JOINT HOSPITAL JOINT HOSPITAL SURGICAL GRAND SURGICAL GRAND

ROUNDROUND

Endoscopic Thyroidectomy-Endoscopic Thyroidectomy-New Development and New Development and

Literature ReviewLiterature Review

Department of SurgeryDepartment of Surgery

Pamela Youde Nethersole Eastern Pamela Youde Nethersole Eastern HospitalHospital

Dr. Alex Leung Lik Hang

Supervisor: Dr. David Tsui, Dr. KK Yau

Photos from Charles et al. World J Surg 2008

Development of Development of Minimal Access Minimal Access Thyroid SurgeryThyroid Surgery

First endoscopic parathyroidectomy First endoscopic parathyroidectomy reported by Gagner in 1996reported by Gagner in 1996

Video-assisted thyroid lobectomy by Video-assisted thyroid lobectomy by Huscher in 1997Huscher in 1997

Ohgami M introduced endoscopic Ohgami M introduced endoscopic thyroidectomy using the breast thyroidectomy using the breast approach in 2000approach in 2000

Ikeda reported axillary endoscopic Ikeda reported axillary endoscopic thyroidectomy in 2000thyroidectomy in 2000

Prevalence of thyroid disease is Prevalence of thyroid disease is much higher in young women much higher in young women than men, than men,

The incidence of thyroid disease The incidence of thyroid disease of young women is increasingof young women is increasing

The trend of endoscopic The trend of endoscopic thyroidectomy would be highly thyroidectomy would be highly beneficial to thembeneficial to them

INDICATIONSINDICATIONS In previous cases series, the usual In previous cases series, the usual

indications:indications: Patient under age of 45Patient under age of 45 Benign lesions <3 cmBenign lesions <3 cm

Yamamoto et al applied the endoscopic Yamamoto et al applied the endoscopic thyroidectomy with breast approach to thyroidectomy with breast approach to Graves’ disease in 2001Graves’ disease in 2001

In 2002, Miccoli et al. applied minimally In 2002, Miccoli et al. applied minimally invasive video-assisted thyroidectomy to invasive video-assisted thyroidectomy to resection of a papillary thyroid resection of a papillary thyroid carcinomacarcinoma

Different Approaches of Different Approaches of Endoscopic Endoscopic

ThyroidectomyThyroidectomy Cervical (since 1997)Cervical (since 1997) Axillary (since 2000)Axillary (since 2000) Breast (since 2000)Breast (since 2000) Anterior chest wallAnterior chest wall Axillo-bilateral-breast(ABBA) (since Axillo-bilateral-breast(ABBA) (since

2003)2003) Bilateral axillo-breast(BABA)(2007)Bilateral axillo-breast(BABA)(2007) No consensus on which approach is No consensus on which approach is

the bestthe best

Axillary ApproachAxillary Approach

First introduced by First introduced by Ikeda 2000, Ikeda 2000,

4-6 cm vertical skin 4-6 cm vertical skin incision in the axilla incision in the axilla for camera port and for camera port and two working portstwo working ports

0.5 cm incision on the 0.5 cm incision on the medial side of the medial side of the anterior chest wallanterior chest wall

Axillary ApproachAxillary Approach

Cosmetic result better Cosmetic result better than the cervical or than the cervical or anterior chest wall anterior chest wall approachapproach

Approaches the lateral Approaches the lateral aspect of the thyroid aspect of the thyroid and identify the and identify the parathyroid and RLN parathyroid and RLN easilyeasily

Kang et al. Endocr. J 2009

Axillary ApproachAxillary Approach

The approach to the The approach to the contralateral superior pole of the contralateral superior pole of the thyroid is relatively difficultthyroid is relatively difficult

Not our usual approach for Not our usual approach for thyroid surgerythyroid surgery

Narrow angle of the instrumentNarrow angle of the instrument

Axillo-Bilateral Breast Axillo-Bilateral Breast Approach(ABBA)Approach(ABBA)

Developed in Japan in 2003Developed in Japan in 2003 Two circumareolar ports and one Two circumareolar ports and one

axillary portaxillary port Allows greater angulation of the Allows greater angulation of the

instrumentinstrument Limited ability to visualize both Limited ability to visualize both

lobes of the thyroid and to perform lobes of the thyroid and to perform total thyroidectomytotal thyroidectomy

Bilateral Axillo-Bilateral Axillo-breast(breast(BABABABA))

Developed by Choe et al in 2007Developed by Choe et al in 2007 1.5 cm Incision made bilaterally at the circumareolar 1.5 cm Incision made bilaterally at the circumareolar

line for endoscope and Harmonic scalpelline for endoscope and Harmonic scalpel Two 5mm incisions made at anterior axillary line Two 5mm incisions made at anterior axillary line

bilaterallybilaterally

Bilateral Axillo-Bilateral Axillo-breast(BABA)breast(BABA)

Subcutaneous dissection bilaterally from the Subcutaneous dissection bilaterally from the incision to the thyroid cartilage and the SCM incision to the thyroid cartilage and the SCM

Bilateral axillo-Bilateral axillo-breast(BABA)breast(BABA)

Dissection methods almost the Dissection methods almost the same as conventional thyroidectomysame as conventional thyroidectomy

Optimal visualization of major Optimal visualization of major structures including the parathyoid, structures including the parathyoid, RLNs and the superior and inferior RLNs and the superior and inferior thyroid vesselsthyroid vessels

Allows dissection of both lobes with Allows dissection of both lobes with the same view and methodsthe same view and methods

Excellent cosmetic resultsExcellent cosmetic results

What is the evidence so far?

Charles et al performed a review of evidence in endoscopic thyroidectomy in 2008

Searched in the Medline database through Sep2007 using the terms: endoscopic thyroidectomy, minimal invasive thyroidectomy/endocrine surgery, thyroidectomy via the axillary/anterior/breast approach

Charles et ah. World J Surg (2008) 32: 1349-1357

What is the evidence so far?

NO RCT identified

Charles et al. World J Surg (2008) 32: 1349-1357

Axillary ApproachNo. of

patientsLevel of evidence

Ikeda et al. 2002 19 5

Udomsawaengsup et al. 2004 13 5

Chantawibul et al. 2003 45 5

Yoon et al. 2006 30 5

Jung et al. 2007 35 5

Witzel et al. 2007 12 5

Duncan et ah. 2007 32 5

Breast ApproachNo. of patients

Level of Evidence

Ohgami et al. 2000 5 5

Yamamoto et al. 2001 12 5

Takami and Ikeda et al. 2002

22 5

Park et al. 2003 100 5

Cho et al. 2007 30 5

Charles et al. World J Surg (2008)

Hybrid Approach: ABBA/BABA

Approach No. of patients

Level of evidence

Kitano et al. 2002 Axilla and chest

20 5

SHimazu et al. 2003

ABBA 12 5

Barlehner and Benhidjeb et al. 2007

ABBA 13 5

Choe et al. 2007 ABBA 25 5

BABA 110 5Charles et al. World J Surg (2008)

LARGEST CASE SERIES for Endoscopic Throidectomy

Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 patients

S.W. Kang et al.

Endocrine Journal. 56(3): 361-9, 2009 Jun

Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical

Outcome of 581 patients

Between Nov. 2001 and Dec. 2007

581 patients with thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach.

171 patients: benign tumors 410 patients: malignant tumor

S.W. Kang et al. Endocrine Journal. Jun 2009

INCLUSION CRITERIAINCLUSION CRITERIA

Thyroid tumor not larger than Thyroid tumor not larger than 5cm and diagnosed as follicular 5cm and diagnosed as follicular neoplasmneoplasm

Papillary thyroid microcarcinoma Papillary thyroid microcarcinoma with low riskwith low risk

S.W. Kang et al. Endocrine Journal. Jun 2009

RESULTS

No conversion to open surgery

Benign Malignant

Mean operating time

129.4+/-51min 135.5+/-47min

Length of postop hospital stay

3.3/-1.7 days 3.4+/-0.9 days

Tumor size 2.7+/-1.2cm 0.78+/-0.5cm

RESULTS

Transient hypocalcemia in 19 patients (3.3%)

Transient hoarseness in 13 patients (2.2%)

Permanent hoarseness in 2 patients (0.3%)

RESULTS In TMN stage,

366 (89.2%): stage I 43(10.5%): stage III 1(0.2%): stage IVa

Patients with RAI(4th-6th wk postop), were followed by whole body scan, serum thyroglobulin (4th months) and neck USG, all showed no local recurrence and distant metastases: too short to draw conclusion on oncological safety

No. of Hospitals performing No. of Hospitals performing Endoscopic Thyroidectomy in Endoscopic Thyroidectomy in

KoreaKorea

02468

101214161820

2000 2001 2002 2003 2004

No.of hospitals

No.of hospitals

SAFE for MALIGNANT SAFE for MALIGNANT THYROID TUMORS???THYROID TUMORS???

Endoscopic Thyroidectomy for Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison Thyroid Malignancies: Comparison

with Conventional Open with Conventional Open ThyroidectomyThyroidectomy

YS Chung et al. World J Surg (2007)

1st COMPARATIVE STUDY PURELY FOR MALIGNANCY

Comparison with Comparison with Conventional Open Conventional Open

ThyroidectomyThyroidectomy 301 patients with papillary 301 patients with papillary

thyroid microcarcinoma between thyroid microcarcinoma between Jan 2003 and June 2006 at Seoul Jan 2003 and June 2006 at Seoul National University Hospital by National University Hospital by one surgeonone surgeon 198: open thyroidectomy198: open thyroidectomy 103: endoscopic thyroidectomy 103: endoscopic thyroidectomy

with BABA approachwith BABA approachYS Chung et al. World J Surg (2007)

INDICATIONS for INDICATIONS for malignant thyroid malignant thyroid

diseasedisease Tumor < 1 cm on preoperative Tumor < 1 cm on preoperative

USGUSG No evidence of lateral LN No evidence of lateral LN

metastasis or local invasion on metastasis or local invasion on preoperative USG and CTpreoperative USG and CT

YS Chung et al. World J Surg (2007)

RESULTSRESULTSOpen thyroidectomy (n=198)

Endoscopic thyroidectomy (n=103)

P value

Sex <0.0001

Male 25(12.6%) 1(1.0%)

Female 173(87.4%) 102(99.0%)

Age (years) 21-75(47.2+/-10.2)

21-53(38.2+/-8.2) <0.0001

Operative Method 0.064

Ipsilateral lobectomy 12(6.1%) 7(6.8%)

Subtotal thyroidectomy 14(7.1%) 8(7.8%)

Total thyroidectomy 156(78.8%) 87(84.5%)

Total thyroidectomy with MRND

16(8.1%) 1(1.0%)

Duration of operation (min)

111.4 165.1 <0.0001

Length of hospitalization (d)

3.2 3.0 0.081

Open thyroidectomy (n=198)

Endoscopic thyroidectomy (n=103)

P value

Transient hypocalcemia 35/198(17.7%) 26/103(25.2%) 0.132

Permanent hypocalcemia 9/198(4.5%) 1/103(1.0%) 0.173

Transient RLN palsy 5/198(2.5%) 26/103(25.2%) <0.0001

Permanent RLN palsy 1/198(0.5%) 0/103 1.000

Bleeding 0/198 1/103(1.0%) 0.342

Infection 0/198 1/103(1.0%) 0.342

Tumor recurrence 13 2

Patients undergone Total Thyoidectomy

Open thyroidectom

y n=172

Endoscopic thyroidectom

yN=88

Postoperative thyroglobuin

were available146/172 72/88

Thyroglobulin in 3 months <1.0 ng/ml

132/146(90.4%)

64/72(88.9%)

P=0.812

Our Experience

CONCLUSION Excellent cosmetic results Feasible and safe method for benign

thyroid tumors, becomes more accepted

Not clear if it is suitable for the treatment of thyroid cancer May be an option for small (<1cm), well

differentiated thyroid cancer without lymph node involvement (Chung YS et ah. World J Surg. 2007)

Problems of endoscopic Problems of endoscopic thyroidectomy…..thyroidectomy…..

More invasive with longer operation time More invasive with longer operation time than open surgery due to more than open surgery due to more extensive dissectionextensive dissection

Greater postoperative painGreater postoperative pain Higher rate of transient RLN palsyHigher rate of transient RLN palsy Steeper learning curveSteeper learning curve The oncological safety in malignant The oncological safety in malignant

tumors remain controversialtumors remain controversial

FUTURE…FUTURE…

To develop dedicated surgical To develop dedicated surgical instrumentsinstruments

Standardization of techniquesStandardization of techniques To optimize patient selection To optimize patient selection

criteria, especially for thyroid criteria, especially for thyroid cancercancer

Large-scale RCTs Large-scale RCTs

Robotic Thyroid Surgery

HD and 3D image HD and 3D image Endowrist function beneficial in LN dissectionEndowrist function beneficial in LN dissection

THANK YOU!

CO2 insufflation vs CO2 insufflation vs GaslessGasless

CO2 insufflation: CO2 insufflation: view easily disturbed by mist from view easily disturbed by mist from

Harmonic Scalpel Harmonic Scalpel Problems of hypercapnia, cervical Problems of hypercapnia, cervical

compression, subcutaneous compression, subcutaneous emphysemaemphysema

CO2 related complications can be CO2 related complications can be avoided by low CO2 pressure avoided by low CO2 pressure during the surgery during the surgery (Ohgami M et al. Surg (Ohgami M et al. Surg Laparosc Endosc Percutan Tech 2000)Laparosc Endosc Percutan Tech 2000)

CO2 insufflation vs CO2 insufflation vs GaslessGasless

Gasless Gasless approach:approach:Using an Using an external external retractor to retractor to maintain working maintain working spacespace

Eliminates the Eliminates the CO2 related CO2 related complicationscomplications

Axillary LN

In CCND, approach between In CCND, approach between the SCM branches, dissects the SCM branches, dissects anterior surface of the carotid anterior surface of the carotid sheath and drops the carotid sheath and drops the carotid sheath just below the strap sheath just below the strap musclemuscle

EXCLUSION CRITERIAEXCLUSION CRITERIA

Definite extra-capsular soft tissue Definite extra-capsular soft tissue invasioninvasion

Multiple lateral neck node Multiple lateral neck node metastasismetastasis

Perinodal infiltration of metastatic Perinodal infiltration of metastatic lymph nodelymph node

Distant metastasisDistant metastasis Lesion located at the posterior Lesion located at the posterior

capsule area of the thyroid, esp at capsule area of the thyroid, esp at the tracheo-esophageal groupthe tracheo-esophageal group

S.W. Kang et al. Endocrine Journal. Jun 2009

Patients with multiple and bilateral Patients with multiple and bilateral lesion, along with a thyroid capsular lesion, along with a thyroid capsular invasion identified during operation, invasion identified during operation, total thyroidectomy performedtotal thyroidectomy performed

Prophylactic ipsilateral central Prophylactic ipsilateral central compartment node dissection for most compartment node dissection for most of the malignant tumor of the malignant tumor

Modified radical neck dissection done Modified radical neck dissection done for case of only 1-2 lateral neck node for case of only 1-2 lateral neck node metastasismetastasis

S.W. Kang et al. Endocrine Journal. Jun 2009

Central compartment lymph node metastasis in 112 patients(27.3%)

Lateral neck lymph node metastasis in 13 patients (3.1%) patients

Common in all approaches

Isolation of RLN and parathyroid Inferior and superior thyroid vessels divided

with Harmonic scalpel or between clips