The location of the tumor was right, n= 30; left, n= 21. 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. It is rare for them to appear after 72 hours. 2016;26:3317. ZYZ modified the design of the study. A completion thyroidectomy is usually done after a thyroid lobectomy reveals cancer in the first half of the thyroid but may also be done for multinodular goiter or hyperthyroidism. If a patient has symptoms caused by low blood calcium, the surgeon may prescribe extra calcium and a vitamin D supplement. 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. Indications for removal of the gland include most types of thyroid cancer, large goiters causing compression of the airway, and Graves disease. It is in this position that patients will be in public situations such as dinner parties and cocktail receptions, and it is in this position the suprasternal notch (the depression created by the medial heads of the sternocleidomastoid muscle) can best be seen. A "thyroidectomy" should not be confused with a "thyroidotomy" ("thyrotomy"), which is a cutting into the thyroid, to get access for a median laryngotomy, or to perform a biopsy. In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. 2020;44:411826. 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). A number of important principles are worth considering when planning a thyroidectomy or parathyroidectomy, and these transcend the specific procedure that is anticipated. Continuous variables are presented as the mean SD and the mean (range). C, D Step two, sternocleidomastoid muscle (SCM) was dissected longitudinally and the sternal head of SCM was elevated by the retractor to expose the strap muscles. Endoscopic hemithyroidectomy with prophylactic ipsilateral central neck dissection via an unilateral axillo-breast approach without gas insufflation for unilateral micropapillary thyroid carcinoma: preliminary report. Novel uses of surgical robotics in head and neck surgery. 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. However, despite careful technique, it is not uncommon to observe skin edges at the end of a procedure (particularly minimally invasive surgery) that are ischemic and traumatized. Rarely, nerve injury to the arm can occur, resulting in impaired arm and/or hand function. Despite the additional trauma resulting from the flap formation, the application of the trans-axillary approach is of some value in suitable circumstances. Jsls. Koh YW, Park JH, Kim JW, Lee SW, Choi EC. Gasless, endoscopic trans-axillary thyroid surgery is a feasible procedure with acceptable safety and better cosmetic results in strictly selected patients. The exclusion criteria were as follows: (1) patients with benign nodules with diameters > 6 cm, (2) patients who needed a total thyroidectomy, and (3) patients for whom endoscopic surgery was not suitable due to past medical history of cervical and chest wall surgeries or other reasons. Several reports with large case cohorts were regarding robotically assisted thyroidectomy [8,9,10]. Figure 42-2 This nonobese gentleman who has a 26-inch neck circumference and a large goiter would not be a candidate for any minimally invasive approach. 4). 2016;23:694700. It provides satisfactory cosmetic outcomes compared with conventional transcervical incision. Fada Xia. Muenscher A, Dalchow C, Kutta H, Knecht R. The endoscopic approach to the neck: a review of the literature, and overview of the various techniques. Comparison of learning curves for retroauricular and transaxillary endoscopic hemithyroidectomy. If the patient was not taking thyroid hormone prior to the operation, the surgeon may prescribe these tablets following surgery. The muscles around the thyroid gland are retracted to expose the thyroid gland. The dissected area is marked in blue, The procedure of thyroidectomy and central neck dissection (CND). Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Incisions in Thyroid and Parathyroid Surgery. While the conventional collar incision is widely used, endoscopic thyroidectomy is gradually becoming accepted for thyroid nodule patients with cosmetic needs [2,3,4].Under the premise of oncological effectiveness, endoscopic thyroidectomy can provide a . When this happens, you can trim the edges or let the glue fall off on its own. The hockey-stick incision (C) avoids trifurcations and provides plentiful exposure for a comprehensive neck dissection. There are a number of factors that affect suitability for this procedure. Because much of the earlier thyroid surgery was done for malignancy, descriptions emerged regarding the appropriate way to accomplish a thyroidectomy combined with a neck dissection. None of the patients developed hypoparathyroidism, esophageal injury, or surgical site infection after the surgery. The dissected area is marked in green. This is the result of the blood calcium level dropping below normal (hypocalcemia) and is usually temporary. Surgery is the most commonly used technique in treating thyroid diseases. However, the da Vinci system is blamed for a prolonged surgery duration and a significantly higher economic cost. Most people take at least 15-30 days to recover. If the seroma is large, the surgeon may drain it with a small needle. 2012;42:83541. 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. Perhaps the most important element in optimizing access while maintaining good cosmesis is choosing the proper location for an incision. And their results showed this procedure was feasible with an acceptable safety profile where the need of conversion to conventional thyroidectomy was found in only 2 (0.45%) cases. Statistical analyses were conducted using the Students t test and one-way ANOVA through the SPSS 23.0 software. No evidence of recurrence was found during the follow-up period. However, it also leads to greater trauma [22]. 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). In this way, the incision can be planned with the patients input and awareness. Meanwhile, the postoperative stiffness and paraesthesia of the SCM can also be ameliorated due to the shorter surgical time, and improved surgical techniques. 2009;146:104855. The sensory change and paralysis results from this technique and patients satisfaction with the cosmesis were also studied. Thyroidectomy is the most common endocrine surgical procedure performed throughout the world.1 In the city of . Comparison between 3-dimensional and 2-dimensional endoscopic thyroidectomy for benign and malignant lesions: a meta-analysis. The operation generally lasts from 2-3 hours. 87 Xiangya Road, Changsha, 410008, China, Rong Cong,Xinying Li,Hui Ouyang,Wenbo Xue,Zeyu Zhang&Fada Xia, You can also search for this author in A, B Step one, dissection of the route to the anterior neck area. A comparison of postoperative pain after conventional open thyroidectomy and single-incision, gasless, endoscopic transaxillary thyroidectomy: a single institute prospective study. Because the thyroid gland is situated directly in front of the trachea, or windpipe, airway obstruction may occur if blood collects in the area after surgery. MIVAT combines the small incision with use of endoscopes to help provide illumination and visualization of the tumor. Feeling that something is stuck in the throat. Acceptable wound cosmetology has become a focus for thyroid surgeons. Surgery is typically recommended for goiters that are causing symptoms. MedicineNet does not provide medical advice, diagnosis or treatment. Total thyroidectomy (sometimes called near-total thyroidectomy) is the surgical removal of the entire thyroid gland. The patient is usually given general anesthesia to numb the. Surg Endosc. Substernal Goiter Surgery. See our Scar Gallery section for examples of minimally invasive thyroid surgery. Minimally invasive thyroidectomy is a surgical approach to remove the thyroid gland through smaller incisions. 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). However, depending on the presence of any visible skin crease, a higher incision at the cricoid level along the visible skin crease is sometimes preferred to enhance the cosmetic outcome (Fig. 1996-2023 MedicineNet, Inc. An Internet Brands company. The 27-year . Last, the strap muscles were dissected laterally, the omohyoid muscle and internal jugular vein (IJV) were also exposed. a skin incision was made using scalpel, 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). However, COT normally requires a long collar incision (usually 5-8 cm in length) on the anterior neck [1]. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. The most recent trend has been to perform thyroid surgery while avoiding any neck incision at all. The final pathology is ready approximately1 week after the operation. 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. Chapter 42 Incisions in Thyroid and Parathyroid Surgery. Gasless, endoscopic trans-axillary thyroid surgery: our series of the first 51 human cases. For patients who develop hypertrophic scars, those who develop keloids and persons who want to do everything possible to avoid an incision on the neck, this procedure is possible. that the dissected flap width in trans-axillary approach is significantly wider than conventional thyroidectomy, causing greater trauma, and potentially more severe pain [20]. See additional information. The neck was entered through a collar incision, and bleeding was controlled with electrocautery. You might notice bruising around your incision or upper chest and slight swelling above the scar when you are upright. 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. Medication to normalize abnormal thyroid hormone levels may help decrease the size of goiters. Department of General Surgery, Xiangya Hospital, Central South University, No. However, the risk of damage to this nerve must be understood prior to surgery. This can also happen after parathyroid surgery. 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. Please see the Expert Consult website for more discussion of this topic. 3). Jules Boeckel of Strasbourg introduced the collar incision to thyroid. Excellent long-term cosmetic outcomes can be expected with minimally invasive endoscopic thyroid surgery (B). The CAT scan will also allow the surgeon to see if the trachea is being moved to one side or the other and if it is being narrowed by the thyroid. Many companies make these suits, and they're washable and reusable. 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. https://doi.org/10.1186/s12957-021-02484-z, DOI: https://doi.org/10.1186/s12957-021-02484-z. If the patient was taking thyroid hormone before the operation, they should continue taking the same dose unless it was changed by the surgeon. 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. Nabhan F, Ringel MD. Lee DY, Oh DJ, Kang KR, Kim MS, Oh KH, Baek SK, et al. 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. The procedure for thyroidectomy and CND was similar to that of other endoscopic and open approaches. 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. The opposite lobe is not removed, and in general the remaining thyroid gland will produce enough thyroid hormone for the body. After the seventh day, reduce the calcium to one Tums Ultra 1000 tablet three times a day until your follow-up appointment. 55 0 obj <>/Filter/FlateDecode/ID[<92107CDBA3A8D84ABDC22C73C8947E84>]/Index[32 48]/Info 31 0 R/Length 106/Prev 453493/Root 33 0 R/Size 80/Type/XRef/W[1 2 1]>>stream After the seventh day, reduce the calcium to one Tums Ultra 1000 tablet three times a day until your follow-up appointment. Figure 42-5 Delivery of a thyroid lobe through a minimal access incision (A), which is just big enough to admit the gland. COT allows good direct exposure for both thyroid lobes and central neck compartment. 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. Minimally invasive incisions might be placed in the hollow between the medial heads of the sternocleidomastoid muscle. This study kept the confidentiality of patient data and strictly complied with the Declaration of Helsinki and its later amendments or comparable ethical standards. While the conventional collar incision is widely used, endoscopic thyroidectomy is gradually becoming accepted for thyroid nodule patients with cosmetic needs [2,3,4]. endstream endobj 33 0 obj <>>> endobj 34 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Thumb 11 0 R/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 35 0 obj <>stream Privacy 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. Indications for this procedure include unilateral goiter and unilateral benign thyroid nodules. In each patient, the indication for surgery was a small nodule of unclear malignant potential. Temporary nerve damage occurs in 6-8% of cases. This consists of removal of one lobe of the thyroid gland, and the isthmus of the gland. 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. No internal jugular vein injury was reported [19]. Incision: A transverse collar incision is usually made 1-2 fingerbreaths above the sternum along the skin crease. However, in the first 24 to 48 hours, patients and their family/friends should observe the incision and neck for signs of bleeding in the neck such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. Have certain genes or a family member with goiters. Thyroidectomy incisions have significantly decreased in size since Kocher first popularized his low collar incision in the late 19 th century 4. Temporarily lowered calcium levels occur in approximately 15-40% of patients, and is treatable with calcium and vitamin D supplementation post-operatively. Thus, gasless endoscopic thyroidectomy without the assistance of robots might be more suitable. Most of the time, the surgery can be done this way. Thyroid nodules and cancer management guidelines: comparisons and controversies. Because these structures are intimately associated with the thyroid gland, your calcium levels may be affected either temporarily or permanently after thyroid surgery. The surgical procedure was similar to the methods described by other surgeon groups [11, 12]. Clinical findings and postoperative complications were analyzed. We also recommend a multivitamin for most patients. 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 . All rights reserved. Transaxillary robotic thyroid lobectomy and transaxillary robotic thyroidectomy were developed in Korea, and over the last several years has been utilized by a small but growing number of surgeons. Thus, the outcome of substernal goiter surgery is usually good. Skin flaps were created deep to the platysma up to the hyoid bone and down to the suprastemal notch. UC Irvine was the first institution on the West Coast of the United States to perform this operation. Patients will receive general anesthesia. MedicineNet does not provide medical advice, diagnosis or treatment. A comparison of surgical outcomes between endoscopic and robotically assisted thyroidectomy: the authors' initial experience. This helps to ensure proper wound healing in the postoperative period. Fifty-one patients (42 PTC patients and 9 thyroid adenoma patients) were included in this study. Prophylactic unilateral lymphadenectomy was also routinely performed among patients with thyroid cancer including the prelaryngeal, pretracheal, and ipsilateral paratracheal areas (Fig. Next, an endoscope with two cameras that produce three-dimensional viewing is inserted into the incision, and three robotic arms are inserted into the incision. Risks of the thyroid surgery include the risks common to all surgeries including risks associated with administration of general anesthesia, bleeding, and infection. We divided the patients into two groups in surgical order to compare the VRSs regarding paralysis of the SCM. Cookies policy. Furthermore, the sensory change and paralysis results from this technique and patients satisfaction with the cosmesis were also studied. 2). A more in-depth study of the learning curve of the procedure via the TA approach is urgently needed. If you experience itching once the collodion is off, you may apply lotion to the scar. Thyroidectomy for substernal usually includes goiters with minimal extension in the thoracic cavity and those that are present in the mediastinum (the area surrounding the chest cavity). In the other case, the hemorrhage of IJV has been controlled by using Harmlock clips (Fig. The patient may be positioned with special pillows under the neck to tilt the head back. volume20, Articlenumber:9 (2022) Google Scholar. 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. A thyroid lobectomy may be done for a variety of diseases including indeterminate lesions on fine needle biopsy (See Thyroid Nodules Diagnosis and Treatment ), a toxic nodule (See Hyperthyroidism ), substernal goiter, and an enlarging thyroid nodule, among others. Incomplete removal of the thyroid and complications in preserving all the critical structures beneath and around the thyroid gland are frequent events among inexperienced and occasional thyroid surgeons. The patient may then be placed on thyroid hormone pills. Modern thyroid surgery found its origins in the late 19th century in the work of Billroth and Kocher. Liang J, Zhan L, Xuan M, Zhao Q, Chen L, Yan J, Kuang J, Tan J, Qiu W. Thyroidectomy for thyroid cancer via transareola single-site endoscopic approach: results of a case-match study with large-scale population. 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). We have been using this approach since 1999. The traditional "Kocher incision", an 8-10 cm collar incision, is regarded as the conventional appropriate incision for thyroidectomy.2 However, many new approaches for thyroid surgery were developed in order to further minimize the size of the surgical incision.3 Post-thyroidectomy scars have a negative effect on quality of life. E, F Step three, the strap muscles were dissected laterally and the retractor was placed beneath the straps muscle to expose the thyroid lobe. 2021;99:26775. Examples of the so-called necklace neck incision associated with a classical thyroidectomy through an open approach (, Delivery of a thyroid lobe through a minimal access incision. The surgeon has excellent magnified visualization, can manipulate the camera to customize the view of the field, and works with surgical instruments that are more maneuverable than the human wrist and hand. The exceptions are blood thinners, aspirin, Plavix, and anti-thyroid medications like PTU and Methimazole. Patients should discuss with their doctors when and if they should restart these medications. This suggests that discomfort in the anterior neck area and SCM is obvious shortly after surgery and is relieved over time in most cases. In the UK, thyroidectomy is not routinely performed under regional anaesthesia. 4 Technologic Permanent nerve damage occurs in approximately 1% of cases performed by a skilled surgeon. Popular incisions included the Lahey incision (Figure 42-1. In addition to the complications of standard thyroid surgeries listed below, there are several complications specific to this operation. If all 4 glands are injured or removed during the operation, the blood calcium levels can become lower than normal called hypocalcemia. This nonobese gentleman who has a 26-inch neck circumference and a large goiter would not be a candidate for any minimally invasive approach. The neck appearance score was low in all cases (either satisfied or very satisfied). Kim SK, Park I, Hur N, Lee JH, Choe JH, Kim JH, et al. In the last decade, we have performed this approach on more than 500 patients and found that patients who undergo this surgery have better cosmetic results compared with the . . Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Although the numbers of identified parathyroid glands have not been calculated, we considered that the recognition and protection of the parathyroid gland would get improvement with the growing experience. 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. They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement. A questionnaire regarding the sensory changes around the anterior chest, paralysis of the SCM, and satisfaction with cosmesis was used to evaluate the quality of life in enrolled patients. Thyroidectomy is the main surgical treatment for thyroid cancer and is a treatment option for certain thyroid conditions, including: Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. It is uncommon, but when it occurs after thyroidectomy, it is usually associated with Grave's disease. 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. The size of the incision is dictated by surgeon preference and need for adequate exposure to remove the tumor. In the hands of our Columbia Thyroid Center surgeons, the chance of having a temporary hoarseness is 3% and the chance of having a permanent hoarseness is less than 1%. When the goiter is caused by a noncancerous. Collar incision was made about 2 1/2cm above the inner ends of the clavicle, through the platysmal muscle. 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]. Duncan TD, Ejeh IA, Speights F, Rashid QN, Ideis M. Endoscopic transaxillary near total thyroidectomy. In addition to classifying the extent of surgical resection, a number of surgical approaches have been described. 4 Also emerging are techniques for remote access thyroid and The supraclavicular lateral collar incision is a feasible and safe approach for thyroidectomy. 1999-2022. During the limited follow-up periods, no recurrence has been found. Thyroid cancer is an increasingly prevalent malignancy worldwide [1]. reported the endoscopic trans-axillary technique. If you are dealing with a thyroid issue, our team at the Columbia Thyroid Center is here to help. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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. The decision as to which thyroid operation to perform depends on a number of factors including the type of disease and the patient's preferences. Later on, in 1880, Jules Boeckel of Strasbourg introduced the collar incision to thyroid surgery, and this approach was popularized, later on, by Theodor Kocher. Written informed consent for publication of their clinical details and clinical images was obtained from all patients. Temporary numbness of the anterior chest is very common after this operation, and can last for several months. The follow-up times were 3 to 10 months. https://emedicine.medscape.com/article/2051665-overview. + )&`30^2{[b#nuwUhSr e4vMHCH qOmo.S2:uZN|/L.J. 82073262) and the Hunan Province Natural Science Foundation (grant number 2021JJ41033 and 2019JJ40475). Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis. Second, we divided the area between the sternal and clavicular head of the SCM, up to the annular cartilage and down to the clavicle. Kim EY, Lee KH, Park YL, Park CH, Lee CR, Jeong JJ, et al. CAT scan of the chest: This test allows the surgeon to evaluate if the thyroid disease is growing down into the chest and if so, how it is affecting the structures in the chest. Prophylactic unilateral central compartment lymph node clearance was conducted. 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. %PDF-1.6 % Due to the working space needed for the flap formation and division of the SCM during an axillary approach, this technique is more time-consuming. This surgical procedure is known as athyroidectomy. 32 0 obj <> endobj In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days. Opening of the chest in the surgical management of substernal goiter is rarely required. WHERE WILL THE INCISION BE? it is possible to perform an open thyroidectomy with an incision of 3.3-4.2cm. Compared with conventional open surgery, gasless endoscopic trans-axillary thyroid surgery requires the dissection of the anterior neck area and splitting the SCM, which has been described in the endoscopic lateral neck dissection [15]; however, the stiffness and paraesthesia of the SCM have not been evaluated. 2021;19:23. A The retractors were used to maintain the working space during the operation. 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. Manage cookies/Do not sell my data we use in the preference centre. Chen GZ, Zhang X, Shi WL, Zhuang ZR, Chen X, Han H. Systematic comparison of cervical and extra-cervical surgical approaches for endoscopic thyroidectomy. In our study, only two cases had temporary vocal cord paralysis.

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