Endoscopic Thyroidectomy— Preliminary Experience from a Tertiary Care Center in Delhi, India

US Endocrinology, 2017;13(1):27–29 DOI: https://doi.org/10.17925/USE.2017.13.01.27

Abstract:

Cosmesis after thyroid surgery has always been a concern for patients approaching thyroid surgery. To achieve a scarless surgery in the neck, endoscopic thyroidectomy using different techniques has been described in the literature. The aim of this article is to study the feasibility of endoscopic combined axillary breast approach for thyroid surgery. This is a retrospective study in the department of Endocrine Surgery from a tertiary care center in Delhi, India. Patients who underwent endoscopic thyroidectomy at our center during May 2010–November 2015 were included. The procedure was carried out in subjects who opted for the procedure with unilateral thyroid nodules of size less than 4 cm, with benign and indeterminate cytology, and with no previous neck surgery or radiation to the neck. The details of demographic profile, operative parameters, and postoperative management were collected for all the cases. All 12 subjects were females. The mean age of the subjects was 27.2 (range 14–45) years. Mean operative time was 187 (range 110–232) minutes. There was a temporary recurrent laryngeal nerve injury in one case, local wound infection in two cases, prolonged subcutaneous emphysema in five cases, and prolonged analgesic requirement (>5 days) in 10 cases. No life-threatening complications were seen in any of the subjects. Cosmetic results were excellent as there was no visible scar in the neck. The combined breast axillary approach using endoscopic technique for unilateral thyroid nodule is feasible with acceptable morbidity and can be offered to selected patients for cosmetic advantage.
Keywords: Endoscopic thyroidectomy, minimally invasive thyroidectomy, thyroid nodule
Disclosure: Vivek Aggarwal, Bhanu Kiran Raja, Monika Garg, Deepak Khandelwal, and Bhoopendra Agarwal have nothing to declare in relation to this article. No funding was received for the publication of this article.
Compliance with Ethics: All procedures were followed in accordance with the responsible committee on human experimentation and with the Helsinki Declaration of 1975 and subsequent revisions
Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
Received: February 26, 2017 Accepted April 10, 2017
Correspondence: Deepak Khandelwal, Department of Endocrinology, Maharaja Agrasen Hospital, Punjabi Bagh, Delhi-110026, India. E: khandelwalaiims@gmail.com
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit.

Ever since thyroid surgery has been described, there is ongoing evolution in the surgical techniques of thyroidectomy. The development aims at increasing safety and improving cosmesis. To achieve safety, surgeons have adopted a number of new technologies such as intraoperative neuromonitoring of recurrent laryngeal nerve (RLN), postoperative parathyroid hormone (PTH) assay, and alternative energy devices such as ultrasonic shears or bipolar coagulation. For achieving cosmesis newer surgical techniques are being validated. These are developed using endoscopic instruments and the high-density telescope which have allowed surgeons to make a smaller incision and take the line of incision away from exposed parts of the body. Any procedure, which involves using an endoscope for thyroid surgery, is often collectively called “endoscopic thyroidectomy.” Since the first report of endoscopic parathyroidectomy in 1996,1 various minimal invasive approaches have been described in the literature. They could be generally classified into direct (cervical) and indirect (extracervical) approaches depending on the location of the incision.2 For the direct (cervical) approach, the small incision is made in the neck area and the thyroid gland is exposed directly, similar to the conventional thyroidectomy but with endoscopic instruments. It is the indirect methods, which give maximal cosmetic benefit but may not be truly minimally invasive as the dissection involved in raising the flap may be actually more than conventional.3,4

Cosmesis is a prime option for many of our patients approaching for thyroid surgery, especially young females who are afraid of having a scar in the neck. So, we planned to study the feasibility of endoscopic combined axillary breast approach for thyroid surgery in our set-up.

Materials and methods
This retrospective study was conducted in the department of Endocrine Surgery at Maharaja Agrasen Hospital, Punjabi Bagh, Delhi, a 400-bed teaching, superspecialty, National Accreditation Board for Hospitals and Healthcare Providers (NABH) and Joint Commission International (JCI) accredited Hospital. All cases who underwent endoscopic thyroidectomy between May 2010 and November 2015 were included. The protocol at our center for selecting patients for endoscopic thyroidectomy includes patients with unilateral thyroid nodules with benign and indeterminate cytology, less than

4 cm with no previous neck surgery or radiation to the neck. Choice of the procedure was decided after informed and shared decision making with the patient. The details of demographic profile, operative parameters, and postoperative management were collected for all the cases. Statistical analysis was performed by the SPSS software, version 17.0 (SPSS, Chicago, Illinois). Continuous variables were presented as mean (min–max) and categorical variables were presented as absolute numbers and in percentages if required.

References:
1. Gagner M, Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism, Br J Surg, 1996;83:875.
2. Slotema ET, Sebag F, Henry JF, What is the evidence for endoscopic thyroidectomy in the management of benign thyroid disease?, World J Surg, 2008;32:1325–32.
3. Tan CT, Cheah WK, Delbridge L, ‘‘Scarless’’ (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques, World J Surg, 2008;32:1349–57.
4. Miyano G, Lobe TE, Wright SK, Bilateral transaxillary endoscopic total thyroidectomy, J Pediatr Surg, 2008;43:299–303.
5. Rafferty M, Miller I, Timon C, Minimal incision for open thyroidectomy, Otolaryngol Head Neck Surg, 2006;135:295–8.
6. Hüscher CS, Chiodini S, Napolitano C, Recher A, Endoscopic right thyroid lobectomy, Surg Endosc, 1997;11:877.
7. Park YL, Han WK, Bae WG, 100 cases of endoscopic thyroidectomy: breast approach, Surg Laparosc Endosc Percutan Tech, 2003;13:20–5.
8. Ohgami M, Ishii S, Arisawa Y, et al., Scarless endoscopic thyroidectomy: breast approach for better cosmesis, Surg Laparosc Endosc Percutan Tech, 2000;10:1–4.
9. Jung EJ, Park ST, Ha WS, et al., Endoscopic thyroidectomy using a gasless axillary approach, J Laparoendosc Adv Surg Tech A, 2007;17:21–5.
10. Ikeda Y, Takami H, Sasaki Y, et al., Comparative study of thyroidectomies. Endoscopic surgery versus conventional open surgery, Surg Endosc, 2002;16:1741–5.
11. Schardey HM, Schopf S, Kammal M, et al., Invisible scar endoscopic thyroidectomy by the dorsal approach: experimental development of a new technique with human cadavers and preliminary clinical results, Surg Endosc, 2008;22:813–20.
12. Yeung GH, Endoscopic thyroid surgery today: a diversity of surgical strategies, Thyroid, 2002;12:703–6.
13. Shimazu K, Shiba E, Tamaki Y, et al., Endoscopic thyroid surgery through the axillo-bilateral-breast approach, Surg Laparosc Endosc Percutan Tech 2003;13:196–201.
14. Yeh TS, Jan YY, Hsu BR, et al., Video-assisted endoscopic thyroidectomy, Am J Surg, 2000;180:82–5.
15. Yoon JH, Park CH, Chung WY, Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases, Surg Laparosc Endosc Percutan Tech, 2006;16:226–31.
16. Chung YS, Choe JH, Kang KH, et al., Endoscopic thyroidectomy for thyroid malignancies: comparison with conventional open thyroidectomy, World J Surg, 2007;31:2302–6.
17. Choe JH, Kim SW, Chung KW, et al., Endoscopic thyroidectomy using a new bilateral axillo-breast approach, World J Surg, 2007;31:601–6.
18. Bellantone R, Lombardi CP, Bossola M, et al., Video-assisted vs conventional thyroid lobectomy: a randomized trial, Arch Surg, 2002;137:301–4.
19. Yoon JH, Park CH, Chung WY, Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases, Surg Laparosc Endosc Percutan Tech, 2006;16:226–31.
20. Bhargav PR, Kusumanjali A, Nagaraju R, Amar V, What is the ideal CO2 insufflation pressure for endoscopic thyroidectomy? Personal experience with five cases of goiter, World J Endocr Surg, 2011;3:3–6.
21. Gottlieb A, Sprung J, Zheng XM, Gagner M, Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation, Anesth Analg, 1997;84:1154–6.
22. Chantawibul S, Lokechareonlarp S, Pokawatana C, Total video endoscopic thyroidectomy by an axillary approach, J Laparoendosc Adv Surg Tech A, 2003;13:295–9.
23. Kang SW, Jeong JJ, Yun JS, et al., Gasless endoscopic thyroidectomy using trans-axillary approach; surgical outcome of 581 patients, Endocr J, 2009;56:361–9.
Keywords: Endoscopic thyroidectomy, minimally invasive thyroidectomy, thyroid nodule