Читать книгу Pearls and Pitfalls in Head and Neck Surgery - Группа авторов - Страница 15
ОглавлениеThyroid and Parathyroid Glands
Cernea CR, Dias FL, Fliss D, Lima RA, Myers EN, Wei WI (eds): Pearls and Pitfalls in Head and Neck Surgery. Basel, Karger, 2012, pp 18–19
DOI: 10.1159/000337468
David J. Terrisa Woong Young Chungb
aDepartment of Otolaryngology, Head and Neck Surgery, Georgia Health Sciences University, Augusta, Ga., USA; b Department of Surgery, Yonsei University, Seoul, South Korea
P E A R L S
• An important key to safe outcomes is careful patient selection, and specifically the absence of thyroiditis, lymphadenopathy, or substernal extension.
• Thorough open dissection reduces the robotic console time needed.
• Key anatomic landmarks should be respected during pocket development.
• Familiarity with both robotic and harmonic technology will minimize intraoperative challenges.
• Laryngeal nerve monitoring is not necessary, but may serve as an important adjunct in remote access surgery.
• Remote access and robotic procedures require a team approach, and a consistent staff may lead to better outcomes.
• The facelift approach may be performed as a drainless outpatient procedure.
P I T F A L L S
• The arm positioning needed for the axillary approach may result in brachial plexus stretch injuries.
• Both remote access options result in numbness that is not typical of conventional thyroid surgery; this will occur in the anterior chest wall in the axillary approach, and in the ear and periauricular region in the facelift approach.
• While contralateral thyroid resection is possible, it is performed as a subtotal or near-total resection and is not suitable for most patients and inexperienced surgeons.
• These procedures are designed to completely eliminate a neck scar for interested individuals, but they are by their nature not minimally invasive.
Introduction
After more than 100 years of performing thyroidectomy as it was described by Theodore Kocher, a number of innovative techniques have emerged. Paolo Miccoli et al. [1] from Pisa pioneered and perfected a minimally invasive video-assisted cervical approach. During the same time frame, remote access endoscopic techniques were developed, with the totally endoscopic axillary insufflation-based approach by Ikeda et al. [2] emerging as one of the most feasible. Lee et al. [3] offered a combined postauricular and axillary access port. These procedures were tedious and somewhat lengthy.
In 2007, Woong Young Chung combined robotic technology with endoscopic remote access approaches to the compartment, developing the robotic axillary thyroidectomy [4–6]. Although this procedure has been exported to the USA [7], because of differences in the North American population, a facelift approach has emerged as an alternative [8–10].
Practical Tips
There are two principal options for remote access robotic thyroidectomy, both of which share a number of features and similar instrumentation. The axillary technique is performed with the arm positioned over the head and involves a prepectoral pocket which crosses over the clavicle and then between the heads of the sternocleidomas-toid muscle to reach the thyroid compartment. The facelift approach begins in the postauricular region and occipital hairline, follows the sternocleidomastoid muscle anteriorly, and reaches the thyroid compartment posterior to the strap muscles.
Proper selection of both patient and surgeon are essential. The procedures are most easily performed with ipsilateral pathology and a normal-sized gland with the maximal dimension of the largest nodule <4 cm and no thyroiditis. There should be no evidence of lymphadenopathy, extrathyroidal spread, or substernal extension. The procedures are best performed by high-volume surgeons who have completed advanced training in both robotic and remote access techniques.
Positioning of the patient, the surgeon, and the robot are important to optimize comfort and ergonomics. For the axillary approach, the ipsilateral arm should be above the head to reduce the distance between the axilla and the thyroid. Some surgeons advocate brachial plexus neuromonitoring to minimize the likelihood of stretch injury. For the facelift approach, the head should be turned slightly away from the side of surgery.
For both surgical approaches, a thorough open dissection prior to deployment of the robot should be accomplished and will substantially reduce the console time.
The robotic segment of the procedure is most easily achieved with the assistance of an experienced field surgeon who provides suction, changes instruments as needed, and can optimize the vector of the robotic arms. The highly magnified 3-D view helps to ensure the safety of the procedure.
Closure may include the use of Surgicel (Ethicon Inc., Somerville, N.J., USA) in the thyroid compartment, and after subcutaneous absorbable sutures, skin adhesive facilitates postoperative management. The facelift procedure is performed on an outpatient basis, while the transaxillary procedure requires an overnight stay.
More than 2,000 transaxillary procedures have been performed, predominantly in Asian countries, with excellent functional outcomes and early oncological outcomes. More than 50 robotic facelift thyroidectomies have been accomplished in a single-center experience, with no recurrent nerve injuries and no hypoparathyroidism.
Conclusions
Remote access robotic thyroidectomy can be successfully accomplished through either a transaxillary or a facelift approach in the hands of experienced endocrine surgeons. Careful patient selection is critical to achieving safe outcomes.
References
1 Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L: Minimally invasive video-assisted thyroidectomy: five years of experience. J Am Coll Surg 2004;199:243–248.
2 Ikeda Y, Takami H, Sasaki Y, Takayama J, Niimi M, Kan S: Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 2003;196:189–195.
3 Lee KE, Kim HY, Park WS, Choe JH, Kwon MR, Oh SK, Youn YK: Postauricular and axillary approach endoscopic neck surgery: a new technique. World J Surg 2009;33:767–772.
4 Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, Nam KH, Chang HS, Chung WY, Park CS: Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 2009;146:1048–1055.
5 Lee J, Kang SW, Jung JJ, Choi UJ, Yun JH, Nam KH, Soh EY, Chung WY: Multicenter study of robotic thyroidectomy: short-term postoperative outcomes and surgeon ergonomic considerations. Ann Surg Oncol 2011;18:2538–2547.
6 Lee S, Ryu HR, Park JH, Kim KH, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS: Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endo-scopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg 2011;253:1060–1066.
7 Lewis CM, Chung WY, Holsinger FC: Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO (2) insufflation. Head Neck 2010;32:121–126.
8 Terris DJ, Haus BM, Nettar K, Ciecko S, Gourin CG: Prospective evaluation of endoscopic approaches to the thyroid compartment. Laryngoscope 2004;114:1377–1382.
9 Terris DJ, Singer MC, Seybt MW: Robotic facelift thyroidectomy: patient selection and technical considerations. Surg Laparosc Endosc Percutan Tech 2011;21:237–242.
10 Terris DJ, Singer MC, Seybt MW: Robotic facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121:1636–1641.
David J. Terris, MD, FACS
Porubsky Professor and Chairman
Department of Otolaryngology
Georgia Health Sciences University
1120 Fifteenth Street, BP-4109
Augusta, GA 30912-4060 (USA)
E-Mail dterris@georgiahealth.edu
