Journal of Minimal Access Surgery

REVIEW ARTICLE
[Download PDF]
Year : 2007  |  Volume : 3  |  Issue : 1  |  Page : 3--7

Endoscopic neck surgery

PK Chowbey, Vandana Soni, R Khullar, Anil Sharma, M Baijal 
 Department of Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
P K Chowbey
Minimal Access and Bariatric Surgery Centre, Room No. 200, Sir Ganga Ram Hospital, New Delhi - 11060
India

Abstract

Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar surgical technique was used for performing thyroidectomy the following year. Most commonly reported endoscopic neck surgery studies in literature have been on thyroid and parathyroid glands. The approaches are divided into two types i.e., the total endoscopic approach using CO2 insufflation and the video-assisted approach without CO2 insufflation. The latter approach has been reported more often. The surgical access (port placements) may vary-the common sites are the neck, anterior chest wall, axilla, and periareolar region. The limiting factors are the size of the gland and malignancy. Few reports are available on endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and feasible in suitable patients with thyroid and parathyroid pathologies. Application of this technique for approaching other cervical organs such as the submandibular gland and carotid artery are still in the early experimental phase.



How to cite this article:
Chowbey P K, Soni V, Khullar R, Sharma A, Baijal M. Endoscopic neck surgery.J Min Access Surg 2007;3:3-7


How to cite this URL:
Chowbey P K, Soni V, Khullar R, Sharma A, Baijal M. Endoscopic neck surgery. J Min Access Surg [serial online] 2007 [cited 2021 Apr 22 ];3:3-7
Available from: https://www.journalofmas.com/text.asp?2007/3/1/3/30679


Full Text

 Introduction



The cervical region comprises a plethora of well-defined anatomical structures systematically arranged in layers with minimal or negligible vascular overlap these well-defined layers form the vascular anatomical planes, which have been exploited by the endoscopic surgeon to create a working space for surgical manipulation. Reported initially in 1996,[1] endoscopic neck surgery has evolved in its application especially due to cosmetic benefits. The primary target organs have been the parathyroid and the thyroid glands,[2],[3],[4],[5],[6],[7],[8],[9] although few studies have reported on its application to other cervical structures, such as the sub-mandibular gland and cervical spine.[9],[10] Furthermore the approaches may be classified into total (pure) endoscopic (CO 2 insufflation).[3],[4],[5],[6] video- assisted endoscopic[11],[12],[13],[14] and minimally invasive mini incision approaches.[15],[16],[17],[18] The total endoscopic approach has been further sub-classified into a supraclavicular, anterior chest wall, axillary, and periareolar breast approach. The latter three have also been attempted in the video assisted endoscopic approach.

 Endoscopic parathyroidectomy



Reported in 1996 by Gagner,[1] the parathyroid glands especially due to their size are amenable to the endoscopic approach. The drawback is their variable position. Minimally invasive parathyroidectomy has evolved due to a parallel progress in imaging and localizing techniques making a targeted approach possible.

The commonly performed localization studies are the 99TC sestamibi scan and cervical ultrasound.[19],[20],[21],[22],[23],[24] A combination of the sestamibi scan along with a radiological investigation has been described as equivalent to an open conventional bilateral exploration of the neck for localizing the parathyroid lesion. High-resolution cervical ultrasonography alone has reported a high success rate of 94% for pre-operative specific side localization of the parathyroid lesion.[20] The sensitivity was reported as 89% with a 98% positive predictive value.

The most popular minimally invasive approach for performing parathyroidectomy is the focused minimally invasive mini incision approach.[25],[26] Few reports are available for total endoscopic parathyroidectomy, reporting on limited number of patients. Currently just below 50% of all parathyroidectomies are being performed by the minimal access approach popularly known as minimally invasive parathyroidectomy (MIP).[27] Restrictions in its applicability are selection criteria such as unilateral disease, (preferably a single adenoma), absence of thyromegaly, no previous neck surgery and no previous history of irradiation to the neck region.[28],[29],[30]

Techniques to ensure complete removal of the hyper functioning parathyroid tissue in MIP reported are intra-operative rapid parathormone assays,[29],[31],[32],[33],[34] frozen section and good clinical judgment followed by post-operative S.Ca++ and PTH level monitoring. Several studies have also reported day care MIP using local/regional anesthesia.[26] Such centers apply techniques, such as chemilumiscent assay for intact PTH level (quick PTH) giving a success rate of 95-98% to ensure a cure for the patient before discharge.[35],[36],[37],[38] However, these results are best observed in patients with uniglandular disease. Provided a careful preoperative patient selection is performed, an MIP will cure the patient whether or not an intra operative QPTH assay is done [Table 1].[25]

Carbon dioxide embolization, a potential life threatening complication has so far not been reported.

Our own experience spans 8 years with 18 patients of primary hyperparathyroidism (PHPT) subjected to total endoscopic parathyroidectomy. About 17 of these patients were diagnosed with a single parathyroid adenoma on 99TC sestamibi scan corroborated by an ultrasonography neck or an magnetic resonance imaging scan. One patient was diagnosed to have parathyroid hyperplasia. Ten procedures (7 procedures with CO 2 insufflation and three procedures video-assisted) were performed by a supraclavicular approach, four by an anterior chest wall approach, and four by a periareolar breast approach. Carbon dioxide insufflation was maintained at 10 mm of Hg. Post-operative monitoring of S Ca++ and S PTH levels were done to confirm complete removal of all hyper functioning parathyroid tissue. There was one conversion due to non-localization of the parathyroid adenoma. The tumor was identified in the tracheo-esophageal groove. Although the number of patients in our experience is small, the results conform to those reported in literature in terms of safety and feasibility.

Our progress from a supraclavicular approach to a periareolar approach is strongly driven by superior cosmetic results, as the dissection involved in this approach is much more than a focused mini-incision approach.

 Endoscopic thyroidectomy



Unlike parathyroidectomy, endoscopic thyroidectomy has progressed toward more remote sites of access to improve cosmesis and provide patients with a scar less neck. This has been more on patient demand as thyroid disease predominantly affects women. Endoscopic thyroidectomy was first reported in 1997[2] since then several reports have been published describing novel ways (neck, chest wall, axilla, and breast)[2],[3],[4],[6],[8],[40],[41] of access to this gland. Indications for endoscopic thyroidectomy in various studies include solitary, benign thyroid nodules, follicular and oxyphilic cell tumors, papillary micro carcinomas ( 2 insufflation. Studies comparing intra operative pain and speed of recovery (return to normal activity) have all reported results in favor of the endoscopic approach[6],[11],[45],[62] reaching statistical significance although analgesic requirement was not different.[52]

Both video-assisted and total endoscopic approaches have been reported for operating on thyroid cancer. The prerequisite are papillary tumors 2sub to 5 x 4.1 cm 2 (the specimen were not weighed).

The sub-mandibular gland and other structures

A few reports have been published over the past 2 years about an endoscopic approach to the sub-mandibular gland.[62],[63] It has been demonstrated in cadaveric models to be possible.[64] Initial attempts, reported injury to facial artery and lingual nerve. Video-assisted approach deploying the harmonic scalpel has also been reported with a 15-20 mm skin incision. Endoscopic sentinel lymph node biopsy in oral malignancy is another area where this potential is being explored.[65] These reports are all in the very early phase and may at the most be described as experimental. The cervical spine is another region where endoscopy is being commonly practiced, but since it involves a specialty branch that is neuro surgery, it has not been discussed here.

 Conclusion



Endoscopic neck surgery offers a definite cosmetic advantage over its conventional counterpart. With increasing skill and patient demand, this surgery is going to be performed in more centers. However careful patient selection is advocated. Though few centers are reporting good results in thyroid malignancy, the role of endoscopy in thyroid malignancy is as yet controversial. Endoscopic approach to other neck structures such as the sub-mandibular gland is as yet in the experimental stage[68].

References

1Gagner M. Endoscopic subtotal para thyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996;83:875.
2Yeung HC, Ng WT, Kong CK. Endoscopic thyroid and parathyroidectomy surgery. Surg Endosc 1997;11:1135.
3Moural M, Pugin F, Elias B, Malaise J, Coche E, Jamar F, et al . Contribution of the video assisted approach to thyroid and parathyroid surgery. Acta Chir Belg 2002;102:323-8.
4Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy and parathyroidectomy by the axillary approach. A preliminary report. Surg Endosc 2002;16:92-5.
5Maeda S, Shimizu K, Minami S, Hayashida N, Kuroki T, Furuichi A, et al . Video-assisted neck surgery for thyroid and parathyroid diseases. Biomed Pharmacother 2002;56:92s-5s.
6Gagner M, Inabnet BW 3rd, Bierthoh L. Endoscopic thyroidectomy for solitary nodules. Ann Chir 2003;128:696-701.
7Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-40.
8Cougard P, Osmak L, Esquis P, Ognois P. Endoscopic thyroidectomy. A preliminary report including 40 patients. Ann Chir 2005;130:81-5.
9Chantawibul S, Lokechareonlarp S, Pokawatana C. Total video endoscopic thyroidectomy by an axillary approach. J Laparoendosc Adv Surg Tech A 2003;13:295-9.
10Guyot L, Duroure F, Richard O, Lebeau J, Passagia JG, Raphael B. Submandibular gland endoscopic resection: A cadaveric study. Int J Oral Maxillofac Surg 2005;34:407-10.
11Ruggieri M, Straniero A, Pacini FM, Maiuolo A, Mascaro A, Genderini M. Video assisted surgery of the thyroid diseases. Eur Rev Med Pharmacol Sci 2003;7:91-6.
12Shimizu K, Tanaka S. Asian perspective on endoscopic thyroidectomy: A review of 193 cases. Asian J Surg 2003;26:92-100.
13Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G. Comparison between minimally invasive video assisted thyroidectomy and conventional thyroidectomy: A prospective randomized study. Surgery 2000;130:1039-43.
14Gauger PG, Reeve TS, Delbridge LW. Minimal access/minimally invasive parathyroidectomy. Br J Surg 1999;86:1563-6.
15Palazzo FF, Delbridge LW. Minimal access/minimally invasive parathyroidectomy for primary hyperparathyroidism. Sirg Clin North Am 2004;84:717-34.
16Gosnell JE, Sackett WR, Sidhu S, Sywak M, Reeve TS, Delbridge LW. Minimal access thyroid surgery: Technique and report of the first 25 cases. ANZ J Surg 2004;74:330-4.
17Malinvaud D, Potard G, Fortun C, Saraux A, Jezequel JA, Marianowski R. Management of primary hyperthyroidism: Toward minimal access surgery. Joint Bone Spine 2004;71:111-6.
18Lowney JK, Weber B, Johnson S, Doherty GM. Minimal incision parathyroidectomy: Care, cosmesis and cost. World J Surg 2000;24:1442-5.
19Ben-Haim M, Zwas T, Mintz Y, Rosin D, Bar-Zakai B, Natur M, et al . Novel approach to parathyroid adenoma: Minimally invasive, focused, scan guided parathyroidectomy-experience from the first 100 cases. Harefuah 2003;142:242-5,320.
20Gilat H, Cohen M, Feinmessr R, Benzion J, Shvero J, Segal K, et al . Minimally invasive procedure for resection of a parathyroid adenoma: The role of preoperative high resolution ultrasonography. J Clin Ultrasound 2005;33:283-7.
21Yamashita H, Noguchi S. Recent advances in the diagnosis and treatment of primary hyperparathyroidism. Nippon Geka Gakkai Zasshi [Japanese] 2005;106:468-71.
22Fuchs SP, Smits AB, de Hooge P, Muller AF, Gelissen JP, van Dalen T. Minimally invasive parathyroidectomy: A good operative procedure for primary hyperparathyroidism even without the use of intraoperative parathyroid hormone assessment or a gamma probe. Ned Tijdschr Geneeskd 2005;149:1463-7.
23Lee JA, Inabnet WB 3rd. The surgeon's armamentarium to the surgical treatment of primary hyperparathyroidism. J Surg Oncol 2005;89:130:5.
24Rodriguez-Carranza S, Caceres M, Aguilar-Salinas CA, Gomez-Perez FT, Herrera MF, Pantoja JP, et al . Localization of parathyroid adenomasby (99 m) Tc-Sestamibir scanning: Upper neck versus lower neck lesions. Endocr Pract 2004;10:472-7.
25Agarwal G, Barraclough B, Reene TS, Delbridge LW. Minimally invasive parathyroidectomy using the "focused" lateral approach;2: Surgical technique. ANZ T Surg 2002;72:147-51.
26Cohen MS, Finkelstein SE, Brunt LM, Haberfeld E, Kangrga I, Moley JF, et al . Outpatient minimally invasive parathyroidectomy using local / regional anaesthesia: A safe and effective operative approach for selected patients. Surgery 2005;138:681-9.
27Sackett WR, Barraclough B, Reeve TS, Delbridge HW. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Arch Surg 2002;137:1055-9.
28Henry JK, Sebag F, Tamagnini P, Forman C, Silaghi H. Endoscopic parathyroid surgery: Results of 365 consecutive procedures. World J Surg 2004;28:1219-23.
29Miccoli P, Bendinelli C, Vignali E, Mazzeo S, Cecchini GM, Pinchera A, et al . Endoscopic parathyroidectomy: Report of an initial experience surgery. 1998;124:1077-80..
30Cougard P, Goudet P, Bilosi M, Peschaud F. Videoendoscopic approach for parathyroid adenomas: Results of a prospective study of 100 patients. Ann Chir 2001;126:314-9.
31Miccoli P, Berti P, Puccini M, Bendinelli C, Conte M, Picone A, et al . Video assisted parathyroidectomy: A series of 85 cases. Chirurgie 1999;124:511-5.
32Henry JF, Sebag F, Maweja S, Hubbard J, Misso C, Da Costa V, et al . Video assisted parathyroidectomy in the management of patients with primary hyper parathyroidism. Ann Chir 2004;128:379-84.
33Jortay AM, Verongstracte G, Wittersheim E, Hooghel L, Bisschop P, Bergmann P. Intraoperative measurement of parathyroid hormone in minimally invasive surgery for parathyroid adenoma. Acta Otohinolaryngeal Belg 2004;58:125-8.
34Schiffmann L, Mann B, Hotz H, Buhr HJ. Minimal invasive surgery for pHPT - which patients will profit? Zentrabl Chir 2003;128:561-5.
35Irvin GL. American Association of Endocrine Surgeons. Presidential address: Chasin' hormones. Surgery 1999;126:993-7.
36Irvin GL 3rd, Carneiro DM. Management changes in primary hyperparathyroidism. JAMA 2000;284:934-6.
37Carneiro DM, Irvin GL 3rd. Late parathyroid function after successful parathyroidectomy guided by intraoperative hormone assay (QpTH) compared with the standard bilateral neck exploration. Surgery 2000;128:925-36.
38Mekel M, Mahajna A, Ish-Shalom S, Barak M, Segal E, Salih AA, et al . Minimally invasive surgery for treatment of hyperparathyroidism. Isr Med Assoc J 2005;7:323-7.
39Carty SE. Prevention and management of complications in parathyroid surgery. Otolaryngol Clin N Am 2004;37:897-907.
40Park YL, Han WK, Bae WG. 100 cases of endoscopic thyroidectomy: Breast approach. Sur Laparosc Endosc Percu Tech 2003;13:20-5.
41Takami H, Ikeda Y. Minimally invasive thyroidectomy. ANZ Surg 2002;72:841-2.
42Takami H, Ikeda Y. Total endoscopic thyroidectomy. Asia J Surg 2003;26:82-5.
43Takami HE, Ikeda Y. Minimally invasive thyroidectomy. Curr Opin Oncol 2006;18:43-7.
44Miccoli P, Berti P, Raffaelli M, Coute M, Materazzi G, Galleri D. Minimally invasive video-assisted thyroidectomy. Am J Surg 2001;181:567-70.
45Miccoli P, Minuto MN, Barellini L, Galleri D, Massi M, D'Agostino J, et al . Minimally invasive video assisted thyroidectomy - techniques and results over 4 years of experience (1992-2002). Ann Ital Chir 2004;75:47-51.
46Miceoli P, Bellantone R, Mourad M, Walz M, Raffaelli M, Berti P. Minimally invasive video-assisted thyroidectomy: Multiinstitutional experience. World J Surg 2002;26:972-5.
47Bellantone R, Lombardi CP, Raffaelli MP, Boscherino M, de Crea C, Alesina PF, et al . Video assisted thyrodiectomy. Asia J Surg 2002;25:315-8.
48Musella M, Lombardi S, Caiazzo P, Milone F, Di Palma R, de Franciscis S, et al . Video-assisted surgery of the thyroid: Outlines of the technique and analysis of the results. Ann Ital Chir 2003;74:3-7.
49Palazzo FF, Sebag F, Henry JF. Endocrine Surgical technique: Endoscopic thyroidectomy via the lateral approach. Surg Endosc 2006;20:339-42.
50Gorness JE, Sackett WR, Sidhu S, Sywak M, Reeve TS, Delbridge LW. Minimal access thyroid surgery: Technique and report of first 25 cases. ANZ J Surg 2004;74:330-4.
51Mourad M, Pugin F. Elias B, Malaise J, Coche E, et al . Contributions of the video assisted approach to thyroid and parathyroid surgery. Acta Chir Belg 2002;102:323-7.
52Gagner M, Inabnet WB 3rd. Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 2001;11:161-3.
53Bellantone R, Lombardi CP, Bossola M, Boscherim M, De Crea C, Alesina PF, et al . Video assisted vs conventional thyroid lobectomy: A randomized trial. Arch Surg 2002;137:301-5.
54Inabnet WB, Gagner M. Endoscopic thyroidectomy: Supraclavicular approach. In : Gagner M, Inabnet WB 3rd, editors. Minimally Invasive Endocrine surgery. Lippincott William and Wilkins: Philadelphia; 2002. p. 44-5.
55Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, De Crea C, Traini E. Video-assisted thyroidectomy. J Am Coll Surg 2002;194:610-4.
56Kim JS, Kim KH, Ahn CH, Jeon HM, Kim EG, Jeon CS. A clinical analysis of gasless endoscopoic thyrodiectomy. Surg Laparosc Endosc Percutan Tech 2001;11:268-72.
57Shimizu K, Akira S, Jasmi AY, Kitamura Y, Kitagawa W, Akasu H, et al . Video-assisted neck surgery: Endoscopic resection of thyroid tumors with a very minimal neck wound. J Am Coll Surg 1999;88-697-703.
58Yeh TS, Jan YY, Hsu BR, Chen KW, Chen MF. Video-assisted endoscopic thyroidectomy. Am J Surg 2000;180:82-5.
59Lombardi CP, Raffaelli M, Princi D, De Crea C, Bellantone R. Videoassisted thyroidectomy: Report of a 7 year experience in Rome. Langenbecks Arch Surg 2006;391:174-7.
60Mourad M, Saab N, Malaise J, Ngongang C, Fournier B, Daumerie C, et al . Minimally invasive video-assisted approach for partial and total thyroidectomy initial experience. Surg Endosc 2001;15:1108-11.
61Palazzo FF, Sywak MS, Sidhu SB, Delbridge LW. Safety and feasibility of thyroid lobectomy via a lateral 2.5-cm incision with a cohort comparison of the first 50 cases: Evolution of a surgical approach. Langenbecks Arch Surg 2005;390:230-5.
62Suzuki S, Takenoshita S. Current topics endoscopic surgery for thyroid cancer. Nippon Geka Gakkai Zassli 2006;107:59-63.
63Komatsuzaki Y, Ochi K, Sugiura N, Hyodo M, Okamoto A. Video-assisted submandibular sialadenectomy using an ultrasonic scalpel. Auris Nasus Larynx 2003;30:S75-8.
64Kessler P, Bloch-Birkholz A, Birkholz T, Neukam FW. Feasibility of an endoscopic approach to submandibular neck region - experimental and clinical results. Br J Oral Maxillofac Surg 2006;44:103-6.
65Guyot L, Duroure F, Richard O, Lebeau J, Passagia JG, Raphael B. Submandibular gland endsocopic resection: A cadaveric study. Int J Oral Maxillofax Surg 2005;34:407-10.
66Pedachenko EG, Tanaseichuk AF, Khizhniak MV, Pedachenko IuE. Endoscopic microsurgery in cervical disc hernias. Zh Vopr Neirokhir Im N N Burdenko [Russian] 2003;1:15-7.
67Sipperstein AE, Berber E, Morkoyun E. The ise o the harmonic scalpel vs conventional knot lying for vessel ligation in thyroid surgery. Arch Surg 2002;137:137-42.
68Pitman KT, Sisk JD. Endoscopic sentinel lymph node biopsy in a porcine model. Laryngoscope 2006;116:804-8.