Recently I had the opportunity to assist Dr. Jaime Vilaça (a great surgeon) performing an endoscopic transaxillary thyroidectomy in Hospital da Arrábida (Vila Nova de Gaia, Portugal). Having interest in minimally invasive surgery and using this approach in several fields of surgery, I was really happy to be given the opportunity to see how this approach can be offered to a diseased thyroid gland. I was impressed with the technique (feasible and safe) and the advantages (cosmesis and good visualization). For the opportunity I have to say thank you to Dr Jaime Vilaça but also to Dr Francisco Miranda. Great surgeons and friends they are. After seeing the fantastic performance, it was imperative for me to read and write something about this good technique. Here it goes…
Thyroidectomy (total, subtotal or lobectomy) is classically performed by a transverse incision in the lower neck described by Kocher. This incision stays in a highly visible area which may be problematic in case of hypertrophic or keloid scar formation. This ugly cosmetic result can promote hyperesthesia, paresthesia and increase self-awareness. Patients with darker skin have a higher risk of keloid scarring. Because of this, Dr. Duncan el al. from Atlanta, USA, started performing endoscopic transaxillary thyroidectomy. This technique offers an enhanced cosmesis and better visualization through video magnification. The advantages of minimally invasive surgery reported in other fields, like better cosmesis, were about to be transported for thyroid surgery.
In 2009, Dr. Duncan et al. from Atlanta, USA, published their first results of endoscopic transaxillary thyroidectomy. They included 53 patients operated between August 2003 and January 2008. Thirty-two with solitary nodule (atypical follicular lesion in 12) and twenty-one with multinodular diffuse goiter. Nodules size ranged from 2,0 cm to 7,9 cm. Two patients with hyperthyroidism and the remaining with thyroid hormones within normal range. No patient was preoperatively diagnosed with thyroid cancer. Lobectomy with isthmectomy was offered to patients with solitary nodule, while patients with multinodular goiter underwent near total thyroidectomy. The authors used three 5 mm ports in the axillary area bellow the anterior axillary line and CO2 insufflation was set to 7 – 9 mmHg pressure. Subcutaneous dissection was conducted beneath the platysma and over the pectoralis major muscle (for technique description please access the full paper). A drain was left in all patients.
All patients were successfully treated by endoscopic transaxillary thyroidectomy. Mean operation time was 147 min, mean blood loss of 36,4 mL and there was no parathyroid lesion nor permanent injuries to the recurrent laryngeal nerve (RLN). Two patients complained of hoarseness, but 3 weeks after surgery voice was normal. Eleven patients (black skin) developed hyperplastic scar, but since it was in the axillary area it stayed unnoted in normal arm position. Patients were very happy with the final outcomes, “cosmesis was excellent”.
I believe this is a technique to use more often. It allows for a good dissection and a good RLN visualization.
Endoscopic transaxillary thyroidectomy (ETT) is presented by the authors as a safe and feasible technique, a good alternative to the classic open technique, and with better cosmetic results. The authors present some advantages of ETT comparing to other minimally invasive approaches to the thyroid (neck and chest wall):
ETT allows to treat larger thyroids because surgeon can enlarge the extraction incision which is located in the axillary fossa
if conversion to open surgery is necessary there will not be the excessive amount of scar in the neck
incidence of hypertrophic scarring is markedly reduced in ETT because of decreased skin tension in the axillary region
From the results presented, the authors conclude with the following idea: “The endoscopic transaxillary approach to thyroidectomy allows for safe dissection, improved cosmetic results, and the capability of managing small- and moderate-size benign thyroid lesions”.
I believe this is a technique to use more often. It allows for a good dissection and a good RLN visualization. Which patients should this technique be offer to? That is a hard question for me to answer. Benign lesions and even small carcinomas without adenopathies would be my first choice. This technique also offers the possibility of entering virgin soft tissues if excision of the contralateral lobe is necessary following pathology. Additionally, if an open approach is necessary in the future, surgeon will not find a great amount of scar tissue (skin, subcutaneous, sternohyoid and sternothyroid muscles) making dissection hard to perform. Operating time seems similar to open approach, though being a little longer. Cosmesis is not the most important outcome, but while patients with malignant disease easily accept a bad cosmetic result, patients with a benign disease will probably not. In that setting, if we can perform a surgical procedure in a safe and efficient way offering better cosmetic results, we should do it. Endoscopic transaxillary thyroidectomy will highly improve the cosmetic result, while assuring a good treatment for thyroid gland diseases. I am anxious to try this technique in a near future.
Open your mind, learn more, increase your skills, be versatile. Knowledge is never too much. Patients are no protocols. Different approaches may be necessary for different patients.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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