Transorale endoskopische Thyreoidektomie

Background

Surgical access trauma in thyroidectomy has been minimized by the adoption of minimally invasive techniques. Extracervical approaches moved the incision lines outside of the visible neck region. However, because of the extensive dissection they no longer comply with the term minimally invasive. Therefore, our goal was to reduce the access trauma and establish a non-traumatic approach according to surgical planes for endoscopic minimally invasive thyroidectomy: the transoral approach.

Material and methods

In a preclinical investigation anatomical dissection was performed on three human cadavers to visualize anatomical relationships and identify safe zones of access to the anterior neck and the submandibular regions. The investigation focused on relevant vascular and neural structures in the floor of mouth. Endoscopic minimally invasive thyroidectomy was additionally performed in five specimens with anatomical dissections for the evaluation of collateral damage.

Results

For a safe approach the optic trocar can be placed sublingually in the midline as there are no relevant vascular or neural structures on the way to the thyroid region. The working trocars can be placed bilaterally in the oral vestibule behind the canine teeth. In this way access and dissection plane are placed directly in an avascular subplatysmal area and the pretracheal working space can be reached easily, safe and fast.

Conclusions

Minimum impact and a gentle dissection according to anatomical planes are the rational for the transoral route to the thyroid gland. Thus based on anatomical dissections the foundations of a novel procedure in the context of natural orifice surgery (NOS) could be established.     

Endoscopic minimally invasive thyroidectomy: first clinical experience

Background

Since Theodor Kocher reduced the mortality rate of thyroidectomy from the 40% reported by Billroth to 0.2% in 1895, a collar incision with open removal of the thyroid gland is the standard procedure [1, 2]. In the past decade, efforts were made to reduce incision size and surgical access trauma by the use of endoscopic techniques. A first attempt was replacement of the central “Kocher incision” with lateral neck incisions and endoscopic removal of a thyroid lobe by Hüscher on 8 July 1996 [3]. This lateral access was limited to removing only one lobe of the gland. The most common technique to date is the one developed by Miccoli et al. [4]. These authors reduced the incision to a size of 20 to 25 mm and operated on the thyroid by the use of video-endoscopic assistance (MIVAT). Several groups have described an access outside the frontal neck region via a chest [5–8], axillary [9], or combined axillary bilateral breast approach [10]. These accesses only moved the entry point from the frontal neck region to other regions, where they are still visible. The aforementioned minimally invasive approach and the conventional open approach do not respect anatomically given surgical planes and may therefore result in patient complaints, especially swallowing disorders after the scaring of the subcutaneous tissues. These extracervical approaches are associated with an extensive dissection in the access area and thus are maximally invasive. Therefore, we developed an exclusively endoscopic approach for thyroid resection [11] with standard instruments used for minimally invasive surgery (diameter, 3.5 mm). This endoscopic minimally invasive thyroidectomy (eMIT) technique was evaluated carefully by anatomic and cadaver dissections as well as ultrasound studies for technical realization and needs for instrument design [12]. To verify the safety and feasibility of the method, an animal trial was conducted in August 2008. Surgery was performed securely on five pigs, with very low blood loss. The postoperative behavior with special regard for feeding and pain reaction was normal until dissection. Especially, no local infection in the oral cavity or cervical spaces was noted.

Methods

All the trials of eMIT showed good results, so we went on to its first clinical application in the spring of 2009. A 53-year-old man had experienced dysphagia for more than a year. During routine diagnosis, the thyroid hormones T3, T4, and TSH were controlled and within normal levels. Thyroid scintigraphy, B-mode ultrasound examination, and laryngoscopy were performed preoperatively. An euthyroid nodular chance of the right hemithyroid with a beginning focal autonomy was diagnosed. After the patient’s informed consent was received, surgery was performed on 18 March 2009 in an interdisciplinary collaboration between a general surgeon and a head and neck surgeon. The first incision was made in the midline sublingually. A 5-mm trocar was directed through the floor of the mouth muscles into the subplatysmal layer and positioned at the level of the cricoid. Carbon dioxide then was insufflated at 6 mmHg to build a tent above the thyroid gland. Next, a second trocar for insertion of the surgical instruments was placed over a vestibular incision into the same subplatysmal layer. This allowed the surgical field to be visualized fully and dissected with 3.7-mm standard minimally-invasive instruments. A third trocar for surgical instruments then was placed through an incision on the left side of the vestibule of the mouth. After a midline incision of the linea alba, the fibrous capsule of the thyroid gland could been seen. The isthmus then was prepared in total. Next, the strap muscles above the right hemithyroid were prepared, showing the right upper pole. With the Harmonic scalpel, the isthmus was divided on the left side. The gland was loosened from the trachea and the adjacent lamella. The vessels of the upper pole were divided by Ultracision (Ethicon-Endosurgery, Cincinnate/Ohio, USA). Under the adjacent lamella, the recurrent nerve was visualized and stimulated. Neuro-monitoring showed an intact function of the nerve. Finally, the lower pole was detached, allowing the thyroid to be freely movable. Recovery of the tumor was performed through the median trocar incision after the optic device was moved through a lateral trocar. The tumor volume was 5.5 ml. The operation site was checked for bleedings and lavaged with sodium chloride. After removal of all the trocars, the wounds were sutured with self-resorbable sutures. Plaster tape was applied for 24 h. No direct postoperative complications occurred. Postoperative histology showed a colloidal struma.

Results

The floor of the mouth healed well, with no local infections at the incision sites or in the cervical spaces. Vocal cord function, evaluated by direct video-laryngoscopy, was normal. The patient had minimal swelling of the neck and a small hematoma, which resolved within 2 weeks. He had neither swallowing disorders nor oral pain. His preoperative dysphagia was gone, and he left the clinic 2 days after surgery without any complaints.

Conclusion

With the development of an exclusively endoscopic approach for thyroid resection (eMIT) and its first clinical application, we could show the safety and feasibility of another natural orifice surgery procedure. One major concern before surgery was possible infection of the cervical spaces by introduction of oral flora to these regions. Investigating this infection risk, Hong and Yang [13] evaluated the surgical results associated with the intraoral approach for submandibulectomy in a series of 77 cases of chronic sialadenitis and benign mixed tumors. The infection rate was 2.6% (2 patients) compared with 7.3% in a control group of 251 patients who underwent a transcervical procedure [13]. Therefore, we estimated the infection risk to be lower than with conventional transcervical approaches. The clear advantages of this technique are its minimally invasive character, its reduction of surgical trauma, its direct access to surgical planes and spaces, its avoidance of swallowing disorders and postoperative dysphagia, and finally, its avoidance of any skin scars. Further trials are already being conducted.     

Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma: a preliminary report

Background  

Traditional open surgery for lateral neck dissection for patients with papillary thyroid carcinoma (PTC) requires a large incision to obtain adequate exposure of the surgical field, leaving an unsightly scar. We applied scarless (in the neck) endoscopic thyroidectomy (SET) via breast approach to lateral neck dissection for PTC and evaluated its feasibility and safety.     

Single Incision (“Scarless”) Laparoscopic Total Abdominal Colectomy with End Ileostomy for Ulcerative Colitis

Introduction  

Total abdominal colectomy with ileal pouch–anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.     

Minimally invasive thyroid and parathyroid surgery is not a question of length of the incision

INTRODUCTION: Postoperative cosmesis in the neck is often a major concern of patients, particularly women, undergoing thyroid or parathyroid surgery. Therefore, a reduction in the length of the cervical incision, and even more so, having no scar in the neck, is particularly appealing to these patients. Over the last years, many different so-called minimally invasive procedures have been proposed for the treatment of thyroid and parathyroid diseases, the primary aim being to improve the cosmetic results. Nevertheless, the concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, minimally invasive thyroidectomy or minimally invasive parathyroidectomy should properly be defined as operations through a short, less than 3 cm, and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection. In addition, type of anesthesia, duration of the operation, postoperative pain, complication and success rates, and long-term outcome should also be taken into account to assess surgical invasiveness. CONCLUSION: Thyroid and parathyroid operations that minimize the incision but keep it in the neck may be considered minimally invasive not only in respect of the size of the skin incision but also, and above all, in respect of the accessibility of the operative field and extent of dissection. These operations have some advantages over conventional cervicotomy in terms of postoperative pain and cosmetic results. Until now, there is no evidence to state that morbidity of these new approaches is at least equal to the conventional equivalent. Operations that employ an extracervical approach, which have the advantage of leaving no scar in the neck, cannot reasonably be described as minimally invasive, as they require more dissection than conventional open surgery.     

Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial

Background  

For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation.     

Endoscopic perineal approach to the presacral space: a feasibility study

Background  Currently, pathologies from the presacral space are explored primarily by using transabdominal approaches. Major complications may occur, including bowel and rectal perforation, or bleeding. To avoid and reduce these potentially severe risks, a new surgical approach to the presacral space, which permits exploration through the perineum with minimal invasive techniques, had already been developed and is now further elaborated in a cadaver and clinical study. Study design  A prospective study was performed using four cadavers with no history of pelvic or perineal disease. A minimally invasive exploration of the presacral retroperitoneum was performed to examine a potential new anatomical surgical space. After positioning the patients in the prone or supine position, a 1-cm vertical median incision was made in the ano-coccygeal ligament. Entry to the presacral space was first established through blunt-finger and balloon dissection. A 30° 10-mm laparoscope was inserted through a 12-mm trocar, and two additional 5-mm trocars were inserted to avoid injury to the sciatic nerve. A clinical pilot study was performed on three patients using this technique. Results  Under direct vision, a wide dissected cavity was observed, with the rectum and mesorectum retracted ventrally. Access and manipulation of posterior pelvic organs were simplified. Placing cadavers in the jack-knife position provided superior accessibility to the presacral space when compared with a supine position. Clear exposure of the sacrum, mesorectum, ureters and bladder, prostate region, iliac vessels (with its branches), and lymph nodes was achieved. Conclusion  Endoscopic perineal approach to the presacral space was considered.     

Minimally invasive videoscopic parathyroidectomy by lateral approach

Methods: A videoscopic parathyroidectomy was performed in 22 patients presenting with primary hyperparathyroidism (PHPT). No patient had undergone previous neck surgery, presented with goiter or had a history of familial PHPT. Ultrasonography and Sestamibi scanning were performed preoperatively. Rapid intact parathormone assay was used during surgery. Through a 15-mm transversal skin incision on the anterior border of the sternocleidomastoid muscle (SCM), the fascia connecting the lateral portion of the strap muscles and the thyroid lobe with the carotid sheath was gently divided, far enough to visualize the prevertebral fascia. Once enough space was created, three trocars were inserted: a 12-mm trocar through the incision and two 2.5-mm trocars on the line of the anterior border of the SCM, above and below the first trocar. Carbon dioxide was insufflated to 8 mmHg. Unilateral video-assisted parathyroid exploration was then carried out using a 10-mm O° endoscope. Once the adenoma had been identified, the trocars were removed. Then, directly through the skin incision, the thyroid lobe was retracted medially and the adenoma was extracted after clipping its pedicle. Results: Among the 23 enlarged glands, 20 (80%) were correctly identified by endoscopic exploration: mean weight 843 mg (100 mg to 5 g). The exploration was unilateral in 17 patients but bilateral in 5. Mean time of unilateral endoscopic exploration was 84 min (40–130 min). Morbidity was represented by two superficial hematomas. All 22 patients were biochemically cured, follow-up ranging from 3 months to 14 months. Conclusions: This preliminary study demonstrates that minimally invasive videoscopic parathyroidectomy by lateral approach is a feasible surgical procedure. Received: 24 November 1998 Accepted: 3 March 1999     

“Scarless” (in the Neck) Endoscopic Thyroidectomy (SET): An Evidence-based Review of Published Techniques

BACKGROUND: Excision of the thyroid through a skin crease incision in the anterior neck provides good direct exposure to facilitate safe dissection and a quick operation with low morbidity and minimal mortality. However, these patients still have a scar in the neck. Technologic innovations have allowed surgeons to remove the thyroid gland from a remote site, providing a scarless outcome in the neck. This study was designed to assess the different techniques of scarless (in the neck) endoscopic thyroidectomy (SET) by reviewing the current literature. METHODS: A computer-assisted search of the Medline database through September 2007 was undertaken. The combination of terms used included the following: endoscopic thyroidectomy; minimally invasive thyroidectomy; minimally invasive endocrine surgery; thyroidectomy via the axillary approach; thyroidectomy via the anterior approach; and thyroidectomy via the breast approach. Additional data were provided based on previously unpublished experience from our own unit with SET. RESULTS: There were seven studies that involved 186 patients in whom the thyroid was excised via the axillary method and five published series that involved 169 patients who had thyroidectomies performed via the anterior approach. There were four published series of thyroidectomies performed via a hybrid approach, which is a combination of both the anterior and axillary approach, involving 180 patients. Four studies compared SET and another approach for a thyroidectomy. In our unpublished series of SET, we performed 20 cases during a 2-year period comprising 11 cases via the axillary approach and 9 cases via the anterior/breast approach. Nineteen cases were lobectomies and one case was an isthmusectomy. SET was associated with a longer operative time and increase postoperative pain. Patients who had SET were satisfied with the aesthetic outcome of the procedure. CONCLUSION: Scarless (in the neck) endoscopic thyroidectomy is not a minimally invasive technique but a maximally invasive one that involves a longer operative time and greater postoperative pain. What it does provide is a safe excision of the thyroid pathology with the absence of a scar in the neck. However, there is a steep learning curve. With experience and newer surgical instruments, the operative time and postoperative pain might decrease.     

Natural orifice translumenal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy

Background  Natural orifice translumenal endoscopic surgery (NOTES), an emerging field in minimally invasive surgery, is driving the development of new technology and techniques. The NOTES approach has several proposed benefits including potentially decreased abdominal pain, wound infections, and hernia formation [1–4]. Cholecystectomy is one of the most commonly performed NOTES procedures to date [5–7]. To perform a safe cholecystectomy and reduce potential bile duct injuries, the cystic duct and artery must first be identified. Establishing this critical view of safety before ligation and division has been shown to reduce bile duct injuries associated with laparoscopic cholecystectomy [8]. This video shows that the critical view of safety can be attained with endoscopic dissection. Methods  In the porcine model, transcolonic peritoneal access is gained using an endoscopic needleknife and balloon dilator. Once orientation is established, the gallbladder is retracted using percutaneous T-tags. The cystic duct and artery bundle are identified and then meticulously dissected using endoscopic graspers, hook cautery, biopsy forceps, and scissors. The individual cystic duct and artery are isolated and identified, establishing the critical view of safety. Endoscopic clip ligation and division are then performed, and the gallbladder is dissected free. Conclusions  Dissection of the critical view of safety can be performed in a completely endoscopic fashion using appropriate instrumentation. By achieving this critical view, the incidence of biliary injury during NOTES should be minimal and similar to the incidence of biliary injury during laparoscopic surgery. While completing this procedure, we identified several remaining technical limitations and deficiencies. Endoscopic retraction of tissue still is challenging with currently available instrumentation. Hemostatic endoscopic clips are not currently available for cystic artery and duct ligation. With the development of such instruments, cholecystectomy and other NOTES procedures will become technically more feasible. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Single-site versus conventional laparoscopic appendectomy: comparison of short-term operative outcomes

Background  

Recent developments in minimally invasive surgery have introduced scarless surgeries such as natural orifice transluminal endoscopic surgery (NOTES) and single-site laparoscopic surgery. Among surgical procedures, the appendectomy is one of those targeted for early adoption of new minimally invasive surgical techniques. To date, however, only a limited number of case series have been reported. Thus, the current study aimed to evaluate the safety and feasibility of single-site laparoscopic appendectomy (SSLA) compared with conventional laparoscopic appendectomy (CLA).     

Surgeon's Approach to the Thyroid Gland: Surgical Anatomy and the Importance of Technique

The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of thyroid anatomy and pathology. With appropriate techniques, total thyroid lobectomy and total thyroidectomy (which should be considered simply as a bilateral total thyroid lobectomy performed during the same operation) can be undertaken with minimal risk of damage to the recurrent laryngeal nerves, the external branches of the superior laryngeal nerves, and the parathyroid glands. Safe surgery requires a specific operative plan, progressing in a series of logical, orderly, anatomically based steps. Exposure of the thyroid gland is followed by careful dissection of the superior pole, utilizing the avascular plane between the superior pole and the cricothyroid muscle to identify and preserve the external branch of the superior laryngeal nerve. Medial retraction of the gland then allows dissection of the lateral aspect of the thyroid lobe. Protection of the recurrent laryngeal nerves and preservation of the blood supply to the parathyroid glands is best achieved by “capsular dissection,” ligating the tertiary branches of the inferior thyroid artery on the gland surface. If a parathyroid gland cannot be preserved or becomes ischemic after dissection of its vascular pedicle, it should be immediately minced and autotransplanted into the ipsilateral sternocleidomastoid muscle. The current evolution of outpatient or short-stay thyroidectomy emphasizes the need to avoid complications by utilizing meticulous surgical technique. Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery.     

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

Background  

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated.     

Minimally invasive Ivor–Lewis esophagogastrectomy for gastric cardia cancer

Introduction  

Gastric cardia cancer with involvement of the esophagus may require an esophagogastrectomy to obtain negative tumor margins. Multiple studies have shown that minimally invasive esophagectomy is a safe approach for the treatment of esophageal cancer [1–3]. We describe the technique of a minimally invasive Ivor–Lewis esophagectomy in a 55-year-old patient with a gastric cardia tumor.     

剥离法在改良Miccoli术中的应用体会

目的探讨剥离法在内镜辅助下经颈部小切口行甲状腺切除术（改良Miccoli术）中的应用价值。方法对39例甲状腺良性疾病患者采用剥离法内镜辅助下颈部小切口甲状腺切除术。按传统Miccoli术方式切开、建腔、显露,按剥离法要求游离、超声刀离断腺体,切除病灶。甲状腺瘤12例,其中11例行单侧甲状腺部分切除,1例行单纯峡部肿物切除;结节性甲状腺肿27例,其中13例行双侧甲状腺部分切除7,例行一侧腺叶大部切除加一侧肿瘤切除,5例双侧腺叶大部切除,2例单侧腺叶全切。结果 39例手术均顺利完成,手术切口平均2.4（1.5～3.0）cm,无中转开放手术;手术时间平均59.6（30～135）min;术中出血17.6（10～60）ml;术后第1 d引流量平均8（6～10）ml;术后住院时间平均4.2（3～6）d。术后术野皮下炎性肿胀3例,无喉返神经损伤或甲状旁腺功能低下等并发症。术后均获随访,平均10（6～12）个月,患者局部不适感轻微,颈部瘢痕不明显,美容效果好,复查甲状腺超声未见复发。结论在改良Miccoli术中采用剥离法手术策略简便、安全,并发症少,值得推广。     

Endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions

Background  The usefulness of various endoscopic thyroid surgery techniques has been reviewed. Recently, the authors developed a unilateral axillo-breast approach for endoscopic hemithyroidectomy to minimize the visible scar in a natural position and to overcome the limitation of instrumentation. The feasibility and safety of endoscopic thyroid surgery was examined via a novel approach without gas insufflation. Methods  This study enrolled 52 consecutive patients undergoing endoscopic hemithyroidectomy via a unilateral axillo-breast approach without gas insufflation. A skin incision parallel to the skin crease was made in the axillary fossa for insertion of a 10–mm 30° rigid endoscope and endoscopic instruments. To create a working space, an external retractor was inserted through the skin incision in the axilla and raised using a lifting device. A second 1.0-cm skin incision was made along the upper margin of the mammary areola on the tumor side for insertion of a 12-mm trocar. Results  Postoperative pathology showed 11 follicular adenomas, 1 follicular carcinoma, and 40 benign thyroid lesions. The operating time for the first 10 hemithyroidectomies was 154 ± 64.88 min, which was 34.77 min longer than for the last 42 hemithyroidectomies (119.23 ± 31.47 min; p = 0.1314). The amount of postoperative drainage was 236.63 ± 118.67 ml, and the duration of drainage was 4.54 ± 1.42 days. The postoperative hospital stay was 6.37 ± 2.83 days. Overall, seven patients (7/52, 13.5%) experienced perioperative complications, including one transient recurrent laryngeal nerve palsy (1.9%), five seromas (9.6%), and one hematoma (1.9%), which arose from a subplatysmal skin flap. Conclusion  Although the aspect of invasiveness could be improved, endoscopic hemithyroidectomy via a unilateral axillo-breast approach without gas insufflation is safe and effective and appears to provide better cosmetic results and a shorter operation time than other endoscopic methods for managing selective unilateral benign thyroid lesions.     

Transoral thyroid and parathyroid surgery

Background  

Translumenal endoscopic interventions via so-called natural orifices are gaining increasing interest because they allow surgical treatment without any incision of the skin. Moreover, minimally invasive procedures have found their way into thyroid and parathyroid surgery. Our goal was to develop a new access for thyroid and parathyroid resection via an entirely transoral approach.     

Minimally invasive open thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize tissue trauma by obviating unnecessary neck exploration. This report describes our technique of performing minimally invasive open thyroidectomy and compares the results with those of conventional thyroidectomy. Minimally invasive open thyroidectomy was performed by making a small skin incision, 3.0–4.5 cm long, and approaching the thyroid directly via a transverse divi-sion of the strap muscles without raising skin flaps. The outcomes of 466 patients who underwent a minimally invasive open thyroidectomy were retrospectively compared with those of 437 patients who underwent conventional thyroidectomy for various types of thyroid nodules. There was no significant difference in the extent of surgery between the group of patients who underwent minimally invasive thyroidectomy and the group of patients who underwent conventional thyroidectomy. However, the length of the skin incision, at 3.7 ± 0.7 vs 9.6 ± 3.3 cm, respectively, operative time, at 57.6 ± 11.7 vs 85.2 ± 32.3 min, respectively, blood loss, at 18.4 ± 15.3 vs 43.1 ± 21.8 ml, respectively, and hospital stay, at 1.6 ± 0.5 vs 4.3 ± 1.6 days, respectively, were significantly reduced in the minimally invasive open thyroidectomy group (P < 0.05). Moreover, the number of patients who required postoperative analgesia was significantly less in the minimally invasive open thyroidectomy group. These results show that minimally invasive open thyroidectomy provides surgeons with a clear operative field, and that it has proven to be simple, safe, and practical for selected patients. Received: September 11, 2000 / Accepted: March 6, 2001     

Single-incision laparoscopic trans-abdominal pre-peritoneal mesh hernia repair: a feasible approach

Background  

Single-incision laparoscopic surgery (SILS) is aimed at improving the cosmetic outcome following surgery. If the incision is made through the umbilicus, the surgery is almost ‘scarless.’ This is increasingly being used for laparoscopic cholecystectomy with good cosmetic results without compromising the safety of the operation. The challenge of this surgery lies in manipulating instruments within the limitations of the closely inserted ports.