I. Why choose this topic
Patients often ask in the clinic: Can I have minimally invasive surgery? My answer is that the decision depends on your situation. There is a more complete set of ideas from diagnosis to treatment, especially the planning of surgery, which is preoperative evaluation and surgical planning. Take thyroid surgery as an example.
(i) Diagnosis
First we need to refine some tests to determine which patients need surgery, see another article “Differential diagnosis of thyroid nodules”, for details
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The cases that require surgery include the following categories.
1, differentiated thyroid cancer, if there is no contraindication to surgery, in principle, all cases should be treated surgically.
2. Benign thyroid nodules, which can be treated conservatively with regular follow-up to avoid surgical treatment, but those with the following phenomena should be considered for surgical treatment.
1）Cancerous changes are clinically considered
(2) The presence of compression symptoms, such as respiratory, digestive, and nerve compression
(3) post-thoracic goiter and tendency to fall down into the mediastinum
4) Combined hyperthyroidism (gradually replaced by radioactive 131I treatment)
5）Serious cosmetic effects, large masses
(6) Patients with excessive concerns affecting their normal life
(B) Pre-operative evaluation
After determining the need for surgery, we will continue to improve some preoperative tests and preparations, including thyroid function, liver and kidney function, electrolytes, coagulation function, blood count, immunity, electrocardiogram, chest X-ray, ultrasound, CT and a series of other tests. For suspected malignancy, FNA, MRI, etc. may also be included. For thyroid malignancy preoperative disease stage (TNM, lymph node partitioning) will also be determined. For patients with underlying diseases such as lung, heart, cerebrovascular, diabetes mellitus, etc. also need to combine with a series of examinations for comprehensive assessment.
(iii) Surgical planning
The surgical plan needs to consider some of the following elements
1. The scope of surgery, how much of the thyroid gland should be removed, whether it is partial or lobar or total or subtotal? For thyroid cancer, it is necessary to consider whether the surrounding tissues, such as the surrounding muscles, need to be removed. Does the lymph nodes need to be cleared, and what is the extent of clearance, VI or both II-VI? What type of lymph node dissection should be used? Is it necessary to preserve the muscles, nerves and blood vessels on the cervical side? etc.
2. Incision or approach, is it minimally invasive or conventional? Is it a cervical incision or an extra cervical incision? Is it a small neck incision or a conventional incision? Is it a curved incision in the lower neck or an L-shaped incision?
In fact, the physician’s thinking is directional and prioritized, necessarily considering the scope of surgery first and then the incision and access. The first priority must be to ensure surgical safety, exposure of the surgical field, and thoroughness of the surgery, rather than other requirements such as aesthetics. After these considerations, some options may be left open for selection according to the patient’s wishes. In this way it is better understood that for benign smaller lesions, the patient has the most options, and may be able to choose traditional surgery or minimally invasive lumpectomy after combining other circumstances, and may be able to choose a full lumpectomy without scarring of the neck or a small sternotomy neck incision; for malignant extensive metastatic invasion patients naturally have little choice, and may only be able to choose a curved neck or L-shaped traditional open surgery The only option for patients with widespread metastatic invasion may be the arched neck or L-shaped traditional open surgery.
Second, what is minimally invasive thyroid surgery?
Traditional open surgery leaves scars on the neck after surgery while treatment. The situation is different for different ethnic groups; white and black people have negligible neck scars. In contrast, in our Asian race, the neck scar may be very visible for the rest of the patient’s life, which may cause heavy psychological trauma to the patient due to cultural differences. Thyroid tumors tend to occur in young and middle-aged female patients, who are quite eager for “cosmetic” or minimally invasive thyroid surgery. Minimally invasive surgical techniques have transformed surgical practice over the past two decades, beginning with laparoscopic cholecystectomy and the first randomized prospective trials comparing open and laparoscopic colectomy. In many cases minimally invasive techniques have been shown to be expected to achieve the same surgical goals as traditional surgical approaches with significant reductions in incision length, pain, and morbidity. As a result, these techniques have replaced many “open” techniques in abdominal, pelvic, and thoracic surgery. The use of minimally invasive techniques in thyroid, parathyroid, and neck surgery has progressed at a much slower pace. The rise in the incidence of thyroid cancer and patient demand has accelerated the evolution of endoscopic neck surgery.
Throughout the years, a series of minimally invasive thyroid surgical approaches have been developed, such as MIVAT, SET, robotic surgery, etc. The approaches are cervical, axillary, areolar, transoral, etc. The total lumpectomy is also single-port, two-port, multi-port, etc.; therefore, this series is dazzling. Some are more widely performed clinically, while others remain experimental in nature not widely recognized or even ethically problematic. If classified one can start with the following
By this classification, thyroid surgery is classified as follows
Modality
Workspace
Visualization
Equipment used
Type I: Direct midline
Traditional
Small incision
No air
Airless
Conventional +/- magnification
Magnifier +/- endoscope
Manual
Manual
Type II: Area
Lateral neck
Submaxillary
Inflatable/non-inflatable
Airless
Endoscopic/stereoscopic
Endoscopic / Stereoscopic
Manual/Robot
Manual/Robot
Type III: distant
Anterior chest wall
Double ring incision Breast
ABBA/BABA
Posterior auricle
Transaxillary
Inflation
Inflatable
Inflatable/non-inflatable
Inflatable/non-inflatable
Inflatable/non-inflatable
Borescope / stereo
Endoscope / stereoscopic
Endoscope / stereo
endoscope / stereo
Endoscope / stereo
Manual/robotic
Manual / robot
Manual / robot
Manual/Robot
Manual/Robot
Type IIIm: Transmucosal
Trans-oral
Air-filled
Endoscopy/stereo
Manual/robotic
Figure 1: Thyroid surgery with an external neck approach, with a natural scar-free neck, but currently only for benign thyroid surgery, and it is controversial whether it can be used for malignant cases.
Figure 2: Small incision thyroid surgery in the neck, suitable for benign thyroid and some strictly screened thyroid cancer patients
Is minimally invasive surgery always better than traditional surgery?
While innovation is exciting, it is important that it occurs in a form that makes sense and is based on consideration of the goals of thyroid surgery. The costs and benefits from multiple perspectives, including patients, surgeons, health care systems, and even society, must also be considered. Innovative use of new technologies does have a learning curve, and patients may be at risk in the process.
For thyroid surgery, there are three main goals.
Goal 1: To treat the disease effectively
Goal 2: Minimize the long-term side effects of surgery and reduce complications
Goal 3: Reduce postoperative discomfort and pain
Of these goals, the most important priority is clearly the effective treatment of the disease. There may be some debate about the relative priority of the other two goals, and such differences of opinion may even exist between physicians and patients.
How do we make individualized choices in our hospitals?
With the advancement of our lumpectomy technology, we are now performing full lumpectomy with extra-cervical access and recommending small incision lumpectomy-assisted surgery (MIVAT) in the neck, and lumpectomy thyroid surgery is widely performed. For benign thyroid nodule surgery, both approaches are possible. However, for malignant thyroid tumors, total lumpectomy is controversial due to the scope of surgery (i.e., surgical thoroughness) and the issue of medical dissemination.
In 1997, Miccoli et al. pioneered the minimally invasive video-assisted thyroidectomy (MIVAT), a small incision in the anterior neck, which is performed under a combination of direct vision and lumpectomy. The MIVAT incision is located 1-2 cm above the sternal notch, and the scar is small but high and aesthetically limited. Our conventional thyroid incision is at the level of the sternal notch (Figure 1), making the scar lower and more easily covered by clothing, reducing the aesthetic impact of the surgical scar on the patient. The sternotomy approach (Figure 2) was initially chosen for our MIVAT to further reduce the aesthetic impact of the surgical incision compared to conventional MIVAT surgery.
From our study, we showed that lumpectomy-assisted radical thyroid cancer treatment via the sternotomy approach can be selectively used for some cN0 papillary thyroid cancers with a maximum diameter of ≤5 mm and no external invasion under strict indications. The preliminary application results showed that this procedure has the same effect as conventional open surgery for radical treatment, with better safety and feasibility.
Further, we also performed lumpectomy-assisted cervical lymph node dissection in some patients with thyroid cancer with lymph node metastasis in the lateral cervical region, reducing the incision in the neck from the traditional large L-shaped incision to a conventional 150px incision similar to that of benign thyroid surgery. A more discreet facial result was achieved.
Figure 4. Conventional L-shaped incision for patients with thyroid cancer with lymph node metastasis in the lateral cervical region
Figure 5. Large curved neck incision for thyroid cancer with lymph node dissection in the lateral cervical region
Figure 6: Small neck incision for thyroid cancer with lymph node dissection in the lateral cervical region
In conclusion, despite the controversies, the increasing use of lumpectomy techniques in thyroid surgery and clinical treatment will inevitably provide individualized options for patients when appropriate. However, it must be emphasized that surgery must necessarily consider the surgical scope first, followed by the incision and access. Priority must be given to surgical safety, exposure of the surgical scope, and thoroughness of the procedure over other requirements such as aesthetics.