80].
However, drains may be blocked by blood clots,
add the patient’s discomfort, deteriorating the
cosmetic result and increasing hospital stay [81].
The routine need for use of drains in thyroid surgery has been debated.
14.5.1.8 Closure
The sterno-thyroid muscles are approximated,
and a small opening is left in the midline at the
t.me/Dr_Mouayyad_AlbtousH
14 Thyroidectomy Procedures
Fig. 14.10 Resection of the thyroid lobe with the parathyroid gland preserved and the recurrent laryngeal nerve
identied and dissected throughout its course
suprasternal notch to allow any clotted blood to
exit. The sterno-hyoid muscles are approximated
in a similar fashion, as is the platysma. The skin
is then closed with a subcuticular stitch. A sterile
dressing is applied [82].
417
gesic requirement. The amount of analgesics
used within the rst 24h after surgery is signicantly less in patients receiving a apless thyroidectomy than those receiving the conventional
thyroidectomy. Similarly, patients receiving apless thyroidectomy experienced less postoperative pain like that in other MITS [84].
The potential advantages of a apless conventional thyroidectomy over a conventional thyroidectomy include (1) less tissue trauma, (2) less
blood loss and seroma formation, (3) less postoperative pain, and (4) less postoperative analgesic
requirement. In addition, the apless procedure
does not require any specialized instruments or
additional charges [84].
14.7 Minimally Invasive Thyroid
Surgery (MITS)
14.7.1 Introduction
14.5.2 Postoperative Care
The duration of a thyroid operation is usually
1–3h, depending on the size and invasiveness of
the tumor, its vascularity, and the location of the
PTGs. Postoperatively, the patient is kept in a low
Fowler position with the head and shoulders elevated 10°–20° for 6–12h to maintain negative
pressure in the veins. The patient typically
resumes eating within 3–4h, and an anti-emetic
is ordered as needed [83].
14.6 Flapless Conventional
Thyroidectomy
The apless conventional thyroidectomy is considered to be a safe and technically feasible surgical modality, which is therefore an effective
alternative to a traditional conventional thyroidectomy. A apless conventional thyroidectomy
could also be listed among other variables when
dening surgical invasiveness, since it is associated with reductions in blood loss, the surgical
cost, postoperative pain, and postoperative anal-
After nearly a hundred years of performing a thyroidectomy essentially the way it was described
by Theodore Kocher [85] in the nineteenth century, the past decades have seen dramatic changes
in modern surgical technique [86, 87]. Much of
this change has been technologically driven, with
the introduction of high-resolution endoscopy
[88, 89].
Minimally invasive surgery is dened as the
ability of the surgeon to perform traditional surgical procedure in novel ways to minimize the
trauma of surgical exposure. Many criteria are
used to dene and discriminate among minimally
invasive techniques (length of incision, pain,
duration of operation, general or local anesthesia,
cost, cosmetic results, and cure of the disease).
When used in the context of the thyroid (and
parathyroid) procedures, the term “minimally
invasive” is currently not specic enough and
overlaps with the conventional open procedure. It
was proposed that this term may be used only to
describe thyroid procedures that are routinely
associated with an incision shorter than 3.0cm
(and 2.5cm for parathyroidectomy) [90–93]. In
recent years, endoscopic surgery has emerged as
an option for thyroid and parathyroid abnormali-
t.me/Dr_Mouayyad_AlbtousH
418
M. Sakr
ties. Surgeons in Japan and Italy have provided
leadership in this eld. It appears to be driven by
patient demand for either a smaller scar on the
neck or no scar at all [11]. The concept of MITS
is attractive because patients are concerned not
only about the result of treating their thyroid disease but also outcomes such as better cosmesis,
reduced hospital stay, and decreased pain
[94–96].
14.7.2 Classication ofMITS
Many different techniques have been developed
for MITS over a short period; these can be
broadly classied into pure/or completely closed
endoscopic techniques, video-assisted techniques, and minimally invasive open surgery.
Ikeda et al. [14] classied minimally invasive
thyroid procedures as follows: (1) Minimally
invasive/mini-incision, (2) minimally invasive
video-assisted thyroidectomy (MIVAT), and (3)
completely closed endoscopic (supraclavicular
approach, axillary approach, anterior chest
approach, and breast approach). However, others
believed that the extra-cervical endoscopic
approaches, while they have the advantage of
avoiding a cervical incision, require extensive
dissection that exceeds that of conventional surgery, and in this regard cannot be considered
minimally- invasive [89, 97–100].
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, minimally
invasive thyroidectomy should properly be
dened as “operations through a short, <3cm, and
discrete incision that permits direct access to the
thyroid, resulting in a focused dissection” [11].
and impact on surgical techniques, it is likely that
these minimally invasive approaches will become
more widely used and easier to perform. As of
now, MITS appears to be a useful addition to conventional thyroid surgery. Long-term follow-up
and comparative trials are needed to validate
these interesting techniques. There is a need to
look into the expanding indications as well as the
completeness of MITS procedures [95].
The application of MITS has expanded in the
last decade and is being considered as an alternative to the conventional. Major advantages of
MITS techniques include reduced tissue trauma,
shorter hospital stay, better cosmetic results, minimal postoperative pain, reduced cost of healthcare and, above all, patient comfort. Video-assisted
endoscopic techniques in addition offer a magnied, illuminated view of the operating eld. The
main disadvantages of MITS procedures are the
longer duration of surgery, steep learning curve,
and increased cost of surgery due to the equipment usage. The reported important complications are similar to those seen after conventional
thyroid surgery [12, 13, 15, 16, 101–105].
Endoscopic surgery does not provide better
results in terms of hospital stay and postoperative
pain when compared with conventional open or
mini-thyroidectomy [106]. In thyroid surgery,
pure endoscopic techniques are more time consuming than conventional techniques. They take
from 90min for a thyroid lobectomy by cervical
access, up to 280min for a TT by a chest wall
approach. Whether minimally invasive procedures are actually less costly than conventional
procedures is difcult to quantify [107, 108].
14.7.4 Direct Access MITS
(Mini-Incision)
14.7.3 Advantages
andDisadvantages ofMITS
Judicious patient selection is the most important
cornerstone for the success of any MITS technique for both benign and malignant thyroid
swellings. As technology continues to develop
t.me/Dr_Mouayyad_AlbtousH
14.7.4.1 Midline Mini-incision
Technique
In MITS performed by a minimized (2.5–3cm)
cervical incision (Fig. 14.11), the access to the
thyroid gland is direct. However, the volume of
the nodule (<30–35mm at largest diameter) and
even more importantly the volume of the thyroid
lobe (<20–30 ml) limit their indications. With
14 Thyroidectomy Procedures
Fig. 14.11 Direct access minimally invasive thyroid surgery (MITS) with a midline (central) mini-incision in the
neck in a 27-year-old lady
advanced energy devices [109, 110] and the evolution of robust laryngeal nerve monitoring [111,
112], a faster and probably safer thyroidectomy
could be accomplished through a smaller incision
than the 6–8cm of conventional open thyroidectomy. This has been widely recognized and is
increasingly embraced [113–115].
Thyroid operations that minimize the incision
but keep it in the neck may be considered minimally invasive. These operations have some
advantages over conventional cervicotomy in
terms of postoperative pain and cosmetic results
[11, 93, 116–120].
14.7.4.2 Lateral Mini-Incision
Technique
In this technique, a small (2.5cm) lateral incision is made over the nodule, and the subplatys-
mal ap is raised to allow skin incision to be
move around the neck and relevant area of dissection. The anterior border of the SCM is incised
to expose the lateral margin of the strap muscle.
The strap muscle is retracted medially, and the
SCM is retracted laterally to expose the lateral
part of the thyroid gland. The middle thyroid vein
is rst divided and then the isthmus is mobilized
and transected to allow maximal mobilization.
The skin incision is then retracted cranially to
expose the upper pole vessels, which are then
divided. The lower pole is mobilized with careful
capsular dissection with preservation of the inferior PTG. The thyroid gland is then delivered
419
through the skin incision. The rest of the procedure is similar to conventional thyroidectomy.
With careful capsular dissection, the superior
PTG and RLN can be dissected away from thyroid gland and preserved.
Compared to conventional hemithyroidectomy, Sywak etal. reported a single arm-blinded
randomized trial. They found that the miniincision approach took an extra 10min, but was
associated with a lower pain score on the rst
postoperative day (2.67 versus 3.43, p= 0.032)
and tenth day (1.5 versus 1.8, p=0.36), greater
cosmetic satisfaction score (6.3 versus 5.0,
p = 0.002), and a smaller wound (2.6 versus
5.4cm, p<0.001) [121]. However, owing to the
fact that the incision is placed on one side of the
neck only, it is limited to hemi-thyroidectomy.
Nevertheless, it is relatively easier to learn than
endoscopic operations [122, 123].
14.7.5 Minimally Invasive Video-
Assisted Thyroidectomy
(MIVAT)
Minimally invasive video-assisted thyroidectomy
(MIVAT) was rst introduced by Miccoli from
Piza, Italy, in 1999 and was rapidly adopted [124,
125]. MIVAT is regarded as a “hybrid procedure”
as opposed to other endoscopic procedures
because it requires both open and laparoscopic
surgical skills.
14.7.5.1 Technique
The MIVAT procedure involves a gasless minimally invasive access to the thyroid gland characterized by external retraction, magnied
endoscopic vision, and dissection by means of
needlescopic and ultrasonic devices. A 1.5-cm
midline incision is then made about 2cm above
the sternal notch. The midline is incised longitudinally for 3–4cm to separate the strap muscles.
The strap muscles are then separated from the
thyroid with a blunt dissection. The operative
eld is developed and maintained by an external
retractor held by an assistant. After that, the operation is conducted in an endoscopic/video-
t.me/Dr_Mouayyad_AlbtousH
420
M. Sakr
assisted manner. A 5-mm 30° telescope is inserted
with the external branch of superior laryngeal
nerve (EB-SLN) identied and preserved with
the help of the optical magnication of the telescope. The superior lobe vessel is then either
clipped or divided by ultrasonic shears. The superior lobe is gradually pulled and delivered through
the wound. Thereafter, the rest of the procedure is
performed not dissimilar to the conventional thyroidectomy. The contra-lateral lobe would be
excised and delivered in similar manner. No drain
is needed, and skin is closed with subcuticular
stitches and sealant.
14.7.5.2 Indications/Contraindications
andOutcome
This technique proved to be feasible, as safe as
traditional surgery, viable for the treatment of
small thyroid nodules [126] and yielded excellent
cosmetic and surgical outcomes [127]. However,
only 10–15% of patients with a small goiter would
be suitable. Only patients with a solitary thyroid
nodule (STN) <35 mm and/or thyroid volume<25ml are considered suitable for MIVAT.In
addition, size, re-done surgery, previous neck irradiation, and locally invasive thyroid carcinoma
are also considered absolute contraindications
[128]. Presence of hyper-vascular gland such as
Graves’ disease or thyroiditis was initially thought
to be contraindications for MIVAT.However, in a
latest review of 1946 patients, 17.9% of patients
with benign disease on nal pathology had thyroiditis while 30.9% of patients with malignancy
had unexpected thyroiditis. Therefore, the presence of thyroiditis is no longer considered a contraindication in MIVAT [129].
Since 1999, the MIVAT approach has been
widely extended and used for both benign and
malignant thyroid lesions in both adult and pediatric patients [130–132]. Later, it was used also to
approach “low-risk” PTCs after demonstrating
its ability to achieve thyroidectomy completeness
for these patients [133]. Finally, the attempt to
perform endoscopic central node compartment
clearance via the same minimal access was
accomplished, and the entire procedure proved to
be viable and oncologically correct for dealing
with a prophylactic TT in RET gene mutation
carrier patient [134]. Patients with PTC who
underwent MIVAT had a good outcome during a
5-year follow-up period. The outcome was similar to that for patients treated with conventional
thyroidectomy and the same degree of exposure
to post-surgical RAI treatment [135]. A study
done by Ruggieri etal. (2010) [121], suggested
that small nodules are one of the best indications
for MIVAT.
The MIVAT has shown to be as safe as the
existing gold standard operation. Furthermore,
the primary outcome measure of pain and secondary outcome measure of cosmesis both
showed statistically signicant better results for
MIVAT compared to conventional thyroidectomy. This was achieved at the expense of operative time, which was signicantly longer for
MIVAT [136]. A recent meta-analysis did not
nd signicant differences in postoperative hypocalcemia and RLN palsy rates, and the MIVAT
generally took longer to complete. However,
MIVAT was associated with a lower pain score at
24h postoperatively and better reported cosmesis
score [121].
Based on their experience on MIVAT and central neck dissection (CND) via an average of
2 cm central neck incision, Bo Wu and Zheng
Ding developed a procedure called “videoassisted selective lateral neck dissection”
(VASLND) for PTC with suspicious node metastasis at level III, IV, or IIa through an extended
4–6cm cervical incision (166–168).
MIVAT appeared to have a comparable oncological outcome as conventional thyroidectomy
for patients with PTC [134]. The thyroglobulin
levels, thyrotrophin-stimulating hormone, and
percentage of radiouptake were not different in
early operations and long term follow-up [135,
136]. There was no signicant difference in cure
rate after a median follow-up of 5years in these
groups of low-risk PTC patient [134].
14.7.6 Pure Endoscopic Techniques
ofThyroidectomy
For simplication, endoscopic approaches (techniques) could be categorized into (A)
t.me/Dr_Mouayyad_AlbtousH
14 Thyroidectomy Procedures
421
cervical/direct approach and (B) extra-cervical/
indirect approach. Each technique or approach
has its own benets and weaknesses. Currently,
there is no preferred approach in the literature
and the choice seems to be determined by the surgeon’s own experience and the patient’s
preference.
14.7.6.1 Cervical/Direct Endoscopic
Approaches
Pure endoscopic techniques using a “cervical
access” are technically challenging due to the
limited room for dissection. They are time consuming, but with increasing experience and
advances in surgical instrument design, shorter
operating times are anticipated. Fear of
insufation- related complications, such as hypercapnia, extensive emphysema, and gas embolisms, is not sustained if appropriate precautions
are taken, i.e. low ow 1L/min, and insufation
pressure<10mmHg [116].
Endoscopic Lateral Approach: Unlike conventional thyroidectomy and MIVAT, the initial incision is made over the SCM muscle. The
thyroid gland is approached laterally through
splitting of strap muscle and SCM.Henry etal.
rst reported their technique on the endoscopic
lateral approach in 1999 [137]. One 10-mm
and two 3-mm ports were inserted along the
SCM.Operating space is maintained with lowpressure CO2 insufation. Vital structures, like
the PTG, RLN, and EB-SLN, could be readily
identied and preserved. With the help of needloscopic instruments and magnication, individual vessels can be controlled and the thyroid
completely dissected free. The specimen is
normally retrieved through a 12-mm incision.
However, one of the disadvantages with this
approach is that only unilateral pathology can be
resected (i.e., hemi-thyroidectomy) because the
incision is only placed on one side of the neck. If
the contralateral side needs to be explored at the
same time, a collar incision (i.e. extension of the
incision) would be required. However, only 5%
will require a conversion if cases are properly
selected [138].
14.7.6.2 Extra-Cervical/Indirect
Endoscopic
Approaches—Combined
Considering the extent of the dissection required
in some of the endoscopic techniques, one can
wonder if the term of minimally invasive is
appropriate. This is particularly true for techniques using an extra- or noncervical approach
or combined approaches. They consist of access
to the thyroid eld through an axillary, anterior
chest, or mammary approach or combined
approaches such as axillary and mammary
approach, or axillary and postauricular approach.
These techniques are most developed in Asia, as
in these countries, extra-cervical scars balance
favorably with cervical scars [102, 139–144].
These operations allow resection of large thyroid tumors, up to 60mm in size, and enlarged
glands, up to 60ml in volume. These 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.
In addition, some of these procedures may require
division of neck muscles. Whether transection of
the omohyoid muscle or strap muscles, sometimes required in extra-cervical approaches,
affects functionality is not clear. Postoperatively,
it may cause an uncomfortable catching sensation on swallowing by adherence of skin or platysma to the sternohyoid muscle.
Following extra-cervical techniques, patients
suffer from moderate to severe pain, gradually
subsiding within a week. Postoperative paresthesias or numbness generally subside within
6 months. A risk of subcutaneous hemorrhage
without any evidence for increasing infection
rates is present as a result of the extensive dissection [102, 139–144].
Anterior Chest/Breast Approach
In 1998, Shimizu etal. reported their experience
of approaching the thyroid gland via the infra-
clavicular incisions. It is termed video-assisted
neck surgery [145]. The operation was aimed to
be “scarless” over the neck. However, due to
t.me/Dr_Mouayyad_AlbtousH
422
M. Sakr
incomplete covering of the infra-clavicular scar
by clothing and a high chance of scar hypertrophic change, Ohgami etal. [102] modied the
incision and placed it at the upper circum-areolar
areas in 2000.
Technique: the initial incision is made at infraclavicular or bilateral upper circum-areolar areas.
The skin ap is raised by blunt dissection of subcutaneous (SC) tissue and the subplatysmal space.
The operating space is maintained by a skin-lifting device (gasless) or CO2 insufation. An additional port is inserted at the infra- clavicular
region. The strap muscle is divided longitudinally
to expose the thyroid gland. The rest of the procedure is similar to open thyroidectomy, with the
dissection initiated from the inferior lobe proceeding postero-laterally and then superiorly
under the aim of endoscopic instruments.
Individual vessels are controlled with ultrasonic
shears and the whole course of the RLN is identied and preserved. Despite good covering of the
scars, some patients do not want any dissection
around the nipple areolar region as the presence of
a breast implant is a concern [146].
Park and coauthors [147] reported a series of
100 patients who underwent endoscopic thyroidectomy via the breast approach. Incisions were
made in both upper circumareolar areas and SC
tunnels were dissected up to the neck through
which endoscopes were placed. CO2 insufation
was used. The remaining dissection was carried
out under visual endoscopic guidance. The incisions on the breast yielded a satisfactory cosmetic result with minimal scarring.
Trans-Axillary Approach
Trans-axillary approach offers good cosmesis as
the axillary wound can be covered by the patient’s
own clothes. It also avoids unnecessary dissection around the areolar region. It was rst
described by Ikeda etal. in 2000 [14].
Technique: The patient is put under general
anesthesia and lies in a supine position. The neck
is slightly extended, and the ipsilateral arm is
raised and xed at the shortest distance between
the axilla and anterior neck. A 4- to 6-cm vertical
incision is made along the outer border of the
pectoris major. The skin ap is raised supercial
to the pectoralis fascia and toward the anterior
neck. The avascular plan between the sternal and
clavicular head of SCM is developed. The anterior part of the thyroid is dissected free from strap
muscles, and the skin ap is raised with a skinlifting device. A 10-mm and a 5-mm trocars are
placed on either end of the axillary wound.
Another 5-mm trocar is placed in the chest. The
inferior pole of the thyroid is carefully dissected
to isolate the RLN and PTGs. Vessels are divided
between clips or by ultrasonic shears. The thyroid is then retracted medially. Berry’s ligament
is dissected and divided. For hemi- thyroidectomy,
the isthmus is transected using ultrasonic shears,
while the medial approach for contralateral thyroid would be needed if bilateral resection is indicated. The specimen is retrieved through the
axillary wound and the operating eld is irrigated. A drain is placed before wound closure.
This approach avoids any scar over the neck. The
distance between the incision and the thyroid is
short and therefore less SC dissection is needed.
However, contralateral dissection is difcult, and
collision of instruments is common due to limited working space.
Results/Outcome: In 2009, Kang et al.
reported the results of 581 patients including 410
with cancer who underwent the gasless endoscopic thyroidectomy [148]. The complication
rates were not high; 3.2% of patients had transient hypocalcemia, 1.5% had transient hoarseness, and 0.2% permanent RLN palsy. Compared
to conventional approach, this approach took a
longer time [149], and patients had more pain but
were more satised [12]. On the other hand,
some studies suggested that the trans-axillary
approach might be associated with a higher rate
of transient hypocalcemia and transient RLN
palsy [150–152]. In a patient with a low-risk papillary thyroid micro-carcinoma, Jeong et al.
reported that trans-axillary thyroidectomy with
prophylactic central neck dissection was feasible.
Oncologically, though smaller numbers of LNs
were retrieved than that of the conventional
approach (5.05 vs 5.96, p=0.007), none of 275
patients who underwent trans-axillary approach
had Tg>1ng/ml [153]. With application of the
da Vinci roboticsystem and maturation of skills,
t.me/Dr_Mouayyad_AlbtousH
14 Thyroidectomy Procedures
423
endoscopic approach on central and lateral neck
dissection has largely shifted to the robotic
approach [152–154].
Further advances in trans-axillary approach
have been proposed to optimize or maximize the
cosmetic outcome of the wound. The presence of
an anterior chest incision was associated with
hypertrophic change or even keloid, especially in
Asian patients. Surgeons from Korea proposed
lowering the incisions and placing them at the
peri-areolar site to decrease the “visibility” of the
scar, namely the unilateral axillo-breast approach
[155]. The central neck compartment and a tumor
nodule ≥4cm could be tackled by this approach
[155, 156]. On the other hand, a single-incision
in the axilla was shown to be feasible [157, 158].
Axillo-Breast (Hybrid) Approach
In the anterior approach and the trans-axillary
approach, the narrow endoscopic view and limited angulation of instruction are the major technical challenges for surgeons. To overcome these
limitations, Shimazu etal. (2000) in Japan rst
described using both axillary and breast incisions
and the so-called “axillo-bilateral-breast
approach” [159].
Technique: The patient is under general anesthesia and the arms are abducted. An ipsilateral
circum-areolar incision is made. The SC and subplatysmal working space is developed with blunt
dissection similar to the anterior chest/breast
approach. The working space is extended to the
level of the thyroid cartilage superiorly and the
medial edge of SCM bilaterally. The working
space is maintained with low-pressure CO2 insufation. Additional ports are inserted through the
ipsilateral axilla and the contralateral circumareolar incision. The rest of the procedure is similar to the anterior chest/breast approach. Through
endoscopic instruments inserted into the axillary
port, a wider triangulation facilitates dissection
and mobilization of the thyroid gland. The
resected thyroid gland is retrieved through the
circum-areolar wound with a plastic bag.
Results: Choe etal. added another incision to
the contralateral axilla, and this is now known as
the “bilateral axillo-breast approach” (BABA)
[160]. From a large series of 512 patients with
thyroidectomy via BABA, Choi et al. [161]
reported a low rate of permanent hypocalcemia
(4.2%) and RLN palsy (1.7%). However, the
transient hypocalcemia rate (31.1%) and the proportion of transient RLN, palsy (20.1%) was relatively high compared to other reported series
(~4%) [160]. This technique involves extensive
SC ap dissection, so it is often criticized for
being “maximally” invasive [161]. It results in
upper chest discomfort, pain, and brosis of the
skin ap and prolongs paraesthesia for up to
12–18 months [162]. Unlike the trans-axillary
approach, the experience of BABA is reported
mainly in Asian countries. We think that this
might be related to better acceptance of the periareolar incision and extensive dissection over SC
tissue over the breast. Furthermore, the
larger- sized breasts commonly seen in the
Caucasian population makes BABA more
difcult.
Postauricular andAxillary Approach
To avoid dissection around the peri-areolar region
and maintain triangulation of manipulation, Lee
etal. [163] reported an approach via an incision
at the bilateral axillary and postauricular region.
Technique: The operation starts with an infusion of a diluted adrenaline solution to the SC
and subplatysmal space of the anterior chest and
neck. After making a 12-mm incision at the ipsilateral axilla, the subcutaneous space is created
with blunt dissection. A 12-mm trocar is inserted
into the axillary wound and the operative space is
inated with low pressure CO2. Another port is
inserted into the contralateral axilla, and two
5-mm trocars are inserted through the bilateral
postauricular incision. A midline incision is
made, and the strap muscle is split and retracted
laterally by the endoscopic instrument through
postauricular ports. The thyroid is dissected and
excised similar to the conventional anterior
approach. It is a technically challenging operation. Branches of the facial nerve were also susceptible to traction injury. Even though it avoids
peri-areolar dissection, this technique is not
popular.
t.me/Dr_Mouayyad_AlbtousH
424
M. Sakr
14.7.6.3 Other Novel Endoscopic
Approaches
Other novel endoscopic approaches were
mostly based on cadavers. These techniques
included (1) retroauricular video-assisted
gasless thyroidectomy [164] and (2) totally
trans-oral video- assisted thyroidectomy
(TOVAT) under gas insufations [165]. In
2008, the trans-oral access for endoscopic thyroid resection was proposed by Witzel et al.
[159].The concept of thyroid surgery, via a nat-
ural orice and without any skin incision, may
be appealing to most patients, but the invasiveness and the potential complications of such
access must be carefully evaluated by prior
experimental studies [159].
In cadaver studies, it is feasible to excise the
thyroid gland through an incision in the oor of
the mouth under gas insufation. Two cases of
trans-oral parathyroidectomy in 2 patients with
primary hyperparathyroidism have been reported
[166]. This approach seems to be technically feasible but is heavily criticized on its safety. The
working space is very limited and potential infection through a relatively contaminated incision is
a major concern [167, 168].
scopic procedures such as reduced range of
motion and impaired eye-hand coordination
[169–172]. Because of this, robotic thyroidectomy has become increasingly popular around
the world [173–175] attracting both surgeons
and patients and allowing for the removal of thyroid glands with a superior cosmetic result [171,
173, 176] when compared to the conventional
open thyroidectomy procedures. Many studies
have described the safety of the remote- access
robotic thyroidectomy procedures and have
demonstrated comparable oncological outcomes
between the robotic and open conventional thyroidectomy [177–180].
Since the initial trans-axillary approach, new
approaches to robotic thyroidectomy have been
developed, including retroauricular (aka “face-
lift”), axillary-breast, and the latest approach;
trans-oral [178, 181, 182]. There have also been
descriptions of combinations and modications
of these approaches [181]. Recently, the American
Thyroid Association (ATA) stated that remoteaccess thyroidectomy may be performed safely
in high-volume centers, acknowledging the role
of robotic thyroidectomy in selected patients and
emphasizing the importance of strict selection
criteria [175].
14.8 Robotic Thyroidectomy
14.8.1 Development ofRobotic
Thyroidectomy
Robotic thyroidectomy, a minimally invasive
surgical technique, was developed in South
Korea. It is also called “robot-assisted thyroid
surgery,” or “robot-assisted endoscopic surgery”.
It is the rst robot-assisted surgery done in the
head and neck. The Da Vinci robotic system
(Intuitive Surgical, Sunnyvale, California) was
rst utilized for trans- axillary thyroidectomy by
Chung in 2007. Chung and his colleagues have
since performed over 5000 robotic trans-axillary
thyroidectomy cases demonstrating the safety
and feasibility of the robotic procedure for thyroidectomy [169]. Using a robotic system helped
to overcome some of the limitations of the endo-
t.me/Dr_Mouayyad_AlbtousH
14.8.2 General Advantages
andDisadvantages ofRobotic
Thyroidectomy
14.8.2.1 Advantages inComparison
toOpen Surgery
– No incision in the neck.
– Better view: The 3D camera gives a magnied
view in robotic thyroidectomy and enables the
surgeon to look at the thyroid directly.
– Better identication of critical structures: Due
to the magnied 3D view, it is easier to identify critical structures, such as the RLN and
PTGs.
– Better dexterity in certain areas: The robotic
instruments give the surgeon a 6° freedom of
motion, which enables easy manipulation during dissection.
Соседние файлы в папке Библиотека им академика М.И. Перельмана