Objective: To verify the effectiveness and cosmetic results of thyroidectomy through a lateral supraclavicular incision. Yan HC, Xiang C, Wang Y, Wang P. Scarless endoscopic thyroidectomy (SET) lateral neck dissection for papillary thyroid carcinoma through breast approach: 10 years of experience. volume20, Articlenumber:9 (2022) It provides a good alternative beyond . Thyroidectomy without Ligatures in Differentiated Thyroid Cancer You might notice bruising around your incision or upper chest and slight swelling above the scar when you are upright. The PSSs were 1 (very satisfied), 2 (satisfied), 3 (unsatisfied), or 4 (very unsatisfied) [13]. The midline fascia was divided and strap muscles separated from the thyroid gland. Lobe TE, Wright SK, Irish MS. OMIT is an open thyroidectomy performed through a short 'collar' incision and does not necessitate special equipment although two assistants are desirable. Thyroid cancer is an increasingly prevalent malignancy worldwide [1]. Your incision will be located on the front of your neck. PDF Creative Commons License [CC BY-NC-ND 4.0] 2022 The Author(s PubMed The 27-year . Because much of the earlier thyroid surgery was done for malignancy, descriptions emerged regarding the appropriate way to accomplish a thyroidectomy combined with a neck dissection. The total mean operative time was 141.6 34.4 min (range 95240 min, from anesthetic intubation to leaving the operating room and entering the postanesthetic care unit (PACU)). If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Gasless, endoscopic trans-axillary thyroid surgery is a feasible procedure with acceptable safety and better cosmetic results in strictly selected patients. B, C The recurrent laryngeal nerve (RLN) was identified and then traced. Mechanical retractors and incision selection. 2021;35(7):3540-3546. https://doi.org/10.1007/s00464-020-07814-y. Perhaps the most important element in optimizing access while maintaining good cosmesis is choosing the proper location for an incision. The operation generally lasts from 2-3 hours. The Procedure of Traditional Low Collar Incision Thyroidectomy The patient was placed in the supine position neck hyperextension. Thyroid. The typical recommendations for pre-operative testing include: In addition, patients may require additional tests in certain situations to help plan the operation. Another variation of the minimally invasive thyroidectomy is the minimally invasive video-assisted thyroid surgery (MIVAT). VRSs were relatively high at the 1-week and 1-month visits and were significantly decreased at the 3rd-month visit. There is no clear definition of what minimally invasive means, and surgical incisions as large as 6 cm. Due to this rare risk of bleeding, patients are observed for 4 hours by our highly trained recovery room staff. Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, et al. During the procedure: Goiters are noncancerous enlargement of the thyroid gland. Rarely, a patient may have temporary changes in the voice such as fluctuations in volume and clarity (hoarseness). 14,17,18 Indications for OMIT are defined as thyroid volume >30ml but <70-80ml and a dominant nodule . This helps to ensure proper wound healing in the postoperative period. Thus, the outcome of substernal goiter surgery is usually good. It has been pointed out by Kang et al. It is not common to need these additional tests, but they may include: Fiberoptic laryngoscopy: This test allows the surgeon to look at how well the vocal cords are moving by passing a thin flexible camera through the nose into the airway. The patient may then be placed on thyroid hormone pills. In about 5% of patients who have thyroid surgery, the parathyroid glands do not function properly immediately after thyroid surgery. The first lymph nodes to be involved are generally the paratracheal lymph nodes. Acceptable wound cosmetology has . Minimally Invasive Thyroid Surgery The typical incision made for thyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collar bone. A number of important principles are worth considering when planning a thyroidectomy or parathyroidectomy, and these transcend the specific procedure that is anticipated. Incision: A transverse collar incision is usually made 1-2 fingerbreaths above the sternum along the skin crease. In the hands of Columbia Thyroid Center surgeons, the risk of having a temporarily low blood calcium level is about 5% and the risk of having a permanently low blood calcium level is less than 1%. Both lobes of the thyroid were noted to be enlarged. These symptoms appear between 24 and 48 hours after surgery. Acceptable wound cosmetology has become a focus for thyroid surgeons. 2017;274:495500. This approach accesses the thyroid through an incision inside the mouth. Closure of skin incision after thyroidectomy through a supraclavicular Most thyroid nodules are small, and performing a full collar incision is not necessary to provide needed surgical exposure to safely remove the thyroid lobe. [] Thyroidectomy : What percentage of the human body is water? Berber E, Bernet V, Fahey TJ 3rd, Kebebew E, Shaha A, Stack BC Jr, et al. For images of a functional neck dissection, see following images. Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis. While the conventional collar incision is widely used, endoscopic thyroidectomy is gradually becoming accepted for thyroid nodule patients with cosmetic needs [2,3,4]. Rarely, nerve injury to the arm can occur, resulting in impaired arm and/or hand function. A P value < 0.05 was considered as statistically significant. Our results revealed the complications rate was relatively low and acceptable (Table 2). Figure 42-6 The optimal position in which to mark the anticipated thyroid incision is with the patient seated upright in the holding area. 2.5cm . Compared with conventional open surgery, gasless endoscopic trans-axillary thyroid surgery requires the dissection of the anterior neck area and splitting the SCM, which has been described in the endoscopic lateral neck dissection [15]; however, the stiffness and paraesthesia of the SCM have not been evaluated. Indications for this procedure include unilateral goiter and unilateral benign thyroid nodules. Typically, patients will be given prescriptions for the following medications after the operation: Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. The neck appearance score (also known as the patient satisfaction score, PSSs) was applied to investigate the cosmetic effects. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al. Popular incisions included the Lahey incision (Figure 42-1. Article This nonobese gentleman who has a 26-inch neck circumference and a large goiter would not be a candidate for any minimally invasive approach. The recurrent laryngeal nerves were clearly identified and preserved in all cases. Thyroidectomy Guide: Causes, Symptoms and Treatment Options - Drugs.com It is in this position that patients will be in public situations such as dinner parties and cocktail receptions, and it is in this position the suprasternal notch (the depression created by the medial heads of the sternocleidomastoid muscle) can best be seen. Endoscopic thyroidectomy. It is usually removed in 1-2 days. Parathyroidectomy For persons with pre-existing shoulder abnormalities, these could be exacerbated by surgery. In addition to the complications of standard thyroid surgeries listed below, there are several complications specific to this operation. A number of technological advances such as advanced energy devices for hemostasis,1 high-resolution endoscopes for improved visualization,2 and laryngeal nerve monitoring3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions.4 Also emerging are techniques for remote access thyroid and parathyroid surgery.5,6 Conventional surgery remains necessary in many circumstances, such as for large substernal goiters or advanced malignancy, and will remain in the endocrine surgeons armamentarium. The neck was entered through a collar incision, and bleeding was controlled with electrocautery. Other risks of thyroid surgery include wound infections and seromas. A The retractors were used to maintain the working space during the operation. The recurrent laryngeal nerve provides nerve input to the vocal cords, and is also intimately involved with the thyroid gland. If the mass is deep inside the chest, the surgeon makes an incision along the middle of the chest bone. The surgeon makes a cut (incision) in the lower part of the neck just above the collar bone to determine if the mass can be removed without opening the chest. Patients should discuss with their doctors when and if they should restart these medications. In the last decade, we have performed this approach on more than 500 patients and found that patients who undergo this surgery have better cosmetic results compared with the . The standard incision is best placed above this suprasternal notch. Surg Endosc. Conventional thyroidectomy In a conventional thyroidectomy, a 3- to 4-inch incision will be made through the skin in the low collar area of your neck (the lower front portion of your neck, above the collarbones and breast bone). A, An extended low cervical collar incision is used when a lateral neck dissection is indicated. Part of Medical records were reviewed retrospectively. This study was approved by the Institutional Ethics Committee of Xiangya Hospital, Central South University (No.202011960). Poor cosmetic result from scarring of the neck or axillary incision may occur and require secondary scar management. Thyroidectomy Basics | Epomedicine Jiang WJ, Yan PJ, Zhao CL, Si MB, Tian W, Zhang YJ, et al. https://emedicine.medscape.com/article/2051665-overview. The optimal position in which to mark the anticipated thyroid incision is with the patient seated upright in the holding area. Many companies make these suits, and they're washable and reusable. 0 The median hospital stay was 1.67 0.74 (range 13) days. Endocr J. The exceptions are blood thinners, aspirin, Plavix, and anti-thyroid medications like PTU and Methimazole. The VRSs in a short time (1 week) were significantly higher in the first 25 cases than in the last 25 cases (the patient whose operation was converted to open surgery was excluded). In this study, we reported our initial experiences with 51 patients who underwent gasless endoscopic trans-axillary thyroid surgery performed by a single experienced surgeon. As the working space is crucial to the surgery, we have summarized this process in three standard steps. It is noteworthy that there is another obvious disadvantage of this technique. All rights reserved. Thyroidectomy is the main surgical treatment for thyroid cancer and is a treatment option for certain thyroid conditions, including: In this operation, an incision is made in the axilla (armpit) and dissection is carried superiorly across the collar bone into the neck. (PDF) Incision Length for Standard Thyroidectomy and - ResearchGate J Laparoendosc Adv Surg Tech A. Although the numbers of identified parathyroid glands have not been calculated, we considered that the recognition and protection of the parathyroid gland would get improvement with the growing experience. 79 0 obj <>stream Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Surg Today. 82073262) and the Hunan Province Natural Science Foundation (grant number 2021JJ41033 and 2019JJ40475). The inclusion criteria were as follows: (1) patients with thyroid nodules diagnosed as papillary thyroid cancer (PTC) by ultrasound-guided fine needle aspiration (FNA) before surgerylobectomy (LT) with prophylactic unilateral (ipsilateral) central neck dissection (CND) was performed for these patients; (2) PTC patients with central lymph nodes that were evaluated as negative by two individual professional ultrasound physicians; and (3) patients with benign unilateral nodules with diameters > 4 cm that needed surgical intervention. Classically 8-12 cm (3-5 inch) incisions were performed. 2013;9:11621. Please see the Expert Consult website for more discussion of this topic, including Figures 42-2, 42-3, 42-4, and 42-5. Only two patients developed temporary vocal cord paralysis and no patients developed other severe complications. Kang JB, Kim EY, Park YL, Park CH, Yun JS. Feeling that something is stuck in the throat. In the past decade, advancements in A c c e p t e d . Only gold members can continue reading. When the goiter is caused by a noncancerous. The complications, including hypoparathyroidism, tracheal injury, esophageal injury, or surgical site infection did not occur. As the scar heals, it will appear to be part of the crease and thus camouflage it. (A and B, Redrawn from Lore JM, Medina JE, editors: Atlas of head and neck surgery, Philadelphia, 2005, Elsevier-Saunders.). 2021;19:23. Surgery of the Thyroid Gland | UC Irvine Medical Center Muenscher A, Dalchow C, Kutta H, Knecht R. The endoscopic approach to the neck: a review of the literature, and overview of the various techniques. Sensory changes around the anterior chest and paralysis of the sternocleidomastoid muscle were evaluated by VRSs. A This case has been converted to open surgery. Retractor was placed beneath the strap muscles to finish creating the working space (Fig. Because these structures are intimately associated with the thyroid gland, your calcium levels may be affected either temporarily or permanently after thyroid surgery. See our Scar Gallery section for examples of minimally invasive thyroid surgery. World J Surg Oncol. Nine patients had solitary or cystic thyroid adenoma, and thus, lobectomy was performed. 4 Technologic This chapter contains additional online-only content, available on expertconsult.com. In certain cases, the surgeon may choose to perform a near-total thyroidectomy in which a small piece of thyroid tissue is left behind usually in the area of the parathyroid glands and recurrent laryngeal nerve in order to avoid damaging these structures. This approach uses smaller incisions in the neck. Written informed consent for publication of their clinical details and clinical images was obtained from all patients. Huang Z, Qin H, Liao J, Meng L, Qin Y, Li B, et al. Surgery. Popular incisions included the Lahey incision (Figure 42-1, A), the MacFee incision (Figure 42-1, B), and eventually a hockey stick type of incision (Figure 42-1, C).8 This last approach developed with recognition of the dangers of a trifurcated incision in which the tips of the trifurcation were prone to ischemia and devitalization, sometimes putting the great vessels of the neck at risk. In our study, only two cases had temporary vocal cord paralysis. Endoscopic hemithyroidectomy with prophylactic ipsilateral central neck dissection via an unilateral axillo-breast approach without gas insufflation for unilateral micropapillary thyroid carcinoma: preliminary report. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Jules Boeckel of Strasbourg introduced the collar incision to thyroid. The hockey-stick incision (C) avoids trifurcations and provides plentiful exposure for a comprehensive neck dissection. 2009;56:3619. After the seventh day, reduce the calcium to one Tums Ultra 1000 tablet three times a day until your follow-up appointment. Nabhan F, Ringel MD. Moreover, the patients arm is raised during the entire operation time which might cause pain in the axilla [20, 21]. Temporarily lowered calcium levels occur in approximately 15-40% of patients, and is treatable with calcium and vitamin D supplementation post-operatively. Surg Endosc. A number of technological advances such as advanced energy devices for hemostasis, 1 high-resolution endoscopes for improved visualization, 2 and laryngeal nerve monitoring 3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions. In conclusion, these results revealed that gasless, endoscopic trans-axillary thyroidectomy is a feasible surgery type with an acceptable safety profile and cosmetic outcomes in strictly selected patients. Substernal Goiter Surgery. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 82073262) and the Hunan Province Natural Science Foundation (grant number 2019JJ40475). If you are dealing with a thyroid issue, our team at the Columbia Thyroid Center is here to help. It is important to note that numbness and tingling may be caused by something other than a parathyroid problem. E, F Step three, the strap muscles were dissected laterally and the retractor was placed beneath the straps muscle to expose the thyroid lobe. They will be monitored closely as they need to recover from the anesthesia. Our study suggested that the lateral supraclavicular incision is a safe and practical approach for thyroidectomy. It provides satisfactory cosmetic outcomes compared with conventional transcervical incision. Incisions as small as 1 inch (2.5 cm) can be performed for patients with favorable neck anatomy and small tumors. If one of these nerves is injured, the voice may become hoarse. Chen GZ, Zhang X, Shi WL, Zhuang ZR, Chen X, Han H. Systematic comparison of cervical and extra-cervical surgical approaches for endoscopic thyroidectomy. 2017;24:R1326. Johri G, Chand G, Mishra A, Mayilvaganan S, Agarwal G, Agarwal A, et al. Surgery is the most commonly used technique in treating thyroid diseases. Cite this article. During the 1850s, operations on the thyroid gland were undertaken via longitudinal, oblique, or vertical neck incisions. World J Surg. Transaxillary robotic thyroid lobectomy and transaxillary robotic thyroidectomy were developed in Korea, and over the last several years has been utilized by a small but growing number of surgeons. 2016;23:40238. The dissected area is marked in blue, The procedure of thyroidectomy and central neck dissection (CND). The contribution of the incision to the cosmetic outcome does not end with the making of the incision itself. The exclusion criteria were as follows: (1) patients with benign nodules with diameters > 6 cm, (2) patients who needed a total thyroidectomy, and (3) patients for whom endoscopic surgery was not suitable due to past medical history of cervical and chest wall surgeries or other reasons. A 5-6 cm transverse collar skin incision was made into the midline of the anterior neck 2 cm above the sternal notch. If there is no sign of bleeding and the patient feels well, he or she may go home. The following possible complications are directly related to the operative experience of the surgeon, and these statistics are based on our own results here at Columbia: As with any operation, there is always a chance of bleeding. The length of the incision will vary depending on the thickness of the neck and the size of the gland or nodule, although it should be noted that virtually always the benign gland or nodule can be bigger than the incision itself, as these structures are compressible and can be manipulated through an incision smaller than the gland. There are two nerves called the recurrent laryngeal nerves that run just behind the thyroid. In the absence of contraindications, substernal goiter should be treated with early surgery rather than having it run the risk of acute airway distress, especially in younger patients.