JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy New

JOINT HOSPITAL SURGICAL GRAND ROUND Endoscopic Thyroidectomy. New Development and Literature Review Dr. Alex Leung Lik Hang Supervisor: Dr. David Tsui, Dr. KK Yau Department of Surgery Pamela Youde Nethersole Eastern Hospital

Photos from Charles et al. World J Surg 2008

Development of Minimal Access Thyroid Surgery First endoscopic parathyroidectomy reported by Gagner in 1996 n Video-assisted thyroid lobectomy by Huscher in 1997 n Ohgami M introduced endoscopic thyroidectomy using the breast approach in 2000 n Ikeda reported axillary endoscopic thyroidectomy in 2000 n

Prevalence of thyroid disease is much higher in young women than men, n The incidence of thyroid disease of young women is increasing n The trend of endoscopic thyroidectomy would be highly beneficial to them n

INDICATIONS n In previous cases series, the usual indications: n Patient under age of 45 n Benign lesions <3 cm Yamamoto et al applied the endoscopic thyroidectomy with breast approach to Graves’ disease in 2001 n In 2002, Miccoli et al. applied minimally invasive video-assisted thyroidectomy to resection of a papillary thyroid carcinoma n

Different Approaches of Endoscopic Thyroidectomy Cervical (since 1997) n Axillary (since 2000) n Breast (since 2000) n Anterior chest wall n Axillo-bilateral-breast(ABBA) (since 2003) n Bilateral axillo-breast(BABA)(2007) n No consensus on which approach is the best n

Axillary Approach n n n First introduced by Ikeda 2000, 4 -6 cm vertical skin incision in the axilla for camera port and two working ports 0. 5 cm incision on the medial side of the anterior chest wall

Axillary Approach n n Cosmetic result better than the cervical or anterior chest wall approach Approaches the lateral aspect of the thyroid and identify the parathyroid and RLN easily Kang et al. Endocr. J 2009

Axillary Approach The approach to the contralateral superior pole of the thyroid is relatively difficult n Not our usual approach for thyroid surgery n Narrow angle of the instrument n

Axillo-Bilateral Breast Approach(ABBA) Developed in Japan in 2003 n Two circumareolar ports and one axillary port n Allows greater angulation of the instrument n Limited ability to visualize both lobes of the thyroid and to perform total thyroidectomy n

Bilateral Axillo-breast(BABA) n n n Developed by Choe et al in 2007 1. 5 cm Incision made bilaterally at the circumareolar line for endoscope and Harmonic scalpel Two 5 mm incisions made at anterior axillary line bilaterally

Bilateral Axillo-breast(BABA) n Subcutaneous dissection bilaterally from the incision to the thyroid cartilage and the SCM

Bilateral axillo-breast(BABA) Dissection methods almost the same as conventional thyroidectomy n Optimal visualization of major structures including the parathyoid, RLNs and the superior and inferior thyroid vessels n Allows dissection of both lobes with the same view and methods n Excellent cosmetic results n

What is the evidence so far? Charles et al performed a review of evidence in endoscopic thyroidectomy in 2008 n Searched in the Medline database through Sep 2007 using the terms: endoscopic n 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 Approach No. of patients Level 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 Approach Ohgami et al. 2000 No. of patients 5 Level of Evidence 5 Yamamoto et al. 2001 12 5 Takami and Ikeda et al. 2002 Park et al. 2003 22 5 100 5 Cho et al. 2007 30 5 Charles et al. World J Surg (2008)

Hybrid Approach: ABBA/BABA Approach Kitano et al. 2002 SHimazu et al. 2003 Barlehner and Benhidjeb et al. 2007 Choe et al. 2007 No. of patients Axilla and 20 chest ABBA 12 Level of evidence 5 5 ABBA 13 5 ABBA 25 5 BABA 110 5 Charles 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 n 581 patients with thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach. n 171 patients: benign tumors n 410 patients: malignant tumor n S. W. Kang et al. Endocrine Journal. Jun 2009

INCLUSION CRITERIA Thyroid tumor not larger than 5 cm and diagnosed as follicular neoplasm n Papillary thyroid microcarcinoma with low risk n S. W. Kang et al. Endocrine Journal. Jun 2009

RESULTS n No conversion to open surgery Benign Mean operating time 129. 4+/-51 min Malignant 135. 5+/-47 min Length of postop 3. 3/-1. 7 days hospital stay 3. 4+/-0. 9 days Tumor size 0. 78+/-0. 5 cm 2. 7+/-1. 2 cm

RESULTS Transient hypocalcemia in 19 patients (3. 3%) n Transient hoarseness in 13 patients (2. 2%) n Permanent hoarseness in 2 patients (0. 3%) n

RESULTS n In TMN stage, 366 (89. 2%): stage I n 43(10. 5%): stage III n 1(0. 2%): stage IVa n n Patients with RAI(4 th-6 th wk postop), were followed by whole body scan, serum thyroglobulin (4 th months) and neck USG, all showed no local recurrence and distant metastases: too short to draw conclusion on oncological safety

No. of Hospitals performing Endoscopic Thyroidectomy in Korea

SAFE for MALIGNANT THYROID TUMORS? ? ? 1 st COMPARATIVE STUDY PURELY FOR MALIGNANCY Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison with Conventional Open Thyroidectomy YS Chung et al. World J Surg (2007)

Comparison with Conventional Open Thyroidectomy n 301 patients with papillary thyroid microcarcinoma between Jan 2003 and June 2006 at Seoul National University Hospital by one surgeon n 198: open thyroidectomy n 103: endoscopic thyroidectomy with BABA approach YS Chung et al. World J Surg (2007)

INDICATIONS for malignant thyroid disease Tumor < 1 cm on preoperative USG n No evidence of lateral LN metastasis or local invasion on preoperative USG and CT n YS Chung et al. World J Surg (2007)

RESULTS Open thyroidectomy (n=198) Endoscopic thyroidectomy (n=103) Sex P value <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) Operative Method <0. 0001 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. 0 0. 081 3. 2

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 thyroidectomy n=172 Endoscopic thyroidectomy N=88 Postoperative thyroglobuin were available 146/172 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 n Feasible and safe method for benign thyroid tumors, becomes more accepted n Not clear if it is suitable for the treatment of thyroid cancer n n May be an option for small (<1 cm), well differentiated thyroid cancer without lymph node involvement (Chung YS et ah. World J Surg. 2007)

Problems of endoscopic thyroidectomy…. . More invasive with longer operation time than open surgery due to more extensive dissection n Greater postoperative pain n Higher rate of transient RLN palsy n Steeper learning curve n The oncological safety in malignant tumors remain controversial n

FUTURE… To develop dedicated surgical instruments n Standardization of techniques n To optimize patient selection criteria, especially for thyroid cancer n Large-scale RCTs n

Robotic Thyroid Surgery n n HD and 3 D image Endowrist function beneficial in LN dissection

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CO 2 insufflation vs Gasless n CO 2 insufflation: n view easily disturbed by mist from Harmonic Scalpel n Problems of hypercapnia, cervical compression, subcutaneous emphysema n CO 2 related complications can be avoided by low CO 2 pressure during the surgery (Ohgami M et al. Surg Laparosc Endosc Percutan Tech 2000)

CO 2 insufflation vs Gasless n n Gasless approach: Using an external retractor to maintain working space Eliminates the CO 2 related complications

Axillary LN n In CCND, approach between the SCM branches, dissects anterior surface of the carotid sheath and drops the carotid sheath just below the strap muscle

EXCLUSION CRITERIA Definite extra-capsular soft tissue invasion n Multiple lateral neck node metastasis n Perinodal infiltration of metastatic lymph node n Distant metastasis n Lesion located at the posterior capsule area of the thyroid, esp at the tracheo -esophageal group n S. W. Kang et al. Endocrine Journal. Jun 2009

Patients with multiple and bilateral lesion, along with a thyroid capsular invasion identified during operation, total thyroidectomy performed n Prophylactic ipsilateral central compartment node dissection for most of the malignant tumor n Modified radical neck dissection done for case of only 1 -2 lateral neck node metastasis S. W. Kang et al. Endocrine Journal. Jun 2009 n

Central compartment lymph node metastasis in 112 patients(27. 3%) n Lateral neck lymph node metastasis in 13 patients (3. 1%) patients n

Common in all approaches n n Isolation of RLN and parathyroid Inferior and superior thyroid vessels divided with Harmonic scalpel or between clips