Thyroid disorders are common in women and they would like to have treatment options with a definite cosmetic appeal. Generally when someone is diagnosed with a single nodule or multiple nodules they need to be evaluated by ultrasound scan of neck and if needed fine needle aspiration cytology. The USG features or FNAC is suspicious of a malignancy then surgery is the solution, even at any size of the swelling. Even if the USG and FNAC suggest benign swelling the option of thyroidectomy needs to be sought if the nodule is more than 4 cm. Depending on the physical examination, USG and FNAC findings surgeon decides to offer a hemithyroidectomy (removal of full lobe on the side of lesion and isthmus) or total thyroidectomy.
The surgical solution available in most of the places is open thyroidectomy which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsighty scar which is not acceptable, especially for women. (Picture 1)
The lateral thyroidectomy by cutting on sides of neck for each side lobe removal – though better than full open surgery – is also not a desirable one. Robotic surgery does not give any advantage on the cosmetic aspect of the thyroid surgery.
The endoscopic thyroidectomy – the keyhole or minimally invasive technique is a very good alternative to other methods. It gives excellent cosmetic outcome especially when done by an axillary approach. It gives equal or even a better surgical outcome as far as the actual thyroid nodule management is considered. There are other less preferred endoscopic approaches like sternal and breast approach.
The procedure of endoscopic thyroidectomy by axillary approach involves the following steps. A 10 mm trocar placement in the axilla towards neck for the telescope; which initially helps in creating the plane and visualization of structures with magnification, precision and clarity.
Then two 5 mm trocars are introduced in to the dissected space (sub platysmal) which are used as working ports. We generally use a less heat generating energy source the harmonic scalpel instead of cautery for tissue dissection. (Picture 2)
Once space is created in the neck the sternomastoids and strap muscles gets exposed. We can open the investing layer in midline and reach the thyroid gland. The gland is mobilized by blunt dissection and vital structures identified. The recurrent laryngeal nerve, the superior laryngeal nerve and parathyroids with their blood supply will be preserved. The vessels are divided and gland detached from trachea. A specimen bag is used to place the thyroid and removed by dilating 10 mm trocar. For a total thyoidectomy one will have to put additional trocars on the opposite side and do the same steps on that side as well.
The investing layer is sutured back, drain is placed and the trocar sites closed. Patient is asked to be in the hospital for 24 hours only and can resume all kinds of activities in a few days. (Picture 3)
These patients will have less wound related problem compared to open surgery group. The cosmetic outcome is such excellent that the small wounds in axilla heals with minimal scarring and gets covered with small inner-wears. (Picture 4, 5, 6)
The earlier belief was that the endoscopic no neck scar option for thyroid swellings are applicable to lesions of less than 4 cm size. But we have observed that swellings of size of even 12 – 15 cm can be tackled very successfully through this method. The only pre-requisite will be a surgeon with good experience, in both laparoscopic surgeries and thyroid surgeries. (Picture 7) The complications of this surgery are very similar to that of open surgery proving that it is a much desirable option. Any kind of pathologies like benign or cancerous nodules, thyoiditis can be safely tackled by endoscopic thyroidectomy. Completion thyroidectomy is much more easier with this technique as one do not dissect the other side while performing the opposite side. Lymph node clearance when indicated can also be comfortably performed by this route
Before surgery After Surgery
Open Surgery Endoscopic Thyroidectomy
TOTAL THYROIDECTOMY SPECIMEN > 6CM each lobe
- T. K. Tan, W. K. Cheah, and L. Delbridge, ““Scarless” (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques,” World Journal of Surgery, vol. 32, no. 7, pp. 1349–1357, 2008. View at Publisher · View at Google Scholar · View at Scopus
- Ikeda, H. Takami, Y. Sasaki, J. I. Takayama, and H. Kurihara, “Are there significant benefits of minimally invasive endoscopic thyroidectomy?” World Journal of Surgery, vol. 28, no. 11, pp. 1075–1078, 2004. View at Publisher · View at Google Scholar · View at Scopus
- Gagner, “Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism,” The British Journal of Surgery, vol. 83, no. 6, p. 875, 1996. View at Scopus
- S. Hüscher, S. Chiodini, C. Napolitano, and A. Recher, “Endoscopic right thyroid lobectomy,” Surgical Endoscopy, vol. 11, no. 8, p. 877, 1997.
- Ikeda, H. Takami, Y. Sasaki, S. Kan, and M. Niimi, “Endoscopic neck surgery by the axillary approach,” Journal of the American College of Surgeons, vol. 191, no. 3, pp. 336–340, 2000. View at Publisher · View at Google Scholar · View at Scopus
Dr. R. Padmakumar MBBS, DNB, MNAMS, DipALS, FAIS
Specialist Surgeon – International Modern Hospital, Dubai
00971567581025 (UAE); 043988888; 044063000
Sunrise Medical Centre, Sharjah (06575700)
Venniyil Medical Center, Sharjah (065682258)
GC Member, Association of Surgeons of India
Vice President, Indian Hernia Society
Founder Member, Obesity and Metabolic Surgery Society Of India
Founder Member, Association of Minimal Access Surgeons of India
International Faculty of IASGO on Hernia and Diabetic Surgery