Mini-thyroidectomy

Minimally invasive thyroid surgery Endoscopic thyroid surgery Video-assisted thyroid surgery Mini-thyroidectomy

I- Endoscopic thyroid surgery Creation of a subplatysmal space Maintenance of the space using CO2 insufflation [1,2] or neck lift device [3] Placement of the trocars: anterior, lateral neck or subareolar Neck lift device 1 Husher Eur J Coelio 1997 2 Gagner et al 2000 3 Shimizu et al J Surg Oncol 1998 4 Ohgami et al

Advantages Precise anatomical detail due to the greatly magnified view Decreased pain ? Smaller scar ?

Limitation Limited to a small (<3cm) nodule Contraindicated in : Suspicion of malignancy Multinodular goiter Grave’s disease Prior surgery Obese patient

Disadvantages Lack of direct palpation and manipulation Small working space Respiratory acidosis and diffuse subcutaneous emphysema from CO2 insufflation Minimal bleeding can obscure operative field Long operative time Multiple scars in case of conversion or reoperation for completion thyroidectomy

II- Video-assisted thyroid surgery 1.5 cm anterior incision A 12 mm trocar is placed. Gas insufflation is used to help developing the space. The trocar is then removed and the rest of the procedure is performed with the space maintained using external retractors. A 5mm endoscope is placed through the incision Laparoscopic and conventional instruments are used for the dissection. Miccoli et al

Video-assisted thyroid surgery Main Access

Advantages Shorter operative time Small incision Prevents subcutaneous emphysema Good lighting and magnification

Disadvantages Small working space Minimal bleeding can obscure operative field Placement of the endoscope in addition to the instruments can be cumbersome Requires a second assistant

III-Mini-thyroidectomy A 2.5 to 3cm incision is performed approximately 3 to 4 cm above the sternal notch Superior and inferior subplatysmal flaps are created

Mini-thyroidectomy The superior pole vessels are approached first

Mini-thyroidectomy The thyroid gland is delivered through the incision The recurrent laryngeal nerve is identified The inferior pole vessels are divided

Patients March 1997 to December 1999 89 thyroid surgeries on 84 patients 13 men and 71 women Age 18 to 95 61 thyroid masses and 23 goiters Procedures: 4 nodulectomies, 54 thyroidectomies, 3 near total and 28 total thyroidectomies

Results Pathology: 33 follicular adenomas, 17 papillary carcinomas, 15 multinodular goiters, 7 colloid nodules, 7 Hashimotos, 4 nodular hyperplasia, 2 mixed papillary-follicular carcinomas, 1 follicular carcinoma and 1 lymphoma Completion thyroidectomy: 5 patients (all through the same incision) Specimen weight: 14 to 421 gm (44.2gm)

Results Hospital stay: Few hours to 2 days (mean 1 day) OR time: 35 to 164 min (mean 76 min) Hospital stay: Few hours to 2 days (mean 1 day) few hours post op: 5 patients < 23 hours post op: 79 patients second day post op: 5 patients Complications: 1 cardiac arrhythmia and 1 transient hypocalcemia

Results Incision length: 2.5 to 10 cm (4.2) 2-3 cm: 25 patients (28%)

Advantages Short operative time It can be done on an out patient basis Excellent postoperative pain control It can be attempted on any thyroid pathology In the case of “conversion” the incision can be extended as needed

Advantages Completion thyroidectomy, when required, can be performed through the same incision The procedure can be performed under local anesthesia It has no complications related to neck insufflation It has an excellent cosmetic result

45 year old patient after right thyroid lobectomy

Conclusions Mini-thyroidectomy is feasible and safe It has excellent cosmetic results It can be applied to all patients regardless of thyroid pathology or size

Conclusions Mini-thyroidectomy (along with video assisted thyroidectomy) compared to totally endoscopic thyroid surgery, have shorter operative times, shorter hospital stays, comparable cosmetic results without complications related to neck insufflation

Conclusions The greatest advantage to mini-thyroidectomy is that it requires no additional technical expertise, and is therefore easier to teach and reproduce