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10.1245/ASO.2006.03.057
Annals of Surgical Oncology 13:182-186 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Minimally Invasive Video-Assisted Thyroidectomy for Follicular Neoplasm: Is There an Advantage Over Conventional Thyroidectomy?

Michael B. Ujiki, MD, Cord Sturgeon, MD, Daphne Denham, MD, Linwah Yip, MD and Peter Angelos, MD, PhD

Department of Surgery, Northwestern University Feinberg School of Medicine, 201 E. Huron Street, Galter 10-105, Chicago, Illinois 60611

Correspondence: Address correspondence and reprint requests to: Peter Angelos, MD, PhD; E-mail: pangelos{at}nmff.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background: Minimally invasive video-assisted thyroidectomy (MIVAT) is safe and effective for selected patients, but its advantages are not clearly defined. Results of MIVAT for follicular neoplasms at a single institution were retrospectively evaluated to define its advantages or disadvantages.

Methods: Between October 2002 and May 2004, 22 patients underwent MIVAT. Twenty-six patients who underwent conventional thyroidectomy during the same time period served as matched controls. Operative times, pathologic findings, complications, analgesic requirements, and incision lengths were retrospectively evaluated.

Results: Four MIVAT and three conventional surgery patients underwent total thyroidectomy. Eighteen MIVAT and 23 conventional patients underwent hemithyroidectomy. The operative time (mean ± SEM) for hemithyroidectomy was 102 ± 4 minutes for MIVAT and 86 ± 3 minutes for conventional surgery (P < .05). In subgroup analysis that excluded patients with thyroiditis, operative times were not significantly different: MIVAT, 99 ± 4 minutes; conventional, 88 ± 4 minutes. The mean incision length was 2.3 ± .5 cm in the MIVAT group. Conventional thyroidectomy was performed through a 4- to 5-cm incision. The average amount of narcotic used was not significantly different (intravenous, 9.9 ± 3.1 mg [MIVAT] vs. 12.4 ± 3.8 mg; oral, 10.3 ± 4.2 mg [MIVAT] vs. 3.5 ± 2.0 mg). The conventional group received more cyclooxygenase 2 inhibitor (527 ± 9 mg vs. 187 ± 84 mg; P < .05). One patient in each group experienced transient hoarseness. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve injury in either group.

Conclusions: MIVAT is as safe and effective as conventional thyroidectomy and is associated with similar narcotic analgesic requirements, but it can be performed through smaller incisions. Operative times were significantly longer for MIVAT, but when patients with thyroiditis were excluded, operative times were not significantly different.

Key Words: Thyroidectomy • Thyroid surgery • Minimally invasive • Video assisted


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Videoscopic thyroid surgery was introduced in Europe in the 1990s in an attempt to decrease scar length and has recently compared favorably to the conventional approach in prospective randomized studies.1–3 The indications for minimally invasive video-assisted thyroidectomy (MIVAT) are relatively limited because of the difficultly encountered during dissection when there is inflammation, such as in Graves’ disease; scar tissue, such as in reoperative cases; or compressed anatomy, such as in large multinodular goiters. Miccoli et al.3 demonstrated that in selected patients, the minimally invasive gasless approach to thyroid surgery offers advantages in terms of postoperative pain and cosmesis without any difference in safety when compared with the conventional approach. To our knowledge, no studies conducted in the United States have been published regarding the minimally invasive gasless thyroidectomy. The aim of this retrospective review was to assess the feasibility, safety, advantages, and disadvantages of MIVAT. We hypothesized that improvements in cosmesis (incision length) and postoperative pain would be the most apparent benefits of the minimally invasive procedure.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Patient Selection
Between October 2002 and May 2004, 22 patients underwent elective thyroid surgery with the MIVAT technique. All patients were found to have at least one indeterminate nodule by fine-needle aspiration (FNA). Initial preoperative selection criteria for MIVAT included indeterminate nodules <2.5 cm and a normal-sized thyroid gland (≤20 cm2) estimated by preoperative ultrasonography. Patients with thyroiditis, previous neck surgery, or a history of neck irradiation or thyroid cancer were excluded. Thyroiditis was diagnosed either by findings on FNA or by the presence of anti–thyroid peroxidase antibodies on preoperative bloodwork. Thyroid volume was estimated by preoperative ultrasound measurements of the thyroid length, width, and depth. The selection criteria were later expanded to include nodules ≤3 cm, and patients were not excluded for thyroiditis. Preoperative evaluation consisted of a history and physical examination, ultrasonography, and FNA. Patients who met criteria were offered a MIVAT. No randomization was performed. Twenty-six patients who underwent conventional thyroidectomy during the same time period served as matched controls. The control group was chosen by review of the records of 50 consecutive patients who had the conventional procedure. Of these patients, 26 had complete records available. All patients gave informed consent for the procedure. The Institutional Review Board of Northwestern University Feinberg School of Medicine approved this retrospective study.

Surgical Technique
All MIVATs and open operations were performed by one of two surgeons (P.A. and D.D.). Both surgeons performed both procedures for this study. The operative technique used was similar to that previously described.4,5 With the patient under general anesthesia, the neck was minimally extended, and a 2-cm transverse collar incision was made 1 to 2 cm above the sternal notch. Minimal subplatysmal flaps were created. The midline was opened, and the strap muscles were retracted laterally. The thyroid gland was then retracted medially, and the 30° 5-mm videoscope was introduced into the incision to allow visualization of the superior pole of the thyroid gland. With the aid of Miccoli retractors, blunt dissection was performed to identify the superior pole vessels, which were then individually ligated by using the UltraCision Harmonic Scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, OH). The superior pole was then mobilized, and the thyroid was delivered through the incision. The remainder of the procedure was then performed under direct visualization. The middle thyroid vein and inferior pole vessels were ligated with the Harmonic Scalpel. An attempt to identify the recurrent laryngeal nerve was always made. The inferior thyroid artery was ligated high on the gland with the Harmonic Scalpel. The isthmus was then divided.

For the total thyroidectomies, the contralateral lobe was addressed in a similar fashion. The strap muscles, as well as the platysma, were then closed with interrupted absorbable sutures, and the skin was closed with a continuous absorbable subcuticular stitch. No drains were used. The operation was performed entirely without insufflation. The same two surgeons performed each procedure with a surgical resident or medical student assisting. The conventional technique was performed without the videoscope and required greater neck extension, a 4- to 5-cm incision, and larger subplatysmal flaps. In all other aspects, the procedures were practically identical. Operating room (OR) times were obtained by records from the circulating nurse and included the time from incision to skin closure.

The amount of analgesic used in the first 24 hours after surgery was obtained from the patient charts. Both intravenous (IV) and oral (PO) analgesics were recorded. The dose of narcotic used was standardized as described by Beaver.6 The only cyclooxygenase (COX)-2 inhibitor used in this study was celecoxib.

Data between groups were compared by using Student’s t-test and Fisher’s exact test, as appropriate. A P value <.05 was considered significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Twenty-two patients underwent thyroid surgery with the MIVAT technique between October 2002 and May 2004. Twenty-six patients who underwent conventional thyroidectomy during the same time period served as matched controls. Table 1Go compares the patient demographics between the two groups. There was no statistically significant difference between the two groups in terms of age, nodule size, and tissue weight. There were more women in the MIVAT group. In the minimally invasive group, four total thyroidectomies were performed: two for bilateral indeterminate nodules and two for papillary cancer found on frozen section examination. In the conventional group, three total thyroidectomies were performed, all for bilateral indeterminate nodules. All of the other patients underwent thyroid lobectomy with isthmusectomy.


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  		TABLE 1. Patient characteristics
 
All of the minimally invasive cases were started with a 2-cm incision, which was lengthened by 1 cm in six patients. Three of these patients were those who underwent a total thyroidectomy. The incision length mean ± SEM) was 2.3 ± .5 cm. All of the patients in the conventional thyroidectomy group received a 4- to 5-cm incision. Data were not available for the exact incision length in all patients in the control group; therefore, statistical comparisons were not attempted.

The recurrent laryngeal nerve was identified in 21 (95%) of 22 MIVAT patients and 24 (92%) of 26 conventional surgery patients. One patient in each group (4%) experienced temporary hoarseness that resolved in less than a month. Incidentally, the recurrent laryngeal nerve was identified in both of these patients. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve injury in either group. There were no deaths, wound hematomas, or wound infections in either group.

Table 2Go lists OR times for both groups. The MIVAT group had a statistically significantly longer mean OR time for both hemithyroidectomy (102 ± 4 vs. 86 ± 3 minutes; P = .004) and total thyroidectomy (190 ± 7 minutes vs. 134 ± 8 minutes; P = .003). However, in subgroup analysis excluding patients with thyroiditis, OR times for hemithyroidectomy were not significantly different (99 ± 4 minutes vs. 88 ± 4 minutes; P = .082).


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  		TABLE 2. Mean operative times
 
All patients had a preoperative diagnosis of an indeterminate follicular nodule based on FNA biopsy. Most patients were ultimately found to have benign disease. Two patients in each group (6% overall) were found to have papillary thyroid cancer. Table 3Go lists the final pathologic diagnoses in each group.


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  		TABLE 3. Final pathologic diagnosis
 
Table 4Go details the average amount of IV and PO narcotic used in the first 24 hours after surgery, as well as the average amount of COX-2 inhibitor used in both groups. There were no statistically significant differences between the groups in terms of IV or PO narcotic used; however, the conventional group used significantly more COX-2 inhibitor.


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  		TABLE 4. Postoperative analgesic requirements
 
Three of the MIVAT patients were discharged home on the same day of surgery. All of the other patients were discharged the following day. One of the patients from the conventional group was discharged the same day of surgery. All of the other patients from the conventional group went home the following day. There was no statistical difference between groups in length of hospital stay.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
FNA has proven to be sensitive in distinguishing between most benign and malignant thyroid nodules; however, indeterminate follicular lesions remain a diagnostic challenge and comprise 10% to 30% of cytopathologic diagnoses.7 For these lesions, thyroidectomy is often performed for diagnostic purposes. Minimally invasive techniques that are potentially less painful and decrease scar length are thus appealing. In our opinion, first, any minimally invasive procedure should be at least equivalent to the established procedure at controlling the disease. Second, it should be safe and not have a higher complication rate. Third, it should have some benefit over the conventional procedure. Finally, the procedure must be feasible.

In this study, thyroid lobectomies were performed through either the MIVAT or conventional approach for diagnostic purposes in patients with indeterminate follicular nodules. In both groups, the above-stated goals for a minimally invasive procedure were met. In the MIVAT group, no patient was converted to the conventional procedure, although the incision was lengthened in some. Even in those patients, however, a 3-cm incision should still be smaller than the 4- to 5-cm incision typically used in the conventional technique.

There were no significant differences in complication rates. One patient in each group had hoarseness that resolved within a month. This 4% rate of recurrent laryngeal nerve palsy is similar to previous reports of a 2% to 6% incidence after the minimally invasive technique.8–11 Most conventional thyroidectomy series report a nerve palsy incidence of 1% to 2%, with a permanent paralysis rate of <1%,12 although some studies have reported a nerve palsy rate as high as 8.5% after conventional surgery.9 The videoscope allows excellent visualization of the critical structures encountered in thyroid surgery. In fact, the magnified view offered by the 30° videoscope allows better visualization of the upper pole vessels, parathyroids, recurrent laryngeal nerve, and inferior thyroid artery. In terms of safety, MIVAT is at least equivalent to the conventional technique.

We hypothesized that improvements in cosmesis (incision length) and postoperative pain would be the most apparent benefits of the minimally invasive procedure. In this study, there was no statistically significant difference in the amount (milligrams) of either hydrocodone (PO) or morphine (IV) used within the first 24 hours after surgery. However, a statistically significantly greater amount of COX-2 inhibitor, again expressed in milligrams, was used in the first 24 hours after surgery in the conventional group. Other studies that have looked at postoperative pain have reported significantly less use of analgesics and less subjective pain according to a visual analogue scale in patients after MIVAT.3,13 It is possible that the shorter incision, minimal neck extension, and smaller subplatysmal flaps play an important role.

Other studies have addressed cosmesis through surveys that have shown higher satisfaction with the smaller scars in the MIVAT groups.3,13 Miccoli et al.3 found a statistically significantly higher satisfaction rate in MIVAT patients through a verbal response scale (MIVAT, 3.8; conventional, 3.1; P = .003) and a numeric scale (MIVAT, 9.2; conventional, 8.0; P = .01). Bellantone et al.13 found similar results by using a numeric scale with MIVAT patients, reporting a mean satisfaction score of 9.2 vs. 5.8 in the conventional group (P < .001). The mean nodule size in this series (2.1 ± .2 cm) was similar to that in previously reported MIVAT series, with nodule sizes of 1.9 to 4.1 cm.3,9,13,14

In terms of feasibility, MIVAT is appealing at our institution because there is, on average, a less than 20-minute difference in the time to complete the MIVAT when compared with the conventional procedure. Operative time is a consideration that has been a limiting factor since the introduction of the video-assisted technique, but with the regular use of the Harmonic Scalpel, as well as the recognition that a learning curve exists with this procedure, others have shown only minor differences from the conventional approach.3,13 A look at our initial experience demonstrates OR times that are longer than the conventional procedure, but we believe that we are still early on the learning curve. Other larger series report mean operative times of 41 to 94 minutes.9,11,14 In subgroup analysis, we found no statistically significant difference in the OR time between MIVAT and conventional groups when patients with thyroiditis were excluded. The tissue reaction around the thyroid in patients with thyroiditis causes adherence to the surrounding structures and makes blunt dissection more difficult, which may explain this statistical trend. Regardless of the method of resection, the surgeon should be prepared for a longer operation when thyroiditis is identified before surgery.

The cost of the procedure has been previously discussed.3 The gasless technique does not require any dedicated laparoscopic instruments and thus requires no additional charge. The equipment used for the procedure, such as the videoscope, is reusable, with the exception of the Harmonic Scalpel, which may be used for the conventional procedures as well. At our institution, there is no charge for the videoscope after the first purchase. The only cost difference between the groups is due to the difference in operative time. With further experience, we expect the operative time to decrease and, therefore, expect the cost for MIVAT to match that for the conventional technique. In terms of cost for hospital stay, patients generally are discharged 24 hours after the conventional procedure at our institution. Three MIVAT patients in this study, however, had a same-day discharge.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
This study demonstrates that in selected patients, MIVAT is safe, effective, and feasible. Patient selection is critical because the feasibility of MIVAT is limited in patients with goiters that are too large to remove through a 2-cm incision and, because of size, do not allow sufficient working space to dissect. Thyroiditis and scarring from prior neck operations also pose limitations to MIVAT. We will continue to use and study the minimally invasive technique. In our early experience, complications rates are no different, and surgical times are longer but still comparable to those with the conventional approach.


   FOOTNOTES
 
Presented at the 58th Annual Cancer Symposium of the Society of Surgical Oncology, Atlanta, Georgia, March 3–5, 2005.

Received for publication March 4, 2005. Accepted for publication August 25, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Huscher CS, Recher A, Napolitano G, Chiodini S. Endoscopic right thyroid lobectomy. Surg Endosc 1997; 11:877.[CrossRef][Medline]
  2. Yeung CH, Ng WT, Kong CK. Endoscopic surgery of the neck: a new frontier. Surg Laparosc Endosc 1998; 8:227–32.[Medline]
  3. Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 2001; 130:1039–43.[CrossRef][Medline]
  4. Bellantone R, Lombardi CP, Raffaelli M, Rubino F, Boscherini M, Perilli W. Minimally invasive, totally gasless video-assisted thyroid lobectomy. Am J Surg 1999; 177:342–3.[CrossRef][Medline]
  5. Miccoli P, Berti P, Raffaelli M, Conte M, Materazzi G, Galleri D. Minimally invasive video-assisted thyroidectomy. Am J Surg 2001; 181:567–70.[Medline]
  6. Beaver WT. Management of cancer pain with parenteral medication. JAMA 1980; 244:2653–7.[Abstract/Free Full Text]
  7. Haugen BR, Woodmansee WW, McDermott MT. Towards improving the utility of fine-needle aspiration biopsy for the diagnosis of thyroid tumors. Clin Endocrinol 2002; 56:281–90.[CrossRef][Medline]
  8. Miccoli P, Bellantone R, Mourad M, Walz M, Raffaelli M, Berti P. Minimally invasive video-assisted thyroidectomy: multiinstitutional experience. World J Surg 2002; 26:972–5.[CrossRef][Medline]
  9. Chao TC, Lin JD, Chen MF. Video-assisted open thyroid lobectomy through a small incision. Surg Laparosc Endosc Percutan Tech 2004; 14:15–9.[Medline]
  10. Schabram J, Vorlander C, Wahl RA. Differentiated operative strategy in minimally invasive, video-assisted thyroid surgery results in 196 patients. World J Surg 2004; 28:1282–6.[Medline]
  11. Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L. Minimally invasive video-assisted thyroidectomy: five years of experience. J Am Coll Surg 2004; 199:243–8.[CrossRef][Medline]
  12. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998; 228:320–30.[CrossRef][Medline]
  13. Bellantone R, Lombardi CP, Bossola M, et al. Video-assisted vs conventional thyroid lobectomy. Arch Surg 2002; 137:301–5.[Abstract/Free Full Text]
  14. 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.[Medline]



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D. J. Terris, P. Angelos, D. L. Steward, and A. A. Simental
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Arch Otolaryngol Head Neck Surg, January 1, 2008; 134(1): 81 - 84.
[Abstract] [Full Text] [PDF]

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