If the patient was not taking thyroid hormone prior to the operation, the surgeon may prescribe these tablets following surgery. 2011;25:135863. Terms of Use. These nerve control the vocal cords. In cases of indeterminate lesions, some surgeons refer to a thyroid lobectomy as a diagnostic lobectomy because the main purpose of the operation is to make a diagnosis cancer or benign thyroid disease. The primary endpoint was the cosmesis of the collar scar six weeks after surgery assessed using the patient and observer scar assessment scale (POSAS). It has been pointed out by Kang et al. Jules Boeckel of Strasbourg introduced the collar incision to thyroid. 2017;274:495500. Mechanical retractors and incision selection. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000 tablets and if the symptoms do not go away after 30 minutes, call your doctor. Eur Arch Otorhinolaryngol. Patients with other significant medical issues may be asked to visit with their medical team to obtain a letter of medical clearance. 2.5cm . As the sternal head of the SCM was elevated by the retractor during the procedure, the decreased VRSs may be partly due to the shorter surgical time and improved surgical techniques. Modern thyroid surgery found its origins in the late 19th century in the work of Billroth and Kocher. Indications for this procedure include unilateral goiter and unilateral benign thyroid nodules. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Written informed consent for publication of their clinical details and clinical images was obtained from all patients. The parathyroid glands are 4 small, delicate glands each the size of a grain of rice that sit behind the thyroid and control the blood calcium levels. From July 2020 to March 2021, 51 patients (49 females and 2 males) underwent operations by gasless, endoscopic trans-axillary approaches, with one patient whose operation was converted to open surgery because of internal jugular vein injury. There is no clear definition of what minimally invasive means, and surgical incisions as large as 6 cm. However, the da Vinci system is blamed for a prolonged surgery duration and a significantly higher economic cost. The follow-up times were 3 to 10 months. The surgeon has excellent magnified visualization, can manipulate the camera to customize the view of the field, and works with surgical instruments that are more maneuverable than the human wrist and hand. It is critical to work with a team of thyroid specialists to choose the right operation for each individual patient. When this happens, you can trim the edges or let the glue fall off on its own. No evidence of recurrence was found during the follow-up period. They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement. Introduction The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. All rights reserved. How helpful the three-dimensional endoscopy or robotic endoscopy to the completion of bilateral (total) thyroidectomy via trans-axillary approach is worth further exploration. Comparison of learning curves for retroauricular and transaxillary endoscopic hemithyroidectomy. https://emedicine.medscape.com/article/2051665-overview. Johri G, Chand G, Mishra A, Mayilvaganan S, Agarwal G, Agarwal A, et al. 2021;99:26775. The addition of robotics can improve surgical dexterity in a difficult-to-reach anatomic region [6]. 4 Technologic Because of the risk of hypertrophic scarring, we recommend resecting a sliver of skin edge whenever and wherever this is recognized (Figure 42-7). This study was approved by the Institutional Ethics Committee of Xiangya Hospital, Central South University (No.202011960). B A 4-cm length incision was made in the natural wrinkle of axilla and an accessory 5-mm incision was made for another operative instrument, Three standard steps method for working space make. Endocr J. Some patients experience a "crawling" sensation in the skin, muscle cramps or headaches. It is prudent to resect a sliver of skin edge on either or both sides of the incision (B), which leads to a more predictable healing result and minimizes the risk of hypertrophic scarring. The inclusion criteria were as follows: (1) patients with thyroid nodules diagnosed as papillary thyroid cancer (PTC) by ultrasound-guided fine needle aspiration (FNA) before surgerylobectomy (LT) with prophylactic unilateral (ipsilateral) central neck dissection (CND) was performed for these patients; (2) PTC patients with central lymph nodes that were evaluated as negative by two individual professional ultrasound physicians; and (3) patients with benign unilateral nodules with diameters > 4 cm that needed surgical intervention. When a large thyroid lobe is delivered through small incisions, it is not uncommon to observe evidence of an ischemic or traumatized skin edge, Technological Innovations in Thyroid and Parathyroid Surgery, Approach to the Mediastinum: Transcervical, Transsternal, and Video-Assisted, Non-Neural Complications of Thyroid and Parathyroid Surgery, Surgery for Locally Advanced Thyroid Cancer: Larynx, Principles in Surgical Management of Primary Hyperparathyroidism, Surgery of the Thyroid and Parathyroid Glands Expert Consult Pre. Routine level 2b dissection may be recommended only in N1b papillary thyroid carcinoma with three- or four-level lateral lymph node metastasis. The middle thyroid vein was then ligated. In addition to classifying the extent of surgical resection, a number of surgical approaches have been described. Patients now expect a more measured approach to their care, which sometimes includes quite small incisions (Figure 42-5). This work was supported by the National Natural Science Foundation of China (grant No. Perhaps the most important element in optimizing access while maintaining good cosmesis is choosing the proper location for an incision. The CAT scan will also allow the surgeon to see if the trachea is being moved to one side or the other and if it is being narrowed by the thyroid. Most thyroid nodules are small, and performing a full collar incision is not necessary to provide needed surgical exposure to safely remove the thyroid lobe. Thyroid hormone levels will then be measured about every 2 months until the hormone levels are stable (levels generally stabilize in 4 to 5 months). Many companies make these suits, and they're washable and reusable. If you are dealing with a thyroid issue, our team at the Columbia Thyroid Center is here to help. The dissected area is marked in green. Patients may also be given a prescription for thyroid hormone medication (Levothyroxine or Synthroid). There are a number of factors that affect suitability for this procedure. The VRSs in a short time (1 week) were significantly higher in the first 25 cases than in the last 25 cases (the patient whose operation was converted to open surgery was excluded). However, it also leads to greater trauma [22]. All authors made substantive intellectual contributions to this study to qualify as authors. Fifty-one patients (42 PTC patients and 9 thyroid adenoma patients) were included in this study. Temporary or sometimes permanent hypoparathyroidism (low blood calcium levels). World J Surg. . Last, the strap muscles were dissected laterally, the omohyoid muscle and internal jugular vein (IJV) were also exposed. (A and B, Redrawn from Lore JM, Medina JE, editors: Atlas of head and neck surgery, Philadelphia, 2005, Elsevier-Saunders.). Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve or fix the voice. Rarely, a surgeon may open the sternum (chest) to remove the goiter. What percentage of the human body is water? Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis. However, depending on the presence of any visible skin crease, a higher incision at the cricoid level along the visible skin crease is sometimes preferred to enhance the cosmetic outcome (Fig. Typically, patients will be given prescriptions for the following medications after the operation: Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. Retractor was placed beneath the strap muscles to finish creating the working space (Fig. It is nearly always preferable to identify and utilize a preexisting skin crease (if present), as this will result in the most optimally camouflaged scar. In addition, the scar may become pink and hard. The supraclavicular lateral collar incision is a feasible and safe approach for thyroidectomy. In addition to using very small incisions, our surgeons "hide" the incision in a natural skin crease which acts like camouflage. All data generated or analyzed during this study are included in this published article. A number of important principles are worth considering when planning a thyroidectomy or parathyroidectomy, and these transcend the specific procedure that is anticipated. As the scar heals, it will appear to be part of the crease and thus camouflage it. Conventional thyroidectomy In a conventional thyroidectomy, a 3- to 4-inch incision will be made through the skin in the low collar area of your neck (the lower front portion of your neck, above the collarbones and breast bone). Thyroid cancer often spreads to lymph nodes in the neck. Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. A thyroidectomy is the surgical removal of all (total thyroidectomy) or part (partial thyroidectomy) of your thyroid gland the butterfly-shaped organ in your neck. Columbia University Irving Medical Center, Department of Surgery, New York, NY. Although the numbers of identified parathyroid glands have not been calculated, we considered that the recognition and protection of the parathyroid gland would get improvement with the growing experience. 2016;23:40238. Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Part of A number of technological advances such as advanced energy devices for hemostasis, 1 high-resolution endoscopes for improved visualization, 2 and laryngeal nerve monitoring 3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions. Ann Surg Treat Res. Moreno Llorente P, E AGL, Alberich Prats M, Francos Martnez JM, Garca Barrasa A. Surgical approaches to thyroid. The internal jugular vein was injured in two of the patients during the making of working space, one patients operation was converted to open surgery. Definition: Thyroidectomy is the surgical removal of all or part of the thyroid gland. A portion of the enlarged thyroid (if possible) or the entire thyroid gland may need to be removed. In certain cases, the surgeon may choose to perform a near-total thyroidectomy in which a small piece of thyroid tissue is left behind usually in the area of the parathyroid glands and recurrent laryngeal nerve in order to avoid damaging these structures. Compared with conventional open surgery, gasless endoscopic trans-axillary thyroid surgery requires the dissection of the anterior neck area and splitting the SCM, which has been described in the endoscopic lateral neck dissection [15]; however, the stiffness and paraesthesia of the SCM have not been evaluated. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al. The primary advantage of this surgical procedure is avoidance of an incision on the neck. Total thyroidectomy (sometimes called near-total thyroidectomy) is the surgical removal of the entire thyroid gland. This can also happen after parathyroid surgery. Incisions as small as 1 inch (2.5 cm) can be performed for patients with favorable neck anatomy and small tumors. A, B Step one, dissection of the route to the anterior neck area. Surgery. C and D, Both the right and the left neck may be thoroughly dissected with appropriate retraction assistance. The skin and subcutaneous tissues were separated, and subplatysmal . Minimally invasive incisions might be placed in the hollow between the medial heads of the sternocleidomastoid muscle. It seems no consensus has been reached on the clinical application of this technique considering the discrepant complications rate. 32 0 obj <> endobj By using this website, you agree to our A comparison of surgical outcomes between endoscopic and robotically assisted thyroidectomy: the authors' initial experience. Thyroid storm, also called thyrotoxic crisis, is a life-threatening medical emergency caused by very high levels of circulating thyroid hormone. The hockey-stick incision (C) avoids trifurcations and provides plentiful exposure for a comprehensive neck dissection. 2023 BioMed Central Ltd unless otherwise stated. endstream endobj 33 0 obj <>>> endobj 34 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Thumb 11 0 R/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 35 0 obj <>stream The two other complications that may occur after thyroid surgery involve two of the structures that are intimately associated with the thyroid gland and that may be affected by surgery, the parathyroid glands and the recurrent laryngeal nerve. . Collar incision was made about 2 1/2cm above the inner ends of the clavicle, through the platysmal muscle.. 2.5cm . In this way, the incision can be planned with the patients input and awareness. Cookies policy. During the 1850s, operations on the thyroid gland were undertaken via longitudinal, oblique, or vertical neck incisions. Standard incisions that are placed too low, spanning this indented suprasternal notch region, may appear asymmetrical and tend to be hypertrophic in their midsegment as opposed to incisions higher, in a more uniform, cylindrical region of the neck. After surgery, the patient will stay in the recovery room for several hours. Some people experience a dull ache, while others feel a sharp pain. There are two nerves called the recurrent laryngeal nerves that run just behind the thyroid. The PSSs were 1 (very satisfied), 2 (satisfied), 3 (unsatisfied), or 4 (very unsatisfied) [13]. The total mean operative time of working space make was 44 12.8 min (range 20120 min). 202011960). We also recommend a multivitamin for most patients. It is noteworthy that there is another obvious disadvantage of this technique. B In this case, the hemorrhage of IJV has been controlled by using Harmlock. 2020;44:411826. Call (212) 305-0444 for appointments. it is possible to perform an open thyroidectomy with an incision of 3.3-4.2cm. American Thyroid Association Statement on Remote-Access Thyroid Surgery. Because much of the earlier thyroid surgery was done for malignancy, descriptions emerged regarding the appropriate way to accomplish a thyroidectomy combined with a neck dissection. Thyroidectomy for substernal usually includes goiters with minimal extension in the thoracic cavity and those that are present in the mediastinum (the area surrounding the chest cavity ). Indications: Proven neoplasm (FNAC) Suspected neoplasm Age: Extreme Sex: Male n7z0#L1gV>>Z1>~G|s1OG3(dzmJ ')6bF1]/Bpp This consists of removal of one lobe of the thyroid gland, and the isthmus of the gland. Correspondence to Great efforts are made during surgery to identify and preserve this nerve on both side of the thyroid gland. Acceptable wound cosmetology has . However, despite careful technique, it is not uncommon to observe skin edges at the end of a procedure (particularly minimally invasive surgery) that are ischemic and traumatized. Classically 8-12 cm (3-5 inch) incisions were performed. Our study suggested that the lateral supraclavicular incision is a safe and practical approach for thyroidectomy. At the Columbia Thyroid Center, 95% of our patients are able to go home after a 4 hour observation period in the recovery room. Clinical findings and postoperative complications were analyzed. Transaxillary robotic thyroid lobectomy and transaxillary robotic thyroidectomy were developed in Korea, and over the last several years has been utilized by a small but growing number of surgeons. Introduction: The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. Moreover, the patients arm is raised during the entire operation time which might cause pain in the axilla [20, 21]. The patient may be positioned with special pillows under the neck to tilt the head back. A first attempt was replacement of the central . Collar incision was made about 2 1/2cm above the inner ends of the clavicle, through the platysmal muscle. Koh YW, Park JH, Kim JW, Lee SW, Choi EC. Your incision is covered with a protective strip of clear glue called collodion. Remote access is focused by many surgeons in the decade to be a feasible technique in thyroidectomy avoiding the neck scar caused by conventional surgery, which includes endoscopic or robotic approaches [16, 17]. Minimally Invasive Thyroid Surgery The typical incision made for thyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collar bone. In about 5% of patients who have thyroid surgery, the parathyroid glands do not function properly immediately after thyroid surgery. XYL, HOY, WBX, and ZYZ performed the study, collected the data, and contributed to the design of the study. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days. Approximately 70% of patients who have half of a normal thyroid gland left in place will not require thyroid hormone replacement pills. Feeling that something is stuck in the throat. Berber E, Bernet V, Fahey TJ 3rd, Kebebew E, Shaha A, Stack BC Jr, et al. This work was supported by the National Natural Science Foundation of China (grant No. Gasless single incision trans-axillary thyroidectomy: the feasibility and safety of a hypo-morbid endoscopic thyroidectomy technique. https://doi.org/10.1186/s12957-021-02484-z, DOI: https://doi.org/10.1186/s12957-021-02484-z. Patients diagnosed with thyroid cancer and thyroid nodules with diameters > 4 cm who underwent trans-axillary thyroid surgery from July 2020 to March 2021 in Xiangya Hospital were retrospectively enrolled. qDH z(a;Lq#t Only two patients developed temporary vocal cord paralysis and no patient developed permanent vocal cord paralysis. The decision as to which thyroid operation to perform depends on a number of factors including the type of disease and the patient's preferences. Patients who are asked to stay overnight generally have very large goiters, advanced cancer, bleeding disorders, a history of taking anticoagulation, or have a personal preference to spend the night. Surg Endosc. The exclusion criteria were as follows: (1) patients with benign nodules with diameters > 6 cm, (2) patients who needed a total thyroidectomy, and (3) patients for whom endoscopic surgery was not suitable due to past medical history of cervical and chest wall surgeries or other reasons. An accessory 5-mm incision was made on the vertical line of the axillary incision (35 cm far away from this incision) for another operating instrument (Fig. Next, a vertical cut will be made through the strap-like muscles located just below the skin, and these muscles . The best suits have snaps in the areas of the penis or vulva and the anus so you don't have to take the suit off when . While the conventional collar incision is widely used, endoscopic thyroidectomy is gradually becoming accepted for thyroid nodule patients with cosmetic needs [2,3,4]. The sensory change and paralysis results from this technique and patients satisfaction with the cosmesis were also studied. 2 ). Substernal Goiter Surgery. revealed that trans-axillary thyroidectomy was associated with a better cosmetic index, however, it was also associated with a longer operation time, aggravated voice changes, paresthesia, and changes in swallowing function [18]. If goiters are not causing any symptoms, the doctor may recommend close observation to monitor for any changes or growth over time. In any case, the surgical team must be ready for complications from massive goiter surgery, such as: Substernal goiter can be removed through a relatively straight forward collar incision in the lower neck. Surg Endosc. Most patients (97%) will not notice any change in their voice after the operation. The retractors (Kangji, Hangzhou, China) were used to maintain the working space during the operation. This is the result of the blood calcium level dropping below normal (hypocalcemia) and is usually temporary. In general, patients may resume taking their normal medications the day after the operation. As per the largest study done, the rate of sternotomy is less than 5%, the complication rates are acceptable, and the mortality is less than 1%. This study was reviewed and approved by the Ethics Committee of Xiangya Hospital, Central South University (No.
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