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Video-assisted endoscopic thyroidectomy
RAPID COMMUNICATION
Video-Assisted Endoscopic Thyroidectomy Ta-Sen Yeh, MD, Yi-Yin Jan, MD, Brend Ray-Sea Hsu, MD, PhD, Kwan-Win Chen, MD, Miin-Fu Chen, MD, Taipei, Taiwan
BACKGROUND: Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS: In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle’s tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS: All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS: VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of
From the Departments of Surgery (TSY, YYJ, MFC) and Metabolism (BRSH, KWC), Chang-Gung Memorial Hospital, ChangGung University, Taipei, Taiwan. Requests for reprints should be addressed to Ta-Sen Yeh, MD, Department of Surgery, Chang-Gung memorial Hospital, 5 FuHsing Street, Taoyuan,Taiwan. Manuscript submitted May 23, 2000, and accepted in revised form June 25, 2000.
82
© 2000 by Excerpta Medica, Inc. All rights reserved.
satisfactory cosmetic results. Am J Surg. 2000; 180:82– 85. © 2000 by Excerpta Medica, Inc.
D
uring the last several years, laparoscopic surgery has begun to replace conventional open surgical techniques for a variety of procedures, including cholecystectomy, appendectomy, herniorrhaphy, Nissen fundoplication, adrenalectomy, and splenectomy. Recent advances in minimally invasive surgical techniques, instrumentations, and devices have the potential to expand endoscopic surgery outside these established body cavities. Since 1996, when Gagner1 first reported endoscopic subtotal parathyroidectomy in a patient with primary hyperparathyroidism, several experimental and clinical reports have appeared concerning endoscopic parathyroid surgery.2–5 Thyroid diseases that lead to surgical intervention are much more prevalent in the general population than are those of the parathyroid glands. Thus, a minimally invasive surgery for the thyroid glands is certainly desirable. So far, clinical reports of endoscopic resections of thyroid tumors have been rare because of the inherently complicated anatomical structures and vascularity of the thyroid glands that make the endoscopic surgical technique more demanding.6, 7 Herein, we present our new method, called video-assisted endoscopic thyroidectomy (VAET), for the treatment of various benign thyroid diseases.
METHODS Patients A total of 16 consecutive patients with benign thyroid diseases who underwent VAET from November 1999 to April 2000 in the Department of Surgery, Chang Gung Memorial Hospital, were retrospectively studied. Informed consent concerning VAET was obtained from all patients. There were 13 women and 3 men, with a mean age of 38 years (range, 16 years to 73 years). Another 2 patients with follicular neoplasm, initially treated successfully with a lobectomy using the VAET technique but finally converted to open total thyroidectomy after the intraoperative cryosection yielded a follicular carcinoma, were excluded. All 16 patients presented with a palpable neck mass that shifted vertically along with the swallowing movement, consistent with the diagnosis of goiter. All 16 patients had undergone a thyroid function profile, thyroid ultrasonographic examination, and fine needle aspiration cytology. All the patients had an euthyroid status when admitted. Surgical Technique The patient’s neck was positioned in hyperextension as in conventional thyroid surgery under general anesthesia (Figure 1). A 2 cm to 3 cm transverse incision, dependent on the tumor size, was made upon the suprasternal notch. The wound was then deepened. The strap muscle was split 0002-9610/00/$–see front matter PII S0002-9610(00)00429-3
VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
Figure 1. Highlights of video-assisted endoscopic thyroidectomy (VAET). (A) A transverse 2 to 3 cm incision made on the suprasternal notch was deepened to approach the underlying trachea from which the plane of the thyroid fascia was accessed directly (arrow). (B) The middle thyroid vein was dissected. (C) The superior thyroid artery was dissected. (D) The right recurrent laryngeal nerve (arrows) was identified. (E) The left upper parathyroid gland (arrows) was identified.
longitudinally and the underlying trachea was exposed. The plane of the thyroid fascia was accessed from inferior aspect directly. Thus, the working space was established with lifting method using conventional instrument without gas insufflation. The laparoscope (4 mm, Storz) connected to the monitors was employed for video-assisted surgery. For those
cases in which lobectomy was intended, the sequence of surgical procedures were as follows: division of the inferior thyroid veins, division of the isthmus, division of the middle thyroid vein, division of the inferior thyroid artery, identification of the recurrent laryngeal nerve and parathyroid glands, division of the superior thyroid vessels, and removal of the diseased thyroid gland. For the first 5 cases,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
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VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
COMMENTS
Figure 2. Using the video-assisted endoscopic thyroidectomy technique, the neck scar is only 2.5 cm in length on suprasternal notch.
the vessels were ligated by either silk or hemoclips, whereas for the later 11 cases, ligation of the vessels and division of the thyroid parenchyma were performed completely using the ultrasonically activated scalpel (AutoSonix system, USSC) with excellent hemostasis. For cases in which partial thyroidectomy (extirpation of the goiter) was intended, division of the thyroid parenchyma was achieved exclusively with the ultrasonically activated scalpel without the necessity of dissection of the feeding vessels. For the initial 4 cases, a pediatric nasogastric tube was placed as a drainage tube. For the latter 12 cases, the drainage tube was considered unnecessary.
RESULTS All 16 patients with benign thyroid diseases underwent VAET successfully without conversion to open thyroidectomy. The final pathologic diagnoses included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle’s tumor and simple cyst in 1 each. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation took less than 40 minutes. The intraoperative blood loss was always less than 20 mL. The tumor size (the maximal dimension) ranged from 3.5 cm to 8.0 cm (mean 5.8 cm).There were no surgical complications, and no complaints of neck hematoma, numbness of the extremities, or hoarseness. All patients were able to have a liquid diet on the first day postoperatively, and shifted to an ordinary diet soon thereafter. Acetaminophen was prescribed for pain relief, and meperidine was not necessary. In the 4 who were equipped with a drainage tube, the amount of discharge ranged from 15 mL to 25 mL, and the tube was always removed on day 2 postoperatively before discharge. All patients except 1, who underwent modified radical mastectomy because of breast carcinoma concomitantly with VAET and stayed for 5 days postoperatively, were discharged on day 2 postoperatively. At the time of this writing, all 16 patients were well, with normal thyroid functioning and a satisfactory cosmetic appearance (Figure 2). 84
Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. Thyroid diseases primarily occur in young to middle-aged women who usually pay a great deal of attention to the cosmetic results after thyroid surgery. A certain portion of patients with benign goiter initially ask for an operation for cosmetic reasons alone. For these patients, open thyroidectomy would only add a more distinct neck scar after the surgery. Therefore, the development of a new surgical technique that minimizes the wound size, changes the wound location to a more obscure place, and can be readily performed by general practitioners, is warranted. Video-assisted neck surgery for endoscopic resection of thyroid tumors has been proposed by Shimizu et al.6, 7 To avoid a scar on the neck, they created three wounds in the upper chest wall below the clavicle and used a Kirschner wire for an anterior neck-lift. The advantage of their method is lack of a scar on the neck. However, the disadvantage is that multiple incisions are needed, and the incision sites are far away from the target. Therefore, a wide blunt dissection of the subplatsymal plane is necessary, as well the division of the sternohyoid muscle and omohyoid muscle. From the viewpoint of minimally invasive surgery, their method seems not so convincing or attractive. To overcome that drawback, we proposed the new method presented herein. We set a single 2 to 3 cm incision wound upon the suprasternal notch to obtain a working space, from which the target could be easily monitored, manipulated, and delivered out by laparoscopy, conventional instruments, a ultrasonically activated scalpel, and suction and irrigation equipment. VAET does not require the creation of skin flaps or the division of any muscle; therefore, the technique is closer to the concept of minimally invasive surgery. Based on the results in the present study, VAET is promising in many respects. The technique does not employ CO2 insufflation, which might induce metabolic changes, hypercapnia, subcutaneous emphysema, and upper airway compression especially for neck surgery.8 Furthermore, this gasless technique allows greater flexibitity in the types of dissecting instruments that can be used. The parathyroid glands and the recurrent laryngeal nerve can be meticulously identified during VAET because of the magnifying effect of the laparoscope and monitor employed (Figure 1D and E). This is reflected in the result that none of our 16 patients sustained the nerve or parathyroid glands injury. Along with the learning curve, the operation time for VAET is becoming comparable with that of conventional open thyroidectomy. Based on our data, using the VAET method, lobectomy and extirpation took 2 hours and 40 minutes, respectively, which is reasonable from the viewpoint of cost effectiveness. Wound pain following VAET is much less when compared with that of conventional thyroidectomy, because there is less dissection and destruction of tissues in the former. Of utmost importance, the VAET wound is only 2 to 3 cm in length upon the suprasternal notch, which is easily covered by a shirt (Figure 2). In our series, even for a 8 cm goiter, the specimen could be delivered out from this small wound. Almost all patients could be discharged 2 days after VAET, without sequelae.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
One of the questions that surgeons might be concerned with is whether VAET is suitable for the management of thyroid carcinoma. This question is similar to that of whether laparoscopic cholecystectomy is justified in early or occult gallbladder carcinoma. The answer remains unclear. We do not recommend using VAET to manage thyroid malignancy until the VAET surgical technique is mature enough to confidently dissect lymph nodes along the carotid sheath. At present, our policy is as follows. In patients who have a definite diagnosis of thyroid carcinoma preoperatively, based on fine needle apiration cytology, we use open thyroidectomy. For those who have a diagnosis of follicular neoplasm preoperatively, with a low risk for malignancy, we prefer to use VAET proceeding lobectomy for the diseased gland and send the specimen for cryosection intraoperatively. If the cryosection report turns out to be malignancy, we convert VAET to conventional open thyroidectomy by extending the initial incision wound. Actually, we have had two experiences of this as forementioned without any problem. Of course, VAET has its limitations. VAET is not suitable for repeated thyroid surgery because adhesions might interfere with the access of laparoscope into the plane of the thyroid fascia. Tumor size is an important factor determining how difficult VAET would be, because the working space provided by the technique is limited. At the time of this writing, the biggest tumor managed by VAET was 8 cm in maximal dimension. We do not recommend performing VAET for goiters larger than this size. We still do not have any experience using VAET dealing with cases with hyperthyroidism. However, we believe that it is absolutely feasible to manage patients with hyperthyroidism using VAET technique by strictly selecting the patients in the very near future. To perform VAET successfully requires extensive experience in open thyroidectomy, as well the exquisite skills gained from other laparoscopic surgeries such as laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and so forth. In our opinion, those who are not familiar with the two fields should not be encouraged to perform VAET. Finally, the performance of VAET relies heavily on the ultrasonically activated scalpel, which we believe is the essential instrument for accomplishing VAET. Unfortunately, the cost of the ultrasonically activated scalpel is high, making VAET an expensive surgery. Because of the small working area in the neck, the use of monopolar cautery is problematic because of smoke generation and
fogging of the laparoscope. The ultrasonically activated scalpel results in some vaporization within the visual field but there is no smoke generation, and thus problems with lens fogging are reduced.9 Most importantly, the ultrasonically activated scalpel does not induce thermal injury to the nerves and parathyroid glands because of the lack of current transmission.10 This type of injury is not uncommon in open thyroidectomy when manipulated by monopolar cautery. Furthermore, the ultrasonically activated scalpel can divide the thyroid parenchyma and thyroid vessels without the need of additional sutures or ligatures, yielding an excellent hemostasis. With increasing experience in VAET, we no longer routinely place a drainage tube. In conclusion, VAET emerges as a promisng surgical technique to replace conventional open thyroidectomy for benign thyroid diseases in selected cases, with the advantage of gratifying cosmetic results.
REFERENCES 1. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83:875– 875. 2. Miccoli P, Cecchini G, Conte M, et al. Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism. J Endocrinol Invest. 1997;20:429 – 430. 3. Miccoli P, Bendinelli C, Vignali E, et al. Endoscopic parathyroidectomy: report of an initial experience. Surgery. 1998; 124:1077–1080. 4. Brunt LM, Jones DB, Wu JS. Experimental development of an endoscopic approach to neck exploration and parathyroidectomy. Surgery. 1997;122:893–901. 5. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery in the neck: an initial report of endoscopic subtotal parathyroidectomy. Surg Endosc. 1997;12:202–205. 6. Shimizu K, Akira S, Jasmi AY, et al. Video-assisted neck surgery: endoscopic resection of thyroid tumors with a very minimal neck wound. J Am Coll Surg. 1999;188:697–703. 7. Shimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign tumor aiming at scarless surgery on the neck. J Surg Oncol. 1998;69:178 –180. 8. Gottlieb A, Sprung J, Zheng XM, Gagner M. massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg. 1997;84:1154 –1156. 9. Amaral JF. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc. 1994; 4:92–99. 10. Gossot D, Buess G, Cuschieri A, et al. Ultrasonic dissection for endoscopic surgery. Surg Endosc. 1999;13:412– 417.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
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Video-Assisted Endoscopic Thyroidectomy Ta-Sen Yeh, MD, Yi-Yin Jan, MD, Brend Ray-Sea Hsu, MD, PhD, Kwan-Win Chen, MD, Miin-Fu Chen, MD, Taipei, Taiwan
BACKGROUND: Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS: In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle’s tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS: All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS: VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of
From the Departments of Surgery (TSY, YYJ, MFC) and Metabolism (BRSH, KWC), Chang-Gung Memorial Hospital, ChangGung University, Taipei, Taiwan. Requests for reprints should be addressed to Ta-Sen Yeh, MD, Department of Surgery, Chang-Gung memorial Hospital, 5 FuHsing Street, Taoyuan,Taiwan. Manuscript submitted May 23, 2000, and accepted in revised form June 25, 2000.
82
© 2000 by Excerpta Medica, Inc. All rights reserved.
satisfactory cosmetic results. Am J Surg. 2000; 180:82– 85. © 2000 by Excerpta Medica, Inc.
D
uring the last several years, laparoscopic surgery has begun to replace conventional open surgical techniques for a variety of procedures, including cholecystectomy, appendectomy, herniorrhaphy, Nissen fundoplication, adrenalectomy, and splenectomy. Recent advances in minimally invasive surgical techniques, instrumentations, and devices have the potential to expand endoscopic surgery outside these established body cavities. Since 1996, when Gagner1 first reported endoscopic subtotal parathyroidectomy in a patient with primary hyperparathyroidism, several experimental and clinical reports have appeared concerning endoscopic parathyroid surgery.2–5 Thyroid diseases that lead to surgical intervention are much more prevalent in the general population than are those of the parathyroid glands. Thus, a minimally invasive surgery for the thyroid glands is certainly desirable. So far, clinical reports of endoscopic resections of thyroid tumors have been rare because of the inherently complicated anatomical structures and vascularity of the thyroid glands that make the endoscopic surgical technique more demanding.6, 7 Herein, we present our new method, called video-assisted endoscopic thyroidectomy (VAET), for the treatment of various benign thyroid diseases.
METHODS Patients A total of 16 consecutive patients with benign thyroid diseases who underwent VAET from November 1999 to April 2000 in the Department of Surgery, Chang Gung Memorial Hospital, were retrospectively studied. Informed consent concerning VAET was obtained from all patients. There were 13 women and 3 men, with a mean age of 38 years (range, 16 years to 73 years). Another 2 patients with follicular neoplasm, initially treated successfully with a lobectomy using the VAET technique but finally converted to open total thyroidectomy after the intraoperative cryosection yielded a follicular carcinoma, were excluded. All 16 patients presented with a palpable neck mass that shifted vertically along with the swallowing movement, consistent with the diagnosis of goiter. All 16 patients had undergone a thyroid function profile, thyroid ultrasonographic examination, and fine needle aspiration cytology. All the patients had an euthyroid status when admitted. Surgical Technique The patient’s neck was positioned in hyperextension as in conventional thyroid surgery under general anesthesia (Figure 1). A 2 cm to 3 cm transverse incision, dependent on the tumor size, was made upon the suprasternal notch. The wound was then deepened. The strap muscle was split 0002-9610/00/$–see front matter PII S0002-9610(00)00429-3
VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
Figure 1. Highlights of video-assisted endoscopic thyroidectomy (VAET). (A) A transverse 2 to 3 cm incision made on the suprasternal notch was deepened to approach the underlying trachea from which the plane of the thyroid fascia was accessed directly (arrow). (B) The middle thyroid vein was dissected. (C) The superior thyroid artery was dissected. (D) The right recurrent laryngeal nerve (arrows) was identified. (E) The left upper parathyroid gland (arrows) was identified.
longitudinally and the underlying trachea was exposed. The plane of the thyroid fascia was accessed from inferior aspect directly. Thus, the working space was established with lifting method using conventional instrument without gas insufflation. The laparoscope (4 mm, Storz) connected to the monitors was employed for video-assisted surgery. For those
cases in which lobectomy was intended, the sequence of surgical procedures were as follows: division of the inferior thyroid veins, division of the isthmus, division of the middle thyroid vein, division of the inferior thyroid artery, identification of the recurrent laryngeal nerve and parathyroid glands, division of the superior thyroid vessels, and removal of the diseased thyroid gland. For the first 5 cases,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
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VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
COMMENTS
Figure 2. Using the video-assisted endoscopic thyroidectomy technique, the neck scar is only 2.5 cm in length on suprasternal notch.
the vessels were ligated by either silk or hemoclips, whereas for the later 11 cases, ligation of the vessels and division of the thyroid parenchyma were performed completely using the ultrasonically activated scalpel (AutoSonix system, USSC) with excellent hemostasis. For cases in which partial thyroidectomy (extirpation of the goiter) was intended, division of the thyroid parenchyma was achieved exclusively with the ultrasonically activated scalpel without the necessity of dissection of the feeding vessels. For the initial 4 cases, a pediatric nasogastric tube was placed as a drainage tube. For the latter 12 cases, the drainage tube was considered unnecessary.
RESULTS All 16 patients with benign thyroid diseases underwent VAET successfully without conversion to open thyroidectomy. The final pathologic diagnoses included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle’s tumor and simple cyst in 1 each. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation took less than 40 minutes. The intraoperative blood loss was always less than 20 mL. The tumor size (the maximal dimension) ranged from 3.5 cm to 8.0 cm (mean 5.8 cm).There were no surgical complications, and no complaints of neck hematoma, numbness of the extremities, or hoarseness. All patients were able to have a liquid diet on the first day postoperatively, and shifted to an ordinary diet soon thereafter. Acetaminophen was prescribed for pain relief, and meperidine was not necessary. In the 4 who were equipped with a drainage tube, the amount of discharge ranged from 15 mL to 25 mL, and the tube was always removed on day 2 postoperatively before discharge. All patients except 1, who underwent modified radical mastectomy because of breast carcinoma concomitantly with VAET and stayed for 5 days postoperatively, were discharged on day 2 postoperatively. At the time of this writing, all 16 patients were well, with normal thyroid functioning and a satisfactory cosmetic appearance (Figure 2). 84
Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. Thyroid diseases primarily occur in young to middle-aged women who usually pay a great deal of attention to the cosmetic results after thyroid surgery. A certain portion of patients with benign goiter initially ask for an operation for cosmetic reasons alone. For these patients, open thyroidectomy would only add a more distinct neck scar after the surgery. Therefore, the development of a new surgical technique that minimizes the wound size, changes the wound location to a more obscure place, and can be readily performed by general practitioners, is warranted. Video-assisted neck surgery for endoscopic resection of thyroid tumors has been proposed by Shimizu et al.6, 7 To avoid a scar on the neck, they created three wounds in the upper chest wall below the clavicle and used a Kirschner wire for an anterior neck-lift. The advantage of their method is lack of a scar on the neck. However, the disadvantage is that multiple incisions are needed, and the incision sites are far away from the target. Therefore, a wide blunt dissection of the subplatsymal plane is necessary, as well the division of the sternohyoid muscle and omohyoid muscle. From the viewpoint of minimally invasive surgery, their method seems not so convincing or attractive. To overcome that drawback, we proposed the new method presented herein. We set a single 2 to 3 cm incision wound upon the suprasternal notch to obtain a working space, from which the target could be easily monitored, manipulated, and delivered out by laparoscopy, conventional instruments, a ultrasonically activated scalpel, and suction and irrigation equipment. VAET does not require the creation of skin flaps or the division of any muscle; therefore, the technique is closer to the concept of minimally invasive surgery. Based on the results in the present study, VAET is promising in many respects. The technique does not employ CO2 insufflation, which might induce metabolic changes, hypercapnia, subcutaneous emphysema, and upper airway compression especially for neck surgery.8 Furthermore, this gasless technique allows greater flexibitity in the types of dissecting instruments that can be used. The parathyroid glands and the recurrent laryngeal nerve can be meticulously identified during VAET because of the magnifying effect of the laparoscope and monitor employed (Figure 1D and E). This is reflected in the result that none of our 16 patients sustained the nerve or parathyroid glands injury. Along with the learning curve, the operation time for VAET is becoming comparable with that of conventional open thyroidectomy. Based on our data, using the VAET method, lobectomy and extirpation took 2 hours and 40 minutes, respectively, which is reasonable from the viewpoint of cost effectiveness. Wound pain following VAET is much less when compared with that of conventional thyroidectomy, because there is less dissection and destruction of tissues in the former. Of utmost importance, the VAET wound is only 2 to 3 cm in length upon the suprasternal notch, which is easily covered by a shirt (Figure 2). In our series, even for a 8 cm goiter, the specimen could be delivered out from this small wound. Almost all patients could be discharged 2 days after VAET, without sequelae.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
VIDEO-ASSISTED ENDOSCOPIC THYROIDECTOMY/YEH ET AL
One of the questions that surgeons might be concerned with is whether VAET is suitable for the management of thyroid carcinoma. This question is similar to that of whether laparoscopic cholecystectomy is justified in early or occult gallbladder carcinoma. The answer remains unclear. We do not recommend using VAET to manage thyroid malignancy until the VAET surgical technique is mature enough to confidently dissect lymph nodes along the carotid sheath. At present, our policy is as follows. In patients who have a definite diagnosis of thyroid carcinoma preoperatively, based on fine needle apiration cytology, we use open thyroidectomy. For those who have a diagnosis of follicular neoplasm preoperatively, with a low risk for malignancy, we prefer to use VAET proceeding lobectomy for the diseased gland and send the specimen for cryosection intraoperatively. If the cryosection report turns out to be malignancy, we convert VAET to conventional open thyroidectomy by extending the initial incision wound. Actually, we have had two experiences of this as forementioned without any problem. Of course, VAET has its limitations. VAET is not suitable for repeated thyroid surgery because adhesions might interfere with the access of laparoscope into the plane of the thyroid fascia. Tumor size is an important factor determining how difficult VAET would be, because the working space provided by the technique is limited. At the time of this writing, the biggest tumor managed by VAET was 8 cm in maximal dimension. We do not recommend performing VAET for goiters larger than this size. We still do not have any experience using VAET dealing with cases with hyperthyroidism. However, we believe that it is absolutely feasible to manage patients with hyperthyroidism using VAET technique by strictly selecting the patients in the very near future. To perform VAET successfully requires extensive experience in open thyroidectomy, as well the exquisite skills gained from other laparoscopic surgeries such as laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and so forth. In our opinion, those who are not familiar with the two fields should not be encouraged to perform VAET. Finally, the performance of VAET relies heavily on the ultrasonically activated scalpel, which we believe is the essential instrument for accomplishing VAET. Unfortunately, the cost of the ultrasonically activated scalpel is high, making VAET an expensive surgery. Because of the small working area in the neck, the use of monopolar cautery is problematic because of smoke generation and
fogging of the laparoscope. The ultrasonically activated scalpel results in some vaporization within the visual field but there is no smoke generation, and thus problems with lens fogging are reduced.9 Most importantly, the ultrasonically activated scalpel does not induce thermal injury to the nerves and parathyroid glands because of the lack of current transmission.10 This type of injury is not uncommon in open thyroidectomy when manipulated by monopolar cautery. Furthermore, the ultrasonically activated scalpel can divide the thyroid parenchyma and thyroid vessels without the need of additional sutures or ligatures, yielding an excellent hemostasis. With increasing experience in VAET, we no longer routinely place a drainage tube. In conclusion, VAET emerges as a promisng surgical technique to replace conventional open thyroidectomy for benign thyroid diseases in selected cases, with the advantage of gratifying cosmetic results.
REFERENCES 1. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83:875– 875. 2. Miccoli P, Cecchini G, Conte M, et al. Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism. J Endocrinol Invest. 1997;20:429 – 430. 3. Miccoli P, Bendinelli C, Vignali E, et al. Endoscopic parathyroidectomy: report of an initial experience. Surgery. 1998; 124:1077–1080. 4. Brunt LM, Jones DB, Wu JS. Experimental development of an endoscopic approach to neck exploration and parathyroidectomy. Surgery. 1997;122:893–901. 5. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery in the neck: an initial report of endoscopic subtotal parathyroidectomy. Surg Endosc. 1997;12:202–205. 6. Shimizu K, Akira S, Jasmi AY, et al. Video-assisted neck surgery: endoscopic resection of thyroid tumors with a very minimal neck wound. J Am Coll Surg. 1999;188:697–703. 7. Shimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign tumor aiming at scarless surgery on the neck. J Surg Oncol. 1998;69:178 –180. 8. Gottlieb A, Sprung J, Zheng XM, Gagner M. massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg. 1997;84:1154 –1156. 9. Amaral JF. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc. 1994; 4:92–99. 10. Gossot D, Buess G, Cuschieri A, et al. Ultrasonic dissection for endoscopic surgery. Surg Endosc. 1999;13:412– 417.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 AUGUST 2000
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