ORIGINAL ARTICLE
New Endoscopic Thyroidectomy With the Transareola Single-site Approach: A Comparison With the Bilateral Areolar Approach Bo-Min Guo, MD, Bo Wu, MD, Jie Kang, MSc, Xian-Zhao Deng, MSc, Huan-Long Qin, MD, and You-Ben Fan, MD
Purpose: We developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas. Here, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the bilateral areolar approach (BAA). Methods: From September 2009 to December 2011, 129 patients with benign thyroid tumors were enrolled in the study. Of these patients, 51 patients underwent endoscopic thyroidectomy by TASSA and 78 patients by BAA. The TASSA technique was performed using one 10 mm trocar and one 5 mm trocar through circumareolar incisions using conventional endoscopic instruments. The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions. Results: Comparing TASSA with BAA, there were significant differences in the mean operative time (141.96 ± 19.85 vs. 98.14 ± 14.15 min) for lobectomy (P < 0.05) and in the subcutaneous dissection area (101.00 ± 6.33 vs. 132.51 ± 5.25 cm2, P < 0.05). However, there were no significant differences in the duration of hospitalization, amount of drainage, occurrence of postoperative complications, and postoperative pain. All the patients were satisfied with the cosmetic result in the 2 groups. Conclusions: Endoscopic thyroidectomy using the TASSA procedure is feasible and safe, and affords the advantages of minimal invasiveness and excellent cosmesis results compared with other approaches including BAA. The 2 procedures are technically more challenging procedures, which may become alternative procedures for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis. Key Words: thyroidectomy, endoscopic, single-site thyroidectomy, bilateral areolar approach
(Surg Laparosc Endosc Percutan Tech 2015;25:178–184)
T
hyroid disease often occurs in women, especially in young women, who are concerned about the aesthetic appearance of the scar resulting from thyroidectomy. Therefore, excellent cosmesis plays important roles in the operative strategy and also in their future life. Scarless in the neck has become an aesthetical pursuit of thyroidectomy.1
Received for publication February 4, 2014; accepted November 3, 2014. From the Department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China. The author declares no conflicts of interest. Reprints: You-Ben Fan, MD, Department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University, Shanghai 200233, China (e-mail: fanyouben2006@ 126.com). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
178 | www.surgical-laparoscopy.com
Since the first introduction of endoscopic parathyroidectomy by Gagner2 in 1996 and endoscopic thyroidectomy by Hu¨scher et al3 in 1997, various techniques for endoscopic thyroidectomy including cervical, axillary, breast, and anterior chest approaches have been widely introduced to improve cosmetic results.4–8 Endoscopic thyroidectomy allows surgeons to remove a thyroid tumor from a remote site, while providing excellent cosmetic results. However, these conventional endoscopic thyroidectomy techniques result in mini-scars hidden in the anterior wall and improve cervical appearance, the invasiveness is their own main disadvantage, because the procedures require a wide subcutaneous tissue dissection just to reach the target site. With increased endoscopic skills and improved instruments, many surgeons have begun to pay more attention to minimally invasive surgical techniques. More recently, endoscopic thyroidectomy by the bilateral areolar approach (BAA) has received favorable attention because of the absence of scar in the midline of the 2 breasts and reduction of the subcutaneous dissection area of tissues and postoperative pain.9 For this reason, we developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas.10,11 In this study, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the BAA.
MATERIALS AND METHODS Patients From September 2009 to December 2011, 129 patients underwent endoscopic thyroidectomy at the department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University. All patients were diagnosed with benign tumors by preoperative fine-needle aspiration cytology. Patients were randomized into 2 groups in accordance with the order of admission. Fiftyone patients underwent endoscopic thyroidectomy by the TASSA technique, and 78 patients underwent endoscopic thyroidectomy by the BAA technique. The selection criteria for endoscopic thyroidectomy were age younger than 60 years, no previous history of neck surgery or irradiation, benign thyroid tumor, preferably located in a single side, and r4.0 cm in diameter. The study was performed with Institutional Ethical Committee approval, and all patients gave informed consent.
Surgical Techniques All the procedures (TASSA and BAA) were performed by the same surgeon. Under general anesthesia, patients were placed in a moderate supine position with a soft pillow
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
New Endoscopic Thyroidectomy With the TASSA
FIGURE 1. Patients position and skin marking.
under the shoulder (Fig. 1). Trocar insertion sites and the operative fields were marked as shown in Figure 1.
The TASSA Procedure Our TASSA technique has been previously described.10,11 Two skin mini-incisions (10 and 5 mm in length), with an interval of 2 to 4 mm, were made through the upper medial aspect of the areolar edge on the side of the tumor to allow for placement of 10 and 5 mm trocars (Fig. 2). The single subcutaneous narrow tunnel to the neck was performed bluntly using 5 and 10 mm dissection sticks (Fig. 3). After establishing the required working space, a 10 mm trocar was inserted. The working space was maintained with CO2 insufflation at a pressure of 6 to 8 mmHg. A 30-degree 10 mm endoscope was then inserted to visualize and magnify the operative space. A 5 mm trocar (low-profile tube) was medially inserted for the operational instruments including the harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH). Subplatysmal space was created bluntly using a harmonic scalpel. The working space was extended to the level of the thyroid cartilage superiorly, to the medial border of each sternocleidomastoid muscle laterally, and to 3 cm inferior to the suprasternal notch inferiorly. The strap muscles were separated longitudinally at the midline with a harmonic scalpel. The ipsilateral strap muscles were suspended anteriorly and laterally with
transcutaneous prolene sutures. After freeing the overlapping tissue from the trachea, identification of the trachea, as a surgical landmark, is critical to avoid unexpected damage. The lower part of the thyroid lobe was also suspended and retracted anteriorly and medially with transcutaneous prolene sutures (Fig. 4). The application of this suspension technique avoids greater extension of the trocar to reveal operative space. Thyroidectomy was performed using a harmonic scalpel under full visualization of superior and inferior thyroid arteries, parathyroid glands, and recurrent laryngeal nerve (RLN). If necessary, contralateral partial lobectomy was similarly performed by initial incisions. The resected specimen was placed into a simple plastic bag and extracted through the 10 mm incision or 10 and 5 mm united incision. A frozen section of the specimen was examined intraoperatively for pathologic confirmation. If the pathology report confirmed a malignant tumor, an open cervical approach was used instead and the patient was also made to undergo contralateral lobectomy and ipsilateral central compartment dissection by initial incisions. After adequate saline irrigation and assurance of hemostasis, the midline was sutured with absorbable sutures. Extracorporeal knotting was performed using a slipknot pusher. A closed suction drain was placed in the thyroid bed through the 5-mm skin incision and the incision was then closed with absorbable sutures (Fig. 5).
FIGURE 2. Ten and 5 mm trocars were inserted through 2 circumareolar incisions in TASSA and BAA.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
179
Guo et al
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
FIGURE 3. A and B, Subcutaneous dissection was made using dissection sticks.
The BAA Procedure The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions with conventional endoscopic instruments. Along the upper medial areola edge of tumors side, 2 close skin mini-incisions (10 and 5 mm) were made to allow for placement of 10 and 5 mm trocars. On the contralateral upper medial circumareolar edge, a 5 mm incision was made to allow for placement of the 5 mm trocar for the operational instruments. The procedure of BAA did not include the presence of use of the neck transcutaneous suture suspension technique. The operation proceeded in the same manner as conventional endoscopic thyroidectomy. Unlike other endoscopic thyroidectomy procedures, the technique only needs 2 subcutaneous narrow tunnels to the neck performed by blunt dissection using dissection sticks and ultrasonic scalpel. A closed suction drain was also inserted through the 5 mm incision.
Outcomes Measured The 2 groups were compared in terms of patient characteristics, conversion, operative time, subcutaneous dissection area, blood loss, perioperative complications
(seroma, vocal cord palsy, hypocalcemia, trachea injury, and esophageal injury), postoperative pain, length of hospital stay, and patient satisfaction. The total operative time was calculated from the time of skin incision to closure. The subcutaneous dissection area was calculated under the guidance of the endoscope light. A line was connected to the center of the light, and the proportion was calculated by painting a 1 cm2 pane (Fig. 6). The weight and size of the excised specimen and perioperative complications were recorded. The incidence of postoperative seroma was assessed for at least 3 weeks postoperatively. The drainage volume was measured over 24 hours. Patients were discharged the day after drain removal. Mobility of the vocal cords was assessed using laryngoscopic examination, performed both preoperatively and within 1 week and 3 months postoperatively. A standard visual analogue score was used to assess the severity of postoperative pain using a scale of 0 (no pain) to 10 (worst pain imaginable) at 12 hours postoperatively. At 3 to 6 months after the operation, all patients were interviewed and their cosmetic results were assessed by the Patient and Satisfaction Score. The Patient and Satisfaction Score is rated from 1 (very satisfied), 2 (satisfied), 3 (unsatisfied), to 4 (very unsatisfied).12
FIGURE 4. A and B, The thyroid lobe and ipsilateral strap muscles were suspended with transcutaneous prolene sutures.
180 | www.surgical-laparoscopy.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
FIGURE 5. A closed suction drain was inserted through skin incision.
Statistical Analysis Data were analyzed using SPSS 18.0 (SPSS Inc., Chicago, IL). All data are expressed as mean ± SD, proportions, or absolute numbers. Continuous variables were compared using the t test, and categorical data were analyzed using w2 tests and Fisher exact tests. A P-value 0.05 > 0.05 < 0.001 < 0.001 0.344 > 0.05 > 0.05
182 | www.surgical-laparoscopy.com
Copyright
Characteristics
r
0.060 0.763 0.312
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
New Endoscopic Thyroidectomy With the TASSA
FIGURE 7. Postoperative incision scar of TASSA (A) and BAA (B) cases.
ultrasonic scalpel should be frequently washed with cool water to lower the temperature of blades. In our series, the rates of subcutaneous seroma were 1/ 51 (1.96%) and 1/78 (1.28%) in the TASSA group and the BAA group, respectively. Shan et al20 reported that the area of subcutaneous tissue dissection space could predispose patients to seroma formation after endoscopic thyroidectomy. More extensive subcutaneous dissection of the neck, chest, and breast would result in a large dead space, which could be the source of seroma formation. Thus, we recommend an adequate subcutaneous dissection space within the anterior chest wall if endoscopic instrumental efficacy is not affected. Percutaneous aspirations, combined with external compression, were implemented in all patients diagnosed with seromas. After aspiration twice, the seromas disappeared without affecting the cosmetic result. For patients with malignant thyroid tumor, our TASSA and BAA procedures have disadvantages when compared with VAT, because the 2 approaches involve difficult operative technique and prolonged operative time. For malignant thyroid tumors, VAT may be a better approach to the endoscopic procedure for the extent of resection required for invasive lesions and the required lymph node dissection. However, the 2 procedures are extremely useful for presumed indications of small low-risk papillary and minimally invasive follicular carcinomas, which require no lymph node dissection. In conclusion, this study contributes to the growing body of evidence showing that both the TASSA and BAA techniques are feasible and safe, with excellent cosmetic results, especially the TASSA technique, compared with other procedures. The 2 procedures are technically more challenging procedures, which may become alternative procedures for
TABLE 3. Cosmetic Results of the Patients
Cosmetic Result
TASSA [n (%)] (n = 49)
Very satisfied Satisfied Unsatisfied Very unsatisfied
Copyright
r
45 4 0 0
(91.8) (8.2) (0) (0)
BAA [n (%)] (n = 77) 56 21 0 0
(72.7) (27.3) (0) (0)
treatment of patients with benign thyroid tumors, especially those with a strong desire for cervical cosmesis. REFERENCES 1. Tan CT, Cheah WK, Delbridge L. “Scarless” (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques. World J Surg. 2008;32:1349–1357. 2. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83:875. 3. Hu¨scher CS, Chiodini S, Napolitano C, et al. Endoscopic right thyroid lobectomy. Surg Endosc. 1997;11:877. 4. Ikeda Y, Takami H, Sasaki Y, et al. Endoscopic resection of thyroid tumors by the axillary approach. J Cardiovasc Surg (Torino). 2000;41:791–792. 5. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech. 2000;10:1–4. 6. Kataoka H, Kitano H, Takeuchi E, et al. Total video endoscopic thyroidectomy via the anterior chest approach using the cervical region-lifting method. Biomed Pharmacother. 2002;56(suppl 1):68s–71s. 7. Schardey HM, Schopf S, Kammal M, et al. Invisible scar endoscopic thyroidectomy by the dorsal approach: experimental development of a new technique with human cadavers and preliminary clinical results. Surg Endosc. 2008;22:813–820. 8. Miccoli P, Pinchera A, Cecchini G, et al. Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism. J Endocrinol Invest. 1997;20:429–430. 9. Hur SM, Kim SH, Lee SK, et al. New endoscopic thyroidectomy with the bilateral areolar approach: a comparison with the bilateral axillo-breast approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e219–e224. 10. Youben F, Bomin G, Bo W, et al. Trans-areola single-incision endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech. 2011;21:e192–e196. 11. Youben F, Bo W, Chunlin Z, et al. Trans-areola single-site endoscopic thyroidectomy: pilot study of 35 cases. Surg Endosc. 2012;26:939–947. 12. Sahm M, Schwarz B, Schmidt S, et al. Long-term cosmetic results after minimally invasive video-assisted thyroidectomy. Surg Endosc. 2011;25:3202–3208. 13. Yoon JH, Park CH, Chung WY. Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases. Surg Laparosc Endosc Percutan Tech. 2006;16:226–231. 14. Ikeda Y, Takami H, Sasaki Y, et al. Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg. 2003;196:189–195.
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
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15. Ikeda Y, Takami H, Sasaki Y, et al. Are there significant benefits of minimally invasive endoscopic thyroidectomy? World J Surg. 2004;28:1075–1078. 16. Fan Y, Guo B, Guo S, et al. Minimally invasive video-assisted thyroidectomy: experience of 300 cases. Surg Endosc. 2010; 24:2393–2400. 17. Park YL, Han WK, Bae WG. 100 cases of endoscopic thyroidectomy: breast approach. Surg Laparosc Endosc Percutan Tech. 2003;13:20–25.
Volume 25, Number 2, April 2015
18. Harold KL, Pollinger H, Matthews BD, et al. Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc. 2003;17:1228–1230. 19. Owaki T, Nakano S, Arimura K, et al. The ultrasonic coagulating and cutting system injures nerve function. Endoscopy. 2002;34:575–579. 20. Shan CX, Zhang W, Jiang DZ, et al. Prevalence, risk factors, and management of seroma formation after breast approach endoscopic thyroidectomy. World J Surg. 2010;34:1817–1822.
RETRACTION Laparoscopic Common Bile Duct Exploration in Cirrhotic Patients with Choledocholithiasis: Retraction To the Editor—The authors of the article “Laparoscopic Common Bile Duct Exploration in Cirrhotic Patients with Choledocholithiasis” (Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 25, 64-68) withdrew consideration of their manuscript. The paper was published in error and is being retracted. Hong Wu Jian Guo Giu Hai Chao Yuan Shu Ting Chen REFERENCE Qiu J, Yuan H, Chen S, et al. Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis. Surg Laparosc Endosc Percutan Tech. 2015;25:64–68.
Modified Pringle maneuver applicable for laparoscopic hepatectomy: Retraction To the Editor—The authors of the article “Modified Pringle maneuver applicable for laparoscopic hepatectomy” (Surgical Laparoscopy Endoscopy & Percutaneous Techniques, published ahead of print) withdraw consideration of their manuscript. The paper was published ahead of print in error and is being retracted. Yutaka Sunose Keitaro Hirai Seshiru Nakazawa Daisuke Yoshinari Hiroomi Ogawa Hiroshi Tsukagoshi Norifumi Takahashi Hodaka Yamazaki Yoko Motegi Yohei Miyamae Igarashi Takamichi Kengo Takahashi Ryuji Katoh Kazumi Tanaka Izumi Takeyoshi
REFERENCE
Sunose Y, Hirai K, Nakazawa S, et al. Modified Pringle Maneuver Applicable for Laparoscopic Hepatectomy. Surg Laparosc Endosc Percutan Tech. 2014. [Epub ahead of print]..
184 | www.surgical-laparoscopy.com
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
New Endoscopic Thyroidectomy With the Transareola Single-site Approach: A Comparison With the Bilateral Areolar Approach Bo-Min Guo, MD, Bo Wu, MD, Jie Kang, MSc, Xian-Zhao Deng, MSc, Huan-Long Qin, MD, and You-Ben Fan, MD
Purpose: We developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas. Here, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the bilateral areolar approach (BAA). Methods: From September 2009 to December 2011, 129 patients with benign thyroid tumors were enrolled in the study. Of these patients, 51 patients underwent endoscopic thyroidectomy by TASSA and 78 patients by BAA. The TASSA technique was performed using one 10 mm trocar and one 5 mm trocar through circumareolar incisions using conventional endoscopic instruments. The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions. Results: Comparing TASSA with BAA, there were significant differences in the mean operative time (141.96 ± 19.85 vs. 98.14 ± 14.15 min) for lobectomy (P < 0.05) and in the subcutaneous dissection area (101.00 ± 6.33 vs. 132.51 ± 5.25 cm2, P < 0.05). However, there were no significant differences in the duration of hospitalization, amount of drainage, occurrence of postoperative complications, and postoperative pain. All the patients were satisfied with the cosmetic result in the 2 groups. Conclusions: Endoscopic thyroidectomy using the TASSA procedure is feasible and safe, and affords the advantages of minimal invasiveness and excellent cosmesis results compared with other approaches including BAA. The 2 procedures are technically more challenging procedures, which may become alternative procedures for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis. Key Words: thyroidectomy, endoscopic, single-site thyroidectomy, bilateral areolar approach
(Surg Laparosc Endosc Percutan Tech 2015;25:178–184)
T
hyroid disease often occurs in women, especially in young women, who are concerned about the aesthetic appearance of the scar resulting from thyroidectomy. Therefore, excellent cosmesis plays important roles in the operative strategy and also in their future life. Scarless in the neck has become an aesthetical pursuit of thyroidectomy.1
Received for publication February 4, 2014; accepted November 3, 2014. From the Department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China. The author declares no conflicts of interest. Reprints: You-Ben Fan, MD, Department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University, Shanghai 200233, China (e-mail: fanyouben2006@ 126.com). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
178 | www.surgical-laparoscopy.com
Since the first introduction of endoscopic parathyroidectomy by Gagner2 in 1996 and endoscopic thyroidectomy by Hu¨scher et al3 in 1997, various techniques for endoscopic thyroidectomy including cervical, axillary, breast, and anterior chest approaches have been widely introduced to improve cosmetic results.4–8 Endoscopic thyroidectomy allows surgeons to remove a thyroid tumor from a remote site, while providing excellent cosmetic results. However, these conventional endoscopic thyroidectomy techniques result in mini-scars hidden in the anterior wall and improve cervical appearance, the invasiveness is their own main disadvantage, because the procedures require a wide subcutaneous tissue dissection just to reach the target site. With increased endoscopic skills and improved instruments, many surgeons have begun to pay more attention to minimally invasive surgical techniques. More recently, endoscopic thyroidectomy by the bilateral areolar approach (BAA) has received favorable attention because of the absence of scar in the midline of the 2 breasts and reduction of the subcutaneous dissection area of tissues and postoperative pain.9 For this reason, we developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas.10,11 In this study, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the BAA.
MATERIALS AND METHODS Patients From September 2009 to December 2011, 129 patients underwent endoscopic thyroidectomy at the department of General Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai JiaoTong University. All patients were diagnosed with benign tumors by preoperative fine-needle aspiration cytology. Patients were randomized into 2 groups in accordance with the order of admission. Fiftyone patients underwent endoscopic thyroidectomy by the TASSA technique, and 78 patients underwent endoscopic thyroidectomy by the BAA technique. The selection criteria for endoscopic thyroidectomy were age younger than 60 years, no previous history of neck surgery or irradiation, benign thyroid tumor, preferably located in a single side, and r4.0 cm in diameter. The study was performed with Institutional Ethical Committee approval, and all patients gave informed consent.
Surgical Techniques All the procedures (TASSA and BAA) were performed by the same surgeon. Under general anesthesia, patients were placed in a moderate supine position with a soft pillow
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
New Endoscopic Thyroidectomy With the TASSA
FIGURE 1. Patients position and skin marking.
under the shoulder (Fig. 1). Trocar insertion sites and the operative fields were marked as shown in Figure 1.
The TASSA Procedure Our TASSA technique has been previously described.10,11 Two skin mini-incisions (10 and 5 mm in length), with an interval of 2 to 4 mm, were made through the upper medial aspect of the areolar edge on the side of the tumor to allow for placement of 10 and 5 mm trocars (Fig. 2). The single subcutaneous narrow tunnel to the neck was performed bluntly using 5 and 10 mm dissection sticks (Fig. 3). After establishing the required working space, a 10 mm trocar was inserted. The working space was maintained with CO2 insufflation at a pressure of 6 to 8 mmHg. A 30-degree 10 mm endoscope was then inserted to visualize and magnify the operative space. A 5 mm trocar (low-profile tube) was medially inserted for the operational instruments including the harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH). Subplatysmal space was created bluntly using a harmonic scalpel. The working space was extended to the level of the thyroid cartilage superiorly, to the medial border of each sternocleidomastoid muscle laterally, and to 3 cm inferior to the suprasternal notch inferiorly. The strap muscles were separated longitudinally at the midline with a harmonic scalpel. The ipsilateral strap muscles were suspended anteriorly and laterally with
transcutaneous prolene sutures. After freeing the overlapping tissue from the trachea, identification of the trachea, as a surgical landmark, is critical to avoid unexpected damage. The lower part of the thyroid lobe was also suspended and retracted anteriorly and medially with transcutaneous prolene sutures (Fig. 4). The application of this suspension technique avoids greater extension of the trocar to reveal operative space. Thyroidectomy was performed using a harmonic scalpel under full visualization of superior and inferior thyroid arteries, parathyroid glands, and recurrent laryngeal nerve (RLN). If necessary, contralateral partial lobectomy was similarly performed by initial incisions. The resected specimen was placed into a simple plastic bag and extracted through the 10 mm incision or 10 and 5 mm united incision. A frozen section of the specimen was examined intraoperatively for pathologic confirmation. If the pathology report confirmed a malignant tumor, an open cervical approach was used instead and the patient was also made to undergo contralateral lobectomy and ipsilateral central compartment dissection by initial incisions. After adequate saline irrigation and assurance of hemostasis, the midline was sutured with absorbable sutures. Extracorporeal knotting was performed using a slipknot pusher. A closed suction drain was placed in the thyroid bed through the 5-mm skin incision and the incision was then closed with absorbable sutures (Fig. 5).
FIGURE 2. Ten and 5 mm trocars were inserted through 2 circumareolar incisions in TASSA and BAA.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
179
Guo et al
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
FIGURE 3. A and B, Subcutaneous dissection was made using dissection sticks.
The BAA Procedure The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions with conventional endoscopic instruments. Along the upper medial areola edge of tumors side, 2 close skin mini-incisions (10 and 5 mm) were made to allow for placement of 10 and 5 mm trocars. On the contralateral upper medial circumareolar edge, a 5 mm incision was made to allow for placement of the 5 mm trocar for the operational instruments. The procedure of BAA did not include the presence of use of the neck transcutaneous suture suspension technique. The operation proceeded in the same manner as conventional endoscopic thyroidectomy. Unlike other endoscopic thyroidectomy procedures, the technique only needs 2 subcutaneous narrow tunnels to the neck performed by blunt dissection using dissection sticks and ultrasonic scalpel. A closed suction drain was also inserted through the 5 mm incision.
Outcomes Measured The 2 groups were compared in terms of patient characteristics, conversion, operative time, subcutaneous dissection area, blood loss, perioperative complications
(seroma, vocal cord palsy, hypocalcemia, trachea injury, and esophageal injury), postoperative pain, length of hospital stay, and patient satisfaction. The total operative time was calculated from the time of skin incision to closure. The subcutaneous dissection area was calculated under the guidance of the endoscope light. A line was connected to the center of the light, and the proportion was calculated by painting a 1 cm2 pane (Fig. 6). The weight and size of the excised specimen and perioperative complications were recorded. The incidence of postoperative seroma was assessed for at least 3 weeks postoperatively. The drainage volume was measured over 24 hours. Patients were discharged the day after drain removal. Mobility of the vocal cords was assessed using laryngoscopic examination, performed both preoperatively and within 1 week and 3 months postoperatively. A standard visual analogue score was used to assess the severity of postoperative pain using a scale of 0 (no pain) to 10 (worst pain imaginable) at 12 hours postoperatively. At 3 to 6 months after the operation, all patients were interviewed and their cosmetic results were assessed by the Patient and Satisfaction Score. The Patient and Satisfaction Score is rated from 1 (very satisfied), 2 (satisfied), 3 (unsatisfied), to 4 (very unsatisfied).12
FIGURE 4. A and B, The thyroid lobe and ipsilateral strap muscles were suspended with transcutaneous prolene sutures.
180 | www.surgical-laparoscopy.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
FIGURE 5. A closed suction drain was inserted through skin incision.
Statistical Analysis Data were analyzed using SPSS 18.0 (SPSS Inc., Chicago, IL). All data are expressed as mean ± SD, proportions, or absolute numbers. Continuous variables were compared using the t test, and categorical data were analyzed using w2 tests and Fisher exact tests. A P-value 0.05 > 0.05 < 0.001 < 0.001 0.344 > 0.05 > 0.05
182 | www.surgical-laparoscopy.com
Copyright
Characteristics
r
0.060 0.763 0.312
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
New Endoscopic Thyroidectomy With the TASSA
FIGURE 7. Postoperative incision scar of TASSA (A) and BAA (B) cases.
ultrasonic scalpel should be frequently washed with cool water to lower the temperature of blades. In our series, the rates of subcutaneous seroma were 1/ 51 (1.96%) and 1/78 (1.28%) in the TASSA group and the BAA group, respectively. Shan et al20 reported that the area of subcutaneous tissue dissection space could predispose patients to seroma formation after endoscopic thyroidectomy. More extensive subcutaneous dissection of the neck, chest, and breast would result in a large dead space, which could be the source of seroma formation. Thus, we recommend an adequate subcutaneous dissection space within the anterior chest wall if endoscopic instrumental efficacy is not affected. Percutaneous aspirations, combined with external compression, were implemented in all patients diagnosed with seromas. After aspiration twice, the seromas disappeared without affecting the cosmetic result. For patients with malignant thyroid tumor, our TASSA and BAA procedures have disadvantages when compared with VAT, because the 2 approaches involve difficult operative technique and prolonged operative time. For malignant thyroid tumors, VAT may be a better approach to the endoscopic procedure for the extent of resection required for invasive lesions and the required lymph node dissection. However, the 2 procedures are extremely useful for presumed indications of small low-risk papillary and minimally invasive follicular carcinomas, which require no lymph node dissection. In conclusion, this study contributes to the growing body of evidence showing that both the TASSA and BAA techniques are feasible and safe, with excellent cosmetic results, especially the TASSA technique, compared with other procedures. The 2 procedures are technically more challenging procedures, which may become alternative procedures for
TABLE 3. Cosmetic Results of the Patients
Cosmetic Result
TASSA [n (%)] (n = 49)
Very satisfied Satisfied Unsatisfied Very unsatisfied
Copyright
r
45 4 0 0
(91.8) (8.2) (0) (0)
BAA [n (%)] (n = 77) 56 21 0 0
(72.7) (27.3) (0) (0)
treatment of patients with benign thyroid tumors, especially those with a strong desire for cervical cosmesis. REFERENCES 1. Tan CT, Cheah WK, Delbridge L. “Scarless” (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques. World J Surg. 2008;32:1349–1357. 2. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83:875. 3. Hu¨scher CS, Chiodini S, Napolitano C, et al. Endoscopic right thyroid lobectomy. Surg Endosc. 1997;11:877. 4. Ikeda Y, Takami H, Sasaki Y, et al. Endoscopic resection of thyroid tumors by the axillary approach. J Cardiovasc Surg (Torino). 2000;41:791–792. 5. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech. 2000;10:1–4. 6. Kataoka H, Kitano H, Takeuchi E, et al. Total video endoscopic thyroidectomy via the anterior chest approach using the cervical region-lifting method. Biomed Pharmacother. 2002;56(suppl 1):68s–71s. 7. Schardey HM, Schopf S, Kammal M, et al. Invisible scar endoscopic thyroidectomy by the dorsal approach: experimental development of a new technique with human cadavers and preliminary clinical results. Surg Endosc. 2008;22:813–820. 8. Miccoli P, Pinchera A, Cecchini G, et al. Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism. J Endocrinol Invest. 1997;20:429–430. 9. Hur SM, Kim SH, Lee SK, et al. New endoscopic thyroidectomy with the bilateral areolar approach: a comparison with the bilateral axillo-breast approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e219–e224. 10. Youben F, Bomin G, Bo W, et al. Trans-areola single-incision endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech. 2011;21:e192–e196. 11. Youben F, Bo W, Chunlin Z, et al. Trans-areola single-site endoscopic thyroidectomy: pilot study of 35 cases. Surg Endosc. 2012;26:939–947. 12. Sahm M, Schwarz B, Schmidt S, et al. Long-term cosmetic results after minimally invasive video-assisted thyroidectomy. Surg Endosc. 2011;25:3202–3208. 13. Yoon JH, Park CH, Chung WY. Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases. Surg Laparosc Endosc Percutan Tech. 2006;16:226–231. 14. Ikeda Y, Takami H, Sasaki Y, et al. Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg. 2003;196:189–195.
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15. Ikeda Y, Takami H, Sasaki Y, et al. Are there significant benefits of minimally invasive endoscopic thyroidectomy? World J Surg. 2004;28:1075–1078. 16. Fan Y, Guo B, Guo S, et al. Minimally invasive video-assisted thyroidectomy: experience of 300 cases. Surg Endosc. 2010; 24:2393–2400. 17. Park YL, Han WK, Bae WG. 100 cases of endoscopic thyroidectomy: breast approach. Surg Laparosc Endosc Percutan Tech. 2003;13:20–25.
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18. Harold KL, Pollinger H, Matthews BD, et al. Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc. 2003;17:1228–1230. 19. Owaki T, Nakano S, Arimura K, et al. The ultrasonic coagulating and cutting system injures nerve function. Endoscopy. 2002;34:575–579. 20. Shan CX, Zhang W, Jiang DZ, et al. Prevalence, risk factors, and management of seroma formation after breast approach endoscopic thyroidectomy. World J Surg. 2010;34:1817–1822.
RETRACTION Laparoscopic Common Bile Duct Exploration in Cirrhotic Patients with Choledocholithiasis: Retraction To the Editor—The authors of the article “Laparoscopic Common Bile Duct Exploration in Cirrhotic Patients with Choledocholithiasis” (Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 25, 64-68) withdrew consideration of their manuscript. The paper was published in error and is being retracted. Hong Wu Jian Guo Giu Hai Chao Yuan Shu Ting Chen REFERENCE Qiu J, Yuan H, Chen S, et al. Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis. Surg Laparosc Endosc Percutan Tech. 2015;25:64–68.
Modified Pringle maneuver applicable for laparoscopic hepatectomy: Retraction To the Editor—The authors of the article “Modified Pringle maneuver applicable for laparoscopic hepatectomy” (Surgical Laparoscopy Endoscopy & Percutaneous Techniques, published ahead of print) withdraw consideration of their manuscript. The paper was published ahead of print in error and is being retracted. Yutaka Sunose Keitaro Hirai Seshiru Nakazawa Daisuke Yoshinari Hiroomi Ogawa Hiroshi Tsukagoshi Norifumi Takahashi Hodaka Yamazaki Yoko Motegi Yohei Miyamae Igarashi Takamichi Kengo Takahashi Ryuji Katoh Kazumi Tanaka Izumi Takeyoshi
REFERENCE
Sunose Y, Hirai K, Nakazawa S, et al. Modified Pringle Maneuver Applicable for Laparoscopic Hepatectomy. Surg Laparosc Endosc Percutan Tech. 2014. [Epub ahead of print]..
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