· minimally invasive thyroid surgery •majority of thyroid surgery in the u.s. is performed for...
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The International Federation of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2017
www.ifhnos.net
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The International Federation of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2017
Ashok R. Shaha
Minimally-Invasive Thyroid Surgery
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2017
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Samuel D. Gross - 1866Philadelphia
A System of Surgery
Thyroid surgery: ‘Horrid butchery’
“No honest and sensible surgeon would everengage in thyroid surgery”
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2017
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2017
The extirpation of
thyroid gland
typifies perhaps
better than any
operation the
supreme triumph of
the surgeon’s art.
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2017
Surgical Procedure
• Anatomically and Biologically Sound
• Reproducible
• Least Complications
• Short Learning Curve
• Easy to Teach, Learn, and Practice
• Cost Effective
• Best Cosmetic and Function Results
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2017
The fact that a new technique is available does not necessarily mean its
implementation is appropriate.
– Leigh Delbridge, MD, FRACS
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Endocrine Procedures by U.S. Residents
1993-1994
% Programs Mean Mode With 0
Thyroid 12.6 7-10 0
Parathyroid 5.6 2 1
Adrenal 0.98 0 38
Pancreas 0.15 0 85
Harness et al
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Minimally Invasive Thyroidectomy
• ‘PURE’ Endoscopic Approach Completely
closed technique with continuous gas
insufflation
•Neck Approach
• Anterior Chest Approach
• Axillary Approach
• Breast (Submammary Approach)
•Video assisted Technique
•Video assisted Neck Dissection
•Video assisted under LA
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2017
Clamp onpurse string
Insufflationtube
Laparoscopebeing insertedinto trocar A
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Minimally Invasive Thyroidectomy
• ‘PURE’ Endoscopic Approach Completely
closed technique with continuous gas
insufflation
•Neck Approach
• Anterior Chest Approach
• Axillary Approach
• Breast (Submammary Approach)
•Video assisted Technique
•Video assisted Neck Dissection
•Video assisted under LA
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Endoscopic Surgery
Minimally Invasive Surgery
Maximally Expensive Surgery
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Minimally Invasive Thyroidectomy
• Minimally Invasive ‘Open’ Surgery
• Mini-incision• Smaller Incision• Lateral Incision• Harmonic Scalpel• Ligasure• Local Anesthesia/Regional• 23 Hour Discharge
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In cosmetic terms, the quality of the scar is more important than
the actual length
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Minimal incision may cause excessive skin stretching,
bruising, forcible retraction, or inadvertent cauterization of the
skin edges
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Advantages of Minimally Invasive Thyroid Surgery
• Smaller Incision
• Better Cosmesis
• Less Pain
• Early Discharge
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Minimally Invasive Thyroid Surgery
• Majority of thyroid surgery in the U.S. is
performed for proven or suspected malignancy
•Paratracheal and nodal evaluation are difficult
• 20% of patients with thyroid cancer have
extrathyroidal extension, which requires adequate
exposure and excision
• Ultrasound detecting bilateral thyroid nodules
requires total thyroidectomy
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Minimally Invasive Thyroid Surgery
• First Principle of Surgery:
• Adequate Exposure
• Adequate Retraction
• Adequate Lighting
• Learning curve
• Difficult to gain expertise
• Medicolegalities of minimally invasive thyroid surgery
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Classification
Minimally
invasive
Thyroidectomy
Robotic
Trans-Axillary
Face-Lift
Mini incision True endoscopic
1. Anterior chest
2. Axillary
3. Areolar
Endoscope
assisted
Cervical
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•Ikeda
•3cm incision
•Isthmusotomy
•Use ligasure LS1200 or harmonic scalpel(focus) to divide
superior pole vessels
•Use ligasure LS1200 or harmonic scalpel(focus) to divide
isthmus
Mini Incision
Ikeda et al. Direct mini incision thyroidectomy. Biomed Pharmacother 2002;56:60s-63s
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Ligasure Precise
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Harmonic Focus Scalpel
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True Endoscopic
2000 Shimizu subclavicular access
2000 Ikeda axillary access
2000 Ohgami breast access
2001 Gagner supraclavicular access
2007 Chung robotic via axillary access
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CO2 (8 mm Hg) insufflation
Central incision (5 mm trocar)
3 additional Trocars: mid linemid border SCMsup border SCM
Gagner Shimizu
External retraction (Kirschner)
Lateral incision (SCM border)
5 cm subclavicular incision
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30 mm skin incision in the axilla
CO2 insufflation (4 mm Hg)
Flexible endoscope
1 additional trocar near the main incision
Ikeda Ohgami
Three incisions: 1 presternal2 periareolarCO2 insufflation
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1999 Miccoli central neck access
Endoscopic Assisted
•Minimally invasive video assisted
thyroidectomy
•Single 1.5cm incision -midline skin crease
•MIVAT
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Nodule < 3.5 cm
Thyroid volume < 25 ml
Benign disease
Malignant disease
Minimally Invasive Video-assisted Thyroidectomy
INDICATIONS
multinodularfollicularToxic adenomaGraves
Low risk Pap CrRET gene carriers
MIVAT
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MIVAT: Contraindications
ABSOLUTE
Large goiters
Previous neck surgery
Thyroiditis
Presence of suspicious lymph nodes
Local advanced carcinoma
RELATIVE
Previous neck irradiation
Graves’ disease
Short neck in obese patients
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MIVAT: 5 steps
1. Incision and access to the operative
space
2. Section of the upper pedicle
3. Identification of recurrent laryngeal
nerve and parathyroids
4. Extraction and resection of the lobe
5. Closure
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Da Vinci Robot
• Two components
• Surgeon console
• Surgical arm cart
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Minimally Invasive Thyroid Surgery
• Majority of thyroid surgery in the U.S. is performed for
proven or suspected malignancy
• Paratracheal and nodal evaluation are difficult
• 20% of patients with thyroid cancer have extrathyroidal
extension, which requires adequate exposure and excision
• Ultrasound detecting bilateral thyroid nodules requires
total thyroidectomy
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2017
Minimally Invasive Thyroid Surgery
• First Principle of Surgery:
• Adequate Exposure
• Adequate Retraction
• Adequate Lighting
• Learning curve
• Difficult to gain expertise
• Medicolegalities of minimally invasive thyroid surgery
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Da Vinci Robot
• Surgical arm cart holds
• 3D camera
• Instruments (2 or 3
arms)
• Grasping forceps
• Scissors
• bipolar bovie
• harmonic scalpel
7 degrees of freedom using
an endo-wrist system
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Approach
• 2 incisions
• Axillary incision
• Camera
• Harmonic scalpel
• Dissecting forceps
• Substernal incision
• Grasping forceps
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Axillary Incision
•6cm axillary incision
•Dissect subcutaneous tunnel over pectoralis major muscle
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Exposure of Thyroid Gland
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Position of Camera and Instrument Arms
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Dissection of Thyroid Gland
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Advantages & Disadvantages• Avoids a central neck incision
• Increased magnification of RLN and parathyroids
• No tremor
BUT
• 6cm axillary incision
• Significant soft tissue dissection
• Lose sensory feedback
• Long OR time 2-4hrs
• Need postop drains
• Not suitable for day surgery
• Difficult to remove the contralateral lobe
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Minimally Invasive Thyroid Surgery
• Majority of thyroid surgery in the U.S. is
performed for proven or suspected malignancy
• Paratracheal and nodal evaluation are difficult
• 20% of patients with thyroid cancer have
extrathyroidal extension, which requires adequate
exposure and excision
• Ultrasound detecting bilateral thyroid nodules
requires total thyroidectomy
![Page 44: · Minimally Invasive Thyroid Surgery •Majority of thyroid surgery in the U.S. is performed for proven or suspected malignancy •Paratracheal and nodal evaluation are difficult](https://reader033.vdocuments.us/reader033/viewer/2022052801/5f11910d7e21c35ba520faac/html5/thumbnails/44.jpg)
2017
“Commonplace clinical
problems in surgery are
approached in
diametrically opposite
ways - by surgeons with
similar training
backgrounds, having read
the literature but
interpreting the available
information differently,
based on unique personal
experience, vision or
surgical prejudice.”
-- Richard Simmons
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Good judgment comes
from experience;
but experience comes
from bad judgment!
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“The best interest
of the patient is the
only interest to be
considered”
William J. Mayo, 1910