Minimally invasive thyroid surgery is gaining popularity. Open surgery can cause an ugly scar with a negative impact on the quality of life. In that setting, minimally invasive thyroid surgery can reduce scar and promote a better cosmesis, while reducing pain. One of the techniques is the transaxillary endoscopic thyroidectomy through the axillo-breast approach, which is already common in Asian countries. In Europe, its popularity is growing slowly because of the lack of comparative studies with the open approach. Thyroidectomy through unilateral axillo-breast approach (UABA) with gas insufflation was first described by Lee in 2013. Techniques without gas insufflation are associated with a much wider subcutaneous dissection and postoperative seroma formation.
Common indications for transaxillary endoscopic thyroidectomy are age > 18 yo, tumor size < 4 cm, Bethesda II-III-IV (no cancer), no prepectoral breast prosthesis, no analytic thyroiditis, no previous surgery, no previous neck radiation. These indications were presented by Dr. Oscar Vidal in Barcelona during the WCES 2021.
In 2021, David Saavedra-Pérez et al published a randomized study comparing the open approach with the UABA with gas insufflation. They included 200 patients with indication for hemithyroidectomy for unilateral node. Patients were randomized in an alternate way to open and UABA. At the end of the randomization process, 100 patients were submitted to open hemithyroidectomy and 100 patients to transaxillary endoscopic thyroidectomy. I would like to highlight that this study had the collaboration and co-authorship of my friend Prof Jaime Vilaça, who contributed with many important data.
In this study, inclusion criteria were:
Bethesda II-III node < 5 cm
Normal breast and axillar ultrasonography
Exclusion criteria were:
Indication for total thyroidectomy
Previous thyroid surgery
Previous radioactive iodine treatment
Previous radiotherapy to the head and neck
Vocal cord paralysis
Lymph node metastasis
Intrathoracic goiters
Previous shoulder surgery or shoulder mobility impairment
The authors used three trocars (12 mm and 2x 5 mm) to perform hemithyroidectomy through UABA. A technical description is summarized in the original paper. Both groups were similar according to tumor size, tumor location, and thyroid function. For me, the results presented were not a surprise. Mean operative time was longer for the endoscopic group (65,6 min vs 31,8 min) because of the time spent in subcutaneous dissection (p<0,0001). Blood loss was minimal in both groups. The conversion rate was 0%. Postoperative dysphonia, pain, and hematoma were similar in both groups. However, the endoscopic group presented temporary hypoesthesia and subcutaneous emphysema, but without a negative impact on recovery. Without surprise, cosmesis satisfaction was significantly higher in the endoscopic group (p<0,001). At 12 months of follow-up, 99% of endoscopic group patients were very happy with the result, contrasting with 81% of open approach patients. I believe we must not forget that a keloid scar on a young woman’s neck will have a negative impact for the rest of her life. On the other hand, keloid scars in the axillar area are uncommon, and with a low negative impact on the quality of life.
According to several authors, hemithyroidectomy through UABA is a safe and effective technique. David Saavedra-Pérez et al concluded that the postoperative complications were similar between endoscopic and open surgery. However, there is an advantage of the endoscopic group the authors did not mention. The working space created by the subcutaneous dissection towards the thyroid can allow for blood accumulation under the skin and avoid an eventual cervical compression in case of postoperative hematoma. Additionally, image magnification with the endoscope can help the surgeon identify the recurrent laryngeal nerve, I think. The great advantage of endoscopic surgery is the cosmetic result. Thyroid nodes are more frequent in women, who also will benefit the most from this technique.
In the future, more studies will be necessary to increase the popularity of hemithyroidectomy through UABA with gas insufflation in European countries. I am convinced that this technique has a role to play in thyroid surgery because there is an increasing awareness of patients to cosmetic results, even more, when a benign disease is being treated.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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