|Year : 2016 | Volume
| Issue : 2 | Page : 75-79
A retrospective analysis of 200 axillary route thyroidectomy cases
Padmakumar Ramakrishnapillai1, Madhukara Pai1, Mary Varghese1, Farish Shams2, PG Shaji3, TS Anithadevi4, Subin Thomas5
1 Department of Laparoscopic and Metabolic Surgery, Sunrise Hospital, Kakkanad, Kochi, India
2 Department of General and Laparoscopic Surgery, VSM Hospital, Mavelikara, India
3 Department of Anesthesiology, Sunrise Hospital, Kakkanad, Kochi, India
4 Department of Bio-statistics, Sunrise Hospital, Kakkanad, Kochi, India
5 Unity Bees, Infopark, Kochi, India
|Date of Web Publication||20-Dec-2016|
Department of Laparoscopic and Metabolic Surgery, Sunrise Hospital, Seaport-Airport Road, Kakkanad, Kochi - 682 030, Kerala
Source of Support: None, Conflict of Interest: None
Background: Thyroid disorders are common in women. The surgical solution available in most places is open thyroidectomy, which can ultimately lead to unsightly scar formation. This can be cosmetically unappealing, especially for women. The endoscopic thyroidectomy is a very good alternative to the traditional open thyroidectomy. It gives excellent cosmetic outcomes, especially when done with an axillary approach, without compromising safety. Methodology: This is a retrospective study conducted on 200 patients who underwent endoscopic thyroidectomy at Sunrise Group of Hospitals, Kochi and Dubai, from July 2013 to March 2016. The procedures performed were total thyroidectomy and hemithyroidectomy. The operation time, thyroid gland/nodule size, duration of hospital stay, and complications were considered for the outcome assessment. Results: A total of 200 endoscopic thyroidectomies were done. The mean age was 38 years, and the mean size of the thyroid was 9.19 ± 3.45 cm. The average time for hemithyroidectomy was 90 ± 12 min, and average time for total thyroidectomy was 150 ± 10 min. Forty-two patients underwent endoscopic hemithyroidectomy, whereas 158 patients underwent endoscopic total thyroidectomy. The histopathological reports revealed that there were 70 adenomas, 41 colloid nodules, 30 thyrotoxicosis, 27 thyroiditis, 26 carcinoma, and 6 Hurthle cell neoplasm cases. Complications, such as permanent hypoparathyroidism, nerve injury, and mortality, were not seen in the study population. Conclusion: Endoscopic thyroidectomy offers excellent cosmetic outcomes with no additional untoward effects. This procedure can be utilized for thyroids as large as 12 cm. All pathologies, including malignancies, can be safely dealt by expert endoscopic surgeon.
Keywords: Axillary approach, endoscopic thyroidectomy, neck scars, thyroid
|How to cite this article:|
Ramakrishnapillai P, Pai M, Varghese M, Shams F, Shaji P G, Anithadevi T S, Thomas S. A retrospective analysis of 200 axillary route thyroidectomy cases. J Head Neck Physicians Surg 2016;4:75-9
|How to cite this URL:|
Ramakrishnapillai P, Pai M, Varghese M, Shams F, Shaji P G, Anithadevi T S, Thomas S. A retrospective analysis of 200 axillary route thyroidectomy cases. J Head Neck Physicians Surg [serial online] 2016 [cited 2019 Oct 16];4:75-9. Available from: http://www.jhnps.org/text.asp?2016/4/2/75/196231
| Introduction|| |
Abnormalities of thyroids are common among women. According to the American Thyroid Association, approximately 90% of all thyroid nodules are benign.  In general, when someone is diagnosed with a single or multiple thyroid nodules, they need to be evaluated with a neck ultrasound scan and if needed, a fine-needle aspiration cytology (FNAC). If the ultrasonography (USG) features or FNAC report shows suspicion of malignancy, then surgery is the solution, regardless of the size of the swelling. Even if the USG and FNAC suggest benign swelling, the thyroidectomy option needs to be sought if the nodule is larger than 4 cm.  Depending on the patient history, physical examinations as well as the USG and FNAC findings, the surgeon may decide to offer a hemithyroidectomy or total thyroidectomy in consultation with patient.
The surgical solution that is available in most places is open thyroidectomy, which involves a large transverse cut across the lower part of the neck. This leads to the formation of long scars that is undesirable, especially for women [Figure 1].
Some surgeons perform lateral thyroidectomy by making an incision on either side of the neck for removal of the lobes on each side. Although it may be better than full open surgery, it is not a desirable option.  Robotic surgery requires a large incision in the retroauricular area or in the axilla. It is difficult to perform removal of opposite lobe unless another incision is made on that side. This eventually results in one or two large scars with associated problems. Very high cost is another drawback. Endoscopic thyroidectomy is a very good alternative to other methods. It gives more precision in identifying and preserving nerves and parathyroid glands. It provides excellent cosmetic outcomes, especially when it is done through an axillary approach. , It gives an equal or even a better surgical outcome as far as the actual thyroid nodule management is considered.  Other endoscopic approaches, such as the sternal approach, are also less preferred. 
| Methodology|| |
This was a retrospective study that was conducted on 200 consecutive patients who underwent endoscopic thyroidectomy at Sunrise Group of Hospitals, Kochi and Dubai, from July 2013 to March 2016. All the patients who underwent endoscopic thyroidectomy were included in the study. The two thyroidectomy procedures performed were total thyroidectomy and hemithyroidectomy. The operation time, thyroid size, duration of hospital stay, and complications were considered for the outcome assessment. The histopathology reports were analyzed to assess the various pathologies that were tackled.
The endoscopic thyroidectomy procedure through the axillary approach involves the following steps. A 10-mm trocar is placed through the axilla and is directed toward the neck, and the telescope is introduced, which initially helps in creating the plane in the neck and allows for structure visualization with magnification, precision, and clarity. Then, two 5-mm trocars are introduced into the subplatysmal space, which is created by a dissection. These are used as working ports [Figure 2]. We generally use a less heat-generating energy source, such as the harmonic scalpel instead of electrocautery for tissue dissection.
Sufficient space is created in the neck subplatysmally to expose the sternocleidomastoid and strap muscles. The investing layer is opened along the midline for a total thyroidectomy and laterally for a hemithyroidectomy. After separating the strap muscles, the gland is mobilized by blunt dissection, and the vital structures are identified. The recurrent laryngeal nerve, superior laryngeal nerve, and parathyroids with their blood supply are preserved. The pedicles are divided, and the gland is detached from the trachea. A specimen bag is used to place the specimen. It is removed by dilating a 10-mm trocar under guidance from a 5-mm telescope through the 5-mm trocar. The investing layer is sutured back, a drained is placed, and the trocar sites are closed [Figure 3]. For a total thyroidectomy, we placed an additional trocar on the other side of the first entry as well [Figure 4] and [Figure 5].
After the procedure, the vocal cords are examined during extubation. The serum calcium and parathyroid hormone levels are monitored 2 h after surgery. A neck examination and drain output monitoring are done for any immediate hemorrhage. Patients are advised to remain in the hospital for 24-48 h, and they are allowed to resume full activity within a few days.
There were 200 patients who underwent endoscopic thyroidectomy. The descriptive statistics were computed with regard to variables such as age, thyroid swelling size, operation time, and hospital stay duration. The procedure types and histopathological outcomes were presented using doughnut and pie diagrams, respectively. All of the statistical analyses were carried out using Statistical Package for Social Sciences version 19.1 (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp) and Microsoft Office Excel 2007.
| Results|| |
A total of 200 endoscopic thyroidectomized patients were included in this study, of which 40 were males and 160 were females with mean age of 38 years (range: 13-61 years). The mean thyroid size was 9.19 ± 3.45 cm. The average time for hemithyroidectomy was 90 ± 10 min, and it was 150 ± 12 min for the total thyroidectomies [Table 1]. Forty-two patients underwent endoscopic hemithyroidectomy, whereas 158 received endoscopic total thyroidectomy [Figure 6]. Histopathological reports revealed that 70 were adenomas, 41 colloid nodules, 30 thyrotoxicosis, 27 thyroiditis, 26 carcinoma, and 6 were Hurthle cell neoplasm cases [Figure 7]. Complications, such as carbon dioxide embolism one (0.5%) and temporary hypoparathyroidism four (2%), were seen in the study population. Major complications such as permanent hypoparathyroidism, nerve injury, or mortality, were not seen in the study group. Seroma formation in the neck is seen in around 10% of patients. No case of chest wall bruising was seen. Mean period of hospitalization was 48 h.
| Discussion|| |
As thyroid disorders are increasing in adults, new updates regarding surgical techniques are desirable. According to earlier studies and statistics, the prevalence of thyroid dysfunction in women is high that too in young women. , In this context, surgical option without a neck incision will be widely appreciated. In 1997, Huscher performed the first endoscopic thyroidectomy. After that, many surgeons introduced various methods, including axillary, breast, and anterior chest approaches for thyroidectomy. 
The present study details the results of 200 endoscopic thyroidectomy cases that were done through an axillary approach. This study highlights the advantages of the axillary approach.
The earlier belief was that the endoscopic "no neck scar option" for thyroid swellings was applicable to lesions that were <4 cm in size. However, we have observed that swellings to sizes that are even 12 cm can be tackled very successfully through this method. Nodule with 12 cm can be taken through a small lateral incision in the neck after gland mobilization endoscopically [Figure 8]. The only prerequisite will be a team with good experience, in both laparoscopic and thyroid surgeries. The cosmetic outcome was excellent because the small wound in the axilla, which heals with minimal scarring and gets covered with innerwear itself [Figure 9] and [Figure 10].
|Figure 8: Endoscopic total thyroidectomy with pyramidal lobe: performed for thyrotoxicosis|
Click here to view
The complications of this surgery are very similar to that of open surgery, proving that it is a very desirable option. Various pathologies, such as benign or cancerous nodules and thyroiditis, can be safely tackled with endoscopic thyroidectomy. Completion thyroidectomy is much easier after endoscopic hemithyroidectomy as the other side has not been dissected during the initial surgery. Lymph node dissection, when indicated, can also be comfortably performed by this route. We found the identification and preservation of recurrent laryngeal nerves; superior laryngeal nerves and parathyroids are more precise with endoscopic thyroidectomy than open method.
| Conclusion|| |
Endoscopic thyroidectomy provides excellent cosmetic outcomes with no untoward effects. This procedure can tackle thyroids that are as large as 12 cm. All pathologies, including malignancies, can be managed successfully with this method. Expertise in performing both thyroidectomies and endoscopic surgery is a prerequisite.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Burch HB, Burman KD, Cooper DS, Hennessey JV, Vietor NO. A 2015 survey of clinical practice patterns in the management of thyroid nodules. J Clin Endocrinol Metab 2016;101:2853-62.
Bomeli SR, LeBeau SO, Ferris RL. Evaluation of a thyroid nodule. Otolaryngol Clin North Am 2010;43:229-38, vii.
Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.
Tan CT, Cheah WK, Delbridge L. "Scarless" (in the neck) endoscopic thyroidectomy (SET): An evidence-based review of published techniques. World J Surg 2008;32:1349-57.
Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-40.
Gagner M, Inabnet WB 3 rd
. Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 2001;11:161-3.
Ikeda Y, Takami H, Sasaki Y, Takayama J, Kurihara H. Are there significant benefits of minimally invasive endoscopic thyroidectomy? World J Surg 2004;28:1075-8.
Usha Menon V, Sundaram KR, Unnikrishnan AG, Jayakumar RV, Nair V, Kumar H. High prevalence of undetected thyroid disorders in an iodine sufficient adult South Indian population. J Indian Med Assoc 2009;107:72-7.
Morganti S, Ceda GP, Saccani M, Milli B, Ugolotti D, Prampolini R, et al.
Thyroid disease in the elderly: Sex-related differences in clinical expression. J Endocrinol Invest 2005;28 11 Suppl: 101-4.
Lee H, Lee J, Sung KY. Comparative study comparing endoscopic thyroidectomy using the axillary approach and open thyroidectomy for papillary thyroid microcarcinoma. World J Surg Oncol 2012;10:269.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]