Thyroid Surgery by Mini-incision


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Thyroid Surgery by Mini-incision

  1. 1. Thyroid surgery by mini-incision Rosemary Hardin MD, Joelle Pierre MD, and George Ferzli MD, FACS SUNY Downstate Medical Center Lutheran Medical Center
  2. 2. <ul><li>A review of our method of thyroid </li></ul><ul><li>surgery via mini-incision, first </li></ul><ul><li>published in JACS (Journal of the </li></ul><ul><li>American College of Surgeons, May </li></ul><ul><li>2001). </li></ul>G Ferzli, P Sayad, Z Abdo, R Cacchione Minimally invasive, non-endoscopic thyroid surgery. J Am Coll Surg May 2001: 192 (5) 665-668
  3. 3. <ul><li>An incision is made along a </li></ul><ul><li>skin crease high up in the neck. </li></ul>Superior and inferior subplatysmal flaps are developed.
  4. 6. <ul><li>The superior pole vessels are </li></ul><ul><li>approached first, from a medial </li></ul><ul><li>to lateral direction, staying close </li></ul><ul><li>to the capsule to avoid the </li></ul><ul><li>external branch of the superior </li></ul><ul><li>laryngeal nerve </li></ul><ul><li>(*Amelita Galli-Curci*, </li></ul><ul><li>Julie Andrews?) </li></ul>* Injury to the Superior Laryngeal Branch of the Vagus During Thyroidectomy: Lesson or Myth? Peter F. Crookes, MD, FACS and James A. Recabaren, MD, FACS From the Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
  5. 8. Delivery through the wound, of the upper pole of the thyroid with medial rotation, will allow a view of the laryngotracheal junction.
  6. 9. Rt. recurrent laryngeal nerve Tubercle of Zuckerkandl Rt. upper parathyroid gland At the laryngotracheal junction, identify the following structures:
  7. 11. <ul><li>Middle thyroid vein </li></ul><ul><li>ligated and divided </li></ul>
  8. 12. The inferior pole vessels are divided If total thyroidectomy, repeat steps on left side Free trachea from thyroid by dividing ligament of Berry Ligament of Berry
  9. 13. Thyroid gland is delivered easily through the wound
  10. 15. PATIENTS <ul><li>264 thyroid surgeries on 256 patients </li></ul><ul><li>55 men and 201 women </li></ul><ul><li>Age – 17 to 95 years (48) </li></ul>
  11. 16. PREOP DIAGNOSIS <ul><li>Mass or nodule = 176 </li></ul><ul><li>Goiter = 74 </li></ul><ul><li>Hyperthyroiditis = 6 </li></ul>
  12. 17. <ul><li>Type of procedures: </li></ul><ul><ul><li>5 nodulectomies </li></ul></ul><ul><ul><li>78 R lobectomies </li></ul></ul><ul><ul><li>65 L lobectomies </li></ul></ul><ul><ul><li>30 near total </li></ul></ul><ul><ul><li>86 total thyroidectomies </li></ul></ul><ul><li>Lymph node dissection </li></ul><ul><ul><li>6 patients </li></ul></ul><ul><li>Length of incision: </li></ul><ul><ul><li>2 cm. = 52 </li></ul></ul><ul><ul><li>2.5 cm. = 32 </li></ul></ul><ul><ul><li>3 cm. = 68 </li></ul></ul><ul><ul><li>4 cm. = 98 </li></ul></ul><ul><ul><li>> 4 cm. = 14 </li></ul></ul>Total 264 Of the 256 patients, 8 who initially underwent unilateral thyroid lobectomy subsequently required resection of the contralateral lobe (completion thyroidectomy using the same incision)
  13. 18. <ul><li>OR TIME </li></ul><ul><li>27’ – 164’ (48.59’) </li></ul><ul><li>(dropped from an average of 76’ in </li></ul><ul><li>2001 in the first 89 patients) </li></ul><ul><li>HOSPITAL STAY </li></ul><ul><li>Outpatient = 26 patients </li></ul><ul><li>23 hours = 210 patients </li></ul><ul><li>Two days = 18 patients </li></ul><ul><li>> Two days = 2 patients </li></ul>
  14. 19. COMPLICATIONS <ul><li>Arrhythmia = 1 patient </li></ul><ul><li>Hematoma (reop) = 1 patient </li></ul><ul><li>(R thyroid) </li></ul><ul><li>Open wound (near total) = 1 patient </li></ul><ul><li>Inadvertent </li></ul><ul><li>parathyroidectomy = 3 patients </li></ul><ul><li>Hypocalcemia = 3 patients </li></ul><ul><li>(2 requiring readmission) </li></ul><ul><li>Nerve injury </li></ul><ul><ul><li>Recurrent laryngeal = 3 (2 transient, 1 permanent) </li></ul></ul>
  15. 20. POST OPERATIVE PATHOLOGY <ul><li>WEIGHT 4–530 gm. (50.05) </li></ul><ul><li>PATHOLOGIES </li></ul><ul><li>Follicular adenomas 68 </li></ul><ul><li>Papillary carcinomas 53 </li></ul><ul><li>Multinodular goiters 38 </li></ul><ul><li>Colloid nodules 11 </li></ul><ul><li>Hashimoto’s thyroiditis 25 </li></ul><ul><li>Mixed papillary-follicular carcinomas 4 </li></ul><ul><li>Follicular carcinoma 10 </li></ul><ul><li>Lymphoma 1 </li></ul><ul><li>Grave’s disease 2 </li></ul><ul><li>Medullary carcinoma 2 </li></ul><ul><li>Chronic lymphocytic thyroiditis 2 </li></ul><ul><li>Hurtle cell cancer 6 </li></ul><ul><li>Nodular hyperplasia 34 </li></ul><ul><li>TOTAL 256 </li></ul>
  16. 21. CONCLUSION <ul><li>Thyroid surgery using mini-incision is </li></ul><ul><li>feasible and safe </li></ul><ul><li>Done on an out-patient basis </li></ul><ul><li>Can be attempted on any thyroid pathology </li></ul><ul><li>Can be performed under local anesthesia </li></ul><ul><li>Compared to endoscopic thyroid surgery, </li></ul><ul><li>it has a shorter operative time, shorter </li></ul><ul><li>hospital stay, comparable cosmetic results </li></ul><ul><li>and no complication related to neck insufflation </li></ul><ul><li>Completion thyroidectomy, when required, can be performed through the same incision </li></ul><ul><li>It has an excellent cosmetic result </li></ul>