Minimally Invasive Approach Can Work For Many Thyroid Patients

Options include minimally invasive thyroidectomy, in which surgeons work through an incision about half the size of the norm, and an endoscopic approach, in which video monitoring and a thin, ultrasonic scalpel reduce incision size another half.

“Both work well; both have a place in a usual practice,” says Dr. David J. Terris, chair of the Medical College of Georgia Department of Otolaryngology – Head and Neck Surgery and lead author on research looking at the safety and efficacy of the newer approaches published in the March issue of Laryngoscope.

The online edition also features accompanying surgery video for the first time. Dr. Terris hopes the video of him performing the endoscopic approach will be a good first step for physicians interested in adopting these techniques. Practice on cadavers as well as observing the surgery first-hand are two important additional steps, he says.

The study looks at 31 patients who underwent minimally invasive removal of the thyroid gland, which helps regulate metabolic function, and 14 patients in whom pairing the endoscope with the harmonic scalpel, which coagulates as it cuts, enabled the smallest incisions yet for this approach.

Dr. Terris began using a minimally invasive approach to thyroid surgery about two years ago. Today, careful selection of patients based on factors such as the size of the diseased organ and the patient’s anatomy enables him to use this approach in most patients.

While most patients with the option prefer a less-invasive approach, the standard approach, which results in a three-to-four-inch incision at the base of the neck, likely always will be needed by some, he says. This includes patients whose gland has grown too large to be removed through a small opening, even with careful manipulation of the gland that typically remains pliable when diseased. In Dr. Terris’ practice, about 30 percent of patients need this approach using a larger incision and moving aside underlying muscle to remove the thyroid.

With one type of minimally invasive technique, surgeons cut through that muscle to gain direct access. During a portion of this surgery, the endoscope enables the surgeon to better see obscure spots such as the very top of the gland and incoming blood vessels. “For the most part we are just looking through a smaller incision,” says Dr. Terris.

A newer technique, fine-tuned by Dr. Paolo Miccoli of the University of Pisa, Italy, enables the surgery through an incision less than an inch by pairing the straw-size endoscope with the equally slender harmonic scalpel.

“The harmonic scalpel allows us to safely secure blood vessels in small spaces without needing to tie the vessels,” Dr. Terris says. “You reach up and ligate vessels through endoscope guidance.”

Slender instruments also enable surgeons to push aside muscles rather than cut through them. Video monitoring equipment attached to the endoscope magnifies the anatomy about 20 times so surgeons actually can see better than they can through the typical glasses with integrated magnification that enlarge the image about two and one-half times.

In addition to an improved cosmetic result, minimally invasive approaches reduce surgical trauma and recovery time with most patients going home within a few hours of surgery. “We don’t even use stitches on the skin,” Dr. Terris says of the endoscopic approach. “We use a little bit of medical-grade glue.”

He notes as the incision gets smaller, surgery time typically gets slightly longer and the surgery team gets larger, including someone to operate the camera with the endoscopic approach.

Co-authors on the Laryngoscope paper include Dr. Christine G. Gourin, MCG otolaryngologist, and Dr. Edward Chin, MCG endocrinologist.