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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 12  |  Page : 1772-1777

Scarless neck endoscopic thyroidectomy via the breast approach: A preliminary report of 45 cases with total or near-total thyroidectomy plus central compartment dissection


1 Department of Thyroid Surgery, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
2 Department of Ultrasound, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
3 Department of Pathology, Second Affiliated Hospital, Zhejiang University, Hangzhou, China

Date of Submission26-Feb-2019
Date of Acceptance18-Jul-2019
Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. P Wang
Department of Thyroid Surgery, Second Affiliated Hospital, Zhejiang University, Hangzhou-310009
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_120_19

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   Abstract 


Background: There are various endoscopic techniques for thyroid carcinoma dissection but few reports regarding the scarless neck technique and central compartment dissection (CCD) via the breast approach, especially for bilateral CCD are available. In this study, we reported 45 cases with scarless neck endoscopic total or near-total thyroidectomy plus CCD via the breast approach. Materials and Methods: Forty-five female patients with papillary thyroid carcinoma (PTC) were enrolled in the study, from January 2011 to March 2013. In brief, 5 mm ultrasonic coagulation device (Harmonic Scalpel, HS; Ethicon Endosurgery, USA) was used to perform thyroid vessel management and thyroidectomy. Twenty patients underwent total thyroidectomy and 25 underwent near-total thyroidectomy. CCD was performed in all 45 patients, including 13 with bilateral CCD and 32 with ipsilateral CCD. Results: The procedure was successful for all 45 patients. Sixteen patients (35.6%) had lymph node metastases in central compartments. Postoperative transient adverse events included voice changes (9 patients) and hypocalcemia (18 patients), including 7 (21.9%) in the unilateral group and 11 (84.6%) in bilateral group. There was no permanent hypocalcemia or recurrent laryngeal nerve (RLN) palsy. None of the case were converted to open surgical procedure. All patients were satisfied with the cosmetic result of the scarless neck endoscopic thyroidectomy (SET). No evidence of residual or recurrent disease was found during a mean follow-up of 22.84 months (range, 12–34 months).Conclusions: Experienced thyroid surgeons performed the scarless neck endoscopic total or near-total thyroidectomy plus unilateral or bilateral CCD via the breast approach for selected PTC patients. The procedure was safe and feasible with excellent cosmetic results.

Keywords: Central compartment dissection, endoscopic thyroidectomy, papillary thyroid carcinoma


How to cite this article:
Yan H, Wang Y, Huang P, Hong Y, Ye Q, Xie Q, Zhao Q, Wang P. Scarless neck endoscopic thyroidectomy via the breast approach: A preliminary report of 45 cases with total or near-total thyroidectomy plus central compartment dissection. Niger J Clin Pract 2019;22:1772-7

How to cite this URL:
Yan H, Wang Y, Huang P, Hong Y, Ye Q, Xie Q, Zhao Q, Wang P. Scarless neck endoscopic thyroidectomy via the breast approach: A preliminary report of 45 cases with total or near-total thyroidectomy plus central compartment dissection. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 14];22:1772-7. Available from: http://www.njcponline.com/text.asp?2019/22/12/1772/272195




   Introduction Top


Endoscopic thyroidectomy was described by Hüscher et al. in 1997. Consequently, benign thyroid disease has been regarded as an indication for endoscopic surgery.[1] Miccoli et al. applied endoscopic technology in the treatment of thyroid carcinoma in 2002.[2],[3] Over the last decade, various endoscopic techniques have been developed to treat thyroid carcinoma. Endoscopic thyroidectomy included scarless neck endoscopic thyroidectomy (SET) and video-assisted thyroidectomy (VAT).[4],[5] Furthermore, SET included total endoscopic thyroidectomy (TET), robotic thyroidectomy (RT), and natural orifice translumenal endoscopic surgery (NOTES).[6],[7],[8],[9],[10],[11]

In this article, we used TET as the operative method for 45 SET patients. In China, TET and VAT are common endoscopic procedures used for Chinese patients with papillary thyroid carcinoma (PTC) while RT is not used often because of its high cost. However, the cosmetic results of VAT are less than that of SET because a cervical scar remains after VAT. After successful endoscopic unilateral lobectomy for selected patients, the TET technology was applied in total or near-total thyroidectomy. Total or near-total thyroidectomy is a high-risk surgical procedure for less experienced surgeons because there is a possibility that severe postoperative complications, such as permanent hypoparathyroidism and bilateral recurrent laryngeal nerve (RLN) palsy, might occur. Few reports showed that total thyroidectomy could be performed endoscopically without a scar on the neck.[12],[13],[14],[15] There were also few reports on central compartment dissection (CCD) via the breast approach, especially for bilateral CCD.

In this study, we reported 45 patients who underwent scarless neck endoscopic total or near-total thyroidectomy plus CCD via the breast approach, including 13 with bilateral CCD and 32 with ipsilateral CCD.


   Methodology Top


Patients

Forty-five female patients with papillary thyroid carcinoma (PTC) were enrolled in the study from January 2011 to March 2013. The inclusion and exclusion criteria were based on the patients who underwent scarless neck endoscopic total or near-total thyroidectomy plus CCD via the breast approach. The clinical characteristics of the 45 patients are shown in [Table 1]. Suspicion of thyroid tumor malignancy was raised preoperatively based on ultrasound (US) findings.[16],[17] The diagnosis of PTC was confirmed using preoperative fine needle aspiration (FNA) or postoperative histology. Preoperative contrast-enhanced ultrasound (CEUS) and enhanced computed tomography (CT) scans were performed on patients with suspected metastatic neck lymph nodes or with a tumor size >1 cm. The serum calcium and parathyroid hormone (PTH) levels of the 45 patients were examined both preoperatively and postoperatively [Table 2]. Written informed consent was obtained in all cases. All protocols were approved by the Second Affiliated Hospital, Zhejiang University Ethics Committee.
Table 1: Clinical characteristics of the 45 SET patients

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Table 2: Comparison of patient characteristics in the unilateral and bilateral CCD groups

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Methods

The method used in this procedure was similar to that described previously by our surgical team [Figure 1].[18],[19] A 5 mm ultrasonic coagulation device (Harmonic Scalpel, HS; Ethicon Endosurgery, USA) was used to perform thyroid vessel management and thyroidectomy. For better exposure, designed retractors (KangJi Medical Equipment Co., Ltd., HangZhou, China) for endoscopic thyroidectomy were used. According to the preoperative FNA and/or the results of intraoperative frozen section analysis, we determined the scope of thyroid surgery. It was observed that, if we located the parathyroid glands during SET, the parathyroid was preserved in situ with an intact vascular supply [Figure 2]. Later, the resected specimens were extracted through a trocar using an endopouch, made to prevent tract recurrence of thyroid neoplasm [Figure 3]. The resected specimens were examined carefully to identify the parathyroid tissue. In case the parathyroid glands were mistakenly removed or could not be preserved in situ; due to the lack of blood supply, they were transplanted endoscopically into the sternocleidomastoid via syringe needle after the parathyroid tissue was cut into pieces and pulsed with 2–3 ml normal saline. A negative pressure drainage tube was placed via an areolar incision and removed after 24–72 hours, depending on the postoperative drainage volume [Figure 4].
Figure 1: The central compartment was exposed by two retractors. One retractor pulled the strap muscles to the right side and another retractor pushed the trachea to the left side

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Figure 2: Some crucial structures were exposed and preserved during SET. (a) The superior parathyroid was located during SET (Sup. = superior). (b) The inferior parathyroid gland was preserved in situ(Inf. = inferior). (c) The anterior and posterior branches of the RLN were exposed during SET (Ant. = anterior; Post. = posterior). (d) A non-RLN nerve was encountered during SET. (Sup. = superior; N = nerve)

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Figure 3: An endo-pouch was made using clinical gloves

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Figure 4: A negative pressure drainage tube was inserted via an areolar incision

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   Results Top


This procedure was performed successfully in all 45 patients. The patients' clinical results are shown in [Table 1] and [Table 2]. Sixteen patients (35.6%) had lymph node metastases in the central compartments [Figure 5]. Neither permanent hypocalcemia nor permanent RLN palsy was noted, and no case was converted to open surgical procedure. All patients were satisfied with the cosmetic result of SET. Twelve patients were treated with radioactive iodine (RAI) therapy postoperatively. No evidence of residual or recurrent disease was found during a mean follow-up of 22.84 months (range 12–34 months). There was no significant bleeding during the operation.
Figure 5: Endoscopic view after bilateral CCD in addition to total thyroidectomy

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   Discussion Top


People of Asian descent often have more obvious scars than Caucasians, especially for patients with a tendency to scar. SET, which was also called oncoplastic thyroid surgery, may be accepted by Asian patients in East Asia. Recently, various methods of oncoplastic thyroid surgery were performed in PTC patients.[20],[21],[22],[23],[24],[25] However, whether or not the endoscopic total thyroidectomy was beneficial is still debated by numerous surgeons.

Many surgeons suspected that there were more postoperative complications, such as RLN injury, following endoscopic total thyroidectomy compared with open total thyroidectomy. Im et al. reported that the incidence of transient RLN palsy in an endoscopic total thyroidectomy group was higher than that in an open total thyroidectomy group performed via the bilateral axillo-breast approach (BABA; 28% vs. 9.5%), but no permanent RLN palsy occurred in either group.[12] CCD was not performed in the above study. In the current article, all patients underwent total or near-total thyroidectomy plus CCD. Transient voice changes occurred in 20% patients, which was lower than that of the above report and no permanent RLN palsy was noted. An additional CCD might not increase the incidence of RLN palsy. Further, to avoid injuries to the RLN, surgeons need to pay attention to several key points as follows: (1) the RLN should be exposed using separating forceps instead of the ultrasonic scalpel to prevent thermal injury since the ultrasonic scalpel temperature is high during harmonic scalpel use; (2) the ultrasonic scalpel should be used at a distance of 3 mm from the RLN; (3) the anterior and posterior branches of the RLN were often encountered and should be preserved carefully during SET; (4) although non-RLN nerves were only seldom encountered, there is a risk of intraoperative injury to these nerves [Figure 2]. If the RLN is easily detectable in its normal location during SET, the surgeon should be aware that anatomical variations exist. Intraoperative neurophysiological monitoring (IONM) might assist in detecting non-RLN nerves.

CCD for differentiated thyroid cancer (DTC) patient is still controversial. According to the American Thyroid Association (ATA) guidelines, CCD is not necessary for all DTC patients.[26] However, Chinese guidelines for thyroid nodules and differentiated thyroid cancer recommend CCD for Chinese DTC patients.[27] At the time of DTC diagnosis, 20–90% of patients had cervical lymph node metastases, most of which occurred in level VI. There were 28–33% of DTC patients who had cervical lymph node metastasis that was not detected preoperatively via imaging examinations, but were confirmed histologically after prophylactic CCD.[27],[28] In the present article, 35.6% of the SET patients had level VI metastases, which were verified by postoperative histology. In addition, if the patients with cervical lymph node metastasis did not undergo CCD during their operation, they might need to undergo central compartment reoperation, which could result in more complications such as hypoparathyroidism and RLN palsy. Thus, CCD is performed in most DTC patients in China.

Hypoparathyroidism resulting in hypocalcemia was a major complication of total thyroidectomy. CCD might result in more postoperative hypoparathyroidism because the parathyroid gland blood supply might be decreased and/or the parathyroid glands might be removed mistakenly during CCD. Im et al. reported 46 total thyroidectomy patients without CCD wherein the incidence of transient hypocalcemia of the endoscopic group was higher than that in the open group (16% vs. 14.3%); however, no permanent hypoparathyroidism was found in the endoscopic group.[12] In this study, all patients underwent CCD, and the transient hypoparathyroidism was 40%, which was higher than that of the above report. The percent of transient hypoparathyroidism in the bilateral CCD group was greater than that in the unilateral CCD group (84.6% vs. 21.9%, [Table 2]), and no permanent hypoparathyroidism was noted. Intraoperatively, the healthy parathyroid gland should be carefully preserved when possible, especially for the superior parathyroid. Knowing whether the superior parathyroid gland and its blood supply were preserved in situ is important, because if the parathyroid gland was cut mistakenly or if the blood supply was interrupted, endoscopic autotransplantation of the parathyroid gland would be necessary.

The lymph node yield (LNY) in the central compartment might be correlated with various causes, such as surgical technique and the extent of dissection. Hur et al. reported that the mean LNY in the BABA group was more than that in bilateral areolar approach (BAA) group (4.6 vs. 3.5).[29] However, the mean LNY in the present article was greater than that of the above reports (8.38 vs. 4.6), and the mean LNY in the bilateral CCD group was greater than that in the unilateral CCD group (10.46 ± 7.47 vs. 7.53 ± 4.96). Delphian lymph node dissection, which may be neglected, was performed in all of the 45 patients.

The mean endoscopic thyroidectomy operation time might also depend on the extent of dissection. Choi et al. reported that the mean operation time for total thyroidectomy with ipsilateral CCD via BABA was 153.3 min.[30] In the current article, the mean operation time for the unilateral CCD group was comparable to that of the above report (154.5 vs. 153.3 min) but was significantly less than that of the bilateral CCD group (154.50 ± 36.47 vs. 201.25 ± 39.97 min).

Endoscopic thyroid surgeons were also careful of thyroid neoplasm tract recurrence.[31] An endo-pouch could be purchased commercially but it was not strong enough. Thus, we made an endo-pouch using clinical gloves [Figure 3], which was elastic and strong enough not to be broken easily. None of the 45 patients had evidence of tract recurrence during 12–34 month follow-up.

In the current report, all 45 patients were female; male patients were excluded for SET. According to our previous SET experience, because a man's muscles were usually stronger than a woman's, it was difficult to expose the surgical field using two retractors in male patients. However, male patients were not an absolute exclusion criterion for SET.

Age was also not an absolute selection criteria. In the current report, most of the 45 patients were not more than 45 years old hence two older patients (49 and 50 years old) were selected for this procedure because they had strong requirements for cosmesis.

Here, the selection criteria for SET used in the Second Affiliated Hospital of Zhejiang University were as follows: (1) the primary condition was that the patients had requirements for cosmesis; (2) the patients had differentiated thyroid carcinoma and belonged to the low-risk group; (3) female; (4) 15–45 years old; (5) tumor size ≤2 cm. The absolute exclusion criteria was that the patients did not have a cosmetic requirement. Relative exclusion criteria were as follows: (1) male; (2) obese; (3) short neck; (4) previous neck or chest surgical history; (5) metastatic lymph nodes in level V or metastatic lymph nodes occurring below the sternoclavicular joint; (6) metastatic cervical lymph nodes mixed together as masses; (7) metastatic cervical lymph nodes fixed to underlying tissues; (8) invasion of surrounding tissue such as the RLN, trachea, and esophagus. The last five exclusion criterions were based on preoperative US, CEUS, and enhanced CT scans.

In summary, the scarless neck endoscopic total or near-total thyroidectomy plus unilateral or bilateral CCD via the breast approach for selected PTC patients was feasible and safe, when performed by experienced thyroid surgeons, and had excellent cosmetic results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

This work was supported by National Nature Science Foundation of China (grant 81000184).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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