Introduction
The use of minimally invasive approach for thyroid surgery has a wonderful advantage of eliminating the unsightly scar of open thyroidectomy procedure. The goals of minimally invasive approaches for thyroidectomy (ET) are:
Limit external scarring
Improve the cosmoses
Reduce postoperative pain
Enhance early postoperative recovery
Achieve these ends without compromising treatment efficacy
Endoscopic thyroidectomy is one of the remote access approaches. The first described endoscopic thyroidectomy was in 1997 by Hüscher et al. There has been a significant advancement in thyroidectomy procedures. 1 The different techniques of endoscopic thyroidectomy are Chest–breast approach (CBA), Bilateral axillo-breast approach (BABA), Trans-axillary approach (TA), Retro auricular approach (RA), Transoral approach (TOA). The other minimally invasive technique is video-assisted thyroidectomy.
Case Report
A 74-year-old female presented to our OP with complaints of selling in the neck for the past one and a half months. She had no other complaints. Upon examination there was firm solitary 3*3 cm swelling in the right lobe of thyroid (Figure 1). We proceeded with a Thyroid function test and ultrasound of neck.
Thyroid function tests were normal. On the USG's neck, there was a 2*1.5cm colloid cyst in the right lobe of the thyroid (TIRADS 2). The patient was advised for endoscopic hemithyroidectomy. The patient was assessed and posted for a minimally invasive hemithyroidectomy procedure. After obtaining appropriate consent, she underwent endoscopic thyroidectomy via an axillary approach.
Operative Technique
Under general anesthesia, the patient was in a supine position, a 10 mm camera port was inserted over the right anterior axillary fold, and 2 lateral 5 mm working ports were made on either side. A subcutaneous plane was elevated, and a working tunnel was created after the insufflation of gas and blunt dissection. Strap muscles retracted laterally, and a plane of cleavage was created all around the right lobe of the thyroid after cauterizing the inferior thyroid pedicle (Figure 2) after preserving right recurrent laryngeal nerve, middle thyroid vein and superior thyroid pedicle (Figure 3) using harmonic vessel sealer.
The right lobe of the thyroid is separated from the isthmus by cauterizing through a glandular substance. Hemostasis achieved. The specimen was retrieved by extending the 5mm working port incision (Figure 4). 12 size Romovac drain was kept, and ports were removed (Figure 5).
Discussion
Thyroid surgery was historically considered to be the most aggressive procedure marked by high mortality and morbidity due to hemorrhage, asphyxia, gangrene and air embolism.2 Over the years, with a better understanding of the anatomy coupled with technical developments in anesthesia, antisepsis and surgery, it has become one of the safest surgical procedures.3 The history of thyroid surgery dates back to ancient times and it is one of the most commonly performed surgical neck procedures.
The neck crease Kocher incision on the neck has remained the standard approach. In the last few decades, there has been a shift towards minimally invasive and endoscopic techniques in order to improve cosmetic outcomes of thyroidectomy patients. Trans-axillary endoscopic thyroidectomy was first described by Ikeda et al.4 This was then modified by Chung et al. in 2006 by utilizing a gasless approach.5 The trans-axillary approach also has excellent cosmesis because the incision is moved to the axilla, it is hardly visible, and its surgical and oncologic outcomes are good.6, 7
The surgical view and instrument direction are from lateral to medial. So it has remarkable advantage in identifying the recurrent laryngeal nerve and parathyroid glands, as well as in dissecting the upper pole or Berry’s ligament. Additionally, compared with other types of endoscopic thyroidectomy, its advantages are:
It provides a relatively larger surgical space, which makes it easier to operate on, particularly for large nodules or thyroid lobes.
Trans-axillary approach has lesser operating time.
Faster learning curve because of its easier subcutaneous dissection and larger working space.
Jantharapattana et al. reported a randomized study to compare the trans-axillary and conventional approach.8 As from the study the complication rates for complications such as vocal cord paresis and seroma, were not significantly different between the two groups. The minimal surgical trauma is another advantage of this approach compared with other endoscopic thyroidectomies.
A review of the literature has overall shown that endoscopic approaches overall, with appropriate patient selection, are safe and generally meet the goals intended. The surgeon learning curve however, seems to be slow and it is accepted, as experienced in this case, that the procedure will initially take longer than open surgery and requires more surgeon experience for instrument handling to see any significant decrease in operative time.
Conclusion
Remote access thyroid surgery is here to stay, though it is largely up to the surgeon to comprehend the indications and limitations of these procedures aimed at safe and effective use. Although the approaches are diverse, the philosophy is consistent in achieving oncologically sound, safe and reliable outcomes. Ascertaining and measuring the enduring benefits of these approaches over and above their redressal of cosmetic concerns calls for elaborate and well-designed trials.
