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Minimal Endoscope-Assisted Thyroidectomy Through a Retroauricular Approach: an Evolving Solo Surgery Technique

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Minimal Endoscope-Assisted Thyroidectomy Through a Retroauricular Approach: an Evolving Solo Surgery Technique ORIGINAL ARTICLE Minimal Endoscope-assisted Thyroidectomy Through a Retroauricular Approach: An Evolving Solo Surgery Technique Myung Jin Ban, MD,*w Jae Won Chang, MD,z Won Shik Kim, MD,y Hyung Kwon Byeon, MD, PhD,y Yoon Woo Koh, MD, PhD,y and Jae Hong Park, MD, PhD* (RA), or transoral approach.1–5 Endoscopic thyroidectomy Abstract: This study aimed to evaluate the feasibility and efficacy of through an RA approach is an especially excellent choice minimal endoscope-assisted thyroidectomy (MEAT) through a for head and neck surgeons because of their familiarity with retroauricular (RA) approach. Most of the thyroidectomy oper- the direction of the approach, the short distance to the ative time was accounted for by direct visualization through the thyroid gland, and a good cosmetic outcome without the RA window, minimizing interference between surgical instruments. 6 Endoscope use was minimized and limited to critical surgical need for additional incisions. aspects, including preservation of the recurrent laryngeal nerve and Despite the advantages of the RA approach, funda- parathyroid glands. The recurrent laryngeal nerve was neuro- mental limitations of endoscopic surgery still exist, includ- monitored throughout the procedure. MEAT through an RA ing a narrow operative field that restricts the free movement approach was performed in 8 patients with papillary thyroid car- of instruments. Gas insufflation, an additional incision for cinoma (mean tumor size, 1.2 ± 0.5 cm). The mean patient age was the endoscope port, robotic arm assistance, and a flexible 41.1 ± 7.5 years. The endoscopic operating time was endoscope holder for solo surgery have all been used to 19 ± 3.4 minutes, and no postoperative hematoma, seroma, or overcome this limitation.3,7,8 vocal cord paralysis was observed. MEAT through an RA To reduce instrument interference, we take advantage approach was feasible and safe. Solo thyroidectomy through the RA approach is possible without depending on an endoscopic view, of the RA approach, especially the short distance to the overcoming limited working space and minimizing instrument thyroid gland from the incision and endoscopic view was interference during endoscopic RA thyroidectomy. minimally used only for critical surgical aspects. We con- ducted this study to evaluate the feasibility and efficacy of Key Words: minimal endoscope-assisted thyroidectomy, retro- minimal endoscope-assisted thyroidectomy (MEAT) auricular approach, papillary thyroid carcinoma, thyroidectomy through an RA approach. (Surg Laparosc Endosc Percutan Tech 2016;26:e109–e112) MATERIALS AND METHODS hyroidectomy is one of the most frequently performed Patients Tsurgeries, and various efforts have been made to reduce Between February 2013 and February 2016, 8 patients morbidity and improve cosmetic outcomes. Various pro- underwent MEAT through an RA approach. All surgeries cedures have been used to accomplish this, including con- were performed by 1 surgeon (J.H.P.) at our institution. ventional thyroidectomy with a minimal incision, minimally The indications for surgery were the same as those pre- invasive video-assisted thyroidectomy, and endoscopic viously reported for endoscopic thyroidectomy through the thyroidectomy through an axillary, breast, retroauricular RA approach: (1) a thyroid nodule with a small malignancy (T1, T2) without cervical lymph node metastasis seen on Received for publication September 26, 2016; accepted October 3, 2016. preoperative imaging studies, (2) a follicular neoplasm of From the *Department of Otorhinolaryngology-Head and Neck Sur- undetermined malignant potential, and (3) a symptomatic gery, Soonchunhyang University College of Medicine, Cheonan; goiter (< 4 cm).4 Patients with a history of neck surgery or wDepartment of Medicine, The Graduate School of Yonsei Uni- versity; yDepartment of Otorhinolaryngology, Yonsei University presenting with a tumor showing gross invasion of local College of Medicine, Seoul; and zDepartment of Otorhinolar- structures were excluded from this study. All procedures yngology, Chungnam National University College of Medicine, were attempted using an RA incision extending along the Daejeon, Korea. hairline at the postauricular sulcus. Although endoscopic Supported by the Soonchunhyang University Research Fund. The authors declare no conflicts of interest. RA thyroidectomy was performed in a manner similar to Reprints: Jae Hong Park, MD, PhD, Department of Otorhino- that of a previous report, we modified the operative pro- laryngology-Head and Neck Surgery, Soonchunhyang University cedure to reduce the potential for instrument interference.1 College of Medicine, 31, Suncheonhyang 6-gil, Dongnam-gu, All patients provided written informed consent after being Cheonan-si, Chungcheongnam-do 330-721, Korea (e-mail: entpar [email protected]). appraised of the risks and benefits of the procedure. This Copyright r 2016 The Authors. Published by Wolters Kluwer Health, Inc. retrospective study was approved by the institutional All rights reserved. This is an open-access article distributed under the review board of the Soonchunhyang University College of terms of the Creative Commons Attribution-Non Commercial-No Medicine. Patients were followed up at 2 weeks post- Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work operatively and at 3 months postoperatively. Data collected cannot be changed in any way or used commercially without permis- from the patient’s chart included total endoscope use time, sion from the journal. total operative time, final pathology, amount of drainage, Surg Laparosc Endosc Percutan Tech Volume 26, Number 6, December 2016 www.surgical-laparoscopy.com | e109 Ban et al Surg Laparosc Endosc Percutan Tech Volume 26, Number 6, December 2016 postoperative days until discharge, and complications such Direct vision was maximized during the procedure for as seroma, hematoma, marginal mandibular nerve injury, simplicity and safety. The thyroid gland was dissected away vocal cord palsy, and skin necrosis. Patients completed a from the lateral carotid sheath and adjacent tissues superiorly retrospective direct questionnaire 1 month postoperatively and inferiorly, including the strap muscles and trachea, by to assess patient cosmetic satisfaction and to evaluate pain digital dissection, Yankauer suction, or harmonic scalpel scores and the presence of paresthesias. Cosmetic sat- dissection (Fig. 2A). To ensure that the thyroid gland had isfaction, pain, and paresthesias were graded by the patient been adequately released for medial retraction, the surgeon with a 10-cm visual analog scale [(Cosmesis; 0 = extremely palpated the tracheoesophageal groove with his index finger satisfied and 10 = extremely dissatisfied), (operative field (Fig. 2B). The thyroid isthmus was transected downwardly pain; 0 = no pain and 10 = pain as bad as it can be), and the midline of the thyroid gland was detached from the (paresthesias of ear lobe; 0 = none and 10 = very severe)]. trachea. After securing an avascular plane between the thy- roid gland and the cricothyroid muscle using a long tonsil Surgical Procedure forcep, we held and retracted the upper pole superiorly, and The surgical technique for RA thyroidectomy was we visualized, divided, and ligated the superior thyroid vessels similar to that of a previous report.4 However, the oper- through direct vision (Fig. 2C). After ligating the middle ating time through direct vision was maximized to prevent thyroidal vein, we dissected the inferior pole along the sub- intraoperative instrument interference or dissociation capsular plane while holding the gland superomedially off the between the operator’s eye and the targeted, magnified trachea. Dissection was cautiously performed around Zuck- operative field visualized with the endoscope. erkandl tubercle with a tonsil forcep. It was often possible to The operator and 2 assistants created a working space identify the RLN by digital palpation under direct vision, and through an RA window under a direct view. Intraoperative identification was confirmed with neuromonitoring (Figs. 2D, monitoring of the recurrent laryngeal nerve (RLN) was per- F, G). If RLN identification was impossible, the endoscope formed routinely with the NIM Nerve Monitoring System was introduced laterally to assist in RLN identification (Medtronic, Minneapolis, MN). The curvilinear skin incision (Fig. 2F). A 30-degree rigid endoscope (10-mm diameter, 30- along the RA sulcus was designed similar to that of the cm length; Stryker Endoscopy, San Jose, CA) was operated thyroidectomy performed by Byeon et al.1,9 After sub- by the assistant. A laparoscopic dissector and Harmonic platysmal flaps were elevated, preserving the external jugular scalpel (Harmonic Ace 23E; Johnson & Johnson Medical, vein and great auricular nerve, a self-retaining retractor Cincinnati, OH) were also utilized. Although the accom- (Sangdosa Inc., Seoul, Korea) was applied. The anterior panying figures show both direct and endoscopic identi- border of the sternocleidomastoid muscle at level II was fication, the surgeon often identified RLN with direct vision. dissected and retracted posteriorly to meet the omohyoid The superior (Fig. 2E) and the inferior parathyroid gland was muscle inferiorly. The omohyoid muscle and other strap preserved with endoscopic visualization by subcapsular dis- muscles were lifted from the thyroid gland and then the self- section. Once RLN identification was accomplished, the sur-
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