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Remote Access Thyroidectomy
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possible, the adequacy of lymph node yield particularly in the lower central neck
may be limited due to limited access of the instruments over the clavicle [10].
Furthermore, there are concerns that exist, particularly in Western female patients,
about the implications of dissection around the breast on the accuracy of subsequent
breast cancer image screening.
4.3 Retroauricular/Facelift Approach
The retroauricular or “facelift” approach maintains a cosmetic scar as the incision is
made posterior to the earlobe and extended into the postauricular crease and inside
the hairline (Fig.3). Patients are positioned supine, with the head rotated away from
the side of the surgical incision. After shaving the occipital hairline, an incision is
made and a subplatysmal ap is created along the anterior border of the SCM to the
clavicle and sternal notch. Preservation of the great auricular nerve and external
jugular vein are important aspects of this ap creation. Next, the thyroid is exposed
using a xed retractor system, and the omohyoid and strap muscles are anteriorly
retracted while the SCM is laterally retracted. The robotic or laparoscopic instruments are placed through the incision, and dissection of the thyroid lobe proceeds in
a superior-to-inferior direction.
The advantages of this approach include its relatively shorter dissection distance
to the target anatomy and its straightforward positioning. However, this approach
more than any other is a true “unilateral” one, with dissection capability limited to
Fig. 3 Incision for the
retroauricular or “facelift”
approach. (From: Graves
and Suh [4])
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L. Arthurs and I. Suh
the ipsilatery thyroid lobe. The incidence of sensory loss in the great auricular nerve
distribution is relatively high even with its identication and preservation, and is
likely related to traction by the retractor. Lastly, this incision is also the longest of
the remote access approaches, with its attendant potential complications including
wound infection, ap necrosis, and hair loss along the incision line.
4.4 Transoral Approach
The transoral endoscopic vestibular approach technique begins with the patient in
supine with slight neck extension, virtually identical to the positioning for a traditional open technique. The operating team is positioned at the patient’s head (Fig.4).
In the midline of the oral vestibule, a 10-mm transverse incision is made, the
mentalis muscle is incised, and a tract is created over the mandible and into the
anterior neck using blunt dissection and cautery. Hydrodissection with tumescence
solution is sometimes helpful in creating the working space within the subplatysmal
plane in the neck. An 11/12-mm balloon trocar is placed in the central incision and
two 50-mm lateral trocars in the oral mucosa, inferomedial to the oral commissure
within the lower lip and at the level of canine teeth (Fig.5). These incisions are
optimally placed to avoid injury along the course of the mental nerve.
The subplatysmal space is created under direct vision endoscopically. The
median raphe is separated, and the strap muscles are retracted laterally with a
transcutaneously- placed suture placed around the muscles. The thyroid isthmus is
transected with an energy device, and dissection of the lobe proceeds in a superiorto- inferior direction starting with the superior pole vessels. As the thyroid lobe is
medially rotated, the upper parathyroid, RLN, and lower parathyroid respectively
are identied and preserved. Once the thyroid is detached at the ligament of Berry,
the specimen is placed in an endoscopic specimen retrieval bag to remove it through
Fig. 4 Operating team positioned at the patient’s head and operating toward the feet. (From:
Graves and Suh [4])
Remote Access Thyroidectomy
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a
Fig. 5 (a) Placement of the incisions relative to the expected course of the mental nerve. (b)
Laparoscopic instruments placed through the three intraoral trocars. (From: Graves and Suh [4])
b
the central port incision. Dissection of the contralateral lobe can continue in a similar fashion to perform a total thyroidectomy.
There are several advantages of the transoral approach, most signicantly in its
total obviation of a visible cutaneous scar. In addition, the distance between the incisions and target anatomy is the shortest among the remote access approaches, and
the midline/central approach enables dissection of both lobes with equal ease.
Central neck dissection is also feasible using this technique. However, there remain
several disadvantages and limitations to this approach, including the inherent technical challenge of approaching the thyroid from an unfamiliar, “upside-down” view.
The technical challenge is further heightened due to the combination of narrowed
triangulation of the instruments due to the smaller working space and obstruction of
the instruments’ path due to the presence of the larynx; as well as the presence of
only two working ports. Lastly, the primary unique complication of this approach is
the possibility of mental nerve injury which can cause hypoesthesia/anesthesia to
the ipsilateral lower lip, chin, and upper neck.
5 Postoperative Care
The same complications can occur after remote access thyroidectomy as with traditional open thyroidectomy, such as RLN injury, hypoparathyroidism, hematoma
causing life-threatening airway compromise, injury to the external branch of the
superior laryngeal nerve, infection, seroma, and keloid formation. Management of
these complications mostly mirror that for the open technique, with the exception of
neck hematoma. Unlike in open thyroidectomy in which immediate reopening of
the cervical incision can rapidly alleviate the risk of airway compromise, remote
access approaches by denition do not have an easily accessible incision. Strategies
for mitigation in these scenarios can include (1) preventative placement of closedsuction drains (which are controversial), (2) reopening of a/the remote access
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incision, and (3) placement of an emergent transcervical incision. These possibilities should be anticipated beforehand by the surgical team and discussed with the
patient as part of the informed consent process.
More specic management depends on the remote access approach. For instance,
after BABA, the anterior chest is compressed with a bra dressing for improved healing and comfort, which may be left for 2weeks [11]. After transoral thyroidectomy,
a pressure dressing is placed around the chin for 24 h, and a modied soft diet
instruction as well as antibiotics may be given for a short postoperative course [12].
References
1. Patel KN, Yip L, Lubitz CC, et al. The American Association of Endocrine Surgeons
guidelines for the denitive surgical management of thyroid disease in adults. Ann Surg.
2020;271(3):e21–93. https://doi.org/10.1097/SLA.0000000000003580.
2. Berber E, Bernet V, Fahey TJ 3rd, etal. American Thyroid Association statement on remoteaccess thyroid surgery. Thyroid. 2016;26(3):331–7. https://doi.org/10.1089/thy.2015.0407.
3. Broekhuis JM, James BC, Grogan RH. Scarless surgery: clinical indications for transoral
endocrine surgery and implications for pathologists. Surg Pathol Clin. 2023;16(1):163–6.
https://doi.org/10.1016/j.path.2022.10.002.
4. Graves CE, Suh I. The current status of remote access thyroidectomy in the United States.
Surgery. 2020;168(5):845–50. https://doi.org/10.1016/j.surg.2020.05.021.
5. Kim EY, Lee KH, Park YL, etal. Single-incision, gasless, endoscopic trans-axillary total thyroidectomy: a feasible and oncologic safe surgery in patients with papillary thyroid carcinoma.
J Laparoendosc Adv Surg Tech. 2017;27:1158–64.
6. Kandil EH, Noureldine SI, Yao L, Slakey DP.Robotic transaxillary thyroidectomy: an examination of the rst one hundred cases. J Am Coll Surg. 2012;214:558–64, discussion 564–566.
7. Zaidi N, Daskalaki D, Quadri P, Okoh A, Giulianotti PC, Berber E. The current status of
robotic transaxillary thyroidectomy in the United States: an experience from two centers.
Gland Surg. 2017;6:380–4.
8. Huang S, Garstka ME, Murcy MA, etal. Somatosensory evoked potential: preventing brachial
plexus injury in transaxillary robotic surgery. Laryngoscope. 2019;129:2663–8.
9. Landry CS, Grubbs EG, Warneke CL, etal. Robot-assisted transaxillary thyroid surgery in the
United States: is it comparable to open thyroid lobectomy? Ann Surg Oncol. 2012;19:1269–74.
10. Shan L, Liu J.Meta-analysis comparison of bilateral axillo-breast approach robotic thyroidectomy and conventional thyroidectomy. Surg Innov. 2019;26:112–23.
11. Lee KE, Choi JY.Bilateral axillo-breast approach (BABA) endoscopic and robotic thyroid surgery. In: Terris D, Singer M, editors. Minimally invasive and robotic thyroid and parathyroid
surgery. NewYork: Springer; 2014. https://doi.org/10.1007/978- 1- 4614- 9011- 1_8.
12. Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, Richmon
JD. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Indications,
techniques and results. Surg Endosc. 2018;32(1):456–65. https://doi.org/10.1007/
s00464- 017- 5705- 8.
Radiofrequency Ablation ofThyroid
https://t.me/med1917
Nodules
ShawnY.Hsu andJenniferH.Kuo
1 Indications
Thyroid nodules are common in the general population. The majority of these nodules are benign and asymptomatic. Some benign thyroid nodules can cause compressive symptoms, hyperthyroidism, or cosmetic concerns. Surgical resection has
traditionally been the standard of care for managing symptomatic benign thyroid
nodules. However, minimally invasive thermal ablative techniques (laser ablation,
radiofrequency ablation, microwave ablation, and high frequency ultrasound) have
been gaining traction as an alternative to surgery for these patients. Of these, radiofrequency ablation (RFA) is the most commonly used. RFA is typically reserved for
benign, solid or mostly solid nodules which are symptomatic. Predominantly cystic
nodules are better served with ethanol ablation. The current standard of care for
malignant or indeterminant nodules is surgical resection, but RFA has been considered for patients who cannot undergo surgery due to comorbidities or anatomic
concerns.
2 Preoperative Considerations
A complete history and physical exam should be performed as well as thyroid ultrasound and thyroid function tests. Malignancy should be ruled out with a minimum
of two ne needle aspiration (FNA) biopsies, or one if combined with benign
S. Y. Hsu (*) · J. H. Kuo
Section of Endocrine Surgery, Columbia University Medical Center, New York, NY, USA
e-mail: jhk2029@cumc.columbia.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_3
19© The Author(s), under exclusive license to Springer Nature
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S. Y. Hsu and J. H. Kuo
sonographic characteristics. If the FNA biopsy is indeterminant, then surgical
biopsy is indicated rather than ablative therapies. If malignancy is found on FNA,
then surgical resection is indicated.
The preoperative ultrasound is essential prior to RFA as it is important to assess
the nodule’s size, degree of cystic and solid components, and surrounding vascularity. It is also critical to understand the nodule’s relation to surrounding structures
such as the recurrent laryngeal nerve, trachea, esophagus, carotid artery, and vagus
nerve. Preoperative voice evaluation is also recommended prior to intervention.
Patients with hoarseness or nodules close to the recurrent laryngeal nerve should
undergo preoperative laryngoscopy.
3 Description ofProcedure
The patient is placed in the supine position with neck slightly extended. The procedure is typically performed under local anesthetic, which is instilled in the skin at
the planned puncture site as well as in the thyroid capsule. Avoidance of general
anesthesia allows for rapid identication of pain during the procedure, which can be
indicative of thermal spread beyond the thyroid gland. It also allows for determination of voice changes intraoperatively, which would suggest injury to the recurrent
laryngeal nerve. The RFA probe is then inserted under ultrasound guidance using a
trans-isthmic approach and the nodule is ablated using the moving shot technique as
described below.
3.1 Trans-Isthmic Approach
The nodule is approached from the contralateral side (from midline to lateral) by
inserting the radiofrequency electrode from the isthmus (Fig. 1). This approach
gives three distinct advantages:
Fig. 1 Trans-isthmic
approach. This gure
demonstrates the transisthmic approach to
radiofrequency ablation of
a thyroid nodule. (Figure
courtesy of STARmed Co.,
Ltd.)
Radiofrequency Ablation ofThyroid Nodules
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a
a
b
Fig. 2 The danger triangle and moving shot technique. (a) The posteromedial zone between the
trachea and the thyroid bilaterally is called the “danger triangle”, which contains the recurrent
laryngeal nerve. (b) The moving shot technique is depicted here. The target thyroid nodule is broken down conceptually into small units and each unit is ablated individually to minimize damage
to the surroundings
1. Increased distance between the probe tip and the skin, which reduces the risk for
cutaneous thermal injury.
2. Helps avoid the “danger triangle” (Fig.2a), which is the posteromedial zone
between the trachea and thyroid containing the recurrent laryngeal nerve.
3. Increases the amount of tissue traversed which stabilizes the movement of the
electrode.
3.2 Moving Shot Technique
One important characteristic of RFA is that energy is delivered over time emanating
from a central source. Radiofrequency waves create local ionic agitation that results
in heat and subsequent cellular injury and death. The heat that is generated gradually spreads from the tip of the catheter. Consequently, the degree of cellular injury
at any given location is a function of energy power settings, the duration of application, and the distance from the tip of the probe. This means that the longer the probe
stays in one place, the larger the ablative zone from thermal spread. Because of this,
the thyroid nodule is conceptually broken down into multiple small units for ablation (Fig.2b). Each of these units are then treated individually. This is done to facilitate ablation of the nodule itself while minimizing the injury to the surrounding
tissue. The deepest portions of the thyroid are typically ablated rst to minimize the
distortion on ultrasonography caused by air bubbles during the ablation.
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S. Y. Hsu and J. H. Kuo
3.3 The Heat Sink Effect
A heat sink describes a reservoir where heat can be dissipated. Since RFA is an ablative technique that relies upon delivery of thermal energy, a heat sink decreases the
effectiveness of ablation in the vicinity of the heat sink. This can be problematic, or
it can be used to our advantage. Special considerations as it pertains to the heat sink
effect are discussed below.
3.4 Marginal Vein Ablation Technique
Many thyroid nodules have prominent marginal draining veins. This causes a heat
sink effect during RFA and can result in incomplete ablation. In order to solve this
issue, the marginal vein is ablated to increase the efcacy of RFA. The marginal
veins are identied on ultrasound and punctured with the RFA probe. Air bubbles
are generated when the venous ablation begins, and ablation is completed when
bubbles no longer continue to ow but remain within the veins.
3.5 Artery-First Ablation Technique
Some thyroid nodules may be hypervascular. This can cause a heat sink effect as
well during RFA.However, another implication is that ablating marginal veins in a
hypervascular thyroid nodule will cause signicant edema, which results in a heat
sink effect as well. Therefore, ablating a dominant feeding vessel rst can be benecial. Furthermore, artery-rst ablation decreases the risk of hemorrhage during the
procedure. Intra-thyroidal hemorrhage during RFA disrupts the ablation due to the
heat sink effect as well as increasing the volume of the nodule that needs to be
ablated.
3.6 Hydrodissection Technique
Hydrodissection takes advantage of the principle of a heat sink. The principle of
Hydrodissection is to inject uid between two structures to create a cushion. This
uid is used to shield critical structures from the heat conducted from the probe tip.
This technique is particularly useful when nodules are close to critical structures.
Hydrodissection is typically performed using 5% dextrose in water to avoid the
electrical conductance associated with ions.
Radiofrequency Ablation ofThyroid Nodules
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4 Postoperative Care
Potential complications after RFA include hematoma formation, skin burns, transient thyrotoxicosis, nausea, vomiting, vasovagal response, recurrent laryngeal
nerve injury, and tracheal injury (Table 1). Immediately after the procedure, an
ultrasound evaluation is performed to determine the extent of ablation and to identify any critical structures that were potentially injured. A clinical evaluation is also
performed to ensure that the patient can speak, swallow, and breath without difculty. Any of the above symptoms should prompt further monitoring and possibly
additional imaging. Anti-inammatory analgesia and cold compresses are typically
sufcient for postoperative analgesia. Follow-up is recommended at 1, 6, and
12months with a clinical exam and ultrasound, then every 6–12months thereafter.
Thermal ablation will cause cellular changes within the nodule that cause them to
have suspicious sonographic characteristics (Fig. 3), such as hypoechogenicity,
irregular borders, and scattered hyperechoic foci. If follow-up will be performed by
someone other than the interventionalist, sonographers should be informed that the
Table 1 Complication rates
for radiofrequency ablation of
benign thyroid nodules
Fig. 3 Post-ablation
thyroid nodule. A
post-ablation thyroid
nodule may demonstrate
suspicious sonographic
changes
(hypoechogenicity,
irregular borders, or
scattered hyperechoic foci)
Complication Rate (%)
Pain [5] Up to 24.6
Hematoma [5, 6] 0.9–17
Nerve injury [5] 1.0–2.0
Nausea/vomiting [5] Up to 2.5
Nodule rupture [5] 0.2–0.5
Skin burns [5] 0.3–3.7
Vasovagal reaction [6] 0.3–2.5
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S. Y. Hsu and J. H. Kuo
nodules have undergone thermal ablation so that these changes can be anticipated,
and patients can avoid unnecessary biopsies. Thyroid function tests are recommended if the patient’s thyroid nodule was hyperfunctioning.
After RFA for benign nodules, thyroid nodule volume can be reduced by up to
68% in the rst 3months, 74% by 6months, and 82% by 12months. This degree of
volume reduction has been shown to persist on 5-year follow-up in some studies.
Approximately 2/3rds of patients will have resolution of compressive symptoms
after RFA and almost all patients will have improvement in cosmesis.
References
1. Baek JH, Lee JH, Valcavi R, Pacella CM, Rhim H, Na DG.Thermal ablation for benign thyroid
nodules: radiofrequency and laser. Korean J Radiol. 2011;12(5):525. https://doi.org/10.3348/
kjr.2011.12.5.525.
2. Bo XW, Lu F, Xu HX, Sun LP, Zhang K. Thermal ablation of benign thyroid nodules and
papillary thyroid microcarcinoma. Front Oncol. 2020;10:580431. https://doi.org/10.3389/
fonc.2020.580431.
3. Cho SJ, Baek JH, Chung SR, Choi YJ, Lee JH.Long-term results of thermal ablation of benign
thyroid nodules: a systematic review and meta-analysis. Endocrinol Metab. 2020;35(2):339–50.
https://doi.org/10.3803/EnM.2020.35.2.339.
4. Hamidi O, Callstrom MR, Lee RA, et al. Outcomes of radiofrequency ablation therapy for
large benign thyroid nodules: a mayo clinic case series. Mayo Clin Proc. 2018;93(8):1018–25.
https://doi.org/10.1016/j.mayocp.2017.12.011.
5. Lim JY, Kuo JH.Thyroid nodule radiofrequency ablation: complications and clinical follow
up. Tech Vasc Interv Radiol. 2022;25(2):100824. https://doi.org/10.1016/j.tvir.2022.100824.
6. Wang JF, Wu T, Hu KP, Xu W, Zheng BW, Tong G, Yao ZC, Liu B, Ren J.Complications fol-
lowing radiofrequency ablation of benign thyroid nodules: a systematic review. Chin Med J
(Engl). 2017;130(11):1361–70. https://doi.org/10.4103/0366- 6999.206347.
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