1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Bilateral Axillo-breast(BABA)
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
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

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
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:

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

16. 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

17. 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)

18. 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)

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. 171 patients: benign tumors 410 patients: malignant tumor
Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 patients
Between Nov 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

21. 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

22. 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

23. 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

24. 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

25. No. of Hospitals performing Endoscopic Thyroidectomy in Korea

26. 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)

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
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)

28. 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)

29. 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.

30. 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

31. 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.

32. 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.

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

34. 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

35. 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

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

37. THANK YOU!

39. 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)

40. CO2 insufflation vs Gasless
Gasless approach:
Using an external retractor to maintain working space
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

42. 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

43. 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

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