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JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy- New Development and Literature Review Department of Surgery Pamela Youde Nethersole Eastern.

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Presentation on theme: "JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy- New Development and Literature Review Department of Surgery Pamela Youde Nethersole Eastern."— Presentation transcript:

1 JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy- New Development and Literature Review Department of Surgery Pamela Youde Nethersole Eastern Hospital Dr. Alex Leung Lik Hang Supervisor: Dr. David Tsui, Dr. KK Yau

2 Photos from Charles et al. World J Surg 2008

3 Development of Minimal Access Thyroid Surgery First endoscopic parathyroidectomy reported by Gagner in 1996 First endoscopic parathyroidectomy reported by Gagner in 1996 Video-assisted thyroid lobectomy by Huscher in 1997 Video-assisted thyroid lobectomy by Huscher in 1997 Ohgami M introduced endoscopic thyroidectomy using the breast approach in 2000 Ohgami M introduced endoscopic thyroidectomy using the breast approach in 2000 Ikeda reported axillary endoscopic thyroidectomy in 2000 Ikeda reported axillary endoscopic thyroidectomy in 2000

4 Prevalence of thyroid disease is much higher in young women than men, Prevalence of thyroid disease is much higher in young women than men, The incidence of thyroid disease of young women is increasing The incidence of thyroid disease of young women is increasing The trend of endoscopic thyroidectomy would be highly beneficial to them The trend of endoscopic thyroidectomy would be highly beneficial to them

5 INDICATIONS In previous cases series, the usual indications: In previous cases series, the usual indications: Patient under age of 45 Patient under age of 45 Benign lesions <3 cm Benign lesions <3 cm Yamamoto et al applied the endoscopic thyroidectomy with breast approach to Graves’ disease in 2001 Yamamoto et al applied the endoscopic thyroidectomy with breast approach to Graves’ disease in 2001 In 2002, Miccoli et al. applied minimally invasive video-assisted thyroidectomy to resection of a papillary thyroid carcinoma In 2002, Miccoli et al. applied minimally invasive video-assisted thyroidectomy to resection of a papillary thyroid carcinoma

6 Different Approaches of Endoscopic Thyroidectomy Cervical (since 1997) Cervical (since 1997) Axillary (since 2000) Axillary (since 2000) Breast (since 2000) Breast (since 2000) Anterior chest wall Anterior chest wall Axillo-bilateral-breast(ABBA) (since 2003) Axillo-bilateral-breast(ABBA) (since 2003) Bilateral axillo-breast(BABA)(2007) Bilateral axillo-breast(BABA)(2007) No consensus on which approach is the best No consensus on which approach is the best

7 Axillary Approach First introduced by Ikeda 2000, First introduced by Ikeda 2000, 4-6 cm vertical skin incision in the axilla for camera port and two working ports 4-6 cm vertical skin incision in the axilla for camera port and two working ports 0.5 cm incision on the medial side of the anterior chest wall 0.5 cm incision on the medial side of the anterior chest wall

8 Axillary Approach Cosmetic result better than the cervical or anterior chest wall approach Cosmetic result better than the cervical or anterior chest wall approach Approaches the lateral aspect of the thyroid and identify the parathyroid and RLN easily Approaches the lateral aspect of the thyroid and identify the parathyroid and RLN easily Kang et al. Endocr. J 2009

9 Axillary Approach The approach to the contralateral superior pole of the thyroid is relatively difficult The approach to the contralateral superior pole of the thyroid is relatively difficult Not our usual approach for thyroid surgery Not our usual approach for thyroid surgery Narrow angle of the instrument Narrow angle of the instrument

10 Axillo-Bilateral Breast Approach(ABBA) Developed in Japan in 2003 Developed in Japan in 2003 Two circumareolar ports and one axillary port Two circumareolar ports and one axillary port Allows greater angulation of the instrument Allows greater angulation of the instrument Limited ability to visualize both lobes of the thyroid and to perform total thyroidectomy Limited ability to visualize both lobes of the thyroid and to perform total thyroidectomy

11 Bilateral Axillo-breast(BABA) Developed by Choe et al in cm Incision made bilaterally at the circumareolar line for endoscope and Harmonic scalpel Two 5mm incisions made at anterior axillary line bilaterally

12 Bilateral Axillo-breast(BABA) Subcutaneous dissection bilaterally from the incision to the thyroid cartilage and the SCM Subcutaneous dissection bilaterally from the incision to the thyroid cartilage and the SCM

13 Bilateral axillo-breast(BABA) Dissection methods almost the same as conventional thyroidectomy Dissection methods almost the same as conventional thyroidectomy Optimal visualization of major structures including the parathyoid, RLNs and the superior and inferior thyroid vessels Optimal visualization of major structures including the parathyoid, RLNs and the superior and inferior thyroid vessels Allows dissection of both lobes with the same view and methods Allows dissection of both lobes with the same view and methods Excellent cosmetic results Excellent cosmetic results

14 What is the evidence so far? Charles et al performed a review of evidence in endoscopic thyroidectomy in 2008 Searched in the Medline database through Sep2007 using the terms: endoscopic thyroidectomy, minimal invasive thyroidectomy/endocrine surgery, thyroidectomy via the axillary/anterior/breast approach Charles et ah. World J Surg (2008) 32:

15 What is the evidence so far? NO RCT identified Charles et al. World J Surg (2008) 32:

16 Axillary Approach No. of patients Level of evidence Ikeda et al Udomsawaengsup et al Chantawibul et al Yoon et al Jung et al Witzel et al Duncan et ah

17 Breast Approach No. of patients Level of Evidence Ohgami et al Yamamoto et al Takami and Ikeda et al Park et al Cho et al Charles et al. World J Surg (2008)

18 Hybrid Approach: ABBA/BABA ApproachNo. of patients Level of evidence Kitano et al. 2002Axilla and chest 205 SHimazu et al. 2003ABBA125 Barlehner and Benhidjeb et al ABBA135 Choe et al. 2007ABBA255 BABA1105 Charles et al. World J Surg (2008)

19 LARGEST CASE SERIES for Endoscopic Throidectomy Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 patients S.W. Kang et al. Endocrine Journal. 56(3): 361-9, 2009 Jun

20 Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 patients Between Nov and Dec patients with thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach. 171 patients: benign tumors 410 patients: malignant tumor S.W. Kang et al. Endocrine Journal. Jun 2009

21 INCLUSION CRITERIA Thyroid tumor not larger than 5cm and diagnosed as follicular neoplasm Thyroid tumor not larger than 5cm and diagnosed as follicular neoplasm Papillary thyroid microcarcinoma with low risk Papillary thyroid microcarcinoma with low risk S.W. Kang et al. Endocrine Journal. Jun 2009

22 RESULTS No conversion to open surgery BenignMalignant Mean operating time /-51min135.5+/-47min Length of postop hospital stay 3.3/-1.7 days3.4+/-0.9 days Tumor size2.7+/-1.2cm0.78+/-0.5cm

23 RESULTS Transient hypocalcemia in 19 patients (3.3%) Transient hoarseness in 13 patients (2.2%) Permanent hoarseness in 2 patients (0.3%)

24 RESULTS In TMN stage, 366 (89.2%): stage I 43(10.5%): stage III 1(0.2%): stage IVa Patients with RAI(4 th -6 th wk postop), were followed by whole body scan, serum thyroglobulin (4 th months) and neck USG, all showed no local recurrence and distant metastases: too short to draw conclusion on oncological safety

25 No. of Hospitals performing Endoscopic Thyroidectomy in Korea

26 SAFE for MALIGNANT THYROID TUMORS??? Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison with Conventional Open Thyroidectomy YS Chung et al. World J Surg (2007) 1 st COMPARATIVE STUDY PURELY FOR MALIGNANCY

27 Comparison with Conventional Open Thyroidectomy 301 patients with papillary thyroid microcarcinoma between Jan 2003 and June 2006 at Seoul National University Hospital by one surgeon 301 patients with papillary thyroid microcarcinoma between Jan 2003 and June 2006 at Seoul National University Hospital by one surgeon 198: open thyroidectomy 198: open thyroidectomy 103: endoscopic thyroidectomy with BABA approach 103: endoscopic thyroidectomy with BABA approach YS Chung et al. World J Surg (2007)

28 INDICATIONS for malignant thyroid disease Tumor < 1 cm on preoperative USG Tumor < 1 cm on preoperative USG No evidence of lateral LN metastasis or local invasion on preoperative USG and CT No evidence of lateral LN metastasis or local invasion on preoperative USG and CT YS Chung et al. World J Surg (2007)

29 RESULTS Open thyroidectomy (n=198) Endoscopic thyroidectomy (n=103) P value Sex< Male25(12.6%)1(1.0%) Female173(87.4%)102(99.0%) Age (years)21-75(47.2+/-10.2)21-53(38.2+/-8.2)< Operative Method0.064 Ipsilateral lobectomy12(6.1%)7(6.8%) Subtotal thyroidectomy14(7.1%)8(7.8%) Total thyroidectomy156(78.8%)87(84.5%) Total thyroidectomy with MRND 16(8.1%)1(1.0%) Duration of operation (min) < Length of hospitalization (d)

30 Open thyroidectomy (n=198) Endoscopic thyroidectomy (n=103) P value Transient hypocalcemia35/198(17.7%)26/103(25.2%)0.132 Permanent hypocalcemia9/198(4.5%)1/103(1.0%)0.173 Transient RLN palsy5/198(2.5%)26/103(25.2%)< Permanent RLN palsy1/198(0.5%)0/ Bleeding0/1981/103(1.0%)0.342 Infection0/1981/103(1.0%)0.342 Tumor recurrence132

31 Patients undergone Total Thyoidectomy Open thyroidectomy n=172 Endoscopic thyroidectomy N=88 Postoperative thyroglobuin were available 146/17272/88 Thyroglobulin in 3 months <1.0 ng/ml 132/146 (90.4%) 64/72 (88.9%) P=0.812

32 Our Experience

33 CONCLUSION Excellent cosmetic results Feasible and safe method for benign thyroid tumors, becomes more accepted Not clear if it is suitable for the treatment of thyroid cancer May be an option for small (<1cm), well differentiated thyroid cancer without lymph node involvement (Chung YS et ah. World J Surg. 2007)

34 Problems of endoscopic thyroidectomy….. More invasive with longer operation time than open surgery due to more extensive dissection More invasive with longer operation time than open surgery due to more extensive dissection Greater postoperative pain Greater postoperative pain Higher rate of transient RLN palsy Higher rate of transient RLN palsy Steeper learning curve Steeper learning curve The oncological safety in malignant tumors remain controversial The oncological safety in malignant tumors remain controversial

35 FUTURE… To develop dedicated surgical instruments To develop dedicated surgical instruments Standardization of techniques Standardization of techniques To optimize patient selection criteria, especially for thyroid cancer To optimize patient selection criteria, especially for thyroid cancer Large-scale RCTs Large-scale RCTs

36 Robotic Thyroid Surgery HD and 3D image Endowrist function beneficial in LN dissection

37 THANK YOU!

38

39 CO2 insufflation vs Gasless CO2 insufflation: CO2 insufflation: view easily disturbed by mist from Harmonic Scalpel view easily disturbed by mist from Harmonic Scalpel Problems of hypercapnia, cervical compression, subcutaneous emphysema Problems of hypercapnia, cervical compression, subcutaneous emphysema CO2 related complications can be avoided by low CO2 pressure during the surgery (Ohgami M et al. Surg Laparosc Endosc Percutan Tech 2000) CO2 related complications can be avoided by low CO2 pressure during the surgery (Ohgami M et al. Surg Laparosc Endosc Percutan Tech 2000)

40 CO2 insufflation vs Gasless Gasless approach: Gasless approach: Using an external retractor to maintain working space Eliminates the CO2 related complications Eliminates the CO2 related complications

41 Axillary LN In CCND, approach between the SCM branches, dissects anterior surface of the carotid sheath and drops the carotid sheath just below the strap muscle In CCND, approach between the SCM branches, dissects anterior surface of the carotid sheath and drops the carotid sheath just below the strap muscle

42 EXCLUSION CRITERIA Definite extra-capsular soft tissue invasion Definite extra-capsular soft tissue invasion Multiple lateral neck node metastasis Multiple lateral neck node metastasis Perinodal infiltration of metastatic lymph node Perinodal infiltration of metastatic lymph node Distant metastasis Distant metastasis Lesion located at the posterior capsule area of the thyroid, esp at the tracheo-esophageal group Lesion located at the posterior capsule area of the thyroid, esp at the tracheo-esophageal group S.W. Kang et al. Endocrine Journal. Jun 2009

43 Patients with multiple and bilateral lesion, along with a thyroid capsular invasion identified during operation, total thyroidectomy performed Patients with multiple and bilateral lesion, along with a thyroid capsular invasion identified during operation, total thyroidectomy performed Prophylactic ipsilateral central compartment node dissection for most of the malignant tumor Prophylactic ipsilateral central compartment node dissection for most of the malignant tumor Modified radical neck dissection done for case of only 1-2 lateral neck node metastasis Modified radical neck dissection done for case of only 1-2 lateral neck node metastasis S.W. Kang et al. Endocrine Journal. Jun 2009

44 Central compartment lymph node metastasis in 112 patients(27.3%) Lateral neck lymph node metastasis in 13 patients (3.1%) patients

45 Common in all approaches Isolation of RLN and parathyroid Inferior and superior thyroid vessels divided with Harmonic scalpel or between clips


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