Transareola Single-Site Endoscopic Thyroidectomy: Clinical Study of 28 Cases with Thyroid Nodules

Introduction

Thyroid nodules are a common medical condition that occurs preferentially in young women. ¹ Although most thyroid nodules are benign, the possibility of thyroid cancer progression must always be considered, and appropriate surgical treatment should be performed. ² Conventional open surgery leaves a 6–8-cm surgical scar on the neck, ³ which seriously affects the appearance of the neck. In addition, some patients may undergo scar hyperplasia and paresthesia, and skin traction and discomfort may even occur during swallowing because of adhesion between skin and trachea.^4,5 Endoscopic subtotal parathyroidectomy was first reported in 1996, and this is the first time for the endoscopic technique to be applied in neck surgery. ⁶ In 1997, endoscopic thyroid lobectomy was reported. ⁷ In 2002, endoscopic thyroid adenoma resection was performed. ⁸ Total endoscopic thyroidectomy changes the traditional incision on the neck and achieves the cosmetic results without a surgical scar on the neck. ⁹ However, such surgery requires three ports, a large-area tunnel should be separated subcutaneously, and the incision scar may produce hyperplasia on the thoracic wall. It is therefore still controversial whether endoscopic thyroidectomy is minimally invasive or not. ¹⁰ Because of the presence of these disputes, transareola single-site endoscopic thyroidectomy was designed in 2012 and has been demonstrated to be associated with improved cosmetic results and minimal invasiveness.^11,12 In this study, we report a further 28 cases who underwent transareola single-site endoscopic thyroidectomy in Fengxian Central Hospital (Shanghai, China) from January 2010 to April 2012. Good therapeutic outcomes were achieved, and no one was converted to an open approach.

Subjects and Methods

Surgical procedure

All subjects underwent general anesthesia and were placed in the supine position, with slight raising of their shoulders and back. The head of the patient was laid back, the two legs were separated, the operator stood between the two legs, the two assistants stood on both sides of the patient, and a television screen was placed at the head of the patient. The operating path (subcutaneous tunnel orientation) (Fig. 1) was marked from the areola on the surface of the affected side to the neck. A 5- or 10-mm incision was cut on the upper edge of the areola at the affected side, some space was separated from the superficial layer of the deep fascia using a subcutaneous separation stick, and a four-way-angulation 5-mm scope electronic laparoscope (EndoEYE™ LTF-VP; Olympus, Tokyo, Japan) or 30° 10-mm rigid laparoscope (Stryker Endoscopy, San Jose, CA) was implanted. CO₂ gas was injected, with a pressure of 6–8 mm Hg. A 5-mm incision was cut on the site adjacent to the endoscopic hole, and an ultrasonic scalpel (model GEN300; Johnson & Johnson, Somerville, NJ) was implanted upward to the thyroid cartilage for separation of surgical space. The linea alba cervicalis was incised using an electric coagulation hook, and the strap muscles were separated. The thyroid gland was exposed using the neck suture suspension technique (one suture), and the middle thyroid vein was cut with an ultrasonic scalpel. The nidus was localized using a type B ultrasound scan and computed tomography, to determine whether partial or subtotal thyroidectomy should be performed. The affected thyroid gland was suspended with one or two sutures, penetrated through the external skin of the neck, and then pulled inward (Fig. 2). The back tissues of the thyroid gland were separated and coagulated with an ultrasonic scalpel. After disarticulation of the upper or lower vessels of the thyroid gland, the thyroid gland was cut, and the residual normal gland was not sutured. The linea alba cervicalis was intermittently sutured with two absorbable sutures (the sutures were knotted with a knot pusher extracorporeally), and the removed specimen was stored in specimen bags (finally, the two neighboring incisions adjacent to the areola were connected to obtain specimens). The presence of bleeding on the wound side was checked. A negative-pressure drainage tube was placed through the incision on the areola (Fig. 3). The incised skin was sutured intradermally, and the wound side was compressed and bandaged.

OPEN IN VIEWER

FIG. 1.

Surgical separation of the flip region, with an area of about 120 cm².

OPEN IN VIEWER

FIG. 2.

Traction of a thyroid adenoma using the suture suspension technique.

OPEN IN VIEWER

FIG. 3.

The completion of surgery.

Results

All surgeries were successfully completed, and no three-port endoscopic surgery or open surgery was performed. Unilateral subtotal thyroidectomy was performed in 12 cases, unilateral partial thyroidectomy in 14 cases, and bilateral partial thyroidectomy in 2 cases. For the first 14 cases, the operation time was 145–205 minutes, with a mean duration of 170 minutes; the operation time ranged from 125 to 150 minutes, with a mean of 135 minutes, for the latter 14 cases. The intraoperative bleeding volume was 15–40 mL, with a mean of 25 mL. The total postoperative wound drainage was 80–135 mL, with a mean of 110 mL. The drainage tube was removed 3–4 days after surgery. Postoperative pathological examination diagnosed thyroid adenoma in 11 cases and nodular goiter in 17 cases. After surgery, no symptoms of cough after drinking water, hoarseness, or tetany was observed. Hematoma occurred in 2 patients, who healed after suction. No infection was present. The visual analog scale score (a score of 0 indicates painlessness, and a score of 10 is most painful) ¹³ was 1–5 at 24 hours postoperatively, with a mean score of 3.10. Two cases received one-time analgesic therapy with bucinperazine after surgery, whereas no analgesic measures were performed in other 26 cases. Two-month postsurgical follow-up revealed no chest wall wound pain and numbness and no discomfort of cervicothoracic tight skin. The cosmetic satisfaction score (a score of 0 indicates extreme dissatisfaction, and a score of 0 indicates extreme satisfaction) was 8–10, with a mean score of 9.5.

Discussion

Laparoendoscopic single-site surgery is one of the research topics, which is mainly applied in appendectomy and cholecystectomy in a department of general surgery,^14,15 with the aim to cover the surgical scar and increase cosmetic efficacy with the help of the umbilicus. Transareola single-site endoscopic thyroidectomy not only covers the surgical scar, but also decreases the area of intraoperative subcutaneous separation area. It is estimated that the separation area is about 120 cm², which is significantly smaller than that in three-port endoscopic thyroidectomy. Therefore, the surgical wound is reduced, which increases the minimal invasivity and cosmetic efficacy of total endoscopic thyroidectomy.

Transareola single-site endoscopic thyroidectomy is performed in a single site and a single channel, and the limited surgical space leads to the characteristics of operative difficulty, difficulty in visceral pulling, and limitation of the operative field.^11,16 In the present study, a four-way-angulation electronic laparoscope was used to increase operative space and effectively avoid the linear view. The thyroid gland and strap muscles were pulled to the medial and lateral sides using the suspension technique during surgery, which led to clearer exposure and safer operation of the single-site endoscopic surgery. In addition, the use of an ultrasonic scalpel during surgery produced little smog and eschar, and the thermal injury was less than 1 mm, which was helpful for precise anatomical separation and stypsis and achieved a good hemostatic effect. The thyroidectomy used in the present study directly disarticulated the thyroid artery and vein, which simplified surgical procedures. Before disarticulation of the upper and lower vessels of the thyroid gland using the ultrasonic scalpel, the proximate end of the heart was precoagulated, and then the distal end was disarticulated, which enabled more exact vascular closure. When the back side of thyroid gland was dissected, the neighboring tissues were pushed aside, and the head of the ultrasonic scalpel was placed upward and separated, which put it in closely contact with the thyroid membrane, so as to avoid damage to the parathyroid and laryngeal recurrent nerve.^17,18

There are currently few experiences in single-site endoscopic thyroidectomy with an ultrasonic scalpel. In the present study, we first selected the cases with a solitary thyroid nodule (diameter of less than 3 cm) and benign signs, which was helpful to enhance the success rate of surgery and accumulate experiences and avoided the accidental injury caused by a long duration of operation and improper operation. The mean duration of operation was 170 minutes for the first 14 cases and 135 minutes for the second 14 cases. With the increased surgical technique, the surgical indications can be gradually loosened. Bilateral partial thyroidectomy has been successfully performed in our hospital this year. When the subcutaneous operation space is separated, the anatomical plane should be accurately understood, and the subcutaneous separation stick should be used under the superficial layer of deep fascia (loose tissues and few vessels), so as to avoid damaging the subcutaneous small vessels or dermis, thereby resulting in subcutaneous fat liquefaction, skin ecchymosis and inflammation, and secondary infections. ¹⁷ Intraoperative CO₂ pressure is very important. Because of the particularity of the surgical sites, high neck pressure may affect the blood return on the neck and the functions of the brain, whereas low pressure may affect the exposure of surgical field. Therefore, the intraoperative CO₂ pressure was set at 6–8 mm Hg. ¹⁹

In the current study, the mean visual analog scale score was 3.10 at 24 hours postoperatively, and only 2 cases received a one-time analgesic therapy with bucinperazine after surgery. Two-month postsurgical follow-up revealed that the mean cosmetic satisfaction score was 9.5. These results are in accordance with previous studies.^11,12 In conclusion, transareola single-site endoscopic thyroidectomy is safe and feasible and has the advantages of a covert incision, minor subcutaneous separation area, and high cosmetic satisfaction. With the increased number of patients undergoing such surgery, the duration of operation will be shortened.