14 Minimally Invasive Thyroid Surgery
14.1 Introduction
Minimally invasive thyroid surgery offers several advantages over the traditional thyroidectomy procedure in carefully selected patients. Shorter incision lengths reduce the cosmetic impact of the operation. A smaller extent of dissection, the omission of postoperative drains, and outpatient management strategies decrease postoperative pain, speed the recovery process, and improve the patient’s postoperative experience. 1 , 2 , 3 Two minimally invasive thyroidectomy procedures are currently performed: minimally invasive nonendoscopic thyroidectomy (MINET) and minimally invasive video-assisted thyroidectomy (MIVAT). MINET is typically performed through a 4 cm incision, whereas MIVAT can be performed through incisions as small as 1.5 cm. 4 MIVAT uses endoscopic assistance to visualize the operative field under the soft tissue envelope; otherwise the procedures are identical. Although this chapter focuses on the MIVAT technique, the principles discussed are easily adapted for the MINET procedure.
14.2 Patient Selection
Strict selection criteria have been described to improve the chance of operative success and minimize complications in MIVAT (Table 14.1). 5 Patients should have benign or indeterminate nodules < 3 to 3.5 cm or low-risk papillary thyroid carcinomas < 2 cm, with an overall thyroid volume < 25 mL. Contraindications include recurrent disease, locally advanced or metastatic carcinoma, and thyroiditis.
Indication | Contraindication |
Benign diseasea | Recurrent disease (previous cervicotomy) |
Graves’ diseasea | Locally advanced and/or metastatic carcinoma |
Indeterminate nodule | Short neck in obese patient |
“Low-risk” papillary carcinoma | Thyroiditis |
aThyroid volume < 25 mL and nodule diameter < 3 cm. | |
14.3 Operative Steps
The MIVAT technique has been previously described in detail 6 and is summarized here. The procedure consists of both open and endoscopic portions. Extending the incision slightly allows the procedure to be performed without endoscopic assistance. In these cases (the MINET procedure), the endoscopic steps are performed under direct visualization.
14.3.1 Step 1: Preparation of the Operative Space
The patient, under general endotracheal anesthesia, is placed in a supine position. Neck hyperextension has to be avoided in order not to reduce the operative space, which is maintained only by an external retraction and not by means of any insufflation. Furthermore, this position is strongly suggested to minimize cervical trauma, which is one of the most important contributors to postoperative pain, particularly in elderly patients, who often suffer from cervical ailments.
The skin is protected by means of a sterile film (Bioclusive, Johnson & Johnson). A 1.5 cm horizontal skin incision is performed in a skin crease approximately 2 cm above the sternal notch in the central cervical area (Fig. 14.1). The monopolar electrocautery blade is protected, leaving just the tip able to coagulate, in order to avoid any possible burning of the skin or the superficial planes. The subcutaneous fat and platysma are carefully dissected while the midline is opened for no more than 2 cm, just enough to allow the endoscope and needlescopic instruments to enter the operative space. Because the absence of positive pressure provided by insufflation cannot limit the bleeding as in the majority of laparoscopic procedures, particular caution is necessary when dividing the strap muscles along the linea alba so as to avoid any bleeding during this phase. Two small, modified, miniaturized Farabeuf retractors give optimal access to the midline (Fig. 14.2).
Blunt dissection of the strap muscles off the thyroid lobe is performed through the skin incision by gentle retraction and using tiny spatulas. When the thyroid lobe is almost completely dissected from the strap muscles, larger and deeper retractors (standard Farabeuf retractors) are placed, one retracting the thyroid lobe, and the other retracting the neck bundle, in particular the carotid artery, which has to be well visualized before being gently retracted (Fig. 14.3 a). The medial retractor should almost completely load the thyroid lobe; when the correct position is achieved, thyroid parenchyma should not be visible through the endoscope, except a minimal portion of the posterior part of the lobe (Fig. 14.3 b). The medial retractor basically plays the role of the hand of the assistant during a conventional thyroidectomy. Then the operative space will be correctly established and will provide an excellent access to all the critical structures during the endoscopic part of the procedure. Then a 5 mm, 30° endoscope is introduced through this cervical access. From this moment on the operation is performed endoscopically until the extraction of the lobe of the gland. Preparation of the thyrotracheal groove is completed using small (2 mm in diameter) instruments, such as spatulas, forceps, a suction spatula, and scissors, under endoscopic visualization (Fig. 14.4).
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