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ORIGINAL ARTICLE
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Endoscopic thyroidectomy: Which one is the better technique for the beginners?


 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Submission27-Aug-2019
Date of Acceptance19-Apr-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Kamal Kataria,
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_184_19

PMID: 32964885

  Abstract 

Introduction: Endoscopic thyroidectomy is an advanced procedure and has a long learning curve. Most commonly employed approach is combined axillary-breast approach (ABA). Recently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) is being popularised as a scarless procedure. However, it is not established whether TOETVA or ABA approach is better to begin with.
Purpose: The purpose of the study was to compare the initial experience of TOETVA and ABA with respect to difficulties and outcomes.
Methodology: A prospective non-randomised interventional study was conducted including the initial ten patients in each group who underwent hemithyroidectomy for benign solitary thyroid nodule. Sigma plot version 12.3 was used for the statistical analysis.
Results: All the patients were female and comparable with respect to age (33.2 vs. 28.2 years) and size of nodule (2.7 vs. 3 cm) (TOETVA vs. ABA). The operative time (121 vs. 138.5 min, P = 0.34) and blood loss (50 vs. 60 ml, P = 0.9) were similar in both the groups. Even though the flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001), it was associated with more difficulty in approaching upper pole (P = 0.02) and lower pole (P < 0.001), more intra-operative events (30% vs. 10%, P = 0.58) and conversions to open (20% vs. 10%, P = 1). Similarly, post-operative pain scoring was more with TOETVA (3 vs. 2, P = 0.04). Hospital stay was similar in both the groups (2.5 vs. 3 days, P = 1). Patients in both the groups had both overall and cosmetic satisfaction.
Conclusions: Axillary-breast approach should be preferred to start learning the endoscopic thyroidectomy, as it is easier and safer than transoral endoscopic vestibular approach.


Keywords: Endoscopic thyroidectomy, minimally invasive thyroidectomy, scarless surgery



How to cite this URL:
Kumar C, Lohani KR, Kataria K, Ranjan P, Dhar A, Srivastava A. Endoscopic thyroidectomy: Which one is the better technique for the beginners?. J Min Access Surg [Epub ahead of print] [cited 2020 Oct 22]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=294956

Authors Kumar C and Lohani KR contributed equally to the research work and both should be considered as first authors



  Introduction Top


Conventionally, the open thyroidectomy has been the gold standard ever since the era of Theodor Kocher.[1] Sometimes, patients, especially young females, do not want a visible scar in the neck and thus delay their surgeries. In today's era, minimally invasive or scarless surgeries are standard of care whenever feasible. Even though the first laparoscopic cholecystectomy was done by Erich in 1985,[2] it took another 12 years to perform the first endoscopic thyroidectomy in 1997 by Hüscher.[3] Miccoli et al. then demonstrated feasibility of minimally invasive video-assisted thyroidectomy in 1998.[4] Various endoscopic thyroidectomies have ever since been attempted with either axillary-breast approach (ABA),[5],[6] transaxillary approach[7],[8] and transoral endoscopic thyroidectomy vestibular approach (TOETVA) approach.[9],[10],[11] However, endoscopic approach has not been widely utilised in developing countries because of non-availability, lack of training and long learning curve.[12]


  Methodology Top


It was a prospective non-randomised interventional study of patients who underwent endoscopic hemi-thyroidectomy with either TOETVA or ABA at the department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India, from June 2016 to March 2018. All endoscopic thyroidectomies were performed by a single surgeon who had experience in endoscopic and laparoscopic surgeries other than thyroid surgeries. All patients who presented to the outpatient department with solitary thyroid nodules of <3 cm were enrolled. They underwent triple assessment including the physical examination, imaging and fine-needle aspiration cytology (FNAC) along with the thyroid function test. Finally, patients with a diagnosis of benign thyroid nodules were included in the study. Patients with evidence of malignancy or metastasis were excluded from the study. Patients were explained about the options of the endoscopic approach for thyroidectomy. Patients were also explained about the possible need to convert it into open procedure in case of intra-operative events. After patients gave informed written consent for the procedure, they underwent routine pre-anaesthetic checkup for fitness. Routine pre-operative indirect laryngoscopy was also performed to evaluate the baseline vocal cord mobility. Patients underwent hemi-thyroidectomy either with ABA or TOETVA. Nasal intubation was done for patients undergoing TOETVA. A total of 78 hemi-thyroidectomies were performed during this period. This included the first 20 endoscopic procedures that formed the study population and included 10 each with ABA or TOETVA. Others were open procedures done under general anaesthesia (n = 10) or under superficial cervical block (n = 48). Of the total 78 patients, only 10 were male and all of them underwent only open procedure.

Pre-operative variables included age, gender, ultrasound size and volume of the tumour and Bethesda grading of FNAC. Intra-operative details included total operative time, blood loss, flap raising time, difficulty level for surgeon during each procedure, conversions, intra-operative events and whether recurrent laryngeal nerve and parathyroid glands were identified or not. Post-operatively, immediate complications were noted along with pain status, patient's overall satisfaction and patient's cosmetic satisfaction confirmed with nursing staff's evaluation. Follow-up details included any long-term complications, histopathological details and any need for completion thyroidectomy.

Likert's scoring system was used for difficulty in the procedure (1–5; very easy, easy, not so difficult, difficult and very difficult), patient's overall satisfaction (1–5; strongly disagree, disagree, neutral, agree and strongly agree) and cosmetic satisfaction (1–5; very unhappy, unhappy, neutral, happy and very happy). Success of the procedure was defined as a score of ≥4. Pain status was assessed using the visual analogue scale (VAS; 0–10). Adequate pain control was defined as VAS score of ≤3.

Procedure

Three standard ports were used for both the techniques, and an additional port was used in ABA if required. Adequate flaps were raised and the midline opened in the case of TOETVA and lateral approach was taken for ABA [Figure 1] and [Figure 2]. Drains were routinely placed after the procedure. Patients were allowed oral sips after 4 hours, followed by clear liquids irrespective of type of the approach. Normal diet was allowed on the next day after surgery. Routine chlorhexidine mouthwash was advised for patients who underwent TOETVA, from the day of surgery. Patients were routinely followed up after 1 week of discharge from the hospital. Indirect laryngoscopy was repeated in symptomatic patients.
Figure 1: Transoral extravestibular approach (a) incisions for ports (b) two 5 mm and one central 10 mm ports placed (c) medial-to-lateral dissection (d) post-operative status

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Figure 2: Axillary-breast approach (a) pre-operative marking for axillary-breast approach (b) One 10 mm peri areolar and two 5 mm axillary ports placed (c) lateral-to-medial dissection (d) post-operative status

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Statistical analysis was carried out with Sigma plot v 12.3. Categorical variables were evaluated using Chi-square or Fisher's exact test. Continuous variables were evaluated using t-test (mean ± standard deviation) or Mann–Whitney Rank Sum Test (Median; 25th– 75th quartile). Statistical significance was kept at P < 0.05.


  Results Top


Pre-operative variables

Both the groups were comparable in terms of age (33.2 vs. 28.2 years) and gender (all females in both the groups) [Table 1]. Bethesda classification based on FNAC (all category II in both groups) and size of the tumor as measured by ultrasound were also comparable between the groups (2.7 vs. 3 cm, P = 0.32).
Table 1: Pre-operative variables

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Operative variables

All patients underwent endoscopic hemi-thyroidectomy for solitary thyroid nodule. Operative time was comparable in both the groups (121 vs. 138.5 min) and so was the operative blood loss (50 vs. 60 ml) (TOETVA vs. ABA) [Table 2]. The flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001). However, the surgeon experienced more difficulty in approaching the upper pole and lower pole of thyroid in TOETVA with higher Likert scoring (4 vs. 2, P = 0.02 and 3.7 vs. 2 P < 0.001, respectively). Intra-operative events were more with TOETVA compared to ABA (30% vs. 10%, P = 0.58). It included intra-operative bleeding in TOETVA (10%) and subcutaneous emphysema (20% in TOETVA vs. 10% in ABA). Twenty percentage of conversions were present in TOETVA versus 10% in ABA (P = 1).
Table 2: Operative variables

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Post-operative outcomes

Patients in both the groups experienced almost similar post-operative complications in the form of transient voice change (10% vs. 20%), flap ecchymosis (0 vs. 10%), neck and face emphysema (20% vs. 10%), dysphagia (50% vs. 40%), flap paraesthesia (30% vs. 50%) and flap insensation (0 vs. 10%) in TEOTVA vs. ABA [Table 3]. Only one patient in ABA continues to have voice changes and is undergoing speech therapy. However, patients who underwent TOETVA experienced significantly more pain (3 vs. 2, P = 0.04) during the immediate post-operative period. Patients in TOETVA group stayed for a median duration of 2.5 days versus 3 days in the ABA group (P = 1). All patients reported overall and cosmetic satisfaction with Likert scoring of 4 versus 5 and 4 versus 4.5, respectively, with TOETVA versus ABA. Evaluation from nursing staff for cosmetic satisfaction revealed similar findings with Likert scoring of 5 versus 5. All patients in either group would recommend other patients for endoscopic procedure.
Table 3: Post-operative outcomes

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Follow-up details

On histopathological examination, majority of the patients were found to have adenomatous goitre (60% vs. 40%), papillary thyroid microcarcinoma (20% vs. 0), follicular adenoma (0 vs. 40%), microinvasive follicular carcinoma (10% vs. 0), follicular variant of papillary thyroid carcinoma (PTC) (0 vs. 10%) and thyroiditis (10% in each group) as TOETVA versus ABA [Table 4]. Weight of the resected gland (7 vs. 9.25 g), size of the resected gland (7.4 vs. 12.23 cc) and size of the tumour (5.8 vs. 6 cc) were comparable in both the groups.
Table 4: Follow up outcomes

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Twenty percentage of patients in TOETVA had to undergo open completion thyroidectomy. One patient had follicular microcarcinoma, which on completion thyroidectomy was found to have no residual foci of malignancy. Another patient had follicular variant of PTC, who underwent completion thyroidectomy along with lymph node dissection. Histopathological examination revealed only adenomatous changes with lymph nodes free of tumour.


  Discussion Top


Endoscopic thyroidectomy has gained importance for having similar efficacy as open with better cosmetic results.[4],[6],[7],[13] In our study, all patients had excellent cosmetic results with either TOETVA or ABA. However, pain was severe with TOETVA compared to ABA. Moreover, surgeon experienced more difficulty with flap raising in TOETVA with limited dissecting planes. Operative time and blood loss were also similar with either approach. Similar findings were noted in patients who underwent endoscopic thyroidectomy via vestibular or areolar approach.[11] Longer operative time has been reported with endoscopic approach, however, with associated less post-operative pain compared to open approach.[13] It can be because of long learning curve for endoscopic thyroidectomy. A study with TOETVA has found learning curve of 7–10 patients for endocrine surgeons who routinely perform laparoscopic procedures.[13] Common causes for conversions were found to be bleeding and difficult plane dissection.[14] In our experience, two patients in TOETVA group (20%) had to be converted to open procedure because of intra-operative bleeding in one patient and dense adhesions in the other. Similarly, dense adhesion was the cause of conversion noted in a patient who underwent thyroidectomy through ABA (10%). Bleeding was also a common cause of conversion in a large study with 425 patients who underwent TOETVA.[13] Proper evaluation and selection of patient is, therefore, essential especially in the early period of learning. This strategy is supported by a study, where in the earlier period of learning curve, young female patients with tumour diameter <5 cm and weight <60 g were selected. The study documented only one conversion out of 1250 patients who underwent endoscopic thyroidectomy via areolar access.[15] Our patient distribution was similar in both the groups except that the thyroid gland removed by TOETVA tended to have lower weight (7 vs. 9.25 g). Incidence of transient hoarseness of voice among patients with TOETVA or ABA was similar in our patients. The incidence of recurrent laryngeal nerve palsy in literature after thyroidectomy has been reported to be up to 7.2% for transient and up to 5.2% for permanent palsy.[16],[17],[18]

Transoral endoscopic vestibular access has the advantage of scarless skin and better cosmetics compared to areolar access.[19] In that sense, ABA approach cannot be considered truly minimally invasive, as it needs longer dissection plane.[9] Our results, however, have shown similar cosmetic satisfaction with either approach. Transoral vestibular approach also has the benefit of midline access which makes it easier for bilateral thyroidectomy and central neck dissection.[10] However, initially, on the learning curve, TOETVA might be difficult approach to start with as demonstrated by the present study.

Endoscopic procedure is feasible even for differentiated thyroid cancers[10],[20] and for completion thyroidectomy.[10] Endoscopic ABA has similar oncological outcome in terms of lymph nodes harvested, radioactive iodine uptake study and thyroglobulin levels for differentiated thyroid cancer who underwent total thyroidectomy and central lymph node dissection.[20] In the present study, however, two of ten patients under TOETVA underwent open completion thyroidectomy for follicular microcarcinoma and follicular variant of PTC. Utilising minimally invasive completion thyroidectomy would be another promising aspect.

Limitations

Small sample size is one of the limitations of the study. This questions its statistical significance and apparently higher percentage of the complications observed. Another aspect is the mixture of various procedures presented in the study that cannot be generalized to any individual procedure.


  Conclusions Top


The study is an initial experience of endoscopic thyroidectomy in a tertiary care setting of a developing country. It highlighted the feasibility, challenges and outcomes of the transoral endoscopic thyroidectomy vestibular approach and axillary-breast approach. Axillary-breast approach is an easier and safer technique of endoscopic thyroidectomy for the beginners.


  Future Directions Top


Our future studies will be focused on a larger study population with individual minimally invasive procedure and the comparison of its outcome with open thyroidectomies. Endeavors should also be taken to increase the implementation of the procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McGreevy PS, Miller FA. Biography of Theodor Kocher. Surgery 1969;65:990-9.  Back to cited text no. 1
    
2.
Litynski GS. Erich Mühe and the rejection of laparoscopic cholecystectomy (1985): A surgeon ahead of his time. JSLS 1998;2:341-6.  Back to cited text no. 2
    
3.
Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.  Back to cited text no. 3
    
4.
Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C. Minimally invasive surgery for thyroid small nodules: Preliminary report. J Endocrinol Invest 1999;22:849-51.  Back to cited text no. 4
    
5.
Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E, Ohashi S, et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 2003;13:196-201.  Back to cited text no. 5
    
6.
Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 2007;31:601-6.  Back to cited text no. 6
    
7.
Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy by the axillary approach. Surg Endosc 2001;15:1362-4.  Back to cited text no. 7
    
8.
Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-40.  Back to cited text no. 8
    
9.
Anuwong A, Kim HY, Dionigi G. Transoral endoscopic thyroidectomy using vestibular approach: Updates and evidences. Gland Surg 2017;6:277-84.  Back to cited text no. 9
    
10.
Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Indications, techniques and results. Surg Endosc 2018;32:456-65.  Back to cited text no. 10
    
11.
Wang C, Zhai H, Liu W, Li J, Yang J, Hu Y, et al. Thyroidectomy: A novel endoscopic oral vestibular approach. Surgery 2014;155:33-8.  Back to cited text no. 11
    
12.
Liu S, Qiu M, Jiang DZ, Zheng XM, Zhang W, Shen HL, et al. The learning curve for endoscopic thyroidectomy: A single surgeon's experience. Surg Endosc 2009;23:1802-6.  Back to cited text no. 12
    
13.
Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. JAMA Surg 2018;153:21-7.  Back to cited text no. 13
    
14.
Miccoli P, Minuto MN, Ugolini C, Pisano R, Fosso A, Berti P. Minimally invasive video-assisted thyroidectomy for benign thyroid disease: An evidence-based review. World J Surg 2008;32:1333-40.  Back to cited text no. 14
    
15.
Wang C, Feng Z, Li J, Yang W, Zhai H, Choi N, et al. Endoscopic thyroidectomy via areola approach: Summary of 1,250 cases in a single institution. Surg Endosc 2015;29:192-201.  Back to cited text no. 15
    
16.
Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 2002;112:124-33.  Back to cited text no. 16
    
17.
Barczyński M, Konturek A, Stopa M, Cichoń S, Richter P, Nowak W. Total thyroidectomy for benign thyroid disease: Is it really worthwhile? Ann Surg 2011;254:724-29.  Back to cited text no. 17
    
18.
Witt RL. Recurrent laryngeal nerve electrophysiologic monitoring in thyroid surgery: The standard of care? J Voice 2005;19:497-500.  Back to cited text no. 18
    
19.
Yang J, Wang C, Li J, Yang W, Cao G, Wong HM, et al. Complete endoscopic thyroidectomy via oral vestibular approach versus areola approach for treatment of thyroid diseases. J Laparoendosc Adv Surg Tech A 2015;25:470-6.  Back to cited text no. 19
    
20.
Qu R, Li J, Yang J, Sun P, Gong J, Wang C. Treatment of differentiated thyroid cancer: Can endoscopic thyroidectomy via a chest-breast approach achieve similar therapeutic effects as open surgery? Surg Endosc 2018;32:4749-56.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04