Thyroid disorders are relatively common in female patients, and traditional surgical neck scars are often difficult to accept. Since Huscher et al. performed the first lumpectomy thyroid lobectomy in 1997, the good cosmetic results have been recognized by most surgeons and patients. In the last few years, endoscopic thyroid surgery techniques with various approaches have been introduced worldwide, and safety and efficacy studies of these approaches have been reported.
We have introduced endoscopic thyroidectomy with a complete areolar approach since April 2012, which allows simultaneous management of bilateral thyroid lesions with small chest scars and concealed sites. We recently reviewed our earlier experience and results of complete areolar approach endoscopic thyroid lobectomy for thyroid tumors to evaluate the safety and efficacy of this approach.
1. Data and Methods
General Data From April 2012 to September 2013, a total of 46 patients with thyroid tumors underwent complete areolar approach endoscopic thyroidectomy (44 females and 2 males, age (20-60 years). All patients were diagnosed preoperatively by clinical examination, ultrasound and hematological tests (including T3, T4, TSH levels). The mean diameter of the mass was (2.35±1.14)(0.7-5.4) cm). CT scans were performed preoperatively to assess thyroid lobe volume, tumor size and lymph node metastasis. three cases of nodular goiter with cystic changes were not examined by FNA. Informed consent was signed after the patients were briefed on their condition, surgical approach, possible complications, and possible conversion to open surgery. The inclusion criteria for endoscopic thyroidectomy were.
(i) benign thyroid disease <5 cm in diameter.
② low risk thyroid cancer (age <45 years, tumor <2 cm, no evidence of local invasion, lymph node metastasis and distant metastasis).
To assess the feasibility and cosmetic outcome of our endoscopic operation, postoperative follow-up was performed for 3-20 months with the following items: postoperative satisfaction with neck performance, cosmetic satisfaction score 1-5 (1 being highly dissatisfied to 5 being highly satisfied), presence or absence of recurrence, presence or absence of swallowing discomfort and discomfort in the anterior thoracic region, and presence or absence of hypertrophic scars.
Surgical operation All patients were under general anesthesia with tracheal intubation, the patient was placed in a flat position with shoulder pads to posteriorly extend the neck, and the lower extremities were placed in a bladder amputation position with the main surgeon standing between the patient’s legs and the supporting mirror hand standing on the patient’s right side. In some of our early patients, we adopted the herringbone position, and subsequently the cystotomy position was always used because of the small space that affected the operation of the main incision. We made 3 incisions of 12, 5, and 5 mm at the margins of the right areola at 4 and 11 o’clock and the left areola at 11 o’clock, respectively. Before establishing the subcutaneous tunnel, 500 ml of saline with 1 ml of epinephrine was injected into the chest wall subcutaneously and at the lower edge of the sternocervical vein incision to stop bleeding during blunt subcutaneous separation.
The subcutaneous tunnel in the neck was then completed by blunt dissection from a 12 mm incision using a special arrow blunt-tipped detacher, and a 12 mm Trocar was placed with CO2 gas to maintain a pressure of 6 mmHg (1 mmHg = 0.133 kPa) to prevent subcutaneous emphysema, at which point the signature “double hole sign” was seen on visualization. The subxiphoid flap was dissected with an ultrasonic knife from the level of the thyroid cartilage to the sternocervical vein incision, and on both sides to the middle edge of each sternocleidomastoid muscle. The median line of the strap muscle is separated from the level of the thyroid cartilage to the sternocervical vein incision, and two silk sutures are inserted through the skin to laterally retract the strap muscle. The isthmus of the thyroid gland is first incised using an ultrasonic knife to expose the trachea.
The inferior thyroid artery is then coagulated with the ultrasonic knife, and the inferior thyroid pole is lifted, and gentle upward traction is maintained continuously as the inferior thyroid pole is carefully separated to expose the recurrent laryngeal nerve and inferior parathyroid gland. After visualization of the recurrent laryngeal nerve, the nerve is dissected immediately above the plane of the nerve until the superior pole is reached. The entire lobe of the gland is then lifted upward and laterally, and the Berry ligament is dissected using an ultrasonic knife. When encountering a patient with a large gland, we advocate a split resection, which effectively increases the operative space and reduces the risk of intermediate surgery. The specimen was placed in a specimen bag and removed through a 12 mm incision. The open median line of the strap muscle was interrupted with a 3-0 antimicrobial microjoe suture.
The puncture tunnel was carefully monitored with a video camera during 12 mm Trocar retrieval. In four cases, we immediately detected active bleeding from the tunnel and immediately stopped the bleeding with a skin gauze compression suture at the bleeding point, avoiding reoperation. A drainage tube was placed in the thyroid fossa and drained from one side of the areolar incision, which was removed when the daily drainage was less than 15 ml. The skin incision was closed with 4-0 absorbable sutures.
2. Results
All 46 cases were successfully resected by endoscopic thyroid lobectomy with isthmus through complete areolar approach, and four cases of thyroid cancer were treated with lymph node dissection in the affected central region. There were no cases of intermediate open surgery. The final postoperative pathological diagnosis of thyroid nodules was reported as follows: including 20 hyperplastic nodules, two of which had combined parathyroid adenomas resected at the same time, 12 with chronic lymphocytic thyroiditis, 6 nodular goiters with cystic changes, 14 follicular adenomas, and 6 papillary thyroid microcarcinomas (all <1 cm in diameter).
The average operative time (65-180 minutes). Intraoperative bleeding was low. The initial 20 patients with benign pathology selected for FNA biopsy were routinely left with a few glands dorsally and the laryngeal recurrent nerve was not routinely exposed intraoperatively. The other 26 cases routinely exposed the recurrent laryngeal nerve, and 6 papillary carcinomas were included in the latter, 4 of which were treated with lymph node dissection in the affected central region. Postoperatively, patients tolerated pain in the anterior thoracic wall and anterior cervical region, and no analgesics were routinely applied except for one case in which additional analgesics were used.
Postoperative complications included 3 cases of transient laryngeal nerve palsy in 1 case with a thyroid mass >5 cm, 1 case with a large mass located dorsally, and 1 case with lymph node dissection in the central region, all of which recovered about 2-3 months after surgery; 1 case of transient hypocalcemia in a patient with papillary microcarcinoma after thyroid lobe plus isthmus and lymph node dissection in the central region of the affected side, which recovered about the 8th day after surgery. One case complained of discomfort in swallowing and three cases complained of abnormal pins-and-needles sensation in the anterior chest wall, all of which lasted for approximately 4 months. The average duration of drainage tube drainage (2-4 days) and the average amount of drainage (50-200 ml).
The mean postoperative hospital stay was (5.13±0.99)(4-8) d. All patients were followed up and during the follow-up examination, serum ionized calcium and thyroid function were normal and there were no cases of hypothyroidism or recurrence. As described above, there were no long term complications and all patients were satisfied with the cosmetic results with a cosmetic satisfaction score of (4.83±0.38).
3. Discussion
Recently, endoscopic surgery of the thyroid has been widely accepted by many surgeons and patients. Although endoscopic thyroidectomy is not a minimally invasive procedure and is even more invasive than conventional open surgery, it achieves cosmetic results that cannot be achieved by conventional surgery by avoiding neck incision scars.
The main approaches for endoscopic thyroid surgery include video-assisted neck surgery, bilateral axillary thoracic approach, axillary pathway, and thoracic breast approach. Among them, the neck approach has a narrow surgical field, poor exposure due to the proximity of tissues to the camera, and difficulty in achieving a scar-free neck. Although the axillary thoracic approach and axillary approach have hidden incisions, it is difficult to visualize the contralateral thyroid gland and thyroid isthmus, therefore, the axillary approach is not recommended for thyroid nodules spreading to the contralateral lobe. However, the anterior chest wall is more prone to hypertrophic scar formation than other parts of the skin, so it is still difficult to meet the cosmetic requirements of some patients.
Therefore, we used a complete areolar approach for endoscopic thyroidectomy. In this approach, because of the darker pigmentation of the areolar skin, the incision at its edge is both concealed and the postoperative scar growth is not obvious, especially in female patients, completely concealing all incisions, so the total areolar approach has better cosmetic results than the breast-breast approach, and another advantage is that the thyroid gland on both sides can be explored simultaneously.
The technical difficulty of the total areola approach is the close distance between the right areola observation hole and the auxiliary operation hole, which can easily affect the operation by intraoperative collision between the lens and the separating forceps, thus leading to longer operation time or increased surgical risk. Our experience is similar to that reported by Dai et al. The right areola incision was chosen in the 11 o’clock and 4 o’clock directions, so that the distance between the lens and the grasping forceps was diagonal and the distance was maximized, and at the same time, the 2 Trocar were kept parallel as much as possible, which would reduce the chance of collision between the auxiliary operating hole instruments and the lens and be more favorable to the surgical operation.
In male patients, the tightness of the anterior chest wall skin affects the flexibility of the operation and makes it more difficult to expose the nerve. For women, the areola is relatively larger and the breast skin is more compliant, and the distance between the right areolar Trocar can be increased by pulling, which reduces the difficulty of the operation, so we believe that the total areola approach is more suitable for female patients.
Due to the long subcutaneous tunnel, it is challenging to separate the flap in the full areola approach. We have encountered cases of perforated flaps and ultrasonic knife burns on the skin of the neck by other surgeons.
Therefore, it is necessary to collect and repeatedly read the relevant literature, carefully watch surgical videos, and even perform animal experiments, and we ask surgeons with experience in open thyroidectomy and laparoscopy to perform endoscopic thyroidectomy. In addition, a detailed preoperative history of breast augmentation should be obtained. 1 of our patients with breast augmentation underwent endoscopic thyroid surgery, which took more time because the sensitivity of the operation was severely compromised to avoid excessive compression of the chest. k. Jeryong et al. noted that after a short learning curve, the endoscopic technique no longer took more time than open thyroidectomy.
We had no cases of reoperation due to postoperative bleeding, and we carefully observed the puncture tunnel with a camera lens while removing the 5 mm Trocar under direct vision and retracting the 12 mm Trocar. We had four cases of active bleeding from the tunnel immediately before the end of the procedure and immediately stopped the bleeding by applying pressure sutures to the skin gauze corresponding to the bleeding point, avoiding reoperation. Moreover, we chose a drainage tube with a longer cephalic end and more lateral holes, which can drain both the thyroid fossa and the subcutaneous fluid, which is of good value in preventing postoperative subcutaneous fluid and edema in patients.
The incidence of transient and permanent recurrent laryngeal nerve palsy after subtotal or near-total thyroidectomy for Graves’ disease has been reported to be 5.9% and 0%, respectively. The incidence of concomitant hypocalcemia after conventional open thyroidectomy ranges from 1.2-40%. In comparison, in our patients, the incidence of both was 6.5% and 2.2%, respectively, indicating that our results are not poor and providing a basis for the safety of this operation. In our complete areolar approach endoscopic thyroidectomy, our experience is that splitting the resection when encountering larger glands, separating the forceps for fine dissection step by step, and reducing the clamping action can further improve the operative field and increase anatomical safety, and using the ultrasonic knife sparingly in the proximity of the recurrent laryngeal nerve to reduce heat transfer and avoid side injuries.
In conclusion, endoscopic thyroidectomy with a complete areolar approach is safe and feasible, and this route has the advantage of no scarring of the neck or chest wall and allows simultaneous management of bilateral thyroid lesions for optimal cosmetic results, especially in female patients, and has clinical promotion value.