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Alternative Approaches to the Thyroid Gland
A lt er n ati ve A p p ro ac h e s to the Thyro id Gland William S. Duke,
MD,
David J. Terris,
MD*
KEYWORDS Thyroid surgery Endoscopic Robotic Minimally invasive KEY POINTS There are 2 separate mechanisms for reducing the cosmetic burden of thyroid surgery: minimally invasive anterior cervical approaches and remote access approaches. Minimally invasive cervical approaches use small incisions on the anterior neck to directly access the thyroid compartment and require limited dissection to remove the thyroid gland. Remote access approaches should not be considered minimally invasive; while the incisions are generally well hidden in these techniques, the extent of dissection required and the subsequent prolonged recovery of these approaches is much greater than that of minimally invasive anterior cervical approaches.
INTRODUCTION
The traditional thyroidectomy technique produces a long scar on the neck that is difficult to conceal. While this approach is still warranted in selected cases, many patients may be candidates for innovative procedures designed to customize the incision size, location, and extent of dissection to the individual thyroid pathology being treated. These procedures, which began to emerge in the 1990s, were driven by patientcentered efforts to improve the cosmetic impact of thyroid surgery. As these novel approaches germinated, 2 divergent avenues of innovation were pursued. Along one pathway, minimally invasive anterior cervical approaches were developed, which sought to reduce the extent of dissection and decrease the length of the cervical scar while still offering direct access to the thyroid. On the other pathway, numerous other techniques were developed that completely remove the thyroidectomy scar from the visible neck. These remote access approaches comprise a heterogeneous group of procedures that use endoscopic or robotic assistance to access the thyroid gland from extracervical incision sites.
Disclosure: None (W.S. Duke); Directed thyroid courses sponsored by Johnson & Johnson (D.J. Terris). Department of Otolaryngology, GRU Thyroid Center, Georgia Regents University, 1120 Fifteenth Street, BP-4109, Augusta, GA 30912-4060, USA * Corresponding author. E-mail address: [email protected] Endocrinol Metab Clin N Am 43 (2014) 459–474 http://dx.doi.org/10.1016/j.ecl.2014.02.009 0889-8529/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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BACKGROUND AND HISTORY
More than a century after becoming a formalized and internationally accepted procedure, thyroid surgery was still being performed as described by Emil Theodor Kocher in the nineteenth century.1 This traditional approach involves making a large 7- to 10-cm transverse cervical incision, elevating subplatysmal flaps, and widely exposing the contents of the thyroid compartment, using surgical drains and inpatient postoperative care. As endoscopic and minimally invasive techniques became more widespread, interest turned to the application of these approaches to neck surgery, where postoperative scars tend to be more conspicuous. Gagner2 described the first endoscopic cervical surgery in 1996, performing a subtotal parathyroidectomy using multiple ports and CO2 insufflation. Although the procedure took 5 hours, generated mild hypercarbia and significant subcutaneous emphysema, and required a 4-day hospital admission, “the cosmetic result was excellent.”3 Although this experience clearly demonstrated obstacles that would need to be addressed when developing alternative approaches to the central region of the neck, the potential to decrease the cosmetic impact of a traditional thyroidectomy scar quickly attracted the attention of both patients and surgeons. Efforts to improve the cosmetic outcome after thyroid surgery simultaneously evolved along 2 separate pathways. Some teams pursued and refined minimally invasive anterior cervical approaches, such as the minimally invasive video-assisted thyroidectomy (MIVAT)4,5 and the minimally invasive nonendoscopic thyroidectomy (MINET).6 These approaches were designed to decrease the length of the cervical scar, reduce the extent of dissection required, and improve the postoperative recovery experience. Other teams sought to remove the scar from the visible portion of the anterior neck completely. These remote access approaches primarily emerged in Asian practices, wherein patients are at an increased risk of hypertrophic scarring and place a premium on the cosmetic appearance of the neck.7,8 The earliest attempts at alternative approaches to the thyroid compartment relied on CO2 insufflation to aid with dissection and maintenance of the operative pocket, and most of them were performed using endoscopic visualization.4,9–11 After Gagner’s3 initially difficult experience with CO2 insufflation was confirmed in a subsequent report,12 surgeons began to develop gasless techniques that could maintain the operative space without the use of CO2. The minimally invasive anterior cervical approaches came to rely on blunt retraction of the soft tissue,5,13 whereas the remote access techniques frequently use either percutaneous suspension techniques14–16 or specialized retractors17 to maintain the operative space. DEFINING ALTERNATIVE APPROACHES
Fundamentally, any method of accessing the thyroid gland that deviates from the traditional Kocher thyroidectomy approach may be considered “alternative.” A distinction should be clearly made, however, between minimally invasive anterior cervical approaches and remote access approaches (Table 1). Minimally invasive alternative anterior cervical approaches such as MINET and MIVAT use small incisions camouflaged in natural neck creases to access the thyroid compartment. The incision is significantly smaller than that of a conventional thyroidectomy and the extent of dissection is reduced. This feature results in less postoperative pain for the patient and obviates postoperative drainage. In many cases, these procedures are performed on an outpatient basis.18 These approaches, therefore, are truly minimally invasive, not just involving a minimal incision.
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Table 1 Alternative thyroidectomy approaches based on incision location Category
Incision Site
Approach
Minimally invasive anterior cervical
Anterior region of the neck
MIVAT MINET
Remote access
Chest or breast
Axillary
Combined Postauricular Oral cavity
CO2-assisted endoscopic Gasless endoscopic Gasless robotic CO2-assisted endoscopic Gasless endoscopic Gasless robotic ABBA BABA endoscopic RFT NOTES
Abbreviations: ABBA, axillobilateral breast approach; BABA, bilateral axillo-breast approach; MINET, minimally invasive non-endoscopic thyroidectomy; MIVAT, minimally invasive video-assisted thyroidectomy; NOTES, natural orifice transluminal endoscopic surgery; RFT, robotic facelift thyroidectomy.
In contrast, a remote access approach to the thyroid removes the surgical scar from the visible neck completely. These techniques transfer the site of entry to a more distant, concealed location and use dissection along natural tissue planes to access the central neck compartment. Remote access procedures generally rely on endoscopic or robotic equipment to facilitate visualization and manipulation of the tissue. These procedures require more dissection than that required in a traditional thyroidectomy, put additional structures at risk that are not normally vulnerable during anterior cervical approaches, and frequently necessitate drainage and postoperative hospital admission.10,11,17,19–21 As such, these procedures neither are minimally invasive nor should they be considered scarless. ADVANTAGES AND DISADVANTAGES OF ALTERNATIVE APPROACHES
Long-term complications and mortality related to traditional thyroid surgery are uncommon22,23 and may be even lower in minimally invasive video-assisted anterior cervical approaches.24,25 MIVAT and MINET afford the surgeon rapid access to the thyroid compartment along a familiar route of dissection. In experienced hands, these approaches are associated with equivalent or shorter operative times, less blood loss, less postoperative pain, and improved cosmetic outcomes than conventional thyroid surgery.24,26 Despite these advantages, MINET and MIVAT may not be appropriate for many patients requiring thyroid surgery. Dissection through minimally invasive incisions may be difficult or unsafe in patients with large goiters, substernal extension, or thyroiditis. Patients with invasive carcinomas or lateral neck lymph node metastases should be treated with a more conventional approach. Although the cosmetic results are generally favorable, patients still may be left with a visible anterior cervical scar. Finally, the MIVAT approach requires an additional assistant to operate the endoscope. Some patients find the prospect of any anterior neck scar unacceptable. For these individuals, remote access procedures, which remove the postoperative scar from a visible location on the anterior part of the neck and replace it with an incision hidden in a less conspicuous location, may be appealing. Owing to the heterogeneity of this group of procedures, very few generalizations can be made about remote access approaches as a whole. It is unclear if these procedures are consistently less painful or result in a faster recovery time than
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conventional thyroid surgery, as the potentially smaller incisions may be offset by the more extensive dissection required.27–29 These procedures generally take longer to perform than anterior cervical approaches, although this parameter may highly depend on the individual technique and the experience of the surgeon.28–30 What is consistently demonstrated, however, is that remote access thyroid surgery uses more medical resources and is more expensive than conventional thyroid surgery, especially if a prolonged inpatient stay is required.27,31–33 Although these procedures may reimburse favorably in some Asian markets, there is currently no reimbursement incentive to offset the increased surgical costs in the United States and other Western markets.32,33 APPROACHES Minimally Invasive Anterior Cervical MIVAT
The procedure begins by marking a 15- to 20-mm incision in a low cervical skin crease while the patient is awake and upright in the holding area. This step helps ensure that the incision is concealed in the most vertically favorable position on the neck. The incision is made in the previously marked skin crease and carried down through the platysma, exposing the sternohyoid and sternothyroid muscles. No subplatysmal flaps are elevated. The strap muscles are separated vertically in the midline and retracted laterally, off the anterior and lateral aspects of the thyroid. A 5-mm 30 laparoscope is introduced into the wound. The avascular space between the inferior constrictor muscle and the medial aspect of the superior pole is bluntly dissected, thereby isolating the superior vascular pedicle. Although initially described using vessel clips, Harmonic-ACE shears (ACE23P, Ethicon EndoSurgery, Inc, Cincinnati, OH, USA) are now used to divide the superior pole vessels close to the thyroid capsule (Fig. 1). The superior parathyroid gland is identified and preserved. The middle thyroid vein is then divided, and the inferior pole is mobilized. The inferior vascular pedicle is divided, and the inferior parathyroid gland is identified and dissected away from the thyroid. The lobe is then exteriorized with liberal use of hemostat clamps placed directly on the gland itself, especially the superior pole (Fig. 2). The lobe is retracted medially and ventrally, and the recurrent laryngeal nerve (RLN) is identified and traced until it courses under the inferior constrictor muscle. The Harmonic device is used to ligate vessels and divide the tissue during this dissection. The isthmus is then divided and the lobe is removed.
Fig. 1. (A, B) Bundle ligation of the superior vascular pedicle (arrow) with an advanced energy device during MIVAT.
Alternative Thyroid Surgery
Fig. 2. Delivery of the thyroid lobe through the MIVAT incision.
The contralateral lobe is removed in a similar manner, if required. The surgical field is irrigated, and Surgicel (Ethicon, Inc, Somerville, NJ, USA) is placed into the thyroid bed. The strap muscles are reapproximated in the midline with a single figure-ofeight 3-0 Vicryl suture (Ethicon, Inc). This single fixation point decreases the risk of postoperative airway obstruction by allowing any fluid accumulation to easily escape the thyroid compartment. The subcutaneous tissues are closed with buried interrupted 4-0 Vicryl sutures, and the skin edges are sealed with tissue adhesive and a horizontal 1/4-inch Steri-Strip (3M Corporation, St. Paul, MN, USA) (Fig. 3). No drain is
Fig. 3. Right thyroid lobe and wound closure after MIVAT.
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used, and the procedure is accomplished on an outpatient basis. Fig. 4 shows the healing incision. Originally reported for the treatment of small-volume benign thyroid disease, cytologically indeterminate nodules, and low-risk differentiated thyroid cancer (DTC), the indications for MIVAT have recently been expanded to include select patients with thyroiditis and intermediate-risk DTC34 and elective central neck dissection has shown to be safe and feasible when combined with this approach.35 Although they vary by report, potential contraindications include patients with nodules larger than 35 mm, an estimated thyroid volume greater than 25 cm3, malignancies larger than 20 mm, and the presence or suspicion of metastatic lymph nodes.34 In an early multiinstitutional trial of 336 patients, the mean operative time with MIVAT was 69.4 minutes for a hemithyroidectomy and 87.4 minutes for a total thyroidectomy.36 Complications included hemorrhage in 0.9% of cases, temporary RLN weakness in 2.1% of cases, permanent RLN weakness in 0.3% of cases, temporary hypocalcemia in 2.7% of cases, permanent hypocalcemia in 0.6% of cases, and a conversion rate of 4.5%.36 This safety profile was validated in a large North American MIVAT study of 228 patients,25 and Terris and Seybt37 described several important modifications (detailed above) designed not only to aid with MIVAT procedures but also to be incorporated into any anterior cervical approach. An important potential limitation of this procedure is that 2 surgical assistants are required: one to maintain the operative field with retractors and one to maneuver the endoscope. MINET
Almost concurrent with the development of MIVAT, a MINET technique was reported from groups in South Korea26 and the United States.38 This approach sought to minimize the tissue trauma associated with conventional thyroidectomy while providing an alternative to endoscopic neck surgery.
Fig. 4. MIVAT incision 2 weeks after surgery. (From Terris DJ, Angelos P, Steward DL, et al. Minimally invasive video-assisted thyroidectomy. A multi-institutional North American experience. Arch Otolaryngol Head Neck Surg 2008;134(1):83; with permission.)
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This approach uses a 3- to 5-cm incision marked in a low cervical skin crease to access the thyroid compartment. Dissection is identical to that in the MIVAT technique, except that the slightly larger skin incision is repositioned with retractors as necessary to maintain an optimal view of the operative field, obviating endoscopic assistance. In addition to complete removal of the thyroid, central neck dissection may be performed using this exposure.26 Closure is the same as for minimally invasive nonendoscopic surgery. No drain is used, and the procedure is accomplished on an outpatient basis. MINET has been shown to be a safe and effective procedure in properly selected patients. A retrospective comparison of 466 patients undergoing MINET with 437 patients undergoing conventional thyroidectomy demonstrated MINET to have a decreased operative time, less blood loss, a shorter hospital stay, decreased drain utilization, and less postoperative pain with no difference in complication rates.26 Remote Access Endoscopic Chest/breast approaches
Ohgami and colleagues10 described the first truly remote access thyroidectomy in 2000 when they reported a series of CO2-assisted endoscopic hemithyroidectomies. The thyroid compartment is accessed through incisions at the parasternal border of one breast and along the superior margins of both areolas. Endoscopic dissection proceeds superiorly over the strap muscles, and the thyroid lobe on the side of the lesion is exposed and removed. Although Ohgami and colleagues10 did not describe their patient selection criteria, they reported removing thyroid nodules ranging from 3 to 7 cm. The mean operative time for this series was nearly 4 hours. Using a low insufflation pressure of 6 mm Hg, they experienced minimal cervical emphysema and no other complications related to CO2 insufflation. Numerous variations of the anterior chest and breast approach have been described since the initial description of the procedure, including isolated anterior chest wall approaches15 as well as bilateral39 and unilateral40 transareolar approaches. Typical indications for these approaches now include unilateral benign lesions less than 3 cm or papillary microcarcinomas in patients with no concerning lymphadenopathy and no prior history of neck surgery or radiation.16,39,40 Despite the lack of cervical scars with these approaches, they do involve incisions on the breast or anterior chest. The anterior chest incisions are subject to hypertrophic scarring,19 and breast scars, however inconspicuous, may be an unappealing alternative in North American patients.41,42 These approaches may also be limited by a narrow operative field and restriction of movement by the rigid endoscopic equipment.19 These factors prompted the development of other remote access techniques. Axillary approaches
The first viable remote access alternative to the anterior chest and breast approaches was the endoscopic axillary approach, pioneered by Ikeda and colleagues.11 The patient is positioned supine on the operating table, and the arm on the side to be dissected is elevated to expose the axilla. An incision is made in the axilla, and dissection proceeds along the pectoralis major muscle until the platysma is encountered. Trocars are placed through the incision, and CO2 insufflation is used to expand the operative field. Using endoscopic visualization, dissection proceeds between the anterior border of the sternocleidomastoid muscle (SCM) and the strap muscles until the thyroid lobe is identified. The strap muscles are divided to expose the thyroid lobe for excision. This approach is associated with improved cosmetic outcomes when compared with open surgery; however, it takes significantly longer to perform than a conventional
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open thyroidectomy.43 This approach is also still subject to the constraints of CO2assisted dissection, namely, relatively narrow operative corridors, the need for rigid specialized endoscopic equipment, and the risks of CO2-related morbidity. To overcome these limitations, gasless remote access techniques that did not require a closed operative pocket and CO2 insufflation were developed.44 This approach was later modified so that dissection occurs between the sternal and clavicular heads of the SCM rather than between the SCM and the sternohyoid muscle.45 Several hybrid approaches were also developed that combine both axillary and areolar incisions. These techniques, which include the axillobilateral breast approach19 and the bilateral axillo-breast approach (BABA)20 were designed to capitalize on the cosmetic benefit of the axillary approaches while providing additional anterior chest working ports without producing a transverse parasternal scar (Fig. 5). Despite their cosmetic appeal, these approaches have been associated with several complications not typically associated with traditional thyroid surgery, including transient neurapraxia of the brachial plexus46 and pneumothorax.20 Transoral approaches
While extracervical approaches to the thyroid succeed in removing the incision from the anterior part of the neck, they generally involve extensive dissection and still result in cutaneous scarring. The rise in natural orifice transluminal endoscopic surgery for pelvic and abdominal procedures led to efforts to incorporate these approaches into thyroid compartment surgery. The feasibility of this approach was demonstrated
Fig. 5. Comparison of the extent of dissection for the axillobilateral breast approach (ABBA) and the bilateral axillo-breast approach (BABA). (Courtesy of Georgia Regents University, Augusta, GA; with permission.)
Alternative Thyroid Surgery
in cadaver and porcine models,47,48 but the inaugural clinical implementation of this technique in 8 patients was met with a conversion rate of 38% and a permanent RLN injury rate of 13%.49 This experience significantly dampened enthusiasm for the technique, with only 1 small series of 8 patients subsequently published.50 Remote Access Robotic Procedures
The incorporation of da Vinci surgical robotic technology (Intuitive Surgical, Inc, Sunnyvale, CA, USA) in remote access thyroid surgery has afforded surgeons a 3-dimensional view of the operative field while incorporating surgical instruments whose range of motion exceeds the capabilities of traditional rigid endoscopic equipment. The first use of the surgical robot in thyroid surgery involved a combined robotic and endoscopic transaxillary thyroid lobectomy using CO2 insufflation.51 Since that time, surgical robotic technology has been incorporated into a CO2-assisted BABA,21 as well as gasless dual incision axillary and chest wall,17 single incision axillary52 and facelift53 approaches (Fig. 6). This technology has also been used to perform central and lateral neck dissections in patients with thyroid malignancies.54 It should be noted that although US Food and Drug Administration approval exists for general surgery procedures, a specific indication for robotic thyroidectomy has not been issued. Robotic axillary thyroidectomy
The first reports of completely robotic surgery of the thyroid compartment emerged from South Korea in 2009.17,28,45 An axillary approach was employed combined
Fig. 6. Comparison of the extent of dissection for the RFT and the RAT. (Courtesy of Georgia Regents University, Augusta, GA; with permission.)
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with a gasless dissection facilitated by inserting a specialized retractor (Chung retractor) to elevate the skin and muscle flap.45 The robotic axillary thyroidectomy (RAT) initially used a secondary parasternal incision on the anterior chest wall (dual incision approach),28,45 but a single incision in the axilla52 is now commonly performed. The dissection is the same as described for the endoscopic transaxillary approach, but robotic assistance is used for removal of the thyroid. There was early enthusiasm that this approach may be widely exportable. However, because of economic considerations and several complications encountered when RAT was initially incorporated into North American practices,31,33,55–58 this procedure has largely been abandoned in the United States. Robotic facelift thyroidectomy
The concerns generated by the RAT experience in Western centers, as well as the need for perioperative drains and postoperative hospital admission after this procedure, prompted exploration into alternative robotic approaches to the thyroid compartment. The robotic facelift thyroidectomy (RFT) was developed to address some of these potential disadvantages associated with RAT.53,59 Patients must meet specific eligibility criteria to be considered for RFT.60 As with all remote access techniques, patients should be highly motivated to avoid a visible cervical scar. However, they should also accept the unlikely risk of conversion to an anterior cervical approach. Patients should also be healthy enough to tolerate the extended general anesthesia exposure necessary with this procedure.53 Patients should not be morbidly obese, although flap elevation in an extremely thin neck must be deliberate to avoid inadvertent skin injury. The thyroid disease must also conform to selection requirements.60 The approach vector and current instrumentation only permit unilateral surgery through a single ipsilateral incision. Although cases of staged bilateral completion RFT procedures or total thyroidectomy through 2 incisions have been reported,53 generally, the thyroid condition to be addressed should be one that is appropriate for unilateral surgery. The largest nodule to be removed should not exceed 4 cm in greatest dimension. There should be no thyroiditis, substernal extension, or concern for malignancy such as pathologic lymphadenopathy or extrathyroidal spread. The RFT incision begins in the postauricular crease and is carried superiorly, crossing into the occipital hairline (Fig. 7). A subplatysmal flap is elevated until the SCM is identified. Dissection proceeds along the SCM as a series of landmarks are encountered, including the great auricular nerve and the external jugular vein. These are preserved as the anteromedial border of the SCM is exposed down to the clavicle. A muscular triangle bounded by the anterior border of the SCM, the superior border of the omohyoid muscle, and the posterior border of the sternohyoid is defined, and the omohyoid and other strap muscles are elevated ventrally to expose the superior pole of the thyroid gland and the superior vascular pedicle (Fig. 8). The modified Chung retractor (Marina Medical, Inc, Sunrise, FL, USA) is positioned to retract the strap muscles ventrally. A Singer hook (Medtronic, Jacksonville, FL, USA) is used to retract the SCM laterally and dorsally, thereby securing the open surgical pocket. The robot is deployed using a 30 down-facing endoscope. A Harmonic device (Ethicon Endo-Surgery, Inc) is placed in the dominant arm, and a Maryland grasper is used in the nondominant arm. The superior vascular pedicle is divided with the Harmonic device. The superior thyroid pole is retracted inferiorly and ventrally to expose the inferior constrictor muscle, taking care to avoid injuring the superior laryngeal nerve. The superior parathyroid gland is reflected away from the posterior aspect of the thyroid. The RLN is then
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Fig. 7. The RFT incision. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1637; with permission.)
identified laterally as it courses under the inferior constrictor (Fig. 9). The nerve is dissected inferiorly, exposing the ligament of Berry. With the nerve under direct visualization, the ligament is transected with the Harmonic device and the thyroid isthmus is divided. The middle thyroid vein is divided. The inferior parathyroid gland is bluntly dissected away from the thyroid, and the inferior vascular pedicle is divided. All remaining attachments between the thyroid lobe and the surrounding soft tissue are divided, and the specimen is removed. The wound is closed as described above for the MIVAT procedure. No drains are used, and the patient is discharged on the day of surgery. Fig. 10 shows a patient after the procedure with no visible neck scar. RFT is a relatively new addition to the remote access armamentarium. More than 60 procedures have been accomplished at the authors’ center. In peer-reviewed
Fig. 8. Dissection pocket in RFT. EJV, external jugular vein; GAN, great auricular nerve. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1638; with permission.)
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Fig. 9. The recurrent laryngeal nerve is visualized at the tip of the nerve stimulating probe during RFT. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1639; with permission.)
publications, the procedures were completed on an outpatient basis without drainage in all but the first patient.53,60,61 There was one incidence of transient vocal fold weakness and 2 seromas, all of which resolved without intervention. There have been no episodes of hypocalcemia and no conversions to an anterior approach. This experience has been repeated in at least 4 centers, with more than 100 procedures accomplished with the same complication profile as described in the original reports.
Fig. 10. Frontal view of a patient after RFT showing no anterior cervical scar.
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SUMMARY
A commitment to patient-centered and personalized surgery has driven the development of alternative approaches to the thyroid gland. These comprise 2 fundamentally different treatment paradigms. Minimally invasive anterior cervical approaches seek to both lessen the cosmetic impact of thyroid surgery by minimizing the length of the visible incision and improve the postoperative experience for the patient by reducing the extent of dissection required. Remote access techniques completely remove the visible scar from the anterior region of the neck, at the expense of greater dissection and potential jeopardy to structures not normally at risk during thyroid surgery. Although these treatment options may not be appropriate for many individuals requiring thyroid surgery, there are patients who, by nature of medical comorbidities, occupation, lifestyle, or desire, will benefit from these innovative techniques. The surgeon and patient should consider individual risk-benefit analysis to determine if the potential advantages afforded by these techniques are warranted. REFERENCES
1. Pinchot S, Chen H, Sippel R. Incisions and exposure of the neck for thyroidectomy and parathyroidectomy. Operat Tech Gen Surg 2008;10:63–76. 2. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996;83:875. 3. Naitoh T, Gagner M, Garcia-Ruiz A, et al. Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg Endosc 1998;12:202–5. 4. Miccoli P, Berti P, Conte M, et al. Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest 1999;22:849–51. 5. Bellantone R, Lombardi CP, Raffaelli M, et al. Minimally invasive, totally gasless video-assisted thyroid lobectomy. Am J Surg 1999;177:342–3. 6. Terris DJ, Seybt MW, Elchoufi M, et al. Cosmetic thyroid surgery: defining the essential principles. Laryngoscope 2007;117:1168–72. 7. McCurdy J. Considerations in Asian cosmetic surgery. Facial Plast Surg Clin North Am 2007;15:387–97. 8. Duh Q. Robot-assisted endoscopic thyroidectomy: has the time come to abandon neck incisions? Ann Surg 2011;253(6):1067–8. 9. Hu¨scher CS, Chiodinin S, Napolitano C, et al. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877. 10. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000;10:1–4. 11. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy by the axillary approach. Surg Endosc 2001;15:1362–4. 12. Gottlieb A, Sprung J, Zheng XM, et al. Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg 1997;84:1154–6. 13. Miccoli P, Berti P, Raffaelli M, et al. Minimally invasive video-assisted thyroidectomy. Am J Surg 2001;181:567–70. 14. Shimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign thyroid tumor aiming at scarless surgery on the neck. J Surg Oncol 1998;69:178–80. 15. Kataoka H, Kitano H, Takeuchi E, et al. Total video endoscopic thyroidectomy via the anterior chest approach using the cervical region-lifting method. Biomed Pharmacother 2002;56:68s–71s.
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16. Youben F, Bo W, Chunlin Z, et al. Trans-areola single-site endoscopic thyroidectomy: pilot study of 35 cases. Surg Endosc 2012;26:939–47. 17. Kang SW, Lee SC, Lee SH, et al. Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 2009;146:1048–55. 18. Terris DJ, Chin E. Clinical implementation of endoscopic thyroidectomy in selected patients. Laryngoscope 2006;116:1745–8. 19. Shimazu K, Shiba E, Tamaki Y, et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 2003; 13:196–201. 20. Choe JH, Kim SW, Chung KW, et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 2007;31:601–6. 21. Lee KE, Rao J, Youn YK. Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique. Our initial experience. Surg Laparosc Endosc Percutan Tech 2009;19:e71–5. 22. Rosato L, Avenia N, Bernante P, et al. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 2004;28:271–6. 23. Gupta PK, Smith RB, Gupta H, et al. Outcomes after thyroidectomy and parathyroidectomy. Head Neck 2012;34:477–84. 24. Miccoli P, Berti P, Materazzi G, et al. Minimally invasive video-assisted thyroidectomy: five years of experience. J Am Coll Surg 2004;199:243–8. 25. Terris DJ, Angelos P, Steward DL, et al. Minimally invasive video-assisted thyroidectomy. A multi-institutional North American experience. Arch Otolaryngol Head Neck Surg 2008;134:81–4. 26. Park CS, Chung WY, Chang HS. Minimally invasive open thyroidectomy. Surg Today 2001;31:665–9. 27. Tan CT, Cheah WK, Delbridge L. “Scarless’’ (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques. World J Surg 2008;32:1349–57. 28. Kang SW, Jeong JJ, Yun JS, et al. Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients. Surg Endosc 2009;23:2399–406. 29. Jackson NR, Yao L, Tufano RP, et al. Safety of robotic thyroidectomy approaches: meta-analysis and systematic review. Head Neck 2013. http://dx. doi.org/10.1002/hed.23223. 30. Lee J, Yun JH, Nam KH, et al. The learning curve for robotic thyroidectomy: a multicenter study. Ann Surg Oncol 2011;18:226–32. 31. Landry C, Grubbs E, Warneke C, et al. Robot-assisted transaxillary thyroid surgery in the United States: is it comparable to open thyroid lobectomy? Ann Surg Oncol 2012;19:1269–74. 32. Cabot JC, Lee CR, Brunaud L, et al. Robotic and endoscopic transaxillary thyroidectomies may be cost prohibitive when compared to standard cervical thyroidectomy: a cost analysis. Surgery 2012;152:1016–24. 33. Perrier N. Why I have abandoned robot-assisted transaxillary thyroid surgery. Surgery 2012;152:1025–6. 34. Minuto MN, Berti P, Miccoli M, et al. Minimally invasive video-assisted thyroidectomy: an analysis of results and a revision of indications. Surg Endosc 2012;26: 818–22. 35. Neidich MJ, Steward DL. Safety and feasibility of elective minimally invasive video-assisted central neck dissection for thyroid carcinoma. Head Neck 2012;34:354–8.
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36. Miccoli P, Bellantone R, Mourad M, et al. Minimally invasive video-assisted thyroidectomy: multiinstitutional experience. World J Surg 2002;26:972–5. 37. Terris DJ, Seybt MW. Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon. Am J Otol 2011;32:392–7. 38. Ferzli GS, Sayad P, Abdo Z, et al. Minimally invasive, nonendoscopic thyroid surgery. J Am Coll Surg 2001;192:665–8. 39. Hur SM, Kim SH, Lee SK, et al. New endoscopic thyroidectomy with the bilateral areolar approach: a comparison with the bilateral axillo-breast approach. Surg Laparosc Endosc Percutan Tech 2011;21:e219–24. 40. Youben F, Bomin G, Bo W, et al. Trans-areola single-incision endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech 2011;21:e192–6. 41. Yeung GH. Endoscopic thyroid surgery today: a diversity of surgical strategies. Thyroid 2002;12:703–6. 42. Ogden J, Lindridge L. The impact of breast scarring on perceptions of attractiveness. An experimental study. J Health Psychol 2008;13:303–10. 43. Ikeda Y, Takami H, Sasaki Y, et al. Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 2003;196:189–95. 44. Yoon JH, Park CH, Chung WO. Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 Cases. Surg Laparosc Endosc Percutan Tech 2006;16:226–31. 45. Kang SW, Jeong JJ, Nam KH, et al. Robot-assisted endoscopic thyroidectomy for thyroid malignancies using a gasless transaxillary approach. J Am Coll Surg 2009;209:e1–7. 46. Ba¨rlehner E, Benhidjeb T. Cervical scarless endoscopic thyroidectomy: axillobilateral-breast approach (ABBA). Surg Endosc 2008;22:154–7. 47. Witzel K, von Rahden BH, Kaminski C, et al. Transoral access for endoscopic thyroid resection. Surg Endosc 2008;22:1871–5. 48. Benhidjeb T, Wilhelm T, Harlaar J, et al. Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 2009;23:1119–20. 49. Wilhelm T, Metzig A. Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg 2011;35:543–51. 50. Nakajo A, Arima H, Hirata M, et al. Trans-oral video-assisted neck surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc 2013;27:1105–10. 51. Lobe T, Wright SK, Irish MS. Novel uses of surgical robotics in head and neck surgery. J Laparoendosc Adv Surg Tech A 2005;15:647–52. 52. Ryu HR, Kang SW, Lee SH, et al. Feasibility and Safety of a New Robotic thyroidectomy through a gasless, transaxillary single-incision approach. J Am Coll Surg 2010;211:e13–9. 53. Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1636–41. 54. Kang SW, Park JH, Jeong JS, et al. Prospects of robotic thyroidectomy using a gasless, transaxillary approach for the management of thyroid carcinoma. Surg Laparosc Endosc Percutan Tech 2011;21:223–9. 55. Dionigi G. Robotic thyroidectomy: Seoul is not Varese. Otolaryngol Head Neck Surg 2013;148:178. 56. Kuppersmith R, Holsinger F. Robotic thyroid surgery: an initial experience with North American patients. Laryngoscope 2011;121:521–6. 57. Kandil E, Noureldine S, Yao L, et al. Robotic transaxillary thyroidectomy: an examination of the first one hundred cases. J Am Coll Surg 2012;214:558–66.
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58. Inabnet WB. Robotic thyroidectomy: must we drive a luxury sedan to arrive at our destination safely? Thyroid 2012;22:988–90. 59. Terris DJ, Singer MC. Qualitative and quantitative differences between 2 robotic thyroidectomy techniques. Otolaryngol Head Neck Surg 2012;147:20–5. 60. Terris D, Singer MC, Seybt MW. Robotic facelift thyroidectomy: patient selection and technical considerations. Surg Laparosc Endosc Percutan Tech 2011;21(4): 237–42. 61. Terris DJ, Singer MC. Robotic facelift thyroidectomy: facilitating remote access surgery. Head Neck 2012;34:746–7.
MD,
David J. Terris,
MD*
KEYWORDS Thyroid surgery Endoscopic Robotic Minimally invasive KEY POINTS There are 2 separate mechanisms for reducing the cosmetic burden of thyroid surgery: minimally invasive anterior cervical approaches and remote access approaches. Minimally invasive cervical approaches use small incisions on the anterior neck to directly access the thyroid compartment and require limited dissection to remove the thyroid gland. Remote access approaches should not be considered minimally invasive; while the incisions are generally well hidden in these techniques, the extent of dissection required and the subsequent prolonged recovery of these approaches is much greater than that of minimally invasive anterior cervical approaches.
INTRODUCTION
The traditional thyroidectomy technique produces a long scar on the neck that is difficult to conceal. While this approach is still warranted in selected cases, many patients may be candidates for innovative procedures designed to customize the incision size, location, and extent of dissection to the individual thyroid pathology being treated. These procedures, which began to emerge in the 1990s, were driven by patientcentered efforts to improve the cosmetic impact of thyroid surgery. As these novel approaches germinated, 2 divergent avenues of innovation were pursued. Along one pathway, minimally invasive anterior cervical approaches were developed, which sought to reduce the extent of dissection and decrease the length of the cervical scar while still offering direct access to the thyroid. On the other pathway, numerous other techniques were developed that completely remove the thyroidectomy scar from the visible neck. These remote access approaches comprise a heterogeneous group of procedures that use endoscopic or robotic assistance to access the thyroid gland from extracervical incision sites.
Disclosure: None (W.S. Duke); Directed thyroid courses sponsored by Johnson & Johnson (D.J. Terris). Department of Otolaryngology, GRU Thyroid Center, Georgia Regents University, 1120 Fifteenth Street, BP-4109, Augusta, GA 30912-4060, USA * Corresponding author. E-mail address: [email protected] Endocrinol Metab Clin N Am 43 (2014) 459–474 http://dx.doi.org/10.1016/j.ecl.2014.02.009 0889-8529/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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BACKGROUND AND HISTORY
More than a century after becoming a formalized and internationally accepted procedure, thyroid surgery was still being performed as described by Emil Theodor Kocher in the nineteenth century.1 This traditional approach involves making a large 7- to 10-cm transverse cervical incision, elevating subplatysmal flaps, and widely exposing the contents of the thyroid compartment, using surgical drains and inpatient postoperative care. As endoscopic and minimally invasive techniques became more widespread, interest turned to the application of these approaches to neck surgery, where postoperative scars tend to be more conspicuous. Gagner2 described the first endoscopic cervical surgery in 1996, performing a subtotal parathyroidectomy using multiple ports and CO2 insufflation. Although the procedure took 5 hours, generated mild hypercarbia and significant subcutaneous emphysema, and required a 4-day hospital admission, “the cosmetic result was excellent.”3 Although this experience clearly demonstrated obstacles that would need to be addressed when developing alternative approaches to the central region of the neck, the potential to decrease the cosmetic impact of a traditional thyroidectomy scar quickly attracted the attention of both patients and surgeons. Efforts to improve the cosmetic outcome after thyroid surgery simultaneously evolved along 2 separate pathways. Some teams pursued and refined minimally invasive anterior cervical approaches, such as the minimally invasive video-assisted thyroidectomy (MIVAT)4,5 and the minimally invasive nonendoscopic thyroidectomy (MINET).6 These approaches were designed to decrease the length of the cervical scar, reduce the extent of dissection required, and improve the postoperative recovery experience. Other teams sought to remove the scar from the visible portion of the anterior neck completely. These remote access approaches primarily emerged in Asian practices, wherein patients are at an increased risk of hypertrophic scarring and place a premium on the cosmetic appearance of the neck.7,8 The earliest attempts at alternative approaches to the thyroid compartment relied on CO2 insufflation to aid with dissection and maintenance of the operative pocket, and most of them were performed using endoscopic visualization.4,9–11 After Gagner’s3 initially difficult experience with CO2 insufflation was confirmed in a subsequent report,12 surgeons began to develop gasless techniques that could maintain the operative space without the use of CO2. The minimally invasive anterior cervical approaches came to rely on blunt retraction of the soft tissue,5,13 whereas the remote access techniques frequently use either percutaneous suspension techniques14–16 or specialized retractors17 to maintain the operative space. DEFINING ALTERNATIVE APPROACHES
Fundamentally, any method of accessing the thyroid gland that deviates from the traditional Kocher thyroidectomy approach may be considered “alternative.” A distinction should be clearly made, however, between minimally invasive anterior cervical approaches and remote access approaches (Table 1). Minimally invasive alternative anterior cervical approaches such as MINET and MIVAT use small incisions camouflaged in natural neck creases to access the thyroid compartment. The incision is significantly smaller than that of a conventional thyroidectomy and the extent of dissection is reduced. This feature results in less postoperative pain for the patient and obviates postoperative drainage. In many cases, these procedures are performed on an outpatient basis.18 These approaches, therefore, are truly minimally invasive, not just involving a minimal incision.
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Table 1 Alternative thyroidectomy approaches based on incision location Category
Incision Site
Approach
Minimally invasive anterior cervical
Anterior region of the neck
MIVAT MINET
Remote access
Chest or breast
Axillary
Combined Postauricular Oral cavity
CO2-assisted endoscopic Gasless endoscopic Gasless robotic CO2-assisted endoscopic Gasless endoscopic Gasless robotic ABBA BABA endoscopic RFT NOTES
Abbreviations: ABBA, axillobilateral breast approach; BABA, bilateral axillo-breast approach; MINET, minimally invasive non-endoscopic thyroidectomy; MIVAT, minimally invasive video-assisted thyroidectomy; NOTES, natural orifice transluminal endoscopic surgery; RFT, robotic facelift thyroidectomy.
In contrast, a remote access approach to the thyroid removes the surgical scar from the visible neck completely. These techniques transfer the site of entry to a more distant, concealed location and use dissection along natural tissue planes to access the central neck compartment. Remote access procedures generally rely on endoscopic or robotic equipment to facilitate visualization and manipulation of the tissue. These procedures require more dissection than that required in a traditional thyroidectomy, put additional structures at risk that are not normally vulnerable during anterior cervical approaches, and frequently necessitate drainage and postoperative hospital admission.10,11,17,19–21 As such, these procedures neither are minimally invasive nor should they be considered scarless. ADVANTAGES AND DISADVANTAGES OF ALTERNATIVE APPROACHES
Long-term complications and mortality related to traditional thyroid surgery are uncommon22,23 and may be even lower in minimally invasive video-assisted anterior cervical approaches.24,25 MIVAT and MINET afford the surgeon rapid access to the thyroid compartment along a familiar route of dissection. In experienced hands, these approaches are associated with equivalent or shorter operative times, less blood loss, less postoperative pain, and improved cosmetic outcomes than conventional thyroid surgery.24,26 Despite these advantages, MINET and MIVAT may not be appropriate for many patients requiring thyroid surgery. Dissection through minimally invasive incisions may be difficult or unsafe in patients with large goiters, substernal extension, or thyroiditis. Patients with invasive carcinomas or lateral neck lymph node metastases should be treated with a more conventional approach. Although the cosmetic results are generally favorable, patients still may be left with a visible anterior cervical scar. Finally, the MIVAT approach requires an additional assistant to operate the endoscope. Some patients find the prospect of any anterior neck scar unacceptable. For these individuals, remote access procedures, which remove the postoperative scar from a visible location on the anterior part of the neck and replace it with an incision hidden in a less conspicuous location, may be appealing. Owing to the heterogeneity of this group of procedures, very few generalizations can be made about remote access approaches as a whole. It is unclear if these procedures are consistently less painful or result in a faster recovery time than
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conventional thyroid surgery, as the potentially smaller incisions may be offset by the more extensive dissection required.27–29 These procedures generally take longer to perform than anterior cervical approaches, although this parameter may highly depend on the individual technique and the experience of the surgeon.28–30 What is consistently demonstrated, however, is that remote access thyroid surgery uses more medical resources and is more expensive than conventional thyroid surgery, especially if a prolonged inpatient stay is required.27,31–33 Although these procedures may reimburse favorably in some Asian markets, there is currently no reimbursement incentive to offset the increased surgical costs in the United States and other Western markets.32,33 APPROACHES Minimally Invasive Anterior Cervical MIVAT
The procedure begins by marking a 15- to 20-mm incision in a low cervical skin crease while the patient is awake and upright in the holding area. This step helps ensure that the incision is concealed in the most vertically favorable position on the neck. The incision is made in the previously marked skin crease and carried down through the platysma, exposing the sternohyoid and sternothyroid muscles. No subplatysmal flaps are elevated. The strap muscles are separated vertically in the midline and retracted laterally, off the anterior and lateral aspects of the thyroid. A 5-mm 30 laparoscope is introduced into the wound. The avascular space between the inferior constrictor muscle and the medial aspect of the superior pole is bluntly dissected, thereby isolating the superior vascular pedicle. Although initially described using vessel clips, Harmonic-ACE shears (ACE23P, Ethicon EndoSurgery, Inc, Cincinnati, OH, USA) are now used to divide the superior pole vessels close to the thyroid capsule (Fig. 1). The superior parathyroid gland is identified and preserved. The middle thyroid vein is then divided, and the inferior pole is mobilized. The inferior vascular pedicle is divided, and the inferior parathyroid gland is identified and dissected away from the thyroid. The lobe is then exteriorized with liberal use of hemostat clamps placed directly on the gland itself, especially the superior pole (Fig. 2). The lobe is retracted medially and ventrally, and the recurrent laryngeal nerve (RLN) is identified and traced until it courses under the inferior constrictor muscle. The Harmonic device is used to ligate vessels and divide the tissue during this dissection. The isthmus is then divided and the lobe is removed.
Fig. 1. (A, B) Bundle ligation of the superior vascular pedicle (arrow) with an advanced energy device during MIVAT.
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Fig. 2. Delivery of the thyroid lobe through the MIVAT incision.
The contralateral lobe is removed in a similar manner, if required. The surgical field is irrigated, and Surgicel (Ethicon, Inc, Somerville, NJ, USA) is placed into the thyroid bed. The strap muscles are reapproximated in the midline with a single figure-ofeight 3-0 Vicryl suture (Ethicon, Inc). This single fixation point decreases the risk of postoperative airway obstruction by allowing any fluid accumulation to easily escape the thyroid compartment. The subcutaneous tissues are closed with buried interrupted 4-0 Vicryl sutures, and the skin edges are sealed with tissue adhesive and a horizontal 1/4-inch Steri-Strip (3M Corporation, St. Paul, MN, USA) (Fig. 3). No drain is
Fig. 3. Right thyroid lobe and wound closure after MIVAT.
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used, and the procedure is accomplished on an outpatient basis. Fig. 4 shows the healing incision. Originally reported for the treatment of small-volume benign thyroid disease, cytologically indeterminate nodules, and low-risk differentiated thyroid cancer (DTC), the indications for MIVAT have recently been expanded to include select patients with thyroiditis and intermediate-risk DTC34 and elective central neck dissection has shown to be safe and feasible when combined with this approach.35 Although they vary by report, potential contraindications include patients with nodules larger than 35 mm, an estimated thyroid volume greater than 25 cm3, malignancies larger than 20 mm, and the presence or suspicion of metastatic lymph nodes.34 In an early multiinstitutional trial of 336 patients, the mean operative time with MIVAT was 69.4 minutes for a hemithyroidectomy and 87.4 minutes for a total thyroidectomy.36 Complications included hemorrhage in 0.9% of cases, temporary RLN weakness in 2.1% of cases, permanent RLN weakness in 0.3% of cases, temporary hypocalcemia in 2.7% of cases, permanent hypocalcemia in 0.6% of cases, and a conversion rate of 4.5%.36 This safety profile was validated in a large North American MIVAT study of 228 patients,25 and Terris and Seybt37 described several important modifications (detailed above) designed not only to aid with MIVAT procedures but also to be incorporated into any anterior cervical approach. An important potential limitation of this procedure is that 2 surgical assistants are required: one to maintain the operative field with retractors and one to maneuver the endoscope. MINET
Almost concurrent with the development of MIVAT, a MINET technique was reported from groups in South Korea26 and the United States.38 This approach sought to minimize the tissue trauma associated with conventional thyroidectomy while providing an alternative to endoscopic neck surgery.
Fig. 4. MIVAT incision 2 weeks after surgery. (From Terris DJ, Angelos P, Steward DL, et al. Minimally invasive video-assisted thyroidectomy. A multi-institutional North American experience. Arch Otolaryngol Head Neck Surg 2008;134(1):83; with permission.)
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This approach uses a 3- to 5-cm incision marked in a low cervical skin crease to access the thyroid compartment. Dissection is identical to that in the MIVAT technique, except that the slightly larger skin incision is repositioned with retractors as necessary to maintain an optimal view of the operative field, obviating endoscopic assistance. In addition to complete removal of the thyroid, central neck dissection may be performed using this exposure.26 Closure is the same as for minimally invasive nonendoscopic surgery. No drain is used, and the procedure is accomplished on an outpatient basis. MINET has been shown to be a safe and effective procedure in properly selected patients. A retrospective comparison of 466 patients undergoing MINET with 437 patients undergoing conventional thyroidectomy demonstrated MINET to have a decreased operative time, less blood loss, a shorter hospital stay, decreased drain utilization, and less postoperative pain with no difference in complication rates.26 Remote Access Endoscopic Chest/breast approaches
Ohgami and colleagues10 described the first truly remote access thyroidectomy in 2000 when they reported a series of CO2-assisted endoscopic hemithyroidectomies. The thyroid compartment is accessed through incisions at the parasternal border of one breast and along the superior margins of both areolas. Endoscopic dissection proceeds superiorly over the strap muscles, and the thyroid lobe on the side of the lesion is exposed and removed. Although Ohgami and colleagues10 did not describe their patient selection criteria, they reported removing thyroid nodules ranging from 3 to 7 cm. The mean operative time for this series was nearly 4 hours. Using a low insufflation pressure of 6 mm Hg, they experienced minimal cervical emphysema and no other complications related to CO2 insufflation. Numerous variations of the anterior chest and breast approach have been described since the initial description of the procedure, including isolated anterior chest wall approaches15 as well as bilateral39 and unilateral40 transareolar approaches. Typical indications for these approaches now include unilateral benign lesions less than 3 cm or papillary microcarcinomas in patients with no concerning lymphadenopathy and no prior history of neck surgery or radiation.16,39,40 Despite the lack of cervical scars with these approaches, they do involve incisions on the breast or anterior chest. The anterior chest incisions are subject to hypertrophic scarring,19 and breast scars, however inconspicuous, may be an unappealing alternative in North American patients.41,42 These approaches may also be limited by a narrow operative field and restriction of movement by the rigid endoscopic equipment.19 These factors prompted the development of other remote access techniques. Axillary approaches
The first viable remote access alternative to the anterior chest and breast approaches was the endoscopic axillary approach, pioneered by Ikeda and colleagues.11 The patient is positioned supine on the operating table, and the arm on the side to be dissected is elevated to expose the axilla. An incision is made in the axilla, and dissection proceeds along the pectoralis major muscle until the platysma is encountered. Trocars are placed through the incision, and CO2 insufflation is used to expand the operative field. Using endoscopic visualization, dissection proceeds between the anterior border of the sternocleidomastoid muscle (SCM) and the strap muscles until the thyroid lobe is identified. The strap muscles are divided to expose the thyroid lobe for excision. This approach is associated with improved cosmetic outcomes when compared with open surgery; however, it takes significantly longer to perform than a conventional
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open thyroidectomy.43 This approach is also still subject to the constraints of CO2assisted dissection, namely, relatively narrow operative corridors, the need for rigid specialized endoscopic equipment, and the risks of CO2-related morbidity. To overcome these limitations, gasless remote access techniques that did not require a closed operative pocket and CO2 insufflation were developed.44 This approach was later modified so that dissection occurs between the sternal and clavicular heads of the SCM rather than between the SCM and the sternohyoid muscle.45 Several hybrid approaches were also developed that combine both axillary and areolar incisions. These techniques, which include the axillobilateral breast approach19 and the bilateral axillo-breast approach (BABA)20 were designed to capitalize on the cosmetic benefit of the axillary approaches while providing additional anterior chest working ports without producing a transverse parasternal scar (Fig. 5). Despite their cosmetic appeal, these approaches have been associated with several complications not typically associated with traditional thyroid surgery, including transient neurapraxia of the brachial plexus46 and pneumothorax.20 Transoral approaches
While extracervical approaches to the thyroid succeed in removing the incision from the anterior part of the neck, they generally involve extensive dissection and still result in cutaneous scarring. The rise in natural orifice transluminal endoscopic surgery for pelvic and abdominal procedures led to efforts to incorporate these approaches into thyroid compartment surgery. The feasibility of this approach was demonstrated
Fig. 5. Comparison of the extent of dissection for the axillobilateral breast approach (ABBA) and the bilateral axillo-breast approach (BABA). (Courtesy of Georgia Regents University, Augusta, GA; with permission.)
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in cadaver and porcine models,47,48 but the inaugural clinical implementation of this technique in 8 patients was met with a conversion rate of 38% and a permanent RLN injury rate of 13%.49 This experience significantly dampened enthusiasm for the technique, with only 1 small series of 8 patients subsequently published.50 Remote Access Robotic Procedures
The incorporation of da Vinci surgical robotic technology (Intuitive Surgical, Inc, Sunnyvale, CA, USA) in remote access thyroid surgery has afforded surgeons a 3-dimensional view of the operative field while incorporating surgical instruments whose range of motion exceeds the capabilities of traditional rigid endoscopic equipment. The first use of the surgical robot in thyroid surgery involved a combined robotic and endoscopic transaxillary thyroid lobectomy using CO2 insufflation.51 Since that time, surgical robotic technology has been incorporated into a CO2-assisted BABA,21 as well as gasless dual incision axillary and chest wall,17 single incision axillary52 and facelift53 approaches (Fig. 6). This technology has also been used to perform central and lateral neck dissections in patients with thyroid malignancies.54 It should be noted that although US Food and Drug Administration approval exists for general surgery procedures, a specific indication for robotic thyroidectomy has not been issued. Robotic axillary thyroidectomy
The first reports of completely robotic surgery of the thyroid compartment emerged from South Korea in 2009.17,28,45 An axillary approach was employed combined
Fig. 6. Comparison of the extent of dissection for the RFT and the RAT. (Courtesy of Georgia Regents University, Augusta, GA; with permission.)
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with a gasless dissection facilitated by inserting a specialized retractor (Chung retractor) to elevate the skin and muscle flap.45 The robotic axillary thyroidectomy (RAT) initially used a secondary parasternal incision on the anterior chest wall (dual incision approach),28,45 but a single incision in the axilla52 is now commonly performed. The dissection is the same as described for the endoscopic transaxillary approach, but robotic assistance is used for removal of the thyroid. There was early enthusiasm that this approach may be widely exportable. However, because of economic considerations and several complications encountered when RAT was initially incorporated into North American practices,31,33,55–58 this procedure has largely been abandoned in the United States. Robotic facelift thyroidectomy
The concerns generated by the RAT experience in Western centers, as well as the need for perioperative drains and postoperative hospital admission after this procedure, prompted exploration into alternative robotic approaches to the thyroid compartment. The robotic facelift thyroidectomy (RFT) was developed to address some of these potential disadvantages associated with RAT.53,59 Patients must meet specific eligibility criteria to be considered for RFT.60 As with all remote access techniques, patients should be highly motivated to avoid a visible cervical scar. However, they should also accept the unlikely risk of conversion to an anterior cervical approach. Patients should also be healthy enough to tolerate the extended general anesthesia exposure necessary with this procedure.53 Patients should not be morbidly obese, although flap elevation in an extremely thin neck must be deliberate to avoid inadvertent skin injury. The thyroid disease must also conform to selection requirements.60 The approach vector and current instrumentation only permit unilateral surgery through a single ipsilateral incision. Although cases of staged bilateral completion RFT procedures or total thyroidectomy through 2 incisions have been reported,53 generally, the thyroid condition to be addressed should be one that is appropriate for unilateral surgery. The largest nodule to be removed should not exceed 4 cm in greatest dimension. There should be no thyroiditis, substernal extension, or concern for malignancy such as pathologic lymphadenopathy or extrathyroidal spread. The RFT incision begins in the postauricular crease and is carried superiorly, crossing into the occipital hairline (Fig. 7). A subplatysmal flap is elevated until the SCM is identified. Dissection proceeds along the SCM as a series of landmarks are encountered, including the great auricular nerve and the external jugular vein. These are preserved as the anteromedial border of the SCM is exposed down to the clavicle. A muscular triangle bounded by the anterior border of the SCM, the superior border of the omohyoid muscle, and the posterior border of the sternohyoid is defined, and the omohyoid and other strap muscles are elevated ventrally to expose the superior pole of the thyroid gland and the superior vascular pedicle (Fig. 8). The modified Chung retractor (Marina Medical, Inc, Sunrise, FL, USA) is positioned to retract the strap muscles ventrally. A Singer hook (Medtronic, Jacksonville, FL, USA) is used to retract the SCM laterally and dorsally, thereby securing the open surgical pocket. The robot is deployed using a 30 down-facing endoscope. A Harmonic device (Ethicon Endo-Surgery, Inc) is placed in the dominant arm, and a Maryland grasper is used in the nondominant arm. The superior vascular pedicle is divided with the Harmonic device. The superior thyroid pole is retracted inferiorly and ventrally to expose the inferior constrictor muscle, taking care to avoid injuring the superior laryngeal nerve. The superior parathyroid gland is reflected away from the posterior aspect of the thyroid. The RLN is then
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Fig. 7. The RFT incision. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1637; with permission.)
identified laterally as it courses under the inferior constrictor (Fig. 9). The nerve is dissected inferiorly, exposing the ligament of Berry. With the nerve under direct visualization, the ligament is transected with the Harmonic device and the thyroid isthmus is divided. The middle thyroid vein is divided. The inferior parathyroid gland is bluntly dissected away from the thyroid, and the inferior vascular pedicle is divided. All remaining attachments between the thyroid lobe and the surrounding soft tissue are divided, and the specimen is removed. The wound is closed as described above for the MIVAT procedure. No drains are used, and the patient is discharged on the day of surgery. Fig. 10 shows a patient after the procedure with no visible neck scar. RFT is a relatively new addition to the remote access armamentarium. More than 60 procedures have been accomplished at the authors’ center. In peer-reviewed
Fig. 8. Dissection pocket in RFT. EJV, external jugular vein; GAN, great auricular nerve. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1638; with permission.)
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Fig. 9. The recurrent laryngeal nerve is visualized at the tip of the nerve stimulating probe during RFT. (From Terris DJ, Singer MC, Seybt MW. Robot facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1639; with permission.)
publications, the procedures were completed on an outpatient basis without drainage in all but the first patient.53,60,61 There was one incidence of transient vocal fold weakness and 2 seromas, all of which resolved without intervention. There have been no episodes of hypocalcemia and no conversions to an anterior approach. This experience has been repeated in at least 4 centers, with more than 100 procedures accomplished with the same complication profile as described in the original reports.
Fig. 10. Frontal view of a patient after RFT showing no anterior cervical scar.
Alternative Thyroid Surgery
SUMMARY
A commitment to patient-centered and personalized surgery has driven the development of alternative approaches to the thyroid gland. These comprise 2 fundamentally different treatment paradigms. Minimally invasive anterior cervical approaches seek to both lessen the cosmetic impact of thyroid surgery by minimizing the length of the visible incision and improve the postoperative experience for the patient by reducing the extent of dissection required. Remote access techniques completely remove the visible scar from the anterior region of the neck, at the expense of greater dissection and potential jeopardy to structures not normally at risk during thyroid surgery. Although these treatment options may not be appropriate for many individuals requiring thyroid surgery, there are patients who, by nature of medical comorbidities, occupation, lifestyle, or desire, will benefit from these innovative techniques. The surgeon and patient should consider individual risk-benefit analysis to determine if the potential advantages afforded by these techniques are warranted. REFERENCES
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