Mini-thyroidectomyMini-thyroidectomy

George Ferzli, MD, FACSPaul Sayad, MD; Robert Cacchione, MD

Department of Laparoscopic SurgeryStaten Island University Hospital

Minimally invasive Minimally invasive thyroid surgerythyroid surgery

Endoscopic thyroid surgeryEndoscopic thyroid surgery Video-assisted thyroid surgeryVideo-assisted thyroid surgery Mini-thyroidectomyMini-thyroidectomy

I- Endoscopic thyroid I- Endoscopic thyroid surgerysurgery

Creation of a Creation of a subplatysmal spacesubplatysmal space

Maintenance of the Maintenance of the space using CO2 space using CO2 insufflation [1,2] or insufflation [1,2] or neck lift device [3]neck lift device [3]

Placement of the Placement of the trocars: anterior, lateral trocars: anterior, lateral neck or subareolar neck or subareolar

Neck lift deviceNeck lift device

1 Husher Eur J Coelio 19971 Husher Eur J Coelio 19972 Gagner et al 20002 Gagner et al 20003 Shimizu et al J Surg Oncol 19983 Shimizu et al J Surg Oncol 19984 Ohgami et al4 Ohgami et al

AdvantagesAdvantages Precise anatomical detail due to Precise anatomical detail due to

the greatly magnified viewthe greatly magnified view Decreased pain ?Decreased pain ? Smaller scar ?Smaller scar ?

LimitationLimitation Limited to a small (<3cm) noduleLimited to a small (<3cm) nodule Contraindicated in :Contraindicated in :

– Suspicion of malignancySuspicion of malignancy– Multinodular goiterMultinodular goiter– Grave’s diseaseGrave’s disease– Prior surgeryPrior surgery– Obese patientObese patient

DisadvantagesDisadvantages Lack of direct palpation and manipulationLack of direct palpation and manipulation Small working spaceSmall working space Respiratory acidosis and diffuse Respiratory acidosis and diffuse

subcutaneous emphysema from CO2 subcutaneous emphysema from CO2 insufflationinsufflation

Minimal bleeding can obscure operative Minimal bleeding can obscure operative fieldfield

Long operative timeLong operative time Multiple scars in case of conversion or Multiple scars in case of conversion or

reoperation for completion thyroidectomyreoperation for completion thyroidectomy

II- Video-assisted II- Video-assisted thyroid surgerythyroid 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. MiccoliMiccoli et al et al

Video-assisted thyroid Video-assisted thyroid surgerysurgery

Main AccessMain Access

AdvantagesAdvantages Shorter operative timeShorter operative time Small incisionSmall incision Prevents subcutaneous Prevents subcutaneous

emphysemaemphysema Good lighting and magnificationGood lighting and magnification

DisadvantagesDisadvantages Small working spaceSmall working space Minimal bleeding can obscure operative Minimal bleeding can obscure operative

fieldfield Placement of the endoscope in addition Placement of the endoscope in addition

to the instruments can be cumbersometo the instruments can be cumbersome Requires a second assistantRequires a second assistant

III-Mini-thyroidectomyIII-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-thyroidectomyMini-thyroidectomy

The superior pole vessels are approached first

Mini-thyroidectomyMini-thyroidectomy The thyroid gland is

delivered through the incision

The recurrent laryngeal nerve is identified

The inferior pole vessels are divided

PatientsPatients March 1997 to December 1999March 1997 to December 1999 89 thyroid surgeries on 84 patients89 thyroid surgeries on 84 patients 13 men and 71 women13 men and 71 women Age 18 to 95Age 18 to 95 61 thyroid masses and 23 goiters61 thyroid masses and 23 goiters Procedures: 4 nodulectomies, 54 Procedures: 4 nodulectomies, 54

thyroidectomies, 3 near total and 28 thyroidectomies, 3 near total and 28 total thyroidectomiestotal thyroidectomies

ResultsResults Pathology:Pathology: 33 follicular adenomas, 17 33 follicular adenomas, 17

papillary carcinomas, 15 multinodular goiters, 7 papillary carcinomas, 15 multinodular goiters, 7 colloid nodules, 7 Hashimotos, 4 nodular colloid nodules, 7 Hashimotos, 4 nodular hyperplasia, 2 mixed papillary-follicular hyperplasia, 2 mixed papillary-follicular carcinomas, 1 follicular carcinoma and 1 carcinomas, 1 follicular carcinoma and 1 lymphomalymphoma

Completion thyroidectomy: 5 patients (all Completion thyroidectomy: 5 patients (all through the same incision)through the same incision)

Specimen weight: 14 to 421 gm (44.2gm)Specimen weight: 14 to 421 gm (44.2gm)

ResultsResults OR time: 35 to 164 min (mean 76 min)OR time: 35 to 164 min (mean 76 min) Hospital stay: Few hours to 2 days Hospital stay: Few hours to 2 days

(mean 1 day)(mean 1 day)– few hours post op: 5 patientsfew hours post op: 5 patients– < 23 hours post op: 79 patients< 23 hours post op: 79 patients– second day post op: 5 patientssecond day post op: 5 patients

Complications: 1 cardiac arrhythmia Complications: 1 cardiac arrhythmia and 1 transient hypocalcemiaand 1 transient hypocalcemia

ResultsResults Incision length: 2.5 to 10 cm (4.2)Incision length: 2.5 to 10 cm (4.2)

– 2-3 cm: 25 patients (28%)2-3 cm: 25 patients (28%)– 3-4 cm: 56 patients (63%)3-4 cm: 56 patients (63%)– >4cm: 8 patients (9%)>4cm: 8 patients (9%)

AdvantagesAdvantages Short operative timeShort operative time It can be done on an out patient basisIt can be done on an out patient basis Excellent postoperative pain controlExcellent postoperative pain control It can be attempted on any thyroid It can be attempted on any thyroid

pathologypathology In the case of “conversion” the In the case of “conversion” the

incision can be extended as neededincision can be extended as needed

AdvantagesAdvantages Completion thyroidectomy, when Completion thyroidectomy, when

required, can be performed through required, can be performed through the same incisionthe same incision

The procedure can be performed The procedure can be performed under local anesthesiaunder local anesthesia

It has no complications related to It has no complications related to neck insufflationneck insufflation

It has an excellent cosmetic resultIt has an excellent cosmetic result

45 year old patient after right thyroid lobectomy45 year old patient after right thyroid lobectomy

ConclusionsConclusions Mini-thyroidectomy is feasible and Mini-thyroidectomy is feasible and

safesafe It has excellent cosmetic resultsIt has excellent cosmetic results It can be applied to all patients It can be applied to all patients

regardless of thyroid pathology or regardless of thyroid pathology or sizesize

ConclusionsConclusions Mini-thyroidectomy (along with Mini-thyroidectomy (along with

video assisted thyroidectomy) video assisted thyroidectomy) compared to totally endoscopic compared to totally endoscopic thyroid surgery, have shorter thyroid surgery, have shorter operative times, shorter hospital operative times, shorter hospital stays, comparable cosmetic results stays, comparable cosmetic results without complications related to without complications related to neck insufflationneck insufflation

ConclusionsConclusions The greatest advantage to mini-The greatest advantage to mini-

thyroidectomy is that it requires no thyroidectomy is that it requires no additional technical expertise, and additional technical expertise, and is therefore easier to teach and is therefore easier to teach and reproducereproduce