Minimally invasive thyroid surgery by A. Shaha
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Minimally invasive thyroid surgery by A. Shaha
- 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012 Minimally-Invasive Thyroid Surgery Ashok R. Shaha
- 2. 2012
- 3. Samuel D. Gross - 1866 Philadelphia A System of Surgery Thyroid surgery: โHorrid butcheryโ โNo honest and sensible surgeon would ever engage in thyroid surgeryโ 2012
- 4. 2012
- 5. The extirpation of thyroid gland typifies perhaps better than any operation the supreme triumph of the surgeonโs art. 2012
- 6. Surgical Procedure โขโฏ Anatomically and Biologically Sound โขโฏ Reproducible โขโฏ Least Complications โขโฏ Short Learning Curve โขโฏ Easy to Teach, Learn, and Practice โขโฏ Cost Effective โขโฏ Best Cosmetic and Function Results 2012
- 7. The fact that a new technique is available does not necessarily mean its implementation is appropriate. โ Leigh Delbridge, MD, FRACS 2012
- 8. Endocrine Procedures by U.S. Residents 1993-1994 % Programs Mean Mode With 0 Thyroid 12.6 7-10 0 Parathyroid 5.6 2 1 Adrenal 0.98 0 38 Pancreas 0.15 0 85 2012 Harness et al
- 9. Minimally Invasive Thyroidectomy โขโฏ โPUREโ Endoscopic Approach Completely closed technique with continuous gas insufflation โขโฏNeck Approach โขโฏ Anterior Chest Approach โขโฏ Axillary Approach โขโฏ Breast (Submammary Approach) โขโฏVideo assisted Technique โขโฏVideo assisted Neck Dissection 2012 โขโฏVideo assisted under LA
- 10. Laparoscope Clamp on Insufflation being inserted purse string tube into trocar A 2012
- 11. 2012
- 12. 2012
- 13. Minimally Invasive Thyroidectomy โขโฏ โPUREโ Endoscopic Approach Completely closed technique with continuous gas insufflation โขโฏNeck Approach โขโฏ Anterior Chest Approach โขโฏ Axillary Approach โขโฏ Breast (Submammary Approach) โขโฏVideo assisted Technique โขโฏVideo assisted Neck Dissection 2012 โขโฏVideo assisted under LA
- 14. Endoscopic Surgery Minimally Invasive Surgery Maximally Expensive Surgery 2012
- 15. Minimally Invasive Thyroidectomy โขโฏ Minimally Invasive โOpenโ Surgery โขโฏ Mini-incision โขโฏ Smaller Incision โขโฏ Lateral Incision โขโฏ Harmonic Scalpel โขโฏ Ligasure โขโฏ Local Anesthesia/Regional 2012 โขโฏ 23 Hour Discharge
- 16. In cosmetic terms, the quality of the scar is more important than the actual length 2012
- 17. Minimal incision may cause excessive skin stretching, bruising, forcible retraction, or inadvertent cauterization of the skin edges 2012
- 18. Use of the Electrothermal Vessel Sealing System Versus Standard Vessel Ligation in Thyroidectomy Comparison of Operating Time and Incision Length Standard Ligation LigaSure Operating Time, hr 3.6 +/- 0.1 2.9 +/- 0.1* Lobectomy time, hr 2.7 +/- 0.1 2.2 +/- 0.1* Thyroidectomy time, hr 4.1 +/- 0.1 3.2 +/- 0.1* Incision length, cm 6.2 +/- 0.1 5.7 +/- 0.1* 2012 *p < 0.05 Shen W, Duh QY, et al. Asian Journal of Surgery; Vol 28, 2, April 2005.
- 19. Advantages of Minimally Invasive Thyroid Surgery โขโฏ Smaller Incision โขโฏ Better Cosmesis โขโฏ Less Pain โขโฏ Early Discharge 2012
- 20. Minimally Invasive Thyroid Surgery โขโฏ Majority of thyroid surgery in the U.S. is performed for proven or suspected malignancy โขโฏParatracheal and nodal evaluation are difficult โขโฏ 20% of patients with thyroid cancer have extrathyroidal extension, which requires adequate exposure and excision โขโฏ Ultrasound detecting bilateral thyroid nodules requires total thyroidectomy 2012
- 21. Minimally Invasive Thyroid Surgery โขโฏ First Principle of Surgery: โขโฏ Adequate Exposure โขโฏ Adequate Retraction โขโฏ Adequate Lighting โขโฏ Learning curve โขโฏ Difficult to gain expertise โขโฏ Medicolegalities of minimally invasive thyroid surgery 2012
- 22. Classification Minimally invasive Thyroidectomy Endoscope Robotic Mini incision True endoscopic assisted 1.โฏ Anterior chest Trans-Axillary 2.โฏ Axillary Cervical 3.โฏ Areolar Face-Lift 2012
- 23. Mini Incision โขโฏIkeda โขโฏ3cm incision โขโฏIsthmusotomy โขโฏUse ligasure LS1200 or harmonic scalpel(focus) to divide superior pole vessels โขโฏUse ligasure LS1200 or harmonic scalpel(focus) to divide isthmus 2012 Ikeda et al. Direct mini incision thyroidectomy. Biomed Pharmacother 2002;56:60s-63s
- 26. True Endoscopic 2000 Shimizu subclavicular access 2000 Ikeda axillary access 2000โฏ Ohgami breast access 2001 Gagner supraclavicular access 2007 Chung robotic via axillary access 2012
- 27. Gagner Shimizu CO2 (8 mm Hg) insufflation External retraction (Kirschner) Central incision (5 mm trocar) Lateral incision (SCM border) 3 additional Trocars: mid line mid border SCM 5 cm subclavicular incision sup border SCM 2012
- 28. Ikeda Ohgami 30โฏ mm skin incision in the axilla CO2 insufflation (4 mm Hg) Three incisions: 1 presternal Flexible endoscope 2 periareolar 1 additional trocar near the main incision CO2 insufflation 2012
- 29. Endoscopic Assisted 1999 Miccoli central neck access โขโฏMinimally invasive video assisted thyroidectomy โขโฏSingle 1.5cm incision -midline skin crease โขโฏMIVAT 2012
- 30. MIVAT Minimally Invasive Video-assisted Thyroidectomy INDICATIONS Nodule < 3.5 cm Thyroid volume < 25 ml multinodular follicular Benign disease Toxic adenoma Graves 2012 Malignant disease Low risk Pap Cr RET gene carriers
- 31. MIVAT: Contraindications Large goiters Previous neck surgery Thyroiditis ABSOLUTE Presence of suspicious lymph nodes Local advanced carcinoma ย Previous neck irradiation RELATIVE Gravesโ disease Short neck in obese patients 2012
- 32. MIVAT: 5 steps 1.โฏ Incision and access to the operative space 2.โฏ Section of the upper pedicle 3.โฏ Identification of recurrent laryngeal nerve and parathyroids 4.โฏ Extraction and resection of the lobe 2012 5.โฏ Closure
- 33. MIVAT: Comparison to Traditional Thyroidectomy โขโฏ Cosmesis Smaller scar Miccoli, Surgery 2001. Prospective study comparing MIVAT to traditional MIVAT>traditional using numeric scale, p=0.01 โขโฏ Operation time Similar BUT is learning curve โขโฏ Complication rate Similar โขโฏ Postop course- better based on patient questionnaire score. Miccoli,Surgery 2001. p=0.003 2012
- 34. Da Vinci Robot โขโฏ Two components โขโฏ Surgeon console โขโฏ Surgical arm cart 2012
- 35. Minimally Invasive Thyroid Surgery โขโฏ Majority of thyroid surgery in the U.S. is performed for proven or suspected malignancy โขโฏ Paratracheal and nodal evaluation are difficult โขโฏ 20% of patients with thyroid cancer have extrathyroidal extension, which requires adequate exposure and excision โขโฏ Ultrasound detecting bilateral thyroid nodules requires total thyroidectomy 2012
- 36. Minimally Invasive Thyroid Surgery โขโฏ First Principle of Surgery: โขโฏ Adequate Exposure โขโฏ Adequate Retraction โขโฏ Adequate Lighting โขโฏ Learning curve โขโฏ Difficult to gain expertise โขโฏ Medicolegalities of minimally invasive thyroid surgery 2012
- 37. Classification Minimally invasive Thyroidectomy Endoscope Robotic Mini incision True endoscopic assisted 1.โฏ Anterior chest Trans-Axillary 2.โฏ Axillary Cervical 3.โฏ Areolar Face-Lift 2012
- 38. Da Vinci Robot โขโฏ Surgical arm cart holds โขโฏ 3D camera โขโฏ Instruments (2 or 3 arms) โขโฏ Grasping forceps โขโฏ Scissors โขโฏ bipolar bovie โขโฏ harmonic scalpel 7 degrees of freedom using 2012 an endo-wrist system
- 39. Approach โขโฏ 2 incisions โขโฏ Axillary incision โขโฏ Camera โขโฏ Harmonic scalpel 2012 โขโฏ Dissecting forceps โขโฏ Substernal incision โขโฏ Grasping forceps
- 40. Axillary Incision 2012 โขโฏ6cm axillary incision โขโฏDissect subcutaneous tunnel over pectoralis major muscle
- 41. Exposure of Thyroid Gland 2012
- 42. Position of Camera and Instrument Arms 2012
- 43. Dissection of Thyroid Gland 2012
- 44. Advantages & Disadvantages โขโฏ Avoids a central neck incision โขโฏ Increased magnification of RLN and parathyroids โขโฏ No tremor BUT โขโฏ 6cm axillary incision โขโฏ Significant soft tissue dissection โขโฏ Lose sensory feedback โขโฏ Long OR time 2-4hrs โขโฏ Need postop drains โขโฏ Not suitable for day surgery 2012 โขโฏ Difficult to remove the contralateral lobe
- 45. โCommonplace clinical problems in surgery are approached in diametrically opposite ways - by surgeons with similar training backgrounds, having read the literature but interpreting the available information differently, based on unique personal experience, vision or 2012 surgical prejudice.โ -- Richard Simmons
- 46. Good judgment comes from experience; but experience comes from bad judgment! 2012
- 47. โThe best interest of the patient is the only interest to be consideredโ William J. Mayo, 1910 2012