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October 09, 2017

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Thyroidectomies using the open method are effective, well-tolerated and safe but involve transverse incision on the neck measuring 7–10 cm in length. Thyroid disorders are more common in women and they find these scars uncomfortable and cosmetically unacceptable. This incision may lead to prominent scarring that can develop into keloid or hypertrophic scars and lead to paraesthesia or hypaesthesia [1].

With the development of laparoscopic and endoscopic surgery, thyroid and parathyroid surgery has recently been attempted using an endoscopic approach. Since endoscopic parathyroidectomy and thyroidectomy were first introduced by Gagner and Huscher et al. [2,3], various endoscopic thyroid surgery (SCARLESS THYROID SURGERY / THYROID SURGERY WITHOUT SCAR) approaches have been devised, including cervical, axillary, breast, and anterior chest approaches.

A 33 year-old Malay lady presented with progressively painless enlarged right thyroid swelling for past 2-3 months. Otherwise, she had no symptoms of obstruction of esophagus and trachea. Clinically, she was euthyroid without significant medical or surgical history.

Clinically, there was a single thyroid swelling over her right lobe, measuring 2x2cm with smooth surface and firm consistency. Ultrasound of thyroid showed solitary right thyroid cyst (2.1 x 1.2 x 2.0 cm) with internal small focal solid component. Her thyroid function test showed normal result. Fine needle aspiration cytology was compatible with colloid nodule.

After in-depth discussion with her, she decided for surgical removal endoscopically. She was admitted on 13 December 2016 electively.

Endoscopic right hemithyroidectomy was done under general anesthesia. Right axillo-breast approach was used for this surgery. 1 x 11mm videoscope port and 2 x 5mm instruments ports were used. They are inserted into right axillary area and right circum-areolar area. A 300 videoscope was used.

Subplatysmal dissection of neck was done using Harmonic Scalpel. It was followed by retraction and splitting of strap muscles, exposing right thyroid lobe. Right thyroid vascular pedicles were secured using Harmonic scalpel and right parathyroid glands were identified and preserved. Right hemithyroidectomy was completed after its release from its Berry Ligaments. Right recurrent laryngeal nerve was identified and isolated. Hemostasis was achieved and drain was inserted into the wound bed. The specimen was removed using endopouch .

The overall surgery took about 1 hour and 40 minutes, comparable to conventional open thyroid surgery. Blood loss was minimal.

Right thyroid lobe removed endoscopically

Post-operatively, she had totally no pain over her neck and right shoulder. She was able to move her neck freely on her first day of surgery. She had no hoarseness of voice. No obvious neck hematoma or bruise was seen during her initial post-operative time. Drain output was also minimal, which was taken off the next day. She was discharged well the next day with simple mild painkiller.
On follow-up, she had no complaint at all. Her histo-pathological report showed benign colloid nodule without any malignancy.

Post-operative review – no neck scar and hematoma

Cosmesis is particularly important to all persons as well as younger women, who constitute a large proportion of patients affected by thyroid diseases. Because the anterior neck is a prominent, constantly exposed part of the body, an unsightly scar can prove very distressing for the patient and for the surgeon [4, 5]. The pursuit of an esthetically pleasing scar after open thyroid surgery has led surgeons to perform endoscopic surgery on the neck. Since endoscopic thyroid surgery was first successfully performed by Hüscher [3], many reports have shown that an endoscopic procedure can be used in selected thyroid nodule cases. [6-18, 19, 20]

To our knowledge, there are about 20 published endoscopic thyroidectomy techniques, including some variations.[20, 21] These can be grouped into those that use small cervical incisions, either ventral or lateral, and those that use the distant chest wall and periareolar, axillary, or combined approaches.

All of the approaches have their own merits and drawbacks; however, few reports have described the feasibility of thyroidectomy using an endoscopic approach for large benign thyroid lesions. [18, 22-25] Furthermore, the use of endoscopic procedures for thyroid cancers remains controversial.

Considering that the most important goal of endoscopic thyroid surgery is to minimize the visible scar in a natural position, incisions on or near the neck, or on the chest wall, which are used in several minimal-access approaches, should be avoided. In fact, cervical approaches can easily cause visible scars on the neck [6, 18] and anterior chest approaches can cause more hypertrophic scarring or keloids than axillary or circumareolar incisions.[7, 19] Our unilateral axillo-breast approach is essentially a surgical resection of the thyroid lobe remote from the neck, thus resulting in no neck scar. The access incisions are not necessarily smaller than those in the neck, but they have been shifted to an area that is covered by clothing.

In general, endoscopic thyroidectomy and open thyroid surgery also requires meticulous surgical dissection, absolute hemostasis, en bloc tumor resection, and adequate visualization of the operative field. To accomplish this goal, another important point in the performance of endoscopic thyroid surgery is the convenience of using endoscopic instruments, which can prevent iatrogenic trauma to the thyroid gland and reduce the risk of an incomplete operation or tumor seeding. By applying surgical instruments (endoscopic dissector and HS) at a 30° angle through the axillary and periareolar ports, we achieved a safe and complete thyroidectomy and/or ipsilateral central neck dissection with little difficulty.

With an endoscope to magnify the surgical field and the approach described here, we easily identified and preserved the recurrent laryngeal nerve and parathyroid glands. The superior parathyroid gland was often easier to identify and dissect from the thyroid gland on a vascular pedicle, as in open thyroidectomy.

Transient vocal cord palsy was related to manipulation of the thyroid gland, postoperative inflammation, edema, thermal injury from the HS, or traction injury during dissection of the recurrent laryngeal nerve. Careful dissection with the endoscopic cottonoid and HS is essential while dissecting the thyroid from the trachea to minimize the remnant thyroid tissue near Berry’s ligament.

But only about 20% of total thyroid surgeries are suitable for this type of surgery.

  1. Size of thyroid swelling is less than 4cm
  2. Total thyroid volume is less than 30cc
  3. Early stage of thyroid cancer, Stage 1 and 2 papillary thyroid cancer
  4. Follicular thyroid lesions
  5. Prophylactic total thyroidectomy in case of hereditary thyroid cancer (eg, medullary thyroid cancer)

  1. Stage 3 or 4 of thyroid cancer
  2. Large multinodular goiter
  3. History of neck radiation, eg radiotherapy on neck for other malignancies
Endoscopic thyroidectomy via a breast approach is a safe, feasible, and minimally invasive surgical method for benign and low-risk malignant thyroid disease. This approach provides good operative results and has a low complication rate. For selected thyroid disease patients who worry about neck scars, endoscopic thyroidectomy via a breast approach is an effective surgical option.
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