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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
2012
Samuel D. Gross - 1866
           Philadelphia
             A System of Surgery

       Thyroid surgery: ‘Horrid butchery’

“No honest and sensible surgeon would ever
        engage in thyroid surgery”

2012
2012
The extirpation of
        thyroid gland
       typifies perhaps
       better than any
        operation the
 supreme triumph of
       the surgeon’s art.
2012
Surgical Procedure

       •    Anatomically and Biologically Sound
       •    Reproducible
       •    Least Complications
       •    Short Learning Curve
       •    Easy to Teach, Learn, and Practice
       •    Cost Effective
       •    Best Cosmetic and Function Results
2012
The fact that a new
  technique is available does
   not necessarily mean its
       implementation is
         appropriate.
             – Leigh Delbridge, MD, FRACS


2012
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
Minimally Invasive Thyroidectomy

       •  ‘PURE’ Endoscopic Approach Completely
       closed technique with continuous gas
       insufflation
       • Neck Approach
       •  Anterior Chest Approach
       •  Axillary Approach
       •  Breast (Submammary Approach)
       • Video assisted Technique
       • Video assisted Neck Dissection
2012   • Video assisted under LA
Laparoscope
        Clamp on      Insufflation   being inserted
       purse string      tube         into trocar A


2012
2012
2012
Minimally Invasive Thyroidectomy

       •  ‘PURE’ Endoscopic Approach Completely
       closed technique with continuous gas
       insufflation
       • Neck Approach
       •  Anterior Chest Approach
       •  Axillary Approach
       •  Breast (Submammary Approach)
       • Video assisted Technique
       • Video assisted Neck Dissection
2012   • Video assisted under LA
Endoscopic
            Surgery


       Minimally Invasive
            Surgery


       Maximally Expensive
            Surgery
2012
Minimally Invasive Thyroidectomy
       •  Minimally Invasive ‘Open’
       Surgery
       •  Mini-incision
       •  Smaller Incision
       •  Lateral Incision
       •  Harmonic Scalpel
       •  Ligasure
       •  Local Anesthesia/Regional
2012   •  23 Hour Discharge
In cosmetic terms, the quality of
 the scar is more important than
        the actual length


2012
Minimal incision may cause
   excessive skin stretching,
 bruising, forcible retraction, or
inadvertent cauterization of the
            skin edges

2012
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.
Advantages of
Minimally Invasive Thyroid Surgery


       •  Smaller Incision
       •  Better Cosmesis
       •  Less Pain
       •  Early Discharge
2012
Minimally Invasive Thyroid Surgery

       •  Majority of thyroid surgery in the U.S. is
       performed for proven or suspected malignancy
       • Paratracheal and nodal evaluation are difficult
       •  20% of patients with thyroid cancer have
       extrathyroidal extension, which requires adequate
       exposure and excision
       •  Ultrasound detecting bilateral thyroid nodules
       requires total thyroidectomy
2012
Minimally Invasive Thyroid Surgery

 •  First Principle of Surgery:
       •  Adequate Exposure
       •  Adequate Retraction
       •  Adequate Lighting
 •  Learning curve
 •  Difficult to gain expertise
 •  Medicolegalities of minimally invasive thyroid surgery

2012
Classification

                                     Minimally
                                      invasive
                                   Thyroidectomy


                                                                Endoscope
       Robotic           Mini incision      True endoscopic
                                                                 assisted


                                           1.  Anterior chest
        Trans-Axillary                     2.  Axillary          Cervical
                                           3.  Areolar



          Face-Lift
2012
Mini Incision
       • Ikeda
       • 3cm incision
       • Isthmusotomy
       • Use ligasure LS1200 or harmonic scalpel(focus) to divide
       superior pole vessels
       • Use ligasure LS1200 or harmonic scalpel(focus) to divide
       isthmus



2012


                 Ikeda et al. Direct mini incision thyroidectomy. Biomed Pharmacother 2002;56:60s-63s
Ligasure Precise




2012
Harmonic Focus Scalpel




2012
True Endoscopic
2000 Shimizu            subclavicular access

2000 Ikeda              axillary access

2000  Ohgami            breast access

2001 Gagner             supraclavicular access

2007 Chung        robotic via axillary access


2012
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
Ikeda                          Ohgami




   30  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
Endoscopic Assisted

       1999 Miccoli                central neck access




        • Minimally invasive video assisted
        thyroidectomy
        • Single 1.5cm incision -midline skin crease
        • MIVAT
2012
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
MIVAT: Contraindications
                  Large   goiters

                  Previous neck surgery

                  Thyroiditis
 ABSOLUTE
                  Presence of suspicious lymph nodes

                  Local advanced carcinoma
                  	
  


                  Previous neck irradiation

       RELATIVE   Graves’ disease

                  Short neck in obese patients
2012
MIVAT: 5 steps

       1.  Incision and access to the operative
          space
       2.  Section of the upper pedicle
       3.  Identification of recurrent laryngeal
          nerve and parathyroids
       4.  Extraction and resection of the lobe

2012
       5.  Closure
MIVAT: Comparison to Traditional
        Thyroidectomy
   •    Cosmesis
        Smaller scar
        Miccoli, Surgery 2001. Prospective study comparing MIVAT
        to traditional
        MIVAT>traditional using numeric scale, p=0.01

   •    Operation time
        Similar BUT is learning curve

   •    Complication rate
        Similar

   •    Postop course- better based on patient questionnaire
        score.
        Miccoli,Surgery 2001. p=0.003
2012
Da Vinci Robot

•  Two components
       •  Surgeon console

       •  Surgical arm cart




2012
Minimally Invasive Thyroid Surgery

       •  Majority of thyroid surgery in the U.S. is performed for
       proven or suspected malignancy


       •  Paratracheal and nodal evaluation are difficult


       •  20% of patients with thyroid cancer have extrathyroidal
       extension, which requires adequate exposure and excision


       •  Ultrasound detecting bilateral thyroid nodules requires
       total thyroidectomy
2012
Minimally Invasive Thyroid Surgery
       •  First Principle of Surgery:
          •  Adequate Exposure
          •  Adequate Retraction
          •  Adequate Lighting


       •  Learning curve


       •  Difficult to gain expertise


       •  Medicolegalities of minimally invasive thyroid surgery
2012
Classification

                                     Minimally
                                      invasive
                                   Thyroidectomy


                                                                Endoscope
       Robotic           Mini incision      True endoscopic
                                                                 assisted


                                           1.  Anterior chest
        Trans-Axillary                     2.  Axillary          Cervical
                                           3.  Areolar



          Face-Lift
2012
Da Vinci Robot

•  Surgical arm cart holds
       •  3D camera
       •  Instruments (2 or 3
         arms)
          •  Grasping forceps
          •  Scissors
          •  bipolar bovie
          •  harmonic scalpel
                                7 degrees of freedom using
2012
                                an endo-wrist system
Approach




       •  2 incisions
       •  Axillary incision
           •  Camera
           •  Harmonic scalpel
2012
           •  Dissecting forceps
       •  Substernal incision
           •  Grasping forceps
Axillary Incision




2012   • 6cm axillary incision
       • Dissect subcutaneous tunnel over pectoralis major muscle
Exposure of Thyroid Gland




2012
Position of Camera and
          Instrument Arms




2012
Dissection of Thyroid Gland




2012
Advantages & Disadvantages
       •    Avoids a central neck incision
       •    Increased magnification of RLN and parathyroids
       •    No tremor


            BUT


       •    6cm axillary incision
       •    Significant soft tissue dissection
       •    Lose sensory feedback
       •    Long OR time 2-4hrs
       •    Need postop drains
       •    Not suitable for day surgery
2012   •    Difficult to remove the contralateral lobe
“Commonplace 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.”
          -- Richard Simmons
Good judgment comes
         from experience;
       but experience comes
        from bad judgment!
2012
“The best interest
of the patient is the
only interest to be
considered”


William J. Mayo, 1910

2012

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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
  • 3. Samuel D. Gross - 1866 Philadelphia A System of Surgery Thyroid surgery: ‘Horrid butchery’ “No honest and sensible surgeon would ever engage in thyroid surgery” 2012
  • 5. The extirpation of thyroid gland typifies perhaps better than any operation the supreme triumph of the surgeon’s art. 2012
  • 6. Surgical Procedure •  Anatomically and Biologically Sound •  Reproducible •  Least Complications •  Short Learning Curve •  Easy to Teach, Learn, and Practice •  Cost Effective •  Best Cosmetic and Function Results 2012
  • 7. The fact that a new technique is available does not necessarily mean its implementation is appropriate. – 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 •  ‘PURE’ Endoscopic Approach Completely closed technique with continuous gas insufflation • Neck Approach •  Anterior Chest Approach •  Axillary Approach •  Breast (Submammary Approach) • Video assisted Technique • Video assisted Neck Dissection 2012 • Video 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 •  ‘PURE’ Endoscopic Approach Completely closed technique with continuous gas insufflation • Neck Approach •  Anterior Chest Approach •  Axillary Approach •  Breast (Submammary Approach) • Video assisted Technique • Video assisted Neck Dissection 2012 • Video assisted under LA
  • 14. Endoscopic Surgery Minimally Invasive Surgery Maximally Expensive Surgery 2012
  • 15. Minimally Invasive Thyroidectomy •  Minimally Invasive ‘Open’ Surgery •  Mini-incision •  Smaller Incision •  Lateral Incision •  Harmonic Scalpel •  Ligasure •  Local Anesthesia/Regional 2012 •  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 •  Smaller Incision •  Better Cosmesis •  Less Pain •  Early Discharge 2012
  • 20. Minimally Invasive Thyroid Surgery •  Majority of thyroid surgery in the U.S. is performed for proven or suspected malignancy • Paratracheal and nodal evaluation are difficult •  20% of patients with thyroid cancer have extrathyroidal extension, which requires adequate exposure and excision •  Ultrasound detecting bilateral thyroid nodules requires total thyroidectomy 2012
  • 21. Minimally Invasive Thyroid Surgery •  First Principle of Surgery: •  Adequate Exposure •  Adequate Retraction •  Adequate Lighting •  Learning curve •  Difficult to gain expertise •  Medicolegalities of minimally invasive thyroid surgery 2012
  • 22. Classification Minimally invasive Thyroidectomy Endoscope Robotic Mini incision True endoscopic assisted 1.  Anterior chest Trans-Axillary 2.  Axillary Cervical 3.  Areolar Face-Lift 2012
  • 23. Mini Incision • Ikeda • 3cm incision • Isthmusotomy • Use ligasure LS1200 or harmonic scalpel(focus) to divide superior pole vessels • Use 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 2000  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 30  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 • Minimally invasive video assisted thyroidectomy • Single 1.5cm incision -midline skin crease • MIVAT 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   Previous neck irradiation RELATIVE Graves’ disease Short neck in obese patients 2012
  • 32. MIVAT: 5 steps 1.  Incision and access to the operative space 2.  Section of the upper pedicle 3.  Identification of recurrent laryngeal nerve and parathyroids 4.  Extraction and resection of the lobe 2012 5.  Closure
  • 33. MIVAT: Comparison to Traditional Thyroidectomy •  Cosmesis Smaller scar Miccoli, Surgery 2001. Prospective study comparing MIVAT to traditional MIVAT>traditional using numeric scale, p=0.01 •  Operation time Similar BUT is learning curve •  Complication rate Similar •  Postop course- better based on patient questionnaire score. Miccoli,Surgery 2001. p=0.003 2012
  • 34. Da Vinci Robot •  Two components •  Surgeon console •  Surgical arm cart 2012
  • 35. Minimally Invasive Thyroid Surgery •  Majority of thyroid surgery in the U.S. is performed for proven or suspected malignancy •  Paratracheal and nodal evaluation are difficult •  20% of patients with thyroid cancer have extrathyroidal extension, which requires adequate exposure and excision •  Ultrasound detecting bilateral thyroid nodules requires total thyroidectomy 2012
  • 36. Minimally Invasive Thyroid Surgery •  First Principle of Surgery: •  Adequate Exposure •  Adequate Retraction •  Adequate Lighting •  Learning curve •  Difficult to gain expertise •  Medicolegalities of minimally invasive thyroid surgery 2012
  • 37. Classification Minimally invasive Thyroidectomy Endoscope Robotic Mini incision True endoscopic assisted 1.  Anterior chest Trans-Axillary 2.  Axillary Cervical 3.  Areolar Face-Lift 2012
  • 38. Da Vinci Robot •  Surgical arm cart holds •  3D camera •  Instruments (2 or 3 arms) •  Grasping forceps •  Scissors •  bipolar bovie •  harmonic scalpel 7 degrees of freedom using 2012 an endo-wrist system
  • 39. Approach •  2 incisions •  Axillary incision •  Camera •  Harmonic scalpel 2012 •  Dissecting forceps •  Substernal incision •  Grasping forceps
  • 40. Axillary Incision 2012 • 6cm axillary incision • Dissect 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 •  Avoids a central neck incision •  Increased magnification of RLN and parathyroids •  No tremor BUT •  6cm axillary incision •  Significant soft tissue dissection •  Lose sensory feedback •  Long OR time 2-4hrs •  Need postop drains •  Not suitable for day surgery 2012 •  Difficult to remove the contralateral lobe
  • 45. “Commonplace 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.” -- Richard Simmons
  • 46. Good judgment comes from experience; but experience comes from bad judgment! 2012
  • 47. “The best interest of the patient is the only interest to be considered” William J. Mayo, 1910 2012