Goals & Objectives. Pros, Cons, and Options. Minimally-Invasive Thyroid Surgery: Pros, Cons, and Options 11/9/2012

Transcription

1 Minimally-Invasive Thyroid Surgery: Pros, Cons, and Options Minimally-Invasive Thyroid Surgery: Pros, Cons, and Options Merry Sebelik, MD, FACS Nothing to Disclose Merry E. Sebelik, MD, FACS University of Tennessee Head & Neck Surgery UCSF Endocrine Surgery Course November 9-10, 2012 Goals & Objectives Outline history of development of minimallyinvasive thyroid surgery techniques Describe varieties of minimally-invasive approaches to thyroid pathology Pros: benefits and indications for minimallyinvasive approaches Cons: limitations of minimally-invasive techniques Summarize evidence-based, minimally-invasive concepts which can be broadly applied 1

2 History of Thyroid Surgery The extirpation of the thyroid gland typifies perhaps better than any operation the supreme triumph of the surgeon s art Kocher won Nobel Prize for thyroid surgery 1997 First case report of minimally invasive thyroidectomy, Miccoli, Gagnier and others 2005 Terris disseminates education efforts for MIVAT following detailed published description of technique 2009 Chung reported first experience with Robotic Thyroidectomy William Stewart Halsted ( ) Evolution of Thyroid Surgical Technique Transaxillary Robotic Thyroidectomy Kuppersmith, RB, Transaxillary Robotic Thyroid Surgery, presented in Celebration, FL, June

3 Transaxillary Robotic Thyroidectomy Transaxillary Robotic Thyroidectomy Kuppersmith, RB, Transaxillary Robotic Thyroid Surgery, presented in Celebration, FL, June 2011 Kuppersmith, RB, Transaxillary Robotic Thyroid Surgery, presented in Celebration, FL, June 2011 Patient education material: While robotic surgery has been safely performed on many patients by our group and other groups around the world, there may be additional and unknown risks relative to traditional approaches. Long-term outcome studies comparing this approach to traditional approaches have not been performed to date. This procedure is currently considered an off-label use of the davinci Surgical System. (website) Roboticthyroid.com/noneckincisions Roboticthyroid.com/noneckincisions 3

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5 MI (+/-VA) T 1. Short incision (tailored to disease and patient 2. Avoidance of subplatysmal flaps with division of straps (Sofferman technique) 3. Use of RLN monitor 4. Use of 30 degree laparoscope (if needed) to assist in take-down of superior pole 5. Use of powered hemostasis 6. Meticulous preservation of nerve, PTs 7. No drain (consider hemostatic agent in thyroid bed 8. Close straps with minimal suture 9. Meticulous skin closure General (and conservative) Indications Non to moderately obese patients Nodule size up to 3 cm No thyroiditis Pathology: Follicular lesions PTC limited to above size and no nodes Small multinodular goiter 5

6 World J Surg Jun;36(6): COSMESIS AND BODY IMAGE AFTER MINIMALLY INVASIVE OR OPEN THYROID SURGERY. Bokor T, Kiffner E, Kotrikova B, Billmann F. RESULTS: Although the mean incision size was significantly shorter in the MI group than in the CO group (2.8 vs. 3.5 cm), the mean scores from the body image questionnaire (body image score, cosmetic score, and self-confidence score) were similar for both groups (p > 0.05). No significant differences in postoperative complications were observed in these groups (p > 0.05). CONCLUSIONS: Studies in the literature that evaluate body image and cosmesis in thyroid surgery using standardized methods are scarce. In our department, the results of a questionnaire showed that the MI approach has no advantage for body image and cosmesis over the CO approach. Further prospective randomized studies using different tools with a larger sample size are needed to investigate the use of MI procedures for thyroid surgery. Image-Guided Incision Image-Guided Incision 6

7 Image-Guided Incision Image-Guided Incision Image guidance determines: 1. Level of pathology 2. Accessibility of superior pole vessels Summary: Pros of MIT Parathyroid and recurrent nerve injury rates equivalent to traditional open surgery Postoperative recovery shorter, better, hospital stays shorter with MIT Neck scars are shorter (MIT/MIVAT) or nonexistent (RATS) Surgeons may care about this more than patients As a marketing tool, has led to more recognition of patient concerns Expense Summary: Pitfalls of MIT Time (OR times longer throughout learning curve) Learning curve Unanticipated consequences (RATS) Applicability continues to be limited to select patients 7

8 Summary: Best of All Worlds Evidence-based components of minimallyinvasive thyroid surgery that can and have been widely adopted: Incision placement (the personalized incision ) Marked sitting up and awake or US-guided Avoid sub-platysmal flaps (the REAL reason patients have less postoperative pain and shorter recovery times) Reserve drains for exceptional situations Skin closure management and incision length both have led to better cosmesis Thank you! 8