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Official Journal of the
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ISSN: 1983-991X
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| Original Article « PDF file » |
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Interventional Techniques of Totally Endoscopic Thyroidectomy
Ricardo Zorrón1; Mirella Melo Metidieri1; Gabriela Cellia de Moraes1
1 Department of Surgery, University Hospital Teresópolis HCTCO-FESO, Rio de Janeiro, Brasil
ABSTRACT
Historical synthesis: The techniques of totally laparoscopic thyroidectomy comes as a trend in the resection of thyroid nodules of small size, since the cosmetic result in this kind of surgery is an important factor for the patients. Objectives: The purpose of this article is to list the techniques of minimally invasive surgery for thyroidectomy citing its scoring procedure and their advantages and disadvantages, between itself and when compared with conventional surgery. To this end was made a literature review of recent studies that expose the results of these surgeries in various situations with a significant number of patients. Discussion: The approaches were considered minimally videoassisted thyroidectomy (MIVAT), endoscopic approach transaxillary (AA), axillo-bilateral-breast approach (ABBA), Endoscopic Thyroidectomy Using Bilateral Axillo-Breast Approach (BABA), Breast-Approach (BA), which all showed significant cosmetic result.
Key words: Thyroidectomy; Endoscopy; Laparoscopy; Minimally invasive surgery; AA, ABBA, BABA, BA.
Braz. J. Video-Sur, 2008, v. 1, n. 3: 116-121
| Accepted after revision: May, 07, 2008. |
INTRODUCTION
 |
ew laparoscopic techniques have been applied
in thyroid surgery. Thyroid surgery may be performed using cervical, breast or axillary incisions
1 (Choe J H et al., 2000).
Surgery for the thyroid may be divided into conventional thyroidectomy (cervical incision >
3cm) and minimally invasive procedure which can be subdivided in cervical approach (MIVAT)
and extracervical approach (AA, ABBA, BABA and BA).
MIVAT, minimally videoassisted thyroi-dectomy, is the method that has become
most widespread to date. However, this technique
is limited because when small incision is
performed the size of the specimen resected to be retrieved
is also restricted1,2. (Choe et al., 2007, Yamashita
H et al.,2002).
AA or endoscopic transaxillary approach to thyroidectomy utilized three 5 mm incisions
placed bellow the anterior axillary line equidistant apart
which leads to an excellent cosmetic outcome, however,
it can only be performed in pre-selected
patients3 (Duncan D T et al; 2007).
ABBA or axillo-bilateral-breast approach is a combination of axillary and breast
approaches, through two incisions on the margin of the areola
and an axillary incision, avoiding a scar on the
neck, therefore achieving as well as in AA
excellent cosmetic results4
5 6 7
8 9 10.
BABA or Endoscopic Thyroidectomy Using Bilateral Axillo-Breast Approach is the
newest endoscopic technique that was developed by
a modification of ABBA. It consists of a bilateral
incision on the areola as well as axillar which enhance
the visualization of the thyroid gland2 (Yamashita H
et al.,2002).
Thyroid nodules are a common occurrence in clinical practice nowadays; most of them
are benign and can be followed clinically without necessity of surgery. However, surgical
extirpation occasionally becomes necessary to exclude
a malignant neoplasia, and although the majority
of surgically excised thyroid lesions are
histologically benign, patients are traditionally left with
a permanent transverse surgical scar in a highly visible
area11. Considering that a significant
number of patients are young women, the surgeon
should take into consideration complete resection and
a better cosmetic result
simultaneously3(Yamashita H et al., 2002).
The objective of this study is to describe the technical aspects of endoscopic thyroidectomy
surgery emphasizing its advantages and disadvantages.
METHODS / RESULTS
Minimally invasive surgical procedures purport to achieve the same results of the open
thyroidectomy, in addition to be a procedure with less pain,
faster recovery and improved cosmetic
results3( AA).
The operative techniques that have been studied are:
· MIVAT (minimally invasive
video-assisted thyroidectomy)12
MIVAT approach is based on a technique described by Miccoli et
al13 with some modifications. The surgeon stands on the right of the patient and
the first assistant on the left both at the cervical
region. The assistant who is responsible for the optical
trocar manipulation stands on the left of the patient
and besides the first assistant (on his left). The
surgical nurse stands on the right of the patient besides
the surgeon, thus a 15mm central incision above the
sternal notch is performed and gas insufflation was
not necessary. Dissection is performed under
endoscopic vision using a zero-degree 5mm optical
trocar(Storz®, Germany) and other endoscopic instruments as
well as conventional instruments. Hemostasis of
superior thyroid pedicle is performed with the Harmonic
scalpel and a CS14C clip (UltraCision®, Ethicon
Endo-Surgery, Inc. - EUA). Drainage is not necessary.
Skin is closed with cyanocrylate sealant( 6- micoli,
do mivat).
AA (axillar-approach)3
All patients are submitted to general anesthesia, and positioned in the supine position.
The neck is slightly extended and the patient's
ipsilateral arm on the side of the thyroid lesion is placed at a
90-degree angle to the axis of the body, exposing
the operative axilla. Three 5-mm incisions are
placed below the anterior axillary line equidistant apart.
Using blunt dissection through these incisions, the
surgeon develops an initial plane beneath the platysma and
on top of the pectoralis major muscle. It is used a
solution of 1,000 ml of Ringer's lactate, 50 ml of 1%
xylocaine and 1 ml of epinephrine, which when is infiltrated
in the operative area it facilitates hemostasis and
controls post-operative pain.
With carbon dioxide gas insufflation at 7_9 mmHg pressure, a 5-mm endoscope is placed
for direct visualization. Scissor dissection is then used
to dissect an avascular plane between the platysma
and the pectoralis major muscle. Dissection is
directed toward the ipsilateral sternocleidomastoid
muscle. When the sternocleidomastoid muscle is identified,
a plane between the sternocleidomastoid and the sternohyoid muscle is dissected. After elevating
the sternohyoid muscle the sternothyroid muscle is visualized and retracted anteriorly, exposing
the ipsilateral thyroid gland. The inferior pedicle
is dissected to identify the recurrent laryngeal nerve
and the parathyroid gland, and then the vessels are
clipped and divided. Smaller vessels were divided with
the harmonic scalpel, exposing the ligament of Berry
which is divided to prevent the recurrent laryngeal nerve
from injury. The thyroid gland is mobilized in a way to
freeing the posterior surface of the thyroid from the
trachea and allowing exposure of the superior thyroid
pedicle. Staying within the capsule of the gland, the
surgeon dissects and divides the superior thyroid vessels.
Once the lateral and posterior attachments of the gland
are divided, the isthmus is exposed, allowing its
division using the harmonic scalpel. After transaction of
the isthmus, the ipsilateral thyroid is completely
mobilized and freed. After a good hemostasis, the gland is
placed in an Endocatch (Ethicon_) bag for retrieval.
The specimen is extracted by extending the center
axillary trocar site. Final inspection of the operative space
was accomplished via an angled 5-mm endoscope. Verification of an intact recurrent laryngeal nerve
was performed in all patients. The specimen is sent to
the pathologist for frozen section diagnosis. A 7-mm
horizontal drain is placed in the operative field and
brought out through a 5-mm axillary trocar site to obliterate
the dead space created and to drain residual fluid. The
drain is removed after an average of 2.5 days (range,
2_8 days). All incisions were closed using 4_0
monofilament absorbable suture. Ice packs were placed on
the operative chest wall site where surgery was
performed and the patient was discharged to the recovery room.
BA (Breast-Approach)14
This technique consists of a direct dissection of the operative space through the subcutaneous
space in the breast area and the subplatysmal space.
For this reason, a 15-mm incision between the nipples
is performed, and CO2 is insufflated at 6 mm Hg.
After three trocars are inserted in this area, and
dissection of the thyroid and division of the thyroid vessels
and parenchyma is performed using an
ultrasonically activated scalpel.
ABBA (Axillo-Bilateral-Breast Approach)15
ABBA is performed under general anesthesia and in supine position. The operating surgeon and
the camera operator should stand on the patient's
right. Regarding the patient's position, there is no
necessity of neck reclination. Both arms are fixed at an
elevation of 90o, with the forearms immobilized. Five mm
bilateral skin incisions are made on the margin of the
areola of nipple, in order to insert a 5 mm trocar, 20 cm
long with a conical tip, through the subcutaneous until
the jugular fossa. Under digital guidance and with
median orientation, the superficial cervical fascia is
perforated. With both trocars in place, a 30x5 mm endoscope
is used to create a virtual space with CO2
insufflation at a gas pressure of 6_8 mmHg (Figures 1 and 2).
 |
Figure 1 - Instruments for Laparoscopic thyroidectomy. |
 |
Figure 2 - ABBA (Axillo-Bilateral-Breast Approach). |
 |
Figure 3 - Intraoperative aspect of inferior thyroid vessels
using ultrassonic dissection. |
After an incision in the right axillar fossa a
5 mm optical trocar is inserted in the
subcutaneous following the postero-anterior direction until
the suprasternal spatium. A Maryland clamp in
axillary position and 5 mm harmonic scalpel via the left
breast trocar permit a clear view of the virtual
space created.
The next step is to prepare the trachea and isthmus. Using delicate blunt dissection, both
thyroid lobes are exposed and examined for
pathological changes. With a median orientation, the
primary isthmus transection is performed with a
harmonic scalpel. With mobilization of the upper thyroid
pole, the vessels are isolated and divided with the
harmonic scalpel close to the thyroid capsule. A clip closure
is not performed. It is absolutely necessary to
observe where the superior laryngeal nerve is running and
to visualize the recurrent laryngeal nerve. The
inferior veins should be divided closely to the thyroid
capsule. Sufficient distance should be ensured among
the heated harmonic scalpel from the recurrent
laryngeal nerve and the parathyroids. The resection is
performed without bleeding with the harmonic scalpel (Figure
3). If necessary, the opposite side is attended to in
the same way.
Via the axillary approach with the incision being widened, a 20 mm trocar is inserted
and advanced up to the thyroid lodge to remove the specimen. For large specimens, it is
recommendable to use a small bag. If the 20 mm trocar sleeve is
too small, blunt digital widening of the subcutaneous
tunnel should be performed. This procedure is
surprisingly easy which means to say that the technique is
not limited by the specimen size. Facultatively, a drain
may be placed in the operative area through the axilla.
BABBA (Endoscopic Thyroidectomy Using a Bilateral Axillo-Breast
Approach)1
This technique was developed from a modification of axillo-bilateral breast approach
_ABBA, where an axillar incision was added. In
this way, a better visualization of the thyroid was obtained.
The surgery is performed under general anesthesia with the patient placed in supine
position. The neck is extended and both arms are abducted
to provide axillar surgical incisions. Diluted
epinephrine solution is injected (1:200,000) into the
subcutaneous space in both breasts and bellow the platysmal
muscle, in order to reduce perioperative bleeding.
Other two incisions are made on both upper circumareolar areas, and ascendant
subcutaneous dissection is performed passing by the
subplatysmal region until the region of the procedure is
reached (which was extended to the level of the
thyroid cartilage superiorly and to the medial border of
each sternocleidomastoid muscle). After establishing
the working space, a 12 mm port is inserted ipsilateral
to the thyroid gland through which the flexible
endoscope was introduced. The operational instruments
including the Harmonic Scalpel are inserted through
the contralateral 12mm port. The working space was established with CO2 insufflation at a pressure of
5_6 mmHg.
First, a midline incision is made on the gland (in the same place for conventional
thyroidectomy). After full visualization of the crico-thyroid
membrane, the isthmus, and the central lymph node group,
the isthmus is dissected and may, in this way, obtain
an optimal lateral and posterior retraction of the
thyroid tissue for dissection. Thyroidectomy is
performed using Harmonic Scalpel under full visualization of
superior and inferior thyroidal arteries, parathyroid
glands, and recurrent laryngeal nerves. The resected
specimen is inserted into a plastic bag and retrieved through
the 12-mm port (areolar). A hispathologic frozen
section of the resected specimen is performed
intraoperatively for histologic confirmation.
Finally, meticulous hemostasis is attained with endosuture in the midline and a suction drain
(Jackson-Pratt) is left in the place, so the skin is
reapproximated cosmetically.
DISCUSSION
According Dedivitis RA e col 12, MIVAT is
a safe procedure with additional advantages in terms
of cosmetic results and postoperative
distress16, when compared to conventional thyroidectomy, as
this technique has a small scar and less postoperative
pain, because the dissection area is reduced and there is
no necessity of hyperextension of the neck during
the procedure. However, only 15% of the patients accomplished the following inclusion
criteria17: thyroid nodule not exceeding 35 mm of maximum
diameter; thyroid volume not exceeding 20 ml, absence of
both ultrasonographic and laboratory signs of
thyroiditis18. In this study the operative time, as well as the
length of hospital stay was not different. There was
no conversion to open surgery and no important complications were observed.
In the study of T.D. Duncan and
col.3, is considered a less invasive and more direct, in spite
of leaving scars in a highly visible region of the
patient's neck. Although such scars are usually well
tolerated, hypertrophic scarring may occasionally occur,
and diminish the patient's self-esteem6. Furthermore
this direct technique typically limits the size of the
specimen to be removed to 3 cm to avoid an undesirable
cosmetic outcome19. The ABBA approach allows a
better visualization of the gland; however, it limits the size
of the specimen to be retrieved in addition to leave
a visible scar (even if small). Whereas the AA
approach does not leave a visible scar when the patient is
with the arm in the normal posture position, besides it
is possible perform extended incisions in the
axillary region to extract the gland completely.
Another advantage of this approach is the good
visualization of the gland, which allows a safest dissection.
The limiting factor of this technique is the necessity
of handling a large amount of tissue to create an
operative space. Herewith, the postoperative pain is a
concern which controlled with analgesics.
It was performed a study in 5 female patients depicting a technique through the sternal
region. According to Ohgami M e col7, the BA is a safe
and feasible approach which provided a good
cosmetic outcome for the patients. In this study, there was
no conversion to open surgery and the patients did
not have any complications.
According to a study performed by Shimazu K e
col.9with 12 patients, a technique derived
from the BA (Breast-Approach) was developed and
called ABBA (Axillo-Bilateral-Breast-Approach),
this technique was described and compared to the
BA. Some advantages such as a better visualization of
the operative space were observed. When compared
to the BA approach the mean operative time was significantly shorter in the ABBA
approach. Furthermore, less bleeding was observed.
Neither conversion to open surgery nor complications
were experienced. The scar is very small and it
became inconspicuous in few weeks. In conclusion ABBA
is a better approach than BA, as it is a safe and
feasible option particularly for young patients who opt for
better cosmetic outcomes.
Benhidjed T e col.15, in a study of 13
patients treated by ABBA, achieved an excellent
cosmetic outcome. The authors observed that with the
technical prerequisites and perfect execution of this
approach, it can be carried out safely and with a minimum
of complications. In this same study he compared
this method with the video-assisted method practiced
by Miccoli; he defined as the main advantage the
absence of a scar on the anterior neck region, in addition
to that this technique is not limited to a maximum
nodule size of 30mm. Even though this technique is
more advantageous, this method is not indicated for
surgery in patients with recurrent nodules and
malignant tumors. In comparison to other approaches,
ABBA permits bilateral thyroid exploration, more space
for instrument use, and the removal of larger nodules.
The only residuum of the approach is an
inconspicuous scar in the axilla and two almost invisible scars in
both nipple areolas.
In a second study performed by Benhidjeb T e
col.18 using ABBA technique in 26 women the
main objective of the method was the cosmetic
result. Conversion to open surgery was not observed,
and postoperatively recurrent laryngeal nerve palsy
and brachial plexus paresis was observed only in
one patient.
In the study of Choe e col.1, 102 patients
were submitted to BABA technique, where the total operative time was 165,3 minutes and length of
hospital stay was 1 to 4 days, it did not differ
from conventional thyroidectomy. Complications such
as unilateral vocal cord (n=4), transient
hypocalcemia (n=4), pneumothorax (n=1) and postoperative
infection (n=1). There was no postoperative bleeding in any
of the cases. However, there were 4 cases of
conversion to open surgery, due to uncontrollable bleeding
during the procedure, tracheal perforation, multiple
nodules and cancer with capsular invasion.
BABA tends to be more invasive than the cervical approach because it requires a wide skin
flap to obtain a bigger virtual space.
Cosmetic result of this approach is excellent, as the scars are almost invisible, even if the
patients elevated their arms. A simple
postoperative questionnaire evaluated patients' satisfaction, in
which the result was: 76,5%(78 out 102)excellent, 20,6%
(21 out of 102) good, 2.9% (3 out of 102) fair, and
there were no bad responses.
CONCLUSION
We can conclude that all endoscopic techniques are safe. Among its advantages, the most
noteworthy is a better cosmetic result, which is relevant
because as it was said before a significant number of
patients are young women with histopathologic benign nodules.
Among the minimally invasive surgeries the AA (Axillar-Approach) is the one with better
cosmetic outcome, and BABA
(Bilateral-Axillo-Breast-Approach) is the one which allows a
better visualization and operative space. However, there
are not enough studies to demonstrate that a method
is superior to other methods, as all of them have advantages and disadvantages.
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Correspondence address:
Ricardo Zorrón
Professor and chief of the Surgical Department at the
Hospital Universitário de Teresópolis HCTCO
Av. Americas 13554 BL.1 AP.207
Barra da Tijuca, Rio de Janeiro, Brazil
E-mail: rzorron@terra.com.br