Video-assisted thyroidectomy

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Video-assisted   thyroidectomy

Authors
P Miccoli
Keywords
operation, resection, thyroid glands, video-assisted, endocrinology
Media type
Duration
21'00''
Publication
2004-09
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1129e.htm

Video-assisted   thyroidectomy

1. Case demonstration 00'17''
You can see that the fat tissue under the skin is opened, and I am searching for the midline. It is very important to make the incision right in the midline because we need a bloodless plane. We use these very small Army-Navy retractors; the electrocautery is isolated and so only the tip of the blade is active, the coagulation is really miniaturized. You see the fat plane is completely retracted and now we should be in a bloodless plane, incising the linea alba. This will allow us to enter the thyroid space, which constitutes the operative space both for parathyroid and thyroid operations. You see that not a single drop of blood is visible, this is very important because otherwise it would not be possible to see anything. The small retractors are now retracting the external layers of the strap muscles. You can see the thyroid space here, the carotid artery that is very visible now, you see the white layer, the carotid artery and already you can see the nodule. We are now preparing these small veins, which separate the nodule and now we are going straight on to the upper pedicle of the thyroid. We are preparing the upper pedicle of the thyroid now. Can you now see the external branch of the superior laryngeal nerve? I am not sure I have enough room but I will try. We have 2 blades in this instrument, this one with the white part is not active, the other is, so it is important to avoid heat on the nerve by always keeping the inactive blade in correspondence with the structures that you want to protect. You can see even the small vessel pulsating, this is the side of the thyroid lobe and this is the side of the carotid artery. Two clips have been put on that small vessel that was bleeding a little bit, after escaping the Ultracision coagulation. Now we go further down in search of the recurrent nerve. We are working with these small spatulas, we need very small instruments. Here you can see quite clearly the inferior pedicle. We know from the anatomy that the recurrent nerve should be lying exactly under the inferior pedicle of the thyroid under the artery. I suspend the artery with my spatula and the assistant is dissecting. The nerve should appear on the screen. You see the inferior pedicle, we are approaching the nerve and dissecting it a little bit from the thyroid nodule. This is the parathyroid. We are going ahead with the dissection of the thyroid, we are now under the inferior pedicle. This is the best view of the nerve, we had seen it from the other side. I am coagulating a little second middle thyroid vein. The recurrent nerve can be better seen from this side. What is also important is that we are dissecting it away from the thyroid. You can see the relationship between the nerve, which lies underneath the artery, so we have a very typical anatomy. We are also checking the upper pedicle. You can see the external branch of the superior laryngeal nerve, the inferior pedicle with the artery and the vein. Of course, it should not be ligated, and underneath the inferior pedicle, the nerve, the recurrent laryngeal nerve that is very visible, you can see the nerve almost completely prepared and separated from the gland. We shall have a second good view once the thyroid lobe has been extracted. Right now, we are trying to extract the thyroid lobe. You can see the upper pole of the thyroid, which has been completely ligated with its upper pedicle so now all the upper part of the thyroid is completely freed. Now the problem is to extract the lower pole because it contains the nodule. We are preparing the last capsular vessels. This is the Zuckerkandl lobe of the thyroid. We are now dissecting the isthmus from the right thyroid lobe. I can show you now the entire lobe. The inferior nodule, which is the largest (22mm) and the other nodule, which is posterior, probably very close to the Zuckerkandl lobe or posterior lobe of the thyroid. Now what remains is to prepare the small inferior vessels and check the nerve once again. This is Berry’s ligament that I am now dissecting, I have checked the nerve underneath, I always keep the inactive blade posteriorly in order not to jeopardize the other structures. You see the trachea completely freed now. What we must say is that we are able to perform an absolutely radical thyroid lobectomy. This is the last part of the isthmus, we had prepared it already. I am now right on the plane of the trachea; once again I keep the inactive blade adequately not to injure the trachea. These are the small veins coming from the inferior pedicle towards the capsule, we dissect it. Now to the inferior part of the isthmus, you can see the opposite side of the thyroid. This is the left lobe of the thyroid so we can say that we can perform a complete lobe isthmusectomy. Should we be faced with a cancer or should we need a total thyroidectomy, it is not difficult from this central access to go to the opposite side, in this case the left lobe, and do the same operation, perform exactly the same operation and end up with a total thyroidectomy. The use of Ultracision allows to save a lot of time. This is the final view, we are checking the upper pedicle, hemostasis is good, we can go down. We close the midline with a single stitch. We do not put any drainage or skin stitches, just sealant such as Dermabond. What are your indications for this kind of minimally invasive video-assisted surgery? The best indications are probably the follicular nodules where there is an indication for thyroid lobectomy, a second one is small low-risk papillary cancers and a third one is the pre-toxic or toxic small adenomas. What is important is the size of the nodule and also the size of the thyroid lobe. It is very difficult to extract out of such a small incision big goiters and anyway nodules are larger than 3 or 4cm. Best indications are probably small nodules harbored inside, normal or not very pathological thyroid lobes. You know that for digestive surgery, laparoscopic surgery has been criticized for cancer, especially when you have no protection of the skin, imagine that you have really a follicular cancer of the thyroid and that you didn’t know that before. Do you think that surgery is really a potential risk and why you don’t protect the skin during the extraction of the specimen? Follicular cancer in itself is not considered an indication, we just talk of papillary cancer. Sometimes, we operate on thyroid follicular nodules, which could potentially be follicular cancers; very rarely, follicular cancers are smaller than 2-3cm, so we choose small follicular nodules, which according to Williamsen and other oncologists of thyroid very rarely can harbor follicular cancers. The protection of the skin would be important but we have partial protection of the skin by placing a plastic film on the skin, so the skin is protected. Of course, all the cancers on the surface of the gland, which are extracapsular, are not a good indication for this surgery. Do you think that in the future we can imagine a total unilateral lobectomy but also with no dissection as we can do for colonic cancer, or gastric cancer for example? I think that for a cancer such as the one you describe, a unilateral thyroidectomy can be enough and of course, we can also remove all the lymph nodes around the recurrent nerve. As you have seen, the vision all along the nerve is very good and in the same way, we can operate on big parathyroid adenomas, which generally lie very deep in the neck. We can also consider lymphadenectomies as a part of the possible indications. Of course, big engagement of the lymph nodes all along the carotid artery and jugular vein does not constitute a good indication for this surgery, we must of course be very careful with malignancies, as in all other fields of endoscopic surgery. Last question about your instruments, and especially your Ultracision. We know that this kind of instrumentation can be dangerous if it is not used. For instance in a Heller procedure, a necrosis has been described because one part of the instrument can be hot at the end of the operation but not the other one, so can you explain how to use it, especially during the dissection of the nerve, without causing injury to the nerve. We must be very careful because we have 2 blades in this instrument, and they behave very differently. This one is not active and it does not ever reach high temperatures, this branch is active and can reach high temperatures, and when you close you must consider that the tip of the instrument can be hot. We must keep in mind what structures you want to protect and put this part of the instrument exactly in correspondence with the part you want to protect. Suppose this is the recurrent nerve, I will put the inactive branch very close to the nerve but I will never put this part of the instrument close to the nerve because I will probably injure it. But if I keep the instrument this way, I can go along the nerve with dissection and coagulation without jeopardizing it.