Minimally Invasive Surgery of the Thyroid

Minimally Invasive Surgery of the Thyroid

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This article focuses on minimally invasive approaches to thyroid surgery. Please refer to other Medscape Reference articles for focused discussions of thyroid nodules, thyroid cancer, benign thyroid conditions, and conventional surgical approaches for thyroidectomy.

Minimally invasive techniques for thyroidectomy were introduced in the late 1990s and early 2000s for the surgical treatment of small thyroid nodules. These approaches were developed to minimize postoperative pain, improve cosmetic results, and potentially reduce the length of hospital stay. Two such approaches are the minimally invasive open thyroidectomy (MIT) and the minimally invasive video-assisted thyroidectomy (MIVAT). Minimally invasive approaches are currently used for both thyroid lobectomy and total thyroidectomy by some groups. [1]

An image depicting minimall invasive surgery of the thyroid can be seen below.

See the list below:

Thyroid nodule: This is a discrete lesion of the thyroid gland that, after physical examination or ultrasound imaging, is determined to be distinct from the remainder of the thyroid parenchyma. [2]

Differentiated thyroid cancer: This is a papillary or follicular thyroid cancer.

The prevalence of palpable thyroid nodules is 3-7% in North America and increases up to 50% in ultrasonography or autopsy data. [3] About 5% of thyroid nodules are positive for thyroid carcinoma on fine-needle aspiration (FNA).

In the United States, approximately 23,500 new cases of differentiated thyroid cancer are diagnosed yearly. [4]

Papillary thyroid cancer accounts for 75-80% of new cases of thyroid cancer; follicular thyroid cancer accounts for 10-20% of new cases. [5]

The following are causes of thyroid nodules: [3]

Benign causes

Multinodular goiter (MNG)

Hashimoto thyroiditis

Thyroid cyst

Follicular adenoma

Subacute thyroiditis

Malignant causes

Papillary carcinoma

Follicular carcinoma

Hürthle cell carcinoma

Medullary carcinoma

Anaplastic carcinoma

Primary thyroid lymphoma

Metastasis

A patient with a thyroid nodule or differentiated thyroid cancer may present with the following:

Palpable thyroid or neck mass

Pressure symptoms such as choking, neck pain, dysphagia, hoarseness, or shortness of breath

Symptoms of hypothyroidism or hyperthyroidism

Incidental finding of thyroid nodule on neck imaging (incidentaloma)

Minimally invasive video-assisted thyroidectomy (MIVAT) is most commonly used for thyroid nodules within specific size limits and for low-stage papillary carcinoma of the thyroid (PCT). [6, 7, 8, 9] The following are the most widely accepted criteria:

A thyroid nodule size less than or equal to 30 mm in diameter

Stage T1 or small T2 PCT (see Staging)

Total thyroid volume less than 30 mL

No history of thyroiditis or neck radiation

Recent studies have demonstrated that MIVAT can be safely used with patients who have histories of prior thyroiditis, prior MIVAT, and a thyroid volume up to 50 mL (see Controversies). [10, 11]

The thyroid is a bilobed gland in the midline neck that overlies the proximal trachea. The thyroid isthmus in the midline connects the 2 lobes, and a pyramidal lobe may be present. Two pairs of parathyroid glands (superior and inferior) are usually closely associated with the posterior aspect of the 2 thyroid lobes. The fascia that encapsulates the thyroid gland forms a dense consolidation at its attachment to the trachea known as the ligament of Berry.

The blood supply consists of the superior thyroid artery (STA) and inferior thyroid artery (ITA). The STA is a branch of the external carotid artery. The ITA emanates from the thyrocervical trunk and is also the main blood supply to the parathyroid glands. Venous drainage consists of the superior, middle, and inferior thyroid veins and the thyroid ima vein.

The external branch of the superior laryngeal nerve (EBSLN) courses near the superior thyroid artery adjacent to the superior pole before entering the larynx through the cricothyroid membrane. The recurrent laryngeal nerve (RLN) ascends in the tracheoesophageal groove and courses closely to the ligament of Berry prior to entering the larynx posteriorly at the cricothyroid articulation.

As minimally invasive video-assisted thyroidectomy (MIVAT) continues to evolve, the only absolute contraindications to this procedure are thyroid malignancy beyond low-stage papillary carcinoma and preoperative evidence of lymph node metastasis.

Nodule diameter above 35 mm and thyroid volume over 30 mL are relative contraindications because some groups have demonstrated questions about safety with larger lesions. [11]

Prior conventional thyroidectomy is considered a contraindication by most authors. Some groups consider patients candidates for completion MIVAT if a prior lobectomy was performed via a MIVAT approach. [10]

A history of prior thyroiditis is considered a relative contraindication because some groups have demonstrated that MIVAT can be safely performed in this population. [11]

Terris DJ, Bonnett A, Gourin CG, Chin E. Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope. 2005 Jun. 115(6):1104-8. [Medline].

Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006 Feb. 16(2):109-42. [Medline].

American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2006 Jan-Feb. 12(1):63-102. [Medline].

Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005 Jan-Feb. 55(1):10-30. [Medline].

Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005 Dec. 237(3):794-800. [Medline].

Lombardi CP, Raffaelli M, Princi P, Lulli P, Rossi ED, Fadda G, et al. Safety of video-assisted thyroidectomy versus conventional surgery. Head Neck. 2005 Jan. 27(1):58-64. [Medline].

Pisanu A, Podda M, Reccia I, Porceddu G, Uccheddu A. Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT). Langenbecks Arch Surg. 2013 Oct 27. [Medline].

Gao W, Liu L, Ye G, Song L. Application of Minimally Invasive Video-assisted Technique in Papillary Thyroid Microcarcinoma. Surg Laparosc Endosc Percutan Tech. 2013 Oct. 23(5):468-73. [Medline].

De Napoli L, Spinelli C, Ambrosini CE, Tomisti L, Giani C, Miccoli P. Minimally Invasive Video-Assisted Thyroidectomy versus Conventional Thyroidectomy in Pediatric Patients. Eur J Pediatr Surg. 2013 Sep 2. [Medline].

Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R. Video-assisted thyroidectomy: report on the experience of a single center in more than four hundred cases. World J Surg. 2006 May. 30(5):794-800; discussion 801. [Medline].

Ruggieri M, Straniero A, Genderini M, D’Armiento M, Fumarola A, Trimboli P, et al. The size criteria in minimally invasive video-assisted thyroidectomy. BMC Surg. 2007 Jan 25. 7:2. [Medline].

American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer; 2002. 77-87. [Full Text].

Lee S, Ryu HR, Park JH, et al. Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg. 2011 Jun. 253(6):1060-6. [Medline].

Hong JY, Kim WO, Chung WY, Yun JS, Kil HK. Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach. World J Surg. 2010 Mar. 34(3):521-6. [Medline]. [Full Text].

Dionigi G, Boni L, Rovera F, Rausei S, Dionigi R. Wound morbidity in mini-invasive thyroidectomy. Surg Endosc. 2011 Jan. 25(1):62-7. [Medline].

Miccoli 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. 2001 Dec. 130(6):1039-43. [Medline].

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS Clinical Assistant Professor, Department of Otolaryngology, Tufts University School of Medicine; Partner and Director, ENT Specialists, Inc

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Massachusetts Medical Society, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Tejas Raval, MD Resident Physician, Department of Otolaryngology, Tufts-New England Medical Center

Tejas Raval, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Minimally Invasive Surgery of the Thyroid

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