Introduction

Please go to expertconsult.com to view related videos Robotic Thyroidectomy: Left Thyroid Lobectomy via a Single Axillary Incision and Robotic Postauricular Thyroid Approach.

Minimally invasive surgical techniques¹ have transformed surgical practice over the past two decades, beginning with arrival of laparoscopic cholecystectomy² and the first randomized prospective trial in surgery comparing open versus laparoscopic colectomy.³ While significantly reducing incision length, pain, and morbidity associated with the traditional surgical approaches, in many cases minimally invasive techniques have been shown prospectively to achieve the same surgical objective. Thus, these techniques have supplanted many “open” procedures in the abdomen, pelvis, and chest. The adoption of minimally invasive techniques for thyroid, parathyroid glands, and neck has proceeded at a much slower pace.

The rising incidence of thyroid cancer and patient-driven demand has accelerated the evolution of endoscopic neck surgery. Davies and Welch reviewed the Surveillance, Epidemiology, and End Results (SEER) database on thyroid cancer mortality from the National Vital Statistics System from 1973 to 2002 and found that the incidence of thyroid cancer rose from 3.6 per 100,000 in 1973 to 8.7 per 100,000 in 2002, representing more than a twofold (p < 0.001) increase.⁴ Most of this increase was related to an increase in new cases of papillary thyroid cancer, which rose from 2.7 to 7.7 per 100,000, almost a threefold increase of this decade (p < 0.001). However, although the incidence of well-differentiated thyroid cancer increased, overall mortality did not change between 1973 and 2002, remaining at an estimated 0.5 deaths per 100,000. These authors suggested that this rise was the result of improved detection of occult small cancers rather than an increase in the true occurrence of clinically significant thyroid cancer. Chen and colleagues reviewed the same National Cancer Institute-SEER database from 1988 to 2005 and found that the rate of all well-differentiated thyroid cancer (WDTC) rose over this time period in both women and men.⁵ In this more recent cohort, the incidence of WDTC increased across all stages, suggesting that increased diagnostic scrutiny alone does not explain his trend. Elisei et al. found a similar trend in Europe.⁶ Certainly more patients, most of them female, are having thyroid surgery in the 21st century. As a result, and especially in light of the favorable prognosis for differentiated thyroid cancer, surgeons are finding new approaches to an old problem. Many surgical innovations rely on an extracervical approach to the thyroid and parathyroid glands, minimizing visible scars (see Chapter 42, Incisions in Thyroid and Parathyroid Surgery). Some are minimally invasive; all are endoscopic.

As technology improves, surgeons are reexamining traditional surgical approaches and developing innovative endoscopic approaches that potentially may offer significant benefits (see Chapter 43, Technological Innovations in Thyroid and Parathyroid Surgery). Traditional thyroid surgery, described by Kocher in the 1880s, has undergone incremental improvements over the years related to enhancements in anesthesia, understanding of the anatomy, and surgical technology (see Chapters 30, Principles in Thyroid Surgery, 31, Minimally Invasive Video-Assisted Thyroidectomy, and 61, Minimally Invasive Video-Assisted Parathyroidectomy). Improved visualization and instrumentation offer the potential to alter surgical approaches to the thyroid and parathyroid. Although innovation can be exciting, it is important that it occurs in a rational fashion and with consideration of the goals of the thyroid surgery. Costs and benefits from multiple perspectives, including patients, surgeons, the health care system, and even society, must also be considered. Innovation is fluid, learning curves do exist, and patients may be at risk during this process.

Goals of Endoscopic Thyroid Surgery

When assessing any surgical technology it is important to consider the goals of the procedure. There may be trade-offs. Accomplishing one goal may occur at the expense of another, so it is important to prioritize surgical goals. Parameters should be set for acceptable outcomes so that potential limitations and trade-offs can be evaluated. Furthermore, the current standard method (traditional open thyroidectomy) should be used as a baseline for comparison in order to evaluate for improvement.

With respect to thyroid surgery, there are three major goals. Of these goals, clearly the most important priority is to efficaciously treat the disease process. There may be some debate about the relative priority of the other two goals, and even a difference of opinion between physicians and their patients.

Costs and Benefits of Innovation

If a new technique potentially provides desirable improvement relative to an existing standard technique, it is important to consider the relative costs and benefits. In many cases, this may be difficult to analyze, as not all benefits can be fully assigned an economic value. Patients, physicians, hospitals, health insurance plans, the government, and even society at large may have vested interests in the outcomes and economic costs. Furthermore, the costs and benefits may accrue to different parties, and economic realities and incentives may dictate whether an advance is ultimately realized. In the case of conflicting economic incentives, alignment may require changes in the delivery model in order to justify the innovation. Although it is important to allow the opportunity for innovation to take place without allowing costs and benefits to stifle progress in the short term, technology should not be adopted in the absence of justified benefits simply because it is available. There is also a tendency for skeptics to reject innovation because comparative data do not exist to justify new costs. Although comparative data are critical, they cannot be collected until after the innovation has been initially explored. Formal cost-benefit analysis may be complicated and even subject to biases, yet it is an important exercise that should be considered as part of the innovation process.

Recent Surgical Innovation

Surgical innovation may occur by applying new technology to a procedure or with new anatomic approaches to accomplish existing surgical goals. Sometimes these innovations may be incremental; in other instances the new technique may be completely unrecognizable from traditional “open” surgery. Several advances in technology have been applied to thyroid surgery, each with potential benefits.

Classification of Surgical Techniques

Since the 1990s there has been a proliferation of new surgical techniques for endoscopic surgery of the thyroid and parathyroid glands. Although many have been deemed “feasible” by publication, few of these techniques are widely practiced beyond the developing institution, with the exception of video-assisted thyroidectomy and parathyroidectomy as described by Miccoli^7–9 and Bellantone¹⁰ (see Chapters 31, Minimally Invasive Video-Assisted Thyroidectomy, and 61, Minimally Invasive Video-Assisted Parathyroidectomy) and, more recently, robotic thyroidectomy via a gasless, transaxillary approach, as described by Chung¹¹ (see Box 36-1 for a detailed description of this technique). Table 36-2 compares these approaches.

Table 36-1 Classification Factors for Thyroid Surgery

Table 36-2 Comparison of Commonly Performed Approaches

Approach	Advantages	Disadvantages
Traditional thyroid surgery  (type I, gasless, manual)	• Can be performed on all patients • Exposure • Lowest equipment costs • Easiest to teach/learn	• Large incision
Small incision  (type I, gasless, endoscopic, manual)	• Smaller incision • Can easily be converted to traditional surgery • No drain	• Limited indications • Learning curve • Expensive equipment required • Requires multiple assistants • Two-dimensional view; loss of depth • Longer operating times < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Follicular Thyroid Cancer Central Neck Dissection: Indications Primary Hyperparathyroidism: Pathophysiology, Surgical Indications, and Preoperative Workup Surgical Management of Multiglandular Parathyroid Disease Stay updated, free articles. Join our Telegram channel Join Tags: Surgery of the Thyroid and Parathyroid Glands Expert Consult Pre Jul 23, 2016 | Posted by admin in OTOLARYNGOLOGY | Comments Off on Robotic and Extracervical Approaches to the Thyroid and Parathyroid Glands: A Modern Classification Scheme Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access