Thyroid disorders are commonly seen in women. Traditional thyroid surgery causes a great psychological burden to female patients due to a surgical scar in the neck and the incision in the neck cutting the dermal nerve leading to postoperative neck discomfort and abnormal sensation. In 1996, Gagnert et al. successfully reported the world’s first lumpectomy for major parathyroidectomy, and in 1997, Huscher et al. completed the first lumpectomy for thyroid lobectomy with satisfactory cosmetic results.
With the improvement of lumpectomy instruments and the development of technology, many scholars started the exploration of lumpectomy thyroid surgery methods. Due to the narrow neck gap, the small surgical space created, the difficulty of surgical operation and hemostasis, and the high proportion of intermediate opening, only a small number of cases were carried out in the United States and Italy at that time, which did not have the value of promotion. Japanese and Chinese scholars continued to explore the subcutaneous separation of the anterior thoracic wall and combined it with the subcutaneous space of the neck, thus expanding the surgical space and meeting the adequate surgical space needed for surgical operation. This has led to further promotion and popularity of the procedure. Especially in recent years, lumpectomy thyroid surgery has been developed significantly.
I. Surgical path of lumpectomy thyroidectomy
At present, there are two types of lumpectomy thyroid surgery: according to the presence or absence of scars in the neck, there are small scar paths in the neck, namely the sternotomy path and the suprasternal fossa path, and scarless paths in the neck, namely the subclavian path, axillary path, anterior chest wall path, double areola path, axillary areola path and postauricular axillary path.
Depending on the method of establishing the operating space, they are classified as.
(1) Total endoscopic thyroid surgery (total endoscpoic approaches): the operating space is created through the co pneumatic cavity and includes six types of approaches: supraclavicular, anterior chest wall, double areola, axillary areola, axillary areola and posterior auricular axillary approaches.
(2) Endoscopic assisted endoscopic approaches to thyroid surgery (video.assisted endoscopic approaches): the operating space is created by suspension method, including 2 types of pathways: sternotomy and subclavian.
(3) Robotic lumpectomy thyroid surgery.
1. lumpectomy-assisted pathway over the sternotomy notch.
Bellantone et al. first reported this method, which involves a 15-30 mm incision above the sternotomy without CO2 inflation and blunt, sharp separation of the subclavian space with conventional surgical instruments. The flap is lifted with a small pull hook to reveal the surgical field. The thyroid surgery is performed through the above small incision with simultaneous access to the lumpectomy and conventional surgical instruments. This approach is convenient, simple, and short, and is often used in conjunction with conventional surgery. It can avoid complications related to CO2 gas cavity and does not require high lumpectomy surgical skills of the operator.
2. Supraclavicular approach.
A 10 mm incision is made above the sternotomy. The subclavian space is bluntly separated and a 10 mm diameter trocar is placed, CO2 gas is injected to establish the operating space, and the pressure of the gas chamber is controlled at 4-6 mm Hg. Two other 5 mm diameter trocar is inserted under lumpectomy guidance, and the puncture point depends on the location of the tumor. This approach is easy to perform. The operation hole is close to the tumor, and the separation incision is small, and the finger can be extended to assist the operation if necessary.
3.The anterior chest wall and areola pathway.
According to the patient’s request, three operating trocars (5~l0 mm in diameter) can be selected in the area from 3 cm below the clavicle to the line of both nipples, after blunt separation along the surface of the pectoralis major muscle fascia, CO2 gas can be injected to establish the operating space, among which the areolar sulcus approach founded by the Japanese is the most ideal and most used method at present. The advantages are that the incision is far from the neck, the cosmetic result is ideal, there is no scar in the neck, and bilateral thyroid lesions can be treated simultaneously. The disadvantage is that the path is far away, the subcutaneous separation is large, the trauma is large, and a small scar of more than 1 cm is needed in the cleavage.
4. Axillary and axillary areolar approaches
The axillary approach was first used by Ekeday [5] in 2000. In this approach, the incision is shifted to the axilla, and a 15-mm incision is made in the axilla with the upper extremity draped over the tumor side, and the pectoralis major fascial surface is bluntly separated to the subxiphoid space. Under lumpectomy guidance. Two other 5 nlnl diameter trocars were inserted. The puncture points are located below the first trocar. One of the puncture points can also be placed next to it, and the subxiphoid surgical field can be revealed by sharp separation with an ultrasonic knife.
Wang Cunchuan et al. designed the axillary areolar path by combining the axillary path with the areolar path, which overcomes the disadvantage of the areolar path that requires a small scar of more than 1 cm in the cleavage. It also requires strict selection and is only suitable for surgical resection of unilateral benign thyroid tumors. Therefore, it is not used much.
5.Subclavian lumpectomy approach
The subclavian approach was proposed by Shimizu et al. in 1999. The incision is located under the affected subclavian bone and the size is 10-15 mm,
The size of the incision is 10-15 mm, depending on the situation. Two 1.2 nlnl diameter Kirscher wires are passed under the latissimus dorsi muscle, and the wires are suspended from a brace to create a surgical maneuvering space under the latissimus dorsi muscle. Two additional small 0.5 cm incisions were made, one in the corresponding location under the contralateral subclavian and one on the cervical side on the side of the lesion. This incision is lower and has a shorter path, which is easily accepted by the patient. However, the scar is still easily exposed and not accepted by female patients.
6. Other pathways.
Shimizut et al. 2002 mentioned the submandibular approach with cervical perforation, which can better solve the problem of the superior pole of the thyroid gland, but it is less applied; Hua Luwei also proposed a retroauricular approach, both of which are being explored. In conclusion, no matter what kind of approach, it must be decided according to the actual situation of the surgery and the requirements of the patient.
Indications and contraindications for surgery.
Due to the different number of cases performed, the indications and contraindications for surgery are reported differently. William B et al. believe that a single nodule or adenoma of 1-3 cm is the best indication, and if the tumor is larger than 3 cm in diameter or multiple, hyperthyroidism, history of neck surgery and short fat patients are relative indications, while thyroid cancer is a contraindication. According to Wang Cunchuan, the indications are: substantial single nodule of thyroid with maximum diameter ≤ 6 cm, cystic nodule can be more than 6 cm in diameter; II. Primary or secondary hyperthyroidism with enlargement to the lumen; low-grade malignant thyroid cancer without lymph node metastasis and local invasion.
Miccoli et al. reported 67 cases of lumpectomy thyroid surgery and successfully completed 65 cases (97%) and concluded that the indications are.
①Single thyroid nodule less than 3 cm in maximum diameter;
(2) Estimated thyroid volume less than 20 ml;
③ Benign or low-grade follicular lesions;
④Papillary adenocarcinoma of low malignancy. Contraindications include
①History of neck surgery;
②Large goiter;
③Malignant tumor with local infiltration;
④ malignant tumor with lymphatic metastasis.
A history of neck radiotherapy, hyperthyroidism and thyroiditis were listed as relative contraindications. In contrast, Yeh et al. reported completed tumors with sizes ranging from 3.5 to 8.0 cm, with a mean of 5.8 cm. In general, the maximum diameter of solid nodules should not exceed 5 cm because of the small operating space in the neck, the technical difficulty of having a tumor that is too large, and the problem of removing large specimens from small incisions. In case of cystic nodules, fluid can be aspirated and decompressed, and their diameter can exceed 5 cm.
With technical proficiency, a number of authors have successfully performed lumpectomy for recurrent hyperthyroidism. Therefore, the indications for surgery are all relative and will be gradually relaxed as the technique improves.