Mini review
Section 2. Thyroid: Total endoscopic thyroidectomy: axillary or anterior chest approach

https://doi.org/10.1016/S0753-3322(02)00274-3Get rights and content

Abstract

We have developed endoscopic thyroidectomy by an anterior chest approach and an axillary approach. In this study, we evaluate the efficacy of these two types of endoscopic procedures and conventional open surgery. The degree of surgical invasiveness and the nature of patients’ complaints after surgery were compared using the results of the operation and a questionnaire. The mean operating time for the endoscopic procedure was significantly longer than that for open surgery; however, there was no difference in postoperative pain in the three groups. Three months after surgery, the incidence of discomfort while swallowing in open surgery was higher than that in endoscopic surgery. All the patients who were treated using the axillary approach were satisfied with the cosmetic results. However, five patients (25%) who were treated using the anterior chest approach and 15 patients (75%; P < 0.01) who underwent open surgery complained abut the cosmetic results. The incidence of postoperative complaints after endoscopic surgery is significantly lower than that after open surgery. Patients who were treated using the axillary approach can obtain superior cosmetic results, compared with those who received other procedures.

Introduction

Thyroidectomies using a direct approach through the neck are effective, well-tolerated and safe. However, they require transverse incisions through the skin of the neck. Diseases of the thyroid gland are more common in women, so a reduction in size or the elimination of the incision in the skin of the neck is often desired.

Minimally invasive surgical techniques have attracted interest in all surgical specialties, and endoscopic surgery has begun to replace conventional open surgical techniques for abdominal and thoracic surgery over the last 10 years. In neck surgery, Gagner described the first endoscopic subtotal parathyroidectomy for hyperparathyroidism with a small neck scar in 1996 and obtained good clinical and cosmetic results 〚1〛. However, even small neck scars are highly unsatisfactory to some individuals. Then, alternative techniques were devised to further improve the results of endoscopic surgery 〚2〛, 〚3〛, 〚4〛, 〚5〛, 〚6〛, 〚7〛. We have developed novel techniques for endoscopic neck surgery by the anterior chest approach 〚8〛, 〚9〛 and by the axillary approach 〚10〛, 〚11〛, 〚12〛.

Here, we compared these two types of endoscopic procedures and conventional open surgery with regard to surgical invasiveness and patients’ complaints after surgery.

Section snippets

Patients and methods

Since August 1999, we have started endoscopic thyroid surgery. Indications for endoscopic thyroidectomy in a thyroid tumor were less than 6 cm in largest diameter as estimated by preoperative ultrasonography and were revealed to be benign follicular adenomas by fine-needle aspiration cytology. Patients with a history of thyroiditis or previous neck surgery and irradiation were excluded from endoscopic surgery. Preoperative informed consent was obtained in all cases.

In this study, 40 patients

Endoscopic procedure by the anterior chest approach

The patient was placed in a supine position with the neck extended while under general anesthesia. A 30-mm skin incision was made about 3.0 cm below the inferior border of the clavicle on the side of the lesion, and the upper portion of the pectoralis major muscle extracted manually. A 12-mm trocar was inserted through the incision, and a purse-string suture was made to prevent gas leakage and stop the trocar from slipping out of the wound. Carbon dioxide was then insufflated up to a pressure

Patient characteristics and surgical parameters

All endoscopic thyroidectomies were performed successfully. None of the patients developed hypercapnia at any time, and no complications of facial subcutaneous emphysema were observed. Subcutaneous emphysema in the neck and anterior chest resolved within the postoperative period.

Patient characteristics are presented in Table 2. The three groups were similar in age, gender and the mean diameter of the thyroid tumor. No statistically significant difference was found between the three groups

Discussion

Endoscopic procedures for minimally invasive surgery have been applied in various surgical specialties, and these surgical techniques are rapidly being applied to neck surgery. Using our endoscopic procedure, the thyroid gland is visualized laterally, and the perithyroid fascia is carefully cut, providing an operative field of view that is equivalent to that obtained during open surgery. This lateral view allows the recurrent laryngeal nerve and the parathyroid glands to be easily identified.

Conclusion

Although endoscopic neck surgery by the anterior chest or the axillary approach created pain and discomfort in the area of dissection between the skin incision and the neck in some patients, most complaints disappeared after about 3 months, leaving good cosmetic results, and no hypesthesia and paresthesia in the neck. Endoscopic thyroidectomy by the anterior chest approach may become the procedure of choice in patients who are anxious for good cosmetic results and less pain, while endoscopic

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