Lateral approach improves surgical access to the superior pole in giant endemic goiters

Abstract

Background: Surgical management of mega-goiters in endemic areas with extreme iodine deficiency presents unique challenges. Based on our initial 5-year experience (2007 to 2011) operating on mega-goiters in Gitwe, Rwanda, Africa, we modified our technique to a lateral approach which affords better exposure of the superior pole vessels and other vital neurovascular structures, thereby improving safety. We describe this lateral approach technique and review outcomes compared to the standard technique Methods: From 2007 to 2019, we have conducted 13 annual surgical missions to low resource setting in Gitwe, Rwanda. Retrospective chart review of surgeries between 2012 and 2019 was performed to study outcomes using standard approach and lateral technique during the same time period.Results: Over a period of 8 years (2012 to 2019), out of 192 total cases, lateral approach was used in 35 patients. No patient experienced significant intra-operative blood loss requiring transfusion. One patient had a post-operative hematoma requiring surgical intervention. Vocal cord mobility testing by transcutaneous laryngeal ultrasound was implemented in 2016. Of all patients, incidence of vocal cord weakness was 8.0% (11/137 patients tested) with less than 1/3 of these symptomatic. There was no statistically significant difference in vocal cord weakness noted in the two approaches (3/23 in lateral approach and 8/114 in standard approach) by Fisher's exact test (P=0.34).Conclusions: Lateral approach, by affording optimal exposure of the great vessels and the laryngeal nerves, reduces the risk of bleeding and nerve injury. Furthermore, inferiorly based strap muscle flap provides excellent coverage and cosmetic outcome.

Outcomes of Short‐Term Surgical Trips in Otolaryngology—Head and Neck Surgery: A Scoping Review

“…The publications covered STSTs from 1989 to 2021, with one study from the 1980s, 18 five from the 1990s, 19–23 15 from the 2000s, 24,25,34–38,26–33 and 26 from 2010 to 2021 39,40,49–58,41,59–61,42–48 . The average study period was 4.14 years with a range of one week to 25 years.…”

“…Head and neck surgery studies are more heterogenous, consisting mostly of thyroids and free flap reconstructions. A thyroid study that presented a new technique to treat massive goiter found complication rates comparable to traditional thyroidectomy in similar LMIC cohorts, suggesting that this technique could be considered as an alternative 46 . However, small sample sizes, author biases, and short‐term follow‐up may limit the generalizability of these conclusions.…”

“…The publications covered STSTs from 1989 to 2021, with one study from the 1980s, 18 five from the 1990s, [19][20][21][22][23] 15 from the 2000s, 24,25,[34][35][36][37][38][26][27][28][29][30][31][32][33] and 26 from 2010 to 2021. 39,40,[49][50][51][52][53][54][55][56][57][58]41,[59][60][61][42][43][44][45][46][47][48] The average study period was 4.14 years with a range of one week to 25 years.…”

“…A thyroid study that presented a new technique to treat massive goiter found complication rates comparable to traditional thyroidectomy in similar LMIC cohorts, suggesting that this technique could be considered as an alternative. 46 However, small sample sizes, author biases, and short-term follow-up may limit the generalizability of these conclusions. A survey study of ablative and free flap surgeries abroad relied on surgeon recall of morbidities and failures, inviting vulnerability to significant bias.…”