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Minimally Invasive Surgery of the Thyroid Treatment & Management

  • Author: Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jul 31, 2015
 

Surgical Therapy

Minimally invasive open thyroidectomy (MIT) is similar to conventional thyroidectomy in its surgical approach. The major difference is the length of the neck incision. A smaller incision improves cosmesis and reduces discomfort. Typically, a skin incision less than 6 cm is considered minimally invasive. The remainder of the procedure is exactly the same as is used in conventional thyroidectomy. Adaptations to this technique include transection rather than lateral retraction of the strap muscles (the Sofferman technique).[1]

Minimally invasive video-assisted thyroidectomy (MIVAT) typically involves a skin incision no greater than 3 cm that is placed slightly higher than the conventional thyroidectomy incision. Open dissection is carried out until the superior thyroid pole is encountered, after which the endoscopic video-assisted techniques are used.

Totally endoscopic techniques that include an axillary approach and the use of gas insufflation have been described, but these have not gained widespread use. Recent evidence suggests that the use of robotic technology may enhance the effectiveness of endoscopic techniques; however, these data are very preliminary.[13]

Videos of minimally invasive thyroidectomy for papillary carcinoma are included below.

Minimally invasive thyroidectomy; identification of the recurrent laryngeal nerve.
Minimally invasive thyroidectomy closure.
Minimally invasive thyroidectomy; division of isthmus and delivery.
Minimally invasive thyroidectomy; incision and exposure.
Minimally invasive thyroidectomy; initial dissection.
Minimally invasive thyroidectomy; superior pole release.
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Preoperative Details

First and foremost, the patient should meet the criteria for candidacy for MIVAT approach.

Preoperative laboratory studies should include baseline serum electrolyte levels, CBC count, coagulation panel, and pregnancy testing, if applicable.

A chest radiograph and electrocardiography should be performed as necessary.

When obtaining consent for MIVAT surgery, the possible need to convert to open, conventional thyroidectomy should always be discussed with the patient.

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Intraoperative Details

The standard thyroidectomy or neck dissection set up is supplemented with a set of Miccoli instruments specially designed for MIVAT (see the first image below). A 5-mm, 29-cm long, 30° endoscope is ideal for endoscopic visualization. Harmonic scalpel scissors (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) are then used to ligate and divide the blood vessels (see the second image below).

Miccoli instrument set designed for MIVAT. Miccoli instrument set designed for MIVAT.
Endoscope and harmonic scalpel. Endoscope and harmonic scalpel.

The patient is placed in the supine position with slight neck extension (see the first image below). The neck is then prepared and draped with sterile technique. A horizontal incision is placed parallel to relaxed skin tension lines that are 3 cm or less in length (see second and third images below). The incision is placed between the sternal notch and cricoid cartilage, usually less than 1 cm inferior to the cricoid.[10]

Patient position. Note the limited neck extension Patient position. Note the limited neck extension as compared with conventional thyroidectomy.
Incision location. Incision location.
MIVAT incision length. MIVAT incision length.

Cautery is used to dissect the subcutaneous tissues until the midline raphe of the strap muscles is identified. The raphe is separated superiorly and inferiorly for a distance of about 3 cm. Anterior jugular veins can be preserved in most cases. Gentle and blunt dissection with peanuts is used to separate straps from the thyroid gland and displace them laterally. The middle thyroid vein or other vessels that are encountered at this time are clipped and divided.

Miccoli retractors are used to retract the strap muscles and soft tissues and expose the superior lobe and vascular bundle. At this point, a 30°, 5-7 mm rigid endoscope is introduced into the field to visualize the superior pole (see the image below). Three persons are required for the procedure at this point: a surgeon, a retractor, and an endoscopist.

Video-assisted dissection of the right superior po Video-assisted dissection of the right superior pole.

The surgeon uses Miccoli spatula-shaped dissectors and aspirator dissectors to dissect the superior pole vascular bundle. Care is taken to identify and preserve the external branch of superior laryngeal nerve, which is identified medial to the superior vascular pedicle. The thyroid lobe is then retracted medially and endoscopic dissection is carried further to dissect the lateral and posterior attachments. The recurrent laryngeal nerve (RLN) is identified and preserved during this step, along with the parathyroid glands (see the image below).

Identification of the recurrent laryngeal nerve du Identification of the recurrent laryngeal nerve during video-assisted right thyroid lobectomy. A parathyroid gland is also identified.

Once the lobe has been sufficiently mobilized, an atraumatic clamp can be used to externalize the lobe from the incision, and the remainder of the dissection can be carried out under direct vision. The isthmus is divided, and the lobectomy is complete. Total thyroidectomy is performed by repeating the same procedure contralaterally.

The wound is irrigated and complete hemostasis is ensured. The strap muscles are reapproximated. The skin is closed in layers with absorbable sutures and skin sealant. No external drainage is required.

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Postoperative Details

Postoperatively, the patient should be given analgesics, antiemetics, and postoperative antibiotic prophylaxis. Any preoperative thyroid hormone supplementation should be continued.

A prospective, double-blind, randomized trial by Hong et al found repeated administration of acetaminophen 1 g IV over the initial 24 hours following thyroidectomy was easy, effective, safe, and well tolerated for pain management in patients with moderate-to-severe postoperative pain. The IV route for acetaminophen is currently investigational in the United States.[14]

For total thyroidectomy, ionized calcium and albumin levels should be checked in the recovery room and every 6-8 hours thereafter. Typically, hypocalcemia is defined as a corrected serum calcium level below 8.0 mg/dL. Early signs of hypocalcemia include perioral numbness or paresthesia and the Chvostek sign (facial spasm upon percussion of the facial nerve). Calcium supplementation may be required in some cases.

Some groups consider patients who undergo MIVAT lobectomy for same-day discharge with close follow-up.

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Follow-up

The patient is seen in the office 1-2 weeks postoperatively (see the first image below), and again 6 weeks later (see the second image below). The wound healing should be assessed, and any pathology results and further treatment plans should be discussed. If the patient experiences hoarseness or shortness of breath, vocal fold movement should be assessed.

Surgical scar at 2 weeks. Surgical scar at 2 weeks.
Surgical scar at 6 weeks. Surgical scar at 6 weeks.
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Complications

Complications from minimally invasive video-assisted thyroidectomy (MIVAT) are the same as with conventional thyroidectomy and occur at a similar rate. However, one study suggests surgical site infections are significantly less with the endoscopic technique.[15] Complications include the following:

  • Bleeding or hematoma
  • Wound infection
  • Transient or permanent recurrent laryngeal nerve (RLN) injury
  • Transient or permanent external branch of the superior laryngeal nerve (EBSLN) injury
  • Hypocalcemia
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Outcome and Prognosis

Cosmetic outcome is much better (see the images below) than that of conventional thyroidectomy. Some series have shown less postoperative pain and discomfort after minimally invasive video-assisted thyroidectomy (MIVAT) than with conventional thyroidectomy.[16] The MIVAT approach has also resulted in shorter hospital stays.[11] In groups with the most experience performing MIVAT, operative time is equivalent to that of conventional thyroidectomy, but a learning curve certainly exists.

Surgical scar at 2 weeks. Surgical scar at 2 weeks.
Surgical scar at 6 weeks. Surgical scar at 6 weeks.

For early papillary thyroid carcinoma (PTC), the oncologic adequacy of MIVAT is comparable with that of conventional thyroidectomy.

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Future and Controversies

Around 15-20% of thyroid nodules that require surgery fit within the size criteria for minimally invasive video-assisted thyroidectomy (MIVAT). MIVAT surgery will likely gain an increasing role in this subsection of thyroid nodules.

Because MIVAT surgery is still relatively new, the following controversies exist:

Size criteria

Most groups advocate for a nodule diameter that is less than 30 mm and a thyroid volume below 30 mL. Some authors have shown that they can safely operate on a nodule size up to 40 mm in diameter and a thyroid volume approaching 50 mL.

Eligibility

Patients with a history of thyroiditis are still excluded from candidacy for MIVAT by certain groups. Some groups now include patients with Graves disease who meet size criteria, and also patients who require prophylactic thyroidectomy for RET germline mutation with normal calcitonin levels and no evidence of medullary thyroid carcinoma (MTC).

Oncologic adequacy

Excessive manipulation of the thyroid and removal of the specimen through a small incision may increase the risk of thyroid capsule rupture and the possible spillage of malignant cells. This has been disproved in at least one study.[6] The adequacy of MIVAT for resection of small, low-grade parathyroid carcinoma (PTC) is also considered controversial.

External drainage

MIVAT is usually performed without external drainage. Most conventional thyroidectomy is performed with external drainage.

Outpatient surgery

The safety of MIVAT as a same-day procedure is still being studied.

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Contributor Information and Disclosures
Author

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS Clinical Assistant Professor, Department of Otolaryngology, Tufts University School of Medicine; Partner and Director, ENT Specialists, Inc

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Massachusetts Medical Society, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Tejas Raval, MD Resident Physician, Department of Otolaryngology, Tufts-New England Medical Center

Tejas Raval, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

References
  1. Terris DJ, Bonnett A, Gourin CG, Chin E. Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope. 2005 Jun. 115(6):1104-8. [Medline].

  2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006 Feb. 16(2):109-42. [Medline].

  3. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2006 Jan-Feb. 12(1):63-102. [Medline].

  4. Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005 Jan-Feb. 55(1):10-30. [Medline].

  5. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005 Dec. 237(3):794-800. [Medline].

  6. Lombardi CP, Raffaelli M, Princi P, Lulli P, Rossi ED, Fadda G, et al. Safety of video-assisted thyroidectomy versus conventional surgery. Head Neck. 2005 Jan. 27(1):58-64. [Medline].

  7. Pisanu A, Podda M, Reccia I, Porceddu G, Uccheddu A. Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT). Langenbecks Arch Surg. 2013 Oct 27. [Medline].

  8. Gao W, Liu L, Ye G, Song L. Application of Minimally Invasive Video-assisted Technique in Papillary Thyroid Microcarcinoma. Surg Laparosc Endosc Percutan Tech. 2013 Oct. 23(5):468-73. [Medline].

  9. De Napoli L, Spinelli C, Ambrosini CE, Tomisti L, Giani C, Miccoli P. Minimally Invasive Video-Assisted Thyroidectomy versus Conventional Thyroidectomy in Pediatric Patients. Eur J Pediatr Surg. 2013 Sep 2. [Medline].

  10. Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R. Video-assisted thyroidectomy: report on the experience of a single center in more than four hundred cases. World J Surg. 2006 May. 30(5):794-800; discussion 801. [Medline].

  11. Ruggieri M, Straniero A, Genderini M, D'Armiento M, Fumarola A, Trimboli P, et al. The size criteria in minimally invasive video-assisted thyroidectomy. BMC Surg. 2007 Jan 25. 7:2. [Medline].

  12. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer; 2002. 77-87. [Full Text].

  13. Lee S, Ryu HR, Park JH, et al. Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg. 2011 Jun. 253(6):1060-6. [Medline].

  14. Hong JY, Kim WO, Chung WY, Yun JS, Kil HK. Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach. World J Surg. 2010 Mar. 34(3):521-6. [Medline]. [Full Text].

  15. Dionigi G, Boni L, Rovera F, Rausei S, Dionigi R. Wound morbidity in mini-invasive thyroidectomy. Surg Endosc. 2011 Jan. 25(1):62-7. [Medline].

  16. Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery. 2001 Dec. 130(6):1039-43. [Medline].

 
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Miccoli instrument set designed for MIVAT.
Endoscope and harmonic scalpel.
Patient position. Note the limited neck extension as compared with conventional thyroidectomy.
Incision location.
MIVAT incision length.
Video-assisted dissection of the right superior pole.
Identification of the recurrent laryngeal nerve during video-assisted right thyroid lobectomy. A parathyroid gland is also identified.
Surgical scar at 2 weeks.
Surgical scar at 6 weeks.
Minimally invasive thyroidectomy; identification of the recurrent laryngeal nerve.
Minimally invasive thyroidectomy closure.
Minimally invasive thyroidectomy; division of isthmus and delivery.
Minimally invasive thyroidectomy; incision and exposure.
Minimally invasive thyroidectomy; initial dissection.
Minimally invasive thyroidectomy; superior pole release.
 
 
 
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