JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy-New Development and Literature Review Dr. Alex Leung Lik Hang Supervisor: Dr. David Tsui, Dr. KK Yau Good morning chairman and dear colleageus, I am going to share with you the new development and have a literature review on endo thyroidectomy Department of Surgery Pamela Youde Nethersole Eastern Hospital

Photos from Charles et al. World J Surg 2008 Do you think there is any great difference on the left and on the right. It may not be a great difference in elderly, but it may be very important in a young lady Photos from Charles et al. World J Surg 2008

Development of Minimal Access Thyroid Surgery First endoscopic parathyroidectomy reported by Gagner in 1996 Video-assisted thyroid lobectomy by Huscher in 1997 Ohgami M introduced endoscopic thyroidectomy using the breast approach in 2000 Ikeda reported axillary endoscopic thyroidectomy in 2000 Development of MAS thyroid surgery started from parathyroidectomy, to VAS with minimal neck wound, fnally to scarless surgery in the neck

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

INDICATIONS In previous cases series, the usual indications: Patient under age of 45 Benign lesions <3 cm 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 previous case series, The usual indications are patient younger than 45 y.o and benign lesion less then 3 cm. The indications then extend to Grave’s disease and and even carcinoma

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

Axillary Approach First introduced by Ikeda 2000, 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 I wound introduce some common scarless approach

Axillary 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 Kang et al. Endocr. J 2009

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

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

Bilateral Axillo-breast(BABA) Developed by Choe et al in 2007 1.5 cm Incision made bilaterally at the circumareolar line for endoscope and Harmonic scalpel Two 5mm incisions made at anterior axillary line bilaterally Developed by Choe et al in 2007 It insert one more axillary port as compared to ABBA

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

Bilateral axillo-breast(BABA) Dissection methods almost the same as conventional thyroidectomy 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 Excellent cosmetic results

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 After knowing many approaches, we would like to know what is the evidence so far to support endoscopic thyroidectomy Charles et ah. World J Surg (2008) 32: 1349-1357

What is the evidence so far? NO RCT identified Charles et al. World J Surg (2008) 32: 1349-1357

Axillary Approach Ikeda et al. 2002 19 5 Udomsawaengsup et al. 2004 13 No. of patients Level of evidence Ikeda et al. 2002 19 5 Udomsawaengsup et al. 2004 13 Chantawibul et al. 2003 45 Yoon et al. 2006 30 Jung et al. 2007 35 Witzel et al. 2007 12 Duncan et ah. 2007 32 7 small case series was performed for axillary approach

Breast Approach No. of patients Level of Evidence Ohgami et al. 2000 5 Yamamoto et al. 2001 12 Takami and Ikeda et al. 2002 22 Park et al. 2003 100 Cho et al. 2007 30 Charles et al. World J Surg (2008)

Hybrid Approach: ABBA/BABA No. of patients Level of evidence Kitano et al. 2002 Axilla and chest 20 5 SHimazu et al. 2003 ABBA 12 Barlehner and Benhidjeb et al. 2007 13 Choe et al. 2007 25 BABA 110 Charles et al. World J Surg (2008)

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

171 patients: benign tumors 410 patients: malignant tumor Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 patients Between Nov. 2001 and Dec. 2007 581 patients with thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach. 171 patients: benign tumors 410 patients: malignant tumor Over the six years, ………..30% patients have benign tumors Others have malignant tumors S.W. Kang et al. Endocrine Journal. Jun 2009

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

RESULTS No conversion to open surgery Benign Malignant Mean operating time 129.4+/-51min 135.5+/-47min Length of postop hospital stay 3.3/-1.7 days 3.4+/-0.9 days Tumor size 2.7+/-1.2cm 0.78+/-0.5cm

RESULTS Transient hypocalcemia in 19 patients (3.3%) Transient hoarseness in 13 patients (2.2%) Permanent hoarseness in 2 patients (0.3%) Transient hypocalcemia occurs in 3% of patients Transient hoarseness in 2 % of patients, only 2 patients have permanent hoarseness

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

No. of Hospitals performing Endoscopic Thyroidectomy in Korea

SAFE for MALIGNANT THYROID TUMORS??? 1st COMPARATIVE STUDY PURELY FOR MALIGNANCY Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison with Conventional Open Thyroidectomy After knowing endo thyroidectomy is safe and feasible for benign lesions. We would like to know if it is safe for malignancy, YS Chung has performed the 1st compartive study purely for malignancy. To compare the results of open and endo thyroidectomhy YS Chung et al. World J Surg (2007)

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 198: open thyroidectomy 103: endoscopic thyroidectomy with BABA approach Over the 3-year period of study, ~ 300 patients were recruited with 2/3 are open while 1/3 are endoscopic. YS Chung et al. World J Surg (2007)

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

RESULTS Open thyroidectomy (n=198) Endoscopic thyroidectomy (n=103) P value Sex <0.0001 Male 25(12.6%) 1(1.0%) Female 173(87.4%) 102(99.0%) Age (years) 21-75(47.2+/-10.2) 21-53(38.2+/-8.2) Operative Method 0.064 Ipsilateral lobectomy 12(6.1%) 7(6.8%) Subtotal thyroidectomy 14(7.1%) 8(7.8%) Total thyroidectomy 156(78.8%) 87(84.5%) Total thyroidectomy with MRND 16(8.1%) Duration of operation (min) 111.4 165.1 Length of hospitalization (d) 3.2 3.0 0.081 Operation time is longer in endoscopic group which is statistically significant.

Open thyroidectomy (n=198) Endoscopic thyroidectomy (n=103) P value Transient hypocalcemia 35/198(17.7%) 26/103(25.2%) 0.132 Permanent hypocalcemia 9/198(4.5%) 1/103(1.0%) 0.173 Transient RLN palsy 5/198(2.5%) <0.0001 Permanent RLN palsy 1/198(0.5%) 0/103 1.000 Bleeding 0/198 0.342 Infection Tumor recurrence 13 2 The complication rate was similar in two groups except transient RLN palsy is significantly higher in endoscopic group

Patients undergone Total Thyoidectomy Open thyroidectomy n=172 Endoscopic thyroidectomy N=88 Postoperative thyroglobuin were available 146/172 72/88 Thyroglobulin in 3 months <1.0 ng/ml 132/146 (90.4%) 64/72 (88.9%) P=0.812 While the post op thyroglobulin level in 3/12 times was comparable in the two groups.

Our Experience I would like to share our local experience for endoscopic left hemithyroidectomy. Essentially this approach is some what similar to conventional open approach. After raising subplatsmal flap with sharp dissection. Isthmectomy is performed. Trachea is identfied below. Harmonic scalpel is used for isthmectomy. Then the thyroid gland can be retracted easily for better identification within the working space.

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) Mr Chairman, my dear colleagues. I would like to conclude that ….

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

FUTURE… To develop dedicated surgical instruments Standardization of techniques To optimize patient selection criteria, especially for thyroid cancer Large-scale RCTs The future of endoscopic thyroid is to

Robotic Thyroid Surgery Robotic thyroid surgery may be the future trend HD and 3D image Endowrist function beneficial in LN dissection

THANK YOU!

CO2 insufflation vs Gasless view easily disturbed by mist from Harmonic Scalpel 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 insufflation vs Gasless Gasless approach: Using an external retractor to maintain working space Eliminates the CO2 related complications

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

EXCLUSION CRITERIA Definite extra-capsular soft tissue invasion Multiple lateral neck node metastasis Perinodal infiltration of metastatic lymph node Distant metastasis 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

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 Modified radical neck dissection done for case of only 1-2 lateral neck node metastasis If there is capsular invasion found, total thyroidectomy will be performed. Ipislateral CND is performed for maligant case. S.W. Kang et al. Endocrine Journal. Jun 2009

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

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