Thyroid Thyroid surgery by surgery by mini-incisionmini-incision

Rosemary Hardin MD, Joelle Pierre MD, Rosemary Hardin MD, Joelle Pierre MD, and George Ferzli MD, FACSand George Ferzli MD, FACS

SUNY Downstate SUNY Downstate Medical CenterMedical Center

Lutheran Lutheran Medical CenterMedical Center

A review of our method of thyroidA review of our method of thyroid

surgery via mini-incision, firstsurgery via mini-incision, first

published in JACS published in JACS (Journal of the(Journal of the

American College of Surgeons, MayAmerican College of Surgeons, May

2001).2001).

G Ferzli, P Sayad, Z Abdo, R Cacchione Minimally invasive, non-endoscopic thyroid surgery. G Ferzli, P Sayad, Z Abdo, R Cacchione Minimally invasive, non-endoscopic thyroid surgery. J Am Coll SurgJ Am Coll Surg May 2001: 192 (5) 665-668 May 2001: 192 (5) 665-668

An incision is made along a An incision is made along a

skin crease high up in the neck.skin crease high up in the neck.

Superior and inferior Superior and inferior subplatysmal flaps are subplatysmal flaps are developed.developed.

The superior pole vessels areThe superior pole vessels areapproached first, from a medialapproached first, from a medialto lateral direction, staying closeto lateral direction, staying closeto the capsule to avoid theto the capsule to avoid theexternal branch of the superiorexternal branch of the superiorlaryngeal nerve laryngeal nerve (*Amelita Galli-Curci*, (*Amelita Galli-Curci*, Julie Andrews?)Julie Andrews?)

* Injury to the Superior Laryngeal Branch of the Vagus During Thyroidectomy: Lesson or Myth? Peter F. Crookes, MD, FACS and James A. Recabaren, MD, FACS From the Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California

Delivery through the wound, of the upper Delivery through the wound, of the upper pole of the thyroid with medial rotation, will pole of the thyroid with medial rotation, will allow a view of the laryngotracheal allow a view of the laryngotracheal junction.junction.

Rt. recurrent laryngeal nerveRt. recurrent laryngeal nerve

Tubercle of ZuckerkandlTubercle of Zuckerkandl

Rt. upper parathyroid glandRt. upper parathyroid gland

At the laryngotracheal At the laryngotracheal junction, identify the junction, identify the following structures:following structures:

Middle thyroid veinMiddle thyroid vein

ligated and dividedligated and divided

The inferior pole vessels The inferior pole vessels are dividedare divided

If total thyroidectomy, repeat If total thyroidectomy, repeat steps on left sidesteps on left side

Free trachea from thyroid by Free trachea from thyroid by dividing ligament of Berrydividing ligament of Berry

Ligament of BerryLigament of Berry

Thyroid gland Thyroid gland is delivered is delivered easilyeasily

through the through the woundwound

PATIENTSPATIENTS

• 264 thyroid surgeries on 264 thyroid surgeries on 256 patients256 patients

• 55 men and 201 women55 men and 201 women• Age – 17 to 95 years (48)Age – 17 to 95 years (48)

PREOP DIAGNOSISPREOP DIAGNOSIS

• Mass or noduleMass or nodule == 176176• GoiterGoiter == 7474• HyperthyroiditisHyperthyroiditis == 66

• Type of procedures: Type of procedures: – 5 nodulectomies 5 nodulectomies – 78 R lobectomies78 R lobectomies– 65 L lobectomies65 L lobectomies– 30 near total 30 near total – 86 total thyroidectomies86 total thyroidectomies

• Lymph node dissectionLymph node dissection– 6 patients6 patients

• Length of incision: Length of incision:

– 2 cm.2 cm. == 5252– 2.5 cm.2.5 cm. == 3232– 3 cm.3 cm. == 6868– 4 cm.4 cm. == 9898– > 4 cm.> 4 cm. == 1414

Total 264Total 264

Of the 256 patients, 8 who initially underwent Of the 256 patients, 8 who initially underwent unilateral thyroid lobectomy subsequently required unilateral thyroid lobectomy subsequently required resection of the contralateral lobe (completion resection of the contralateral lobe (completion thyroidectomy using the same incision)thyroidectomy using the same incision)

OR TIMEOR TIME 27’ – 164’ (48.59’)27’ – 164’ (48.59’)(dropped from an average of 76’ in(dropped from an average of 76’ in2001 in the first 89 patients)2001 in the first 89 patients)

HOSPITAL STAYHOSPITAL STAYOutpatientOutpatient == 26 patients26 patients23 hours23 hours == 210 patients210 patientsTwo daysTwo days == 18 patients18 patients> Two days> Two days == 2 patients2 patients

COMPLICATIONSCOMPLICATIONS

• ArrhythmiaArrhythmia == 1 patient1 patient • Hematoma (reop)Hematoma (reop) == 1 patient 1 patient

(R thyroid)(R thyroid)

• Open wound (near total)Open wound (near total) == 1 patient1 patient

• InadvertentInadvertentparathyroidectomyparathyroidectomy == 3 patients3 patients

• HypocalcemiaHypocalcemia == 3 patients3 patients (2 requiring readmission)(2 requiring readmission)

• Nerve injuryNerve injury– Recurrent laryngealRecurrent laryngeal == 3 (2 transient, 1 3 (2 transient, 1

permanent)permanent)

POST OPERATIVE PATHOLOGYPOST OPERATIVE PATHOLOGY

WEIGHT WEIGHT 4–530 gm. 4–530 gm. (50.05) (50.05)

PATHOLOGIESPATHOLOGIESFollicular adenomasFollicular adenomas 6868Papillary carcinomasPapillary carcinomas 5353Multinodular goitersMultinodular goiters 3838Colloid nodulesColloid nodules 1111Hashimoto’s thyroiditisHashimoto’s thyroiditis 2525Mixed papillary-follicular carcinomasMixed papillary-follicular carcinomas 44Follicular carcinomaFollicular carcinoma 10 10 LymphomaLymphoma 11Grave’s diseaseGrave’s disease 22Medullary carcinomaMedullary carcinoma 22Chronic lymphocytic thyroiditisChronic lymphocytic thyroiditis 22Hurtle cell cancerHurtle cell cancer 66Nodular hyperplasiaNodular hyperplasia 3434

TOTALTOTAL 256256

CONCLUSIONCONCLUSION• Thyroid surgery using mini-incision is Thyroid surgery using mini-incision is

feasible and safefeasible and safe

• Done on an out-patient basisDone on an out-patient basis

• Can be attempted on any thyroid pathologyCan be attempted on any thyroid pathology

• Can be performed under local anesthesiaCan be performed under local anesthesia

• Compared to endoscopic thyroid surgery, Compared to endoscopic thyroid surgery, it has a shorter operative time, shorter it has a shorter operative time, shorter hospital stay, comparable cosmetic results hospital stay, comparable cosmetic results and no complication related to neck insufflationand no complication related to neck insufflation

• Completion thyroidectomy, when required, can be performed through the Completion thyroidectomy, when required, can be performed through the same incisionsame incision

• It has an excellent cosmetic resultIt has an excellent cosmetic result