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Endoscopic minimally invasive thyroidectomy: first clinicalexperience

Thomas Wilhelm • Andreas Metzig

Received: 13 May 2009 / Accepted: 2 December 2009 / Published online: 25 December 2009

� Springer Science+Business Media, LLC 2009

Abstract

Background Since Theodor Kocher reduced the mortality

rate of thyroidectomy from the 40% reported by Billroth to

0.2% in 1895, a collar incision with open removal of the

thyroid gland is the standard procedure [1, 2]. In the past

decade, efforts were made to reduce incision size and

surgical access trauma by the use of endoscopic techniques.

A first attempt was replacement of the central ‘‘Kocher

incision’’ with lateral neck incisions and endoscopic

removal of a thyroid lobe by Huscher on 8 July 1996 [3].

This lateral access was limited to removing only one lobe

of the gland. The most common technique to date is the

one developed by Miccoli et al. [4]. These authors reduced

the incision to a size of 20 to 25 mm and operated on

the thyroid by the use of video-endoscopic assistance

(MIVAT).

Several groups have described an access outside the frontal

neck region via a chest [5–8], axillary [9], or combined

axillary bilateral breast approach [10]. These accesses only

moved the entry point from the frontal neck region to other

regions, where they are still visible. The aforementioned

minimally invasive approach and the conventional open

approach do not respect anatomically given surgical planes

and may therefore result in patient complaints, especially

swallowing disorders after the scaring of the subcutaneous

tissues. These extracervical approaches are associated with

an extensive dissection in the access area and thus are

maximally invasive.

Therefore, we developed an exclusively endoscopic

approach for thyroid resection [11] with standard instru-

ments used for minimally invasive surgery (diameter,

3.5 mm). This endoscopic minimally invasive thyroidec-

tomy (eMIT) technique was evaluated carefully by ana-

tomic and cadaver dissections as well as ultrasound studies

for technical realization and needs for instrument design

[12]. To verify the safety and feasibility of the method, an

animal trial was conducted in August 2008. Surgery was

performed securely on five pigs, with very low blood loss.

The postoperative behavior with special regard for feeding

and pain reaction was normal until dissection. Especially,

no local infection in the oral cavity or cervical spaces was

noted.

Methods All the trials of eMIT showed good results, so

we went on to its first clinical application in the spring of

2009. A 53-year-old man had experienced dysphagia for

more than a year. During routine diagnosis, the thyroid

hormones T3, T4, and TSH were controlled and within

normal levels. Thyroid scintigraphy, B-mode ultrasound

examination, and laryngoscopy were performed preopera-

tively. An euthyroid nodular change of the right hemithy-

roid with a beginning focal autonomy was diagnosed. After

the patient’s informed consent was received, surgery was

performed on 18 March 2009 in an interdisciplinary col-

laboration between a general surgeon and a head and neck

surgeon.

The first incision was made in the midline sublingually. A

5-mm trocar was directed through the floor of the mouth

Electronic supplementary material The online version of thisarticle (doi:10.1007/s00464-009-0820-9) contains supplementarymaterial, which is available to authorized users.

T. Wilhelm (&)

Department of Otolaryngology, Head, Neck, and Facial Plastic

Surgery, Helios Kliniken Leipziger Land, Rudolf-Virchow-

Strasse 2, D-04552 Borna, Germany

e-mail: thomas.wilhelm@helios-kliniken.de

A. Metzig

Department of General, Visceral, and Vascular Surgery,

Helios Kliniken Leipziger Land, Rudolf-Virchow-Strasse 2,

D-04552 Borna, Germany

123

Surg Endosc (2010) 24:1757–1758

DOI 10.1007/s00464-009-0820-9

muscles into the subplatysmal layer and positioned at the

level of the cricoid. Carbon dioxide then was insufflated at

6 mmHg to build a tent above the thyroid gland. Next, a

second trocar for insertion of the surgical instruments was

placed over a vestibular incision into the same subplatys-

mal layer. This allowed the surgical field to be visualized

fully and dissected with 3.7-mm standard minimally-

invasive instruments. A third trocar for surgical instru-

ments then was placed through an incision on the left side

of the vestibule of the mouth.

After a midline incision of the linea alba, the fibrous cap-

sule of the thyroid gland could been seen. The isthmus then

was prepared in total. Next, the strap muscles above the

right hemithyroid were prepared, showing the right upper

pole. With the Harmonic scalpel, the isthmus was divided

on the left side. The gland was loosened from the trachea

and the adjacent lamella. The vessels of the upper pole

were divided by Ultracision (Ethicon-Endosurgery, Cin-

cinnate/Ohio, USA). Under the adjacent lamella, the

recurrent nerve was visualized and stimulated. Neuro-

monitoring showed an intact function of the nerve. Finally,

the lower pole was detached, allowing the thyroid to be

freely movable.

Recovery of the tumor was performed through the median

trocar incision after the optic device was moved through a

lateral trocar. The tumor volume was 5.5 ml. The operation

site was checked for bleedings and lavaged with sodium

chloride. After removal of all the trocars, the wounds were

sutured with self-resorbable sutures. Plaster tape was

applied for 24 h. No direct postoperative complications

occurred. Postoperative histology showed a colloidal

struma.

Results The floor of the mouth healed well, with no local

infections at the incision sites or in the cervical spaces.

Vocal cord function, evaluated by direct video-laryngos-

copy, was normal. The patient had minimal swelling of the

neck and a small hematoma, which resolved within

2 weeks. He had neither swallowing disorders nor oral

pain. His preoperative dysphagia was gone, and he left the

clinic 2 days after surgery without any complaints.

Conclusion With the development of an exclusively

endoscopic approach for thyroid resection (eMIT) and its

first clinical application, we could show the safety and

feasibility of another natural orifice surgery procedure. One

major concern before surgery was possible infection of the

cervical spaces by introduction of oral flora to these

regions. Investigating this infection risk, Hong and Yang

[13] evaluated the surgical results associated with the

intraoral approach for submandibulectomy in a series of

77 cases of chronic sialadenitis and benign mixed tumors.

The infection rate was 2.6% (2 patients) compared with

7.3% in a control group of 251 patients who underwent a

transcervical procedure [13]. Therefore, we estimated the

infection risk to be lower than with conventional trans-

cervical approaches.

The clear advantages of this technique are its minimally

invasive character, its reduction of surgical trauma, its

direct access to surgical planes and spaces, its avoidance of

swallowing disorders and postoperative dysphagia, and

finally, its avoidance of any skin scars. Further trials are

already being conducted.

Disclosures Thomas Wilhelm and Andreas Metzig have no con-

flicts of interest or financial ties to disclose.

References

1. Welbourn RB (1996) Highlights from endocrine surgical history.

World J Surg 20:603–612

2. Pinchot S, Chen H, Sippel R (2008) Incisions and exposure of the

neck for thyroidectomy and parathyroidectomy. Operat Tech Gen

Surg 10:63–76

3. Huscher CSG, Chiodini S, Napolitano C, Recher A (1997)

Endoscopic right thyroid lobectomy. Surg Endosc 11:877

4. Miccoli P, Berti P, Coute M, Bendinelli C, Marcocci C (1999)

Minimally invasive surgery for thyroid small nodules: pre-

liminary report. J Endocrinol Invest 22:849–851

5. Gagner M (1996) Endoscopic subtotal parathyroidectomy in

patients with primary hyperparathyroidism. Br J Surg 83:875

6. Brunt LM, Jones DB, Wu JS, Quasebarth MA, Meininger T,

Soper NJ (1997) Experimental development of an endoscopic

approach to neck exploration and parathyroidectomy. Surg

122:893–901

7. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT (1998)

Endoscopic endocrine surgery in the neck. an initial report of

endoscopic subtotal parathyroidectomy. Surg Endosc 12:202–205

8. Yeung GH (1998) Endoscopic surgery of the neck: a new fron-

tier. Surg Laparosc Endosc 8:227–232

9. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M (2000) Endo-

scopic neck surgery by the axillary approach. J Am Coll Surg

191:336–340

10. Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T,

Kitajima M (2000) Scarless endoscopic thyroidectomy: breast

approach for better cosmesis. Surg Laparosc Endosc Percutan

Tech 10:1–4

11. Wilhelm T, Benhidjeb T, Harlaar J, KJeinrensink G-J, Schneider

TAJ, Stark M (2008) Surgical anatomy of the floor of the mouth

and the cervical spaces as a rationale for transoral, minimally

invasive, and endoscopic procedures: results of cadaver studies.

Min Inv Ther 17:220–221

12. Wilhelm T, Kruger J, Benhidjeb T, Harlaar J, Kleinrensink G-J,

Schneider TAJ, Stark M (2008) Ultrasound studies on the shift of

cervical tissues in different head and neck positions: impact on

transoral, sublingual thyroidectomy. Min Inv Ther 17:242

13. Hong KW, Yang YS (2008) Surgical results of the intraoral

removal of the submandibular gland. Otolaryngol Head Neck

Surg 139:530–534

1758 Surg Endosc (2010) 24:1757–1758

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