Feasibility of Endoscopic Thyroidectomy via Axilla and Breast Approaches for Larger Goiters: Widening the Horizons

Abstract

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4–6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

Extracervical Approaches to Thyroid Surgery: Evolution and Review

“…For example, primary indications initially included benign thyroid nodules with a maximum diameter of 6cm and maximum thyroid gland volume of 60ml [16, 21, 46, 49]. As operative experience has increased, larger tumours (up to 10cm in diameter), goiters, and low-grade malignancies have all successfully been attempted [13, 91, 92]. Common contraindications include previous surgery or irradiation and invasive malignant tumours [42].…”

“…Lateral approaches such as the axillary approach have poor visualization of the contralateral thyroid lobe and therefore poor identification of the contralateral RLN which limits bilateral thyroidectomy being performed in such approaches [61]. More recent approaches including the BABA and transoral approaches have more symmetrical approaches allowing for bilateral thyroid dissection and potentially larger nodules [91].…”

Thyroid cancer surgery – in what direction are we going? A mini-review

“…7 Some authors have emphasized that female patients have played a main role in the rapid emergence and acceptance of ET. 10 Additionally, Malandrino et al 11 noticed that unilateral PTMC, which is the most suitable tumor for endoscopic approaches, occurs more frequently in young women.…”

“…32 The currently recommended size of thyroid tumors that can be treated by scarless ET is 4 to 6 cm. 10 However, some other authors have expressed doubts about the effectiveness, efficiency, and oncological safety of ET. 33 In their opinion, all endoscopic techniques used in the treatment of TC should be critically evaluated.…”

Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy

“…[ 1 ] to achieve a better cosmetic outcome by avoiding obvious scarring. Various alternative approaches to the thyroid were developed by changing the site of the incision to hidden parts of the body including the axilla,[ 2 3 4 5 6 7 ] breast[ 8 9 10 11 12 ] and retroauricular region. [ 13 14 15 16 17 18 ] However, these techniques still left a scar on the skin.…”