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MINIMALLY INVASIVE THYROIDECTOMY

There are a variety of surgical approaches to the thyroid gland. Please see below.

The most common approach is the midline neck incision. Most incisions for a total thyroidectomy are 4-5cm and most incisions for hemi-thyroidectomy are between 3.5-4cm. (which is as long as this line —————————). I do realize that the appearance of the scar is important, and I will do my best to keep the scar as small as possible, given the circumstances of the case.

BUT, as a patient, you should understand what the indication for your thyroid surgery is, and based on that, you should have realistic expectations.

For example, if your thyroid nodule is 10cm, it is IMPOSSIBLE to bring it out of the neck through a 3-4cm incision, which I can offer selected patients. It just won’t fit!

ADDITIONALLY, there are some patients who request a minimally invasive or endoscopic approach for thyroid cancer.

I can understand their concerns, but they should understand that in order to do an effective job in terms of evaluating and treating the lymph nodes in the central compartment (which may be required in some cases), it is extremely difficult to do a thorough job through a very small 3cm incision.

Minimally invasive refers to the fact that we are minimizing the amount of dissection around the thyroid gland while making the incision as small as possible. The advantages are a smaller scar, less pain for the patient, a shorter hospital stay, and a quicker recovery.

There are two approaches for minimally invasive thyroidectomy. Minimally invasive non-endoscopic thyroidectomy (MINET) and minimally invasive video assisted thyroidectomy (MIVAT).

Minimally invasive non-endoscopic thyroidectomy (MINET)

The technique briefly involves:

• Minimal incision (3-5 cm)
• Small or no drain
• 23-hour overnight or outpatient surgery

Are you a candidate? The criteria for minimally invasive non-endoscopic thyroid (MINET) surgery are listed below.

• Non-obese individuals. If you have a BMI greater than , medically you are considered obese and may not be a candidate for minimally invasive thyroid surgery.
• Nodule size 6cm or greater. This is very important. The size of the thyroid nodule has to be small enough to be removed through a 4-5cm incision. If the nodule is larger than that, it is very difficult to remove.
• Suspicious lateral compartment (Level 2,3,or 4) or central compartment (level 6) lymph nodes. If extensive lymph node dissection needs to be performed for clearance of cancer, then you may not be a candidate for a minimally invasive approach.

Minimally invasive video-assisted thyroidectomy (MIVAT)

The technique briefly involves:

• Very small incision (3/4”)
• Reduced dissection (no flaps)
• No stitches or clips
• No drain
• Outpatient surgery in certain cases

Are you a candidate? The criteria for minimally invasive video-assisted thyroid (MIVAT) surgery are listed below.

• Non-obese individuals. If you have a BMI greater than , medically you are considered obese and may not be a candidate for minimally invasive thyroid surgery.
• Nodule size ≤ 2.5cm. This is very important. The size of the thyroid nodule has to be small enough to be removed through either a ¾” incision or a 4-5cm incision. If the nodule is larger than that, it is very difficult to remove it through a ¾” incision.
• Thyroid size ≤ 20 cc. This is very important. The size of the thyroid gland has to be small enough to be removed through either a ¾” incision.
• No thyroiditis. If you have a diagnosis of Hashimoto’s thyroiditis or Graves’ disease, then you are not a candidate for a minimally invasive endoscopic approach
• Follicular lesions, PTC, small MNG
• Suspicious lateral compartment (Level 2,3,or 4) or central compartment (level 6) lymph nodes. If extensive dissection needs to be performed for clearance of cancer, then you may not be a candidate for a minimally invasive approach.
• Prior neck surgery. This is a contraindication for MIVAT.

Remote access thyroid surgery

Is it minimally invasive? Technically, remote access thyroid surgery is the opposite of minimally invasive surgery. Remote access surgery involves placing incisions far from the thyroid gland, and lifting up the skin with very long metal retractors in order to obtain access to the thyroid gland.

There are several approaches which fall into this category.

Totally endoscopic axillary thyroid surgery. Briefly, this involves making a large incision (red arrow) in the armpit area, lifting the upper breast or chest and skin out of the way, and then using long telescopes to remove the thyroid gland. If a total thyroidectomy needs to be performed, then another incision needs to be made on the opposite side with a similar amount of extensive dissection required to get access to the thyroid gland.

Robotic thyroid surgery
Is it minimally invasive? Technically it is the opposite of minimally invasive surgery. Robotic surgery involves placing incisions far from the thyroid gland, and lifting up the skin with a very long retractor in order to obtain access to the thyroid gland.
There are several approaches used for access to the thyroid gland. Shown below is the most common approach used. It involves a large incision in the axilla or armpit, and then a second incision in the mid chest for insertion of the telescope. The robot is then used for removal of the thyroid.

Advantages of robotic thyroid surgery:

No neck incision
Improved magnification

Disadvantages of robotic thyroid surgery:

• Large incision in the axilla (on one side or both)
• Drain necessary
• Long inpatient hospitalization
• More pain
• Take much longer.

Rare complications of robotic thyroid surgery:

• Esophageal perforation (food and saliva contents spilling into the neck)
• Brachial plexus injury (numbness and tingling in the arm and hand, and in severe cases inability to move the arm)
• Excessive bleeding (more than 1 liter of blood loss)
• Missed thyroid tissue (in the setting of thyroid cancer, this could translate to poor outcome)

BOTTOM LINE:

Robotic thyroid surgery is a useful technique when applied to the right patients. Unfortunately, unless the surgeon is doing several thyroid surgeries a week using this technique, his/her outcomes may be poor.

If you decide to have this technique performed, make sure you go to someone who performs them often, and that your condition is appropriately treated by robotic thyroid surgery.