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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: [email protected]
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.
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