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  1. 1. Mini-thyroidectomy George Ferzli, MD, FACS Paul Sayad, MD; Robert Cacchione, MD Department of Laparoscopic Surgery Staten Island University Hospital
  2. 2. Minimally invasive thyroid surgery <ul><li>Endoscopic thyroid surgery </li></ul><ul><li>Video-assisted thyroid surgery </li></ul><ul><li>Mini-thyroidectomy </li></ul>
  3. 3. I- Endoscopic thyroid surgery <ul><li>Creation of a subplatysmal space </li></ul><ul><li>Maintenance of the space using CO2 insufflation [1,2] or neck lift device [3] </li></ul><ul><li>Placement of the trocars: anterior, lateral neck or subareolar </li></ul>Neck lift device 1 Husher Eur J Coelio 1997 2 Gagner et al 2000 3 Shimizu et al J Surg Oncol 1998 4 Ohgami et al
  4. 4. Advantages <ul><li>Precise anatomical detail due to the greatly magnified view </li></ul><ul><li>Decreased pain ? </li></ul><ul><li>Smaller scar ? </li></ul>
  5. 5. Limitation <ul><li>Limited to a small (<3cm) nodule </li></ul><ul><li>Contraindicated in : </li></ul><ul><ul><li>Suspicion of malignancy </li></ul></ul><ul><ul><li>Multinodular goiter </li></ul></ul><ul><ul><li>Grave’s disease </li></ul></ul><ul><ul><li>Prior surgery </li></ul></ul><ul><ul><li>Obese patient </li></ul></ul>
  6. 6. Disadvantages <ul><li>Lack of direct palpation and manipulation </li></ul><ul><li>Small working space </li></ul><ul><li>Respiratory acidosis and diffuse subcutaneous emphysema from CO2 insufflation </li></ul><ul><li>Minimal bleeding can obscure operative field </li></ul><ul><li>Long operative time </li></ul><ul><li>Multiple scars in case of conversion or reoperation for completion thyroidectomy </li></ul>
  7. 7. II- Video-assisted thyroid surgery <ul><li>1.5 cm anterior incision </li></ul><ul><li>A 12 mm trocar is placed. Gas insufflation is used to help developing the space. </li></ul><ul><li>The trocar is then removed and the rest of the procedure is performed with the space maintained using external retractors. </li></ul><ul><li>A 5mm endoscope is placed through the incision </li></ul><ul><li>Laparoscopic and conventional instruments are used for the dissection. </li></ul>Miccoli et al
  8. 8. Video-assisted thyroid surgery Main Access
  9. 9. Advantages <ul><li>Shorter operative time </li></ul><ul><li>Small incision </li></ul><ul><li>Prevents subcutaneous emphysema </li></ul><ul><li>Good lighting and magnification </li></ul>
  10. 10. Disadvantages <ul><li>Small working space </li></ul><ul><li>Minimal bleeding can obscure operative field </li></ul><ul><li>Placement of the endoscope in addition to the instruments can be cumbersome </li></ul><ul><li>Requires a second assistant </li></ul>
  11. 11. III-Mini-thyroidectomy <ul><li>A 2.5 to 3cm incision is performed approximately 3 to 4 cm above the sternal notch </li></ul><ul><li>Superior and inferior subplatysmal flaps are created </li></ul>
  12. 14. Mini-thyroidectomy <ul><li>The superior pole vessels are approached first </li></ul>
  13. 16. Mini-thyroidectomy <ul><li>The thyroid gland is delivered through the incision </li></ul><ul><li>The recurrent laryngeal nerve is identified </li></ul><ul><li>The inferior pole vessels are divided </li></ul>
  14. 20. Patients <ul><li>March 1997 to December 1999 </li></ul><ul><li>89 thyroid surgeries on 84 patients </li></ul><ul><li>13 men and 71 women </li></ul><ul><li>Age 18 to 95 </li></ul><ul><li>61 thyroid masses and 23 goiters </li></ul><ul><li>Procedures: 4 nodulectomies, 54 thyroidectomies, 3 near total and 28 total thyroidectomies </li></ul>
  15. 21. Results <ul><li>Pathology: 33 follicular adenomas, 17 papillary carcinomas, 15 multinodular goiters, 7 colloid nodules, 7 Hashimotos, 4 nodular hyperplasia, 2 mixed papillary-follicular carcinomas, 1 follicular carcinoma and 1 lymphoma </li></ul><ul><li>Completion thyroidectomy: 5 patients (all through the same incision) </li></ul><ul><li>Specimen weight: 14 to 421 gm (44.2gm) </li></ul>
  16. 22. Results <ul><li>OR time: 35 to 164 min (mean 76 min) </li></ul><ul><li>Hospital stay: Few hours to 2 days (mean 1 day) </li></ul><ul><ul><li>few hours post op: 5 patients </li></ul></ul><ul><ul><li>< 23 hours post op: 79 patients </li></ul></ul><ul><ul><li>second day post op: 5 patients </li></ul></ul><ul><li>Complications: 1 cardiac arrhythmia and 1 transient hypocalcemia </li></ul>
  17. 23. Results <ul><li>Incision length: 2.5 to 10 cm (4.2) </li></ul><ul><ul><li>2-3 cm: 25 patients (28%) </li></ul></ul><ul><ul><li>3-4 cm: 56 patients (63%) </li></ul></ul><ul><ul><li>>4cm: 8 patients (9%) </li></ul></ul>
  18. 24. Advantages <ul><li>Short operative time </li></ul><ul><li>It can be done on an out patient basis </li></ul><ul><li>Excellent postoperative pain control </li></ul><ul><li>It can be attempted on any thyroid pathology </li></ul><ul><li>In the case of “conversion” the incision can be extended as needed </li></ul>
  19. 25. Advantages <ul><li>Completion thyroidectomy, when required, can be performed through the same incision </li></ul><ul><li>The procedure can be performed under local anesthesia </li></ul><ul><li>It has no complications related to neck insufflation </li></ul><ul><li>It has an excellent cosmetic result </li></ul>
  20. 26. 45 year old patient after right thyroid lobectomy
  21. 28. Conclusions <ul><li>Mini-thyroidectomy is feasible and safe </li></ul><ul><li>It has excellent cosmetic results </li></ul><ul><li>It can be applied to all patients regardless of thyroid pathology or size </li></ul>
  22. 29. Conclusions <ul><li>Mini-thyroidectomy (along with video assisted thyroidectomy) compared to totally endoscopic thyroid surgery, have shorter operative times, shorter hospital stays, comparable cosmetic results without complications related to neck insufflation </li></ul>
  23. 30. Conclusions <ul><li>The greatest advantage to mini-thyroidectomy is that it requires no additional technical expertise, and is therefore easier to teach and reproduce </li></ul>