Advances in Thyroid Surgery

8/10/2019 Advances in Thyroid Surgery

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Rohaizak Muhammad

B.Sc, M.B.Ch.B, M.S, FRCS, FAMMBreast and Endocrine Surgeon

UKM Medical Centre


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In the prehistoric era

division of the umbilical cord andother minor procedures

human teeth and nails Apocryphal tales suggest certain Rabbi used

sharpened thumbnails for circumcision ofthe newborn

later with plant, animal and mineral

substitutes


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Introduction of haemostatic forceps by SpencerWells andJules Pear (1874)

More meticulous and safe surgery


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Most commonly performed surgical procedures

worldwide

fundamental to surgical training

Extensive vascular network of the thyroid gland

Adequate haemostasis is very important

Identify important structure to avoid injury to important

structure

Minimal post-operative bleeding/haematoma can be lethal

Suture ligation with bipolar or monopolar

electrocoagulation for smaller vessels remains the

gold standard


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Electric monopolar coagulation

transmission of electric power

diffusion of heat to nearby tissue

Ligation and division of the thyroid vessels

time-consuming sometimes difficult in small space

Upper pole vessel

Need assistant

Risk of knot slipping

Mechanical devices such as titanium clips would shortenoperative time

clip dislodge

Cost


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Electrothermal bipolar vessel sealing system and the

harmonic scalpel

Adequate haemostasis

Minimal thermal spread

Minimal tissue damage

No foreign bodies

Single-person operation (Hand-held or pedal control)

Faster surgery as doesnt need assistant

Safety and efficacy proven in laparoscopic and endoscopic surgery


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Harmonic scalpel (Focus)

Ligasure (Small Jaw)

Thunderbeat


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No conflict of interest

Both studies sponsored by the university and

approved by the UKM ethic committee

Do not receive any grant or contribution by any

pharmaceutical company


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Aim

To compare the operating time, length of hospital stay, overall drainage volume

as well as surgical complications between the two techniques.

To perform a cost-effectiveness analysis comparing both surgical techniques of

sutureless and conventional thyroidectomy by virtue of direct cost incurred

involving both techniques and surgical outcome measures like length ofhospital stay, seroma or haematoma complications and nerve injury

Method

Retrospective comparative study

Group A (20002006) ~ Conventional knot tying

Group B (20062011) ~ Harmonic Scalpel

66 patients were selected randomly from the available database by selecting 10patients at a time

Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages


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All costs incurred were calculated Preoperative

preoperative assessment of thyroid function, thyroid antibodies, serum calcium, ultrasoundand computed tomography scanning of the neck where deemed necessary

intraoperative

postoperative

include operating theatre cost, building costs, laboratory and investigation costs, buildingcosts, equipment costs and medication

Capital costs include building, furniture and equipment costs.

All capital costs were discounted at the rate of 5% per annum.

The useful life of building is assumed to be 20 years while life span of furniture andequipment was 5 years.

All equipment that cost above RM 500 were considered as capital (incl thegenerators)

Recurrent costs Personnel salary, consumables, laboratory investigations, drugs and maintenance of

equipment



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Individual costs

Calculations for each individual according to the laboratory,investigations performed, the costs of analgesia required, the length ofhospital stay and the post-operative care rounds performed byinvolved personals based on their salary and time spent.

Consumables include the number of gauze used, drains and blades

Disposable Harmonic Scalpel/Focus shear

Recycled up to 3 times (approved by the hospital management)

Sterilised using STERRAD

Price is 1/3 of purchasing price



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Techniques N Median Range P

Duration of Operation (mins) Conventional 33 140.00 (112.5-198) 0.001**Sutureless 33 104.00 (75-135)

Length Of Stay (days) Conventional 33 4 (2.5-5) 0.59

Sutureless 33 3 (3-4.5)

Weight of Thyroid Gland Removed (g) Conventional33 25.90 (11.1-82.4) 0.22

Sutureless 33 54.00 (18.1-92.0)

Volume of Gland (ml) Conventional 33 60.00 (17.30-189.37) 0.22

Sutureless 33 110.00 (31-248.87)Overall Drainage Volume( ml) Conventional 18 76 (36.25-128.75) 0.68

Sutureless 16 84 (59.50-121.75)

n Median(OT time)

range p

Total thyroidectomy(HS)

17 120.0 90.0-147.5 0.01

Total thyroidectomy(C)

10 211.0 146.0- 255.0

Hemithyroidectomy(HS)

16 90.0 60.0-122.0 0.001

Hemithyroidectomy(C)

23 135.0 116.3-158.8



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Techniques

Conventional Sutureless 2 PComplication-RLNinjury Yes 2 (6.0) 0 2.06 0.36

No 31 (94) 33 (100)

Complication-

Haematoma

No32 (97.0) 32 (97.0) 0.00 1.00

Yes 1 (3.0) 1 (3.0)

Complication-Seroma No 31 (93.9) 33 (100) 2.06 0.15

Yes 2 (6.1) 0

Complication

Hypocalcaemia

No25 (75.8) 26 (78.8) 0.09 0.77

Yes 8 (24.2) 7 (21.2)



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Average(RM)/patient


3888.11 P= 0.244

Total thyroidectomy

(C)

4409.67

Hemithyroidectomy

(HS)

3108.79 P=0.543

Hemithyroidectomy

(C)

3171.60

By recycling the HS for 3 cycles, we found that there was a saving of RM521.56(USD160) for each total thyroidectomy performed and a saving of RM62.81(USD20)

for each hemithyroidectomy performed using the sutureless method not significant

Despite significant reduction in operating time, the total cost using HS issignificantly higher if the instrument were used only once in hemithyroidectomy(Total thyroid =RM618.44 and Hemithyroid =RM1077.19)

Average(RM)/patient


5028.11 p=0.170

Total thyroidectomy

(C)

4409.67

Hemithyroidectomy

(HS)

4248.79 P=0.027

Hemithyroidectomy

(C)

3171.60

Recycle 3 times Single use



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In 1935, The surprising voice is gone forever;she had specter of a ghost replaced the velvetsoftness


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Recurrent Laryngeal Nerve Paresis (RLNP) followingthyroid surgery one of the leading reasons for medico-legal litigation against

surgeons

Lahey of Boston (1938) and Riddell of London(1956) advocated routine identification and dissection of the RLN

Rare complication of thyroid surgery in expert hands Permanent (0.33%)

Transient (38%)

Higher in re-operative surgery (2-30%)

Extent of surgery (12.6 times greater risk (P = 0.01))

Less experienced RLNP rates of 0.72% for surgeons performing greater than 45 NAR

procedures per year vs 1.06% in those with less than 45 NAR per year (P =0.003)


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Technique/Tool that facilitate the identification,

preparation and preservation of important

structures

Subcapsular dissection

Magnifying glasses

Bipolar coagulation forceps

Ultrasonic shears

Ligasure

Intra-operative Nerve Monitoring (IONM)


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Stay away from the nerveif the nerve is seen, it is injured

Identify the nervePresuming the location;

know the anatomical landmarks and variations.Limitations: - Nerve may not be identified even after thoroughsearching. -Differentiate nerve from blood vessel or fibrous strands.A structurally intact nerve does not mean a functioning nerve.

Identify the nerve and functionIONM, Intraoperative Nerve monitoring.Identify the nerve even without seeing it.

Hear it, before see it


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Continuous IONM


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Started in August 2013

First hospital in Asia to use CIONM(Continuous intra operative nerve monitoring)

Has performed more than 100 cases Data to be audited


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One of the indication is cosmetic Development of keloid or hypertrophied scar

Exposed part of the body


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Incisions in the neck (Cervical) Smaller incision

Mini thyroidectomy

Minimally invasive video-assisted thyroidectomy

Incision in a not visible area(Extra-cervical) such as Incisions outside the neck

the axilla

around the nipple

Endoscopic thyroidectomy via the chest

Axillary endoscopic thyroidectomy

Endoscopic thyroidectomy through the breast


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The usual indications: Young patient

Patient under age of 45

Small and Benign lesions

Up to 5 cm Yamamoto et al applied the endoscopic

thyroidectomy with breast approach to Gravesdisease in 2001

In 2002, Miccoli et al. applied minimally invasivevideo-assisted thyroidectomy to resection of apapillary thyroid carcinoma


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Cervical

Extra-cervical Axillary

Breast

Anterior chest wall

Axillo-bilateral-breast(ABBA)

Bilateral axillo-breast(BABA)

Shoulder Axillo Breast EndoThyroidectomy (SABET)modifications to the technique

No consensus on which approach is the best


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Advantages enables the surgeon to control the 3-dimensional high-

definition camera,

reducing physiological tremors

enabling free dexterity of movement using articulatedinstruments

yield similar oncologic outcomes as conventional openprocedures

superior surgeon ergonomics


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SABET (Shoulder Axillo Breast

EndoThyroidectomy)

Gas insufflation of 12 mmHg

Dr Nguc Luong (Vietnam)


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Patient given option of Open Mini thyroidectomy (3 cm incision) Endoscopic thyroidectomy

Performed by 3 endocrine surgeons

All had experienced in laparoscopic surgery, suturelessthyroidectomy and lateral approach

Routine ultrasound Done by radiologist

Size less than 5 cm at its widest diameter

Not suspicious of malignancy Routine FNAC

Malignancy excluded Include indeterminate or inconclusive cytology


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3 ports technique Axilla-Breast

Shoulder approach

CO2 at 12 mm Hg Post-op

All patients haddrained


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Initial 19 patients from for analysis

11

8

Right

Left

17

2

Female

Male


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AxisTitle

Average : 116 min

ConvertedSecondSurgeon


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Lateral approach Open lateral and midline approach

Endoscopic surgery Need to familiar with endoscopic/laparoscopic surgery

Sutureless thyroidectomy

? Surgeon performed ultrasonography

Not popular


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Size < 5 cm

Majority of thyroid in

UKMMC are huge goitre

Benign condition

Not keen for surgery

Opted for conservative

?? private


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?? Long neck

Culture/Religion

Covered by veil/hijab

Aesthetic clinic Colourless scar


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New medical technologies implicated in the rising costs of healthcare

Depends partly on our ability to control their use

Control technology diffusion

Staff need to perfect their skill at using the intervention, patient selection has to be refinedand patient numbers need to build up to economically viable levels

Conduct research to assess clinical and cost effectiveness

trials might either underestimate or overestimate clinical and cost effectiveness ifconducted too early

But control is difficult

Pressures

media public demand

manufacturers

professional enthusiasm

provider competitiveness


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Advancement of technique/ technology in

thyroid surgery

vs clinical expertise/ infrastructure

vs Cost (incl OT/Staff/ hospital stay/morbidity)

vs Local Scenario/Culture/Religion

vs Patients convenience/Cosmesis


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Advances in Thyroid Surgery

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