We aimed to test the hypothesis that Minimally Invasive Video-assisted Thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery, when dealing with patients with unilateral thyroid nodules or follicular lesions, in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain and hospital stay.
MATERIALS AND METHODS:
This was a single-blinded randomised controlled trial comparing the MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain after 24 and 48 hours from operation and self-rated patient satisfaction with cosmetic outcome three months postoperatively. The secondary outcome measures were operative time, incidence of temporary and permanent recurrent laryngeal nerve injury, postoperative haematoma formation, length of incision, and duration of hospital stay.
Operative time was significantly less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Blood loss did not reach significance between procedures. Comparisons between the two procedures with regard to pain scores after 24 and 48 hours, respectively, depicted statistically significant differences in favour of the MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfactory cosmetic results. There were statistically no significant differences between both procedures for the presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism.
MIVAT is a safe procedure that produces outcomes, in view of short-term adverse events, similar to those of open thyroidectomy, and is superior in terms of immediate postoperative pain and cosmetic results.
Thyroid surgery; minimally invasive
The targets of minimally invasive surgery (MIVA) could be summarised by: achievement of the same results as those obtained with traditional surgery, less trauma, better post-operative course, early discharge from hospital and improved cosmetic results. The minimally invasive techniques in thyroid surgery can be described as either endoscopic "pure" approach (completely closed approach with or without CO2 insufflation), or "open approach" with central neck mini-incision or "open video-assisted approach". Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. The minimally invasive approach wound is much shorter (1.5 cm for small nodules, up to 2–3 cm for the largest ones, in respect of the exclusion criteria) upon the suprasternal notch.
Patients also experience much less pain after MIVA surgery than after conventional thyroidectomy. This is due to less dissection and destruction of tissues.
Pathologies treated are mainly nodular goiter; the only kind of thyroid cancer which may be approached with endoscopic surgery is a small differentiated carcinoma without lymph node involvement.
The patients were considered eligible for MIVA hemithyroidectomy and thyroidectomy on the basis of some criteria, such as gland volume and the kind of disease. In our experience we have chosen the minimally invasive open video-assisted approach of Miccoli et al. (2002). The aim of this work was to verify the suitability of the technique and the applicability in clinical practice.
A completely gasless procedure was carried out through a 15–30 mm central incision about 20 mm above the sternal notch. Dissection was mainly performed under endoscopic vision using conventional endoscopic instruments. The video aided group included 11 patients. All patients were women with a average age of 54.
We performed thyroidectomy in 8 cases and hemithyroidectomy in 3 cases. The operative average time has been 170 minutes.
Nowadays this minimally invasive surgery, in selected patients, clearly demonstrates excellent results regarding patient cure rate and comfort, with shorter hospital stay, reduced postoperative pain and most attractive cosmetic results.
minimally invasive thyroidectomy; MIVA; video-assisted surgery
Minimally invasive thyroidectomy is still in its phase of evolution with various techniques being practiced only in certain centers internationally. The conventional thyroidectomy performed by the Kocher's cervicotomy often leaves an undesirable scar over the neck, the size of which is usually around 8–10 cm long. The main aim of minimally invasive thyroid surgery is to minimize or avoid the scar over the neck. Endoscopic thyroid surgery in India, especially in the state of Kerala, is still in its infancy. Here, we describe the first case report of a modified technique of video-assisted thyroid surgery using a laparoscope and conventional open surgical instruments. Video-assisted thyroidectomy enables adequate visualization of the operative field and provides a magnified view of the vital structures like the parathyroid gland, the recurrent laryngeal nerve, and the thyroid vasculature. The procedure described here can be considered as a more cost-effective alternative to the conventional minimally invasive video-assisted thyroidectomy (MIVAT), and therefore is feasible in a rural setup.
Endoscopic thyroidectomy; minimally invasive thyroidectomy; thyroid surgery; video-assisted thyroidectomy
A chest wall approach combined with a gasless technique appears to make single-incision endoscopic thyroidectomy feasible and practicable.
Endoscopic thyroidectomy making the scar outside the neck area has a cosmetic appeal for patients. Based on an anterior chest wall approach combined with the gasless technique, we developed a novel method for gasless endoscopic thyroidectomy with a single incision.
Materials and Methods:
From March 2009 to November 2010, 48 patients with benign thyroid nodules underwent thyroidectomy with the gasless single-incision endoscopic surgery technique via the anterior chest wall approach. A 3-cm long skin incision parallel to the clavicle was made on the anterior chest wall on the side of the lesion. The platysma flap was lifted up to maintain working space from the incision to the thyroid cartilage. Dissection of the thyroid was begun from the inferior pole of the thyroid. The line of resection was selected to preserve recurrent laryngeal nerve and parathyroids. A 5-mm drainage tube was inserted into the lower portion of the operative space through the incision after the thyroid gland and the lesion were resected using the Harmonic scalpel.
The overall operating time was 126 minutes (range, 90 to 210), 138 minutes (range, 80 to 160) in first 24 cases; and 112 minutes in the second 24 patients (P<.05). Three cases were converted to the conventional procedure: 2 because of a malignancy diagnosed on frozen section, and one due to uncontrolled bleeding from the middle thyroid vein. Another malignancy diagnosed on final pathological examination was treated with additional surgery to complete the thyroidectomy by using the conventional open method. There were 2 cases of postoperative complications: transient hoarseness and hematoma. No wound infection occurred in our series. The scar was well hidden beneath the clothes, and the patients were satisfied with the cosmetic result of the surgery.
Advantages of the chest wall approach combined with the gasless technique have made single-incision endoscopic thyroidectomy more feasible and practicable.
Endoscopic surgery; Thyroidectomy; Gasless; Single-incision surgery
Minimally invasive total hip arthroplasty using a short skin incision is a subject of much debate in the literature. The present study estimates the possible minimal length of the exposure in an unselected patient cohort and compares the lateral mini-incision technique and traditional total hip arthroplasty (THA). One hundred and two patients were divided into three groups according to the type of surgery and length of incision: mini-incision (less than 10 cm) was performed in 38 patients; midi-incision (10–14 cm) in 43; and standard-incision (longer than 14 cm) in 21 patients. No statistical difference was found with regard to intraoperative and total blood loss, the rate of complications, and postoperative recovery. Significantly decreased body mass index (BMI), shorter operative time, and higher number of hips with malpositioning of the acetabular cup were found in the mini-incision group. These patients, however, experienced less pain in the early postoperative period and were highly satisfied with the cosmetic results. The length of incision was shortened and optimized (less than 14 cm) in 82% of patients, and mini-incision was performed in 38 patients of this unselected cohort. Because of the understandable demand of the patients for less invasive intervention, the surgeon should use a smaller but not necessarily mini-incision with minimal soft tissue trauma that still allows him to perform the procedure well, without compromising the type of implants and the otherwise excellent long-term results. Randomized prospective studies are needed to explore the real value of the minimally invasive total hip arthroplasty.
To evaluate the effectiveness of minimally invasive surgery total hip arthroplasty (THA) using the two-incision technique as described by Mears.
From January 2003 to December 2006, sixty-four patients underwent total hip arthroplasty using the one-incision (group I) and two-incision (group II) technique by one surgeon. There were 34 hips in group I and 30 hips in group II. There was no difference in age, gender, and causes of THA between the two groups. We evaluated the operation time, bleeding amount, incision length, ambulation, hospital stay, and complications between the two groups.
There was no difference in the bleeding amount between the two groups. Operation time was longer in the two-incision group than in the one-incision group. Operation time of the two-incision technique could be reduced after 15 cases. Patients started ambulation after surgery earlier in group II than group I, and the hospital stay was shorter in group II than in group I. There was no difference in clinical results between the two groups. There was no difference in component position of the acetabular cup and femoral stem between the two groups. Intraoperative periprosthetic fracture occurred in four cases (13.3%) in group II.
Two-incision THA has the advantage of rapid recovery and shorter hospital stay. However, longer operation time and a high complication rate compared to one-incision are problems that need to be solved in the two-incision technique.
Total hip arthroplasty; Minimal invasive surgery; Two-incision technique
Thyroid nodules are a common clinical problem for surgeons. The clinical importance of nodules is the need to exclude thyroid cancer, which occurs in 5%–15% of patients. If fine needle aspiration cytology is positive, or suspicious for malignancy, surgery is recommended. During the past decade, with the tendency to develop smaller incisions, an endoscopic approach has been applied to thyroid surgery, called minimally invasive video-assisted thyroidectomy. This approach was immediately followed by other minimally invasive or scarless neck techniques, such as the breast approach, axillary-breast approach, and robot-assisted method. All these techniques follow the same principles of surgery and oncology. This review presents the current surgical management of the thyroid gland, including the surgical techniques and compares them by describing benefits and drawbacks of each one.
thyroidectomy; surgical techniques; thyroid cancer
Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique.
Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO2 insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely.
Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days.
We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.
Transoral; Video assisted neck surgery; Endoscopic thyroidectomy; Minimally invasive thyroidectomy; Endoscopic lymphadenectomy; TOVANS
An alternative method to laparoscopic surgery has been developed for urological procedures.
The surgery is minimal access because the length of the single skin incision ranges
from 3–6 cm depending on the type of operation. It is direct access because the surgeon
sees the operative area directly and stereoscopically by eye without video-optical support.
The procedure requires a special open-lumen retractorscope (JakoscopeTM) with a
high intensity fiberoptic light system and modified standard hand instruments. Among
the procedures performed nephrectomy, ureterolithotomy, prostatic adenomectomy,
spermatic vein ligation and others have been performed. The kidney procedures have
been operated retroperitoneally through a minilumbotomy incision. The procedures are
simple, rapid and the instruments are inexpensive. The postoperative pain and morbidity
are comparable to the laparoscopic approach.
The concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, MIT or MIP should properly be defined as operations through a short and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection.
Parathyroid glands are particularly suitable for minimally invasive surgery as most parathyroid tumors are small and benign. MIP are performed through a limited or discrete incision when compared to classic open transverse cervical incision and are targeted on one specific parathyroid gland. The concept of these limited explorations is based on the fact that 85% of patients will have single-gland disease. MIP must be proposed only for patients with sporadic hyperparathyroidism in whom a single adenoma has been clearly localized by preoperative imaging studies.
The minimal access approaches to the thyroid gland may be broadly classified into three groups: the mini-open lateral approach via a small incision, minimally invasive video-assisted thyroidectomy via the midline and various endoscopic techniques. Endoscopic extracervical approaches have the main advantage of leaving no scar in the neck but cannot reasonably be described as minimally invasive as they require more dissection than conventional open surgery.
Initially the indications for MIT were a solitary thyroid nodule of less than 3 cm in diameter in an otherwise normal gland. Today, MIT are also proposed in patients with small nodular goiters, Graves’s diseases and low risk papillary thyroid cancers. Some concern remains about the radicality of MIT in this latter group but preliminary results are comparable to those of conventional surgery both in terms of I-131 uptake and serum thyroglobuline levels.
Demonstrating the advantages of MIT and MIP over conventional surgery is not easy. Main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in conventional surgery. Several studies comparing conventional surgery with minimally invasive techniques using a cervical access have shown a diminution of postoperative pain, and better cosmetic results with minimally invasive techniques. MIP and MIT seem overall to be an advance but only randomized studies will demonstrate the real benefit.
Minimally invasive surgery; thyroidectomy; parathyroidectomy
Minimally-invasive, video-assisted thyroidectomy (MIVAT) was developed to reduce scarring/trauma associated with cervical incisions used in open thyroidectomy. Results from various centres have been published internationally but none from the UK. This study reports the first results from the UK and compares them with other centres. We also aim to compare the results of a single-surgeon experience in a small/moderately-sized hospital to those of larger tertiary centres.
PATIENTS AND METHODS
Retrospective analysis of a single surgeon experience in a district general hospital
The cohort was 55 patients (52 female, 3 male), mean age 48 years (range, 21-77 years) who had 64 MIVAT procedures. There were 49 hemithyroidectomies (HTs), 2 isthmusectomy, 4 total thyroidectomies (TTs) and 9 completion thyroidec-tomies (CTs) with median operating time of 86 min (IQR 66-110 min). Individual operating times were HT 85 min (IQR 60-110 min); TT 130 min (IQR 100-140 min) and CT 77 min (IQR 70-98 min). Median operating time was shorter in the second half of this series (76 min vs 92 min; P < 0.001). Length of stay was < 1 day in 92%. Conversions occurred in 6.3% with no haematoma or re-operation. Transient voice change was present in 7 (11%), permanent unilateral recurrent laryngeal nerve palsy in 2 (3%), and transient hypocalcaemia in 2 (3%).
The first results from the UK are similar to those of other international centres. A single-surgeon practice can obtain results comparable to larger tertiary centres provided there is sufficient case-load. MIVAT is safe and effective, but has a steep learning curve with rapid improvement observed within first 30 cases. Future studies should focus on objective assessment of scar/cosmesis and cost-effectiveness. MIVAT is an acceptable alternative to open surgery in highly selected patients.
Minimally invasive; Thyroidectomy; Education
The main advantage of minimally invasive thyroidectomy is a good cosmetic effect. Minimally invasive video-assisted thyroidectomy (MIVAT) is performed without gas insufflation in contrast to endoscopic thyroidectomy. In general, MIVAT is carried out through an incision in the middle part of the neck, not covered with clothes. The MIVAT thyroid lobectomy can also be done through the subclavicular approach. We describe a case of a 19-year-old female patient with a tumour of the left side of the neck. Thyroid ultrasound scan (UST) with thyroid fine-needle aspiration and cytological examination (FNAC) were performed. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and anti-tyreoperoxidase (ATPO) were checked. Video-assisted hemithyroidectomy was performed through an incision below the left clavicle. Intraoperative pathology examination of the specimen was carried out. The UST showed a solitary 13 mm × 23 mm nodule in the left lobe of the thyroid, the FNAC showed benign pathology. Thyroid function tests were normal (TSH 0.90 mIU/l; FT3 4.70 pmol/l). Video-assisted hemithyroidectomy was done through the incision below the left clavicle. Histopathological examination proved thyroid hyperplasia nodosum. There were no intra- or postoperative complications. The patient was discharged on the second day. Clinical and cosmetic outcomes 2 months after surgery were good. Minimally invasive video-assisted thyroid lobectomy performed via the subclavicular area is feasible and provides good cosmetic outcomes.
thyroid surgery; video-assisted thyroidectomy; minimally invasive thyroidectomy
The aim of this study is to present the new technique of transcervical-subxiphoid-videothoracoscopic “maximal”thymectomy introduced by the authors of this study for myasthenia gravis.
Materials and Methods:
Two hundred and sixteen patients with Osserman scores ranging from I–III were operated on from 1/9/2000 to 31/12/2006 for this study. The operation was performed through four incisions: a transverse 5–8 cm incision in the neck, a 4–6 cm subxiphoid incision and two 1 cm incisions for videothoracoscopic (VTS) ports. The cervical part of the procedure was performed with an open technique while the intrathoracic part was performed using a video assisted thoracoscopic surgical (VATS) technique. The whole thymus with the surrounding fatty tissue containing possible ectopic foci of the thymic tissue was removed. Such an operation can be performed by one surgical team (the one team approach) or by two teams working simultaneously (two team approach). The early and late results as well as the incidence and localization of ectopic thymic foci have been presented in this report.
There were 216 patients in this study of which 178 were women and 38 were men. The ages of the patients ranged from 11 to 69 years (mean 29.7 years). The duration of myasthenia was 2–180 months (mean 28.3 months). Osserman scores were in the range of I–III. Almost 27% of the patients were taking steroids or immunosuppressive drugs preoperatively. The mean operative time was 201.5 min (120–330 min) for a one-team approach and it was 146 (95–210 min) for a two-team approach (P < 0.05). While there was no postoperative mortality, the postoperative morbidity was 12%. The incidence of ectopic thymic foci was 68.4%. The rates of complete remission after one, two, three, four and five years of follow-up were 26.3, 36.5, 42.9, 46.8 and 50.2%, respectively.
Transcervical-subxiphoid-VTS maximal thymectomy is a complete and highly effective treatment modality for myasthenia gravis. The need for sternotomy is avoided while the completeness of the operation is retained.
Mediastinum; myasthenia; thymectomy; thymus; video-assisted thoracoscopic surgery; videothoracoscopy
In selected patients, video-assisted thyroidectomy can be considered a safe and validated procedure offering significant advantages over conventional surgery, with no additional morbidity. Aim of this study was to evaluate the results obtained in a series of patients selected for video-assisted thyroidectomy over a 10-years period. All patients who underwent video-assisted thyroidectomy from June 1998 to June 2009 were considered. The eligibility criteria for video-assisted thyroidectomy are: thyroid nodules ≤ 35 mm; estimated thyroid volume < 30 ml; no previous conventional neck surgery and/or radiation therapy; small, low-risk papillary thyroid carcinoma. A total of 1363 video-assisted thyroidectomies were attempted in the time period considered. Conversion to the conventional procedure was necessary in 7 cases. Thyroid lobectomy was successfully performed in 157 cases, total thyroidectomy in 1175, and completion thyroidectomy in 24. In 126 patients, the central neck nodes were removed through the same access. Simultaneous video-assisted parathyroidectomy, for a parathyroid adenoma, was performed in 42 patients. Pathological studies showed benign disease in 986 cases, papillary thyroid carcinoma in 368 cases, C-cells hyperplasia in 1 case, and medullary microcarcinoma in 1 patients with RET germline mutation. Post-operative complications included 27 transient and 1 definitive recurrent laryngeal nerve palsy, 230 transient hypocalcemia, 10 definitive hypoparathyroidism, 4 postoperative hematoma and 5 wound infection.
Thyroidectomy; Minimally invasive thyroidectomy; Endoscopic thyroidectomy
Endoscopic transaxillary total thyroidectomy (ETTT) was found to be a safe and feasible alternative to open thyroidectomy.
Background and Objective:
Endoscopic neck surgery for the thyroid and parathyroid is being tested as an alternative to open thyroidectomy. The aim of this study was to determine the safety and feasibility of endoscopic transaxillary total thyroidectomy (ETTT).
Methods and Results:
Twenty-two consecutive patients from January 2006 to September 2008 underwent ETTT. No conversions to open were necessary. Mean age was 49.3±12.9 years, 20 were female, and 2 were male. Mean operating time was 238 minutes±72.7. Mean blood loss was 40mL±28.3mL. Mean weight of the gland was 137.05g±129.21g. The recurrent laryngeal nerve was identified with no permanent injury. Six patients developed hoarseness of the voice for a mean of 15.1±8.01 days. No patient developed tetany or hypocalcemia requiring treatment. Six patients experienced transient numbness in the anterior chest wall lasting 2 weeks in 5 patients and 2 months in one. All patients were discharged within 24 hours of admission.
ETTT requires additional operative time compared with the open approach, but is cosmetically favorable. Visualization of the nerve and parathyroid is much better. Although the learning curve is steep, with experience the operative time will decrease. ETTT is different but safe and feasible.
Minimal; Invasive; Endoscopic; Thyroidectomy; Transaxillary
Open radical retropubic prostatectomy (ORP) has traditionally been performed through a lower midline incision. Prior efforts to reduce pain and expedite recovery include a variety of alterations in length and the orientation of the incision. The aim of our study is to compare the safety, efficacy, and cosmetic outcomes associated with transverse and longitudinal mini-radical prostatectomy incisions.
Materials and Methods:
Consecutive patients undergoing ORP at a single institution were studied. Patients were randomized to receive either a modified transverse or longitudinal incision. In all patients, the length of the incision was 7cm. The following parameters were compared between the two groups: Perioperative blood loss, duration of surgery, technical factors, pain and analgesic requirements, length of hospital stay (LOS), and pathological stage. The Patient and Observer Scar Assessment Scale (POSAS) was used to compare the cosmetic aspects associated with the incisions.
Fifty-six patients underwent a transverse (n=27) and longitudinal (n=29) mini- incision ORP. No significant differences were noted in the perioperative parameters that were compared (P>0.116). None of the patients required blood transfusion, there were no wound complications. Perioperative pain and analgesic requirements were not significantly different among the two study arms (P>0.433). The POSAS indicated no significant difference in cosmesis scores with both incisions (P>0.09).
Seven-centimeter transverse and longitudinal mini-incisions offer alternatives to the standard ORP incision, and to minimally invasive approaches. Both incisions are safe, associated with little postoperative pain, and a short postoperative LOS. Both incisions provide highly satisfactory cosmesis for the patient.
Cosmesis; localized prostate cancer; prostate cancer treatment; radical prostatectomy
Laparoscopic cholecystectomy has traditionally been performed using multiple small sites. Single-incision laparoscopic surgery has emerged as an alternative technique to improve cosmesis and minimize complications associated with multiple incisions. A retrospective study was performed of all patients who underwent laparoscopic cholecystectomy by a single surgeon (DTA) from April 2008 to August 2011. Charts were reviewed for surgical indication, operative technique (multiple vs. single transumbilical incision), operative time, length of stay, and surgical complications. Sixty-three patients underwent laparoscopic cholecystectomy using a traditional approach of four skin incisions, while 62 patients underwent a single-incision transumbilical approach. Average age and sex were comparable between the two groups. Indications for surgery included cholelithiasis, cholecystitis, biliary dyskinesia, biliary pancreatitis, and porcelain gallbladder. Of those undergoing single-incision cholecystectomy, 85% (53/62) went home the same day, compared with 70% (44/63) of those undergoing four-incision cholecystectomy (P = 0.03). Among those not discharged on the same day of surgery, the average length of stay trended shorter in the single-incision group (2.8 days, range 1–6) compared with the four-incision group (3.3 days, range 1–12; P = NS). Operative time was slightly longer for those undergoing single-incision surgery (65 minutes, range 35–141) versus traditional four-incision surgery (51 minutes, range 41–109) (P < 0.001). With this single surgeon's single-incision transumbilical technique, costs were comparable between the two groups. One patient who underwent traditional four-incision cholecystectomy was readmitted for biliary pancreatitis and bacteremia on postoperative day 3. In the single-incision group, one patient was readmitted 1 month later with pancreatitis. In conclusion, single-incision transumbilical laparoscopic cholecystectomy can be an effective alternative to traditional four-incision cholecystectomy, with the added benefit of minimized scarring and a shorter length of stay. A longer operative time may be needed initially to adjust for a learning curve. This technique can be performed safely for patients with a multitude of gallbladder diseases without resulting in additional complications.
The mini-incision anterior approach in total hip replacement is not new, but uses a shorter incision than the traditional Hueter approach, typically only 6–8 cm in length. Despite its size, the single anterior incision allows good exposure. It is very atraumatic, preserves muscles and tendons, and allows the patient early mobilisation and fast postoperative recovery. Although, a special table (e.g., a Judet table) and specific tools (e.g., a curved reamer) are needed to perform hip replacement via the mini-anterior approach, any kind of hip prosthesis (cemented or uncemented) can be implanted. As there is a significant learning curve in mastering the mini-incision anterior approach, surgeons are advised to start with a longer incision and then to decrease its length with increasing experience.
Video-assisted thoracoscopic surgery (VATS) involving wedge resection of bulla and lung biopsy can be done by two or three-port incisions. Controversy exists as to which approach is superior. We communicate our experience with two-port VATS for these procedures.
We retrospectively analyzed the charts of all patients who underwent a VATS procedure by two-port incisions from July 2001 to July 2007 by two thoracic surgeons (S.C., S.C.) We included in the study all patients who underwent wedge resections for primary or secondary spontaneous pneumothorax and biopsies for pulmonary infiltrates and small nodules.
A total of 319 patients’ charts were examined, and 217 of whom had undergone two-port incisions fitted in the inclusion criteria. There were 136 (65.7%) males and 81 (37.3%) females with a mean age of 47 years. Pneumothorax was the main diagnosis for 98 (45%) patients, followed by pulmonary infiltrates for 69 (32%) patients and lung nodules for 50 (23%) patients. The mean operative time and the number of post-op days for chest tube removal and to discharge home in each group have also been recorded. There were few post-operative complications, such as 11 (5%) cases of persistent air leak, 11 (5%) cases of transient fever of unknown origin, 3 (1.4%) cases of pneumonia, 3 (1.4%) cases of bleeding within, one reoperated, and 1 (0.46%) case of C. difficile colitis. The 30-day mortality was 0%.
The thoracoscopic (VATS) wedge biopsy via two-port incisions is a safe operation for patients presenting with pneumothorax or requiring a lung biopsy. A two-port approach seems to be a reasonable alternative to three-port incision procedures for these types of diagnosis, regarding post-operative pain and cosmetic benefits particularly for young patients.
VATS; pneumothorax; bullectomy; thoracoscopy; pleurodesis; pulmonary nodule; pulmonary infiltrates; lung neoplasms
Minimally invasive video-assisted thyroidectomy (MIVAT), the modified Miccoli’s thyroid surgery, is the most widespread minimally invasive technique and has been widely used for treatment of thyroid disease. This study aimed to verify the potential benefits of the modified Miccoli’s thyroid surgery, determine the feasibility of the MIVAT for early-stage differential thyroid carcinoma and evaluate the likelihood of the surgical method as a standard operation for early malignant thyroid carcinoma.
A total of 135 patients were retrospectively compared which included two groups of patients: the first group underwent the conventional thyroidectomy; the other group underwent MIVAT. Patients with thyroid nodule smaller than 20 mm and without previous neck surgery were included while those with wide-ranging and distant metastases of cervical tissues, or any suspected thyroid nodal metastases were excluded for analysis. MIVAT and the central compartment (level VI) lymph nodes dissection (LND) were considered as a new treatment method for this retrospective study. In addition to the comparison of surgical outcomes between the new treatment and the conventional thyroid surgery, other surgical parameters including operative time, operative volume of hemorrhage, incisional length, postoperative volume of drainage, length of hospitalization, accidence of hoarse voice, accidence of bucking, accidence of hypocalcemia and peak angle of cervical axial rotation were also compared.
Out of 135 patients, 111 patients underwent conventional thyroid surgery and 24 patients underwent MIVAT plus level VI LND for treatment of early-stage differential malignant carcinoma. Patients who received the new surgical treatment had significantly shorter incisional length (3.1 cm vs. 6.9 cm, p < 0.0001), shorter operative time (109 min vs. 139 min, p = 0.014) and fewer operative hemorrhage (29.5 ml vs. 69.7 ml, p < 0.0001) when compared to the conventional treatment. Postoperative peak angle of cervical axial rotation of patients treated with MIVAT was less than those treated with conventional surgery (L: 31.5° vs. 39.0°, p < 0.0001; R: 31.5° vs. 38.0°, p < 0.0001). Incisional wound infection, postoperative hoarse voice, bucking and hypocalcemia were not observed in all patients. Postoperative analgetica was not required as well.
Compared with conventional thyroid surgery for early-stage differential thyroid carcinoma, the new surgical treatment could be considered as an alternative surgical method for treatment of early-stage thyroid carcinoma since it was feasible, safe and clinically effective with better surgical and cosmetic outcomes.
Background. We reported our two initial experiences in the treatment of thyroid disease with endoscopic thyroidectomy. Minimally invasive video-assisted technique (MIVAT) was initially introduced by Miccoli. The modification was made by using axillary and breast technique.
Method. Two young women patients, with 4 and 5 cm right lobe thyroid disease suspected to be benign. From physical examination, sonography, and FNAB findings, the two cases were categorized as benign. We performed endoscopic right lobectomy through incision of 5–10 mm on axillary line and breast using CO2 insufflation. Result. Duration of first operation was 300 minutes and the second one was 120 minutes, with minimal blood loss and no major complication. Patients were discharged 24 hours after operation. Cosmetic result was excellent. Postoperative complications were shoulder discomfort and neck swelling.
Conclusion. We reported two cases of endoscopic right lobectomy as a safe, reproducible technique with an indication in a minority of patients candidates for thyroidectomy and is characterized by less postoperative discomfort.
The choice of surgical incision is determined by access to the surgical field, particularly when an oncological resection is required. Special consideration is also given to other factors, such as postoperative pain and its sequelae, fewer complications in the early postoperative period and a lower occurrence of incisional hernias. The purpose of this study is to compare the right Kocher’s and the midline incision, for patients undergoing right hemicolectomy, by focusing on short- and longterm results.
Between 1995 and 2009, hospital records for 213 patients that had undergone a right hemicolectomy for a right- sided adenocarcinoma were retrospectively studied. 113 patients had been operated via a Kocher’s and 100 via a midline incision. Demographic details, operative data (explorative access to the peritoneal cavity, time of operation), recovery parameters (time with IV analgesic medication, time to first oral fluid intake, time to first solid meal, time to discharge), and oncological parameters (lymph node harvest, TNM stage and resection margins) were analyzed. Postoperative complications were also recorded. The two groups were retrospectively well matched with respect to demographic parameters and oncological status of the tumor.
The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). The duration of the surgery for the Kocher’s incision group was significantly shorter (median time 70 vs 85 min, p < 0.001). In three patients we performed wedge resection of liver metastasis and in one patient we performed a typical right hepatectomy that lasted 190 min. No major operative complications were noted. There was no immediate or 30- day postoperative mortality. The Kocher’s incision group had a significantly shorter hospital stay (median time 5 vs 8 days). All patients underwent wide tumor excision and clear resection margins were obtained in all cases. No significant difference was noted regarding analgesia requirements and early postoperative complications. Late postoperative complications included 2 incisional hernias and three patients presented with one episode of obstructive ileus, that resolved conservatively.
The Kocher’s incision approach for right- sided colon cancer is technically feasible, safe and overall very well tolerated. It can achieve the same standards of tumor resection and surgical field accessibility as the midline approach, while reducing postoperative recovery.
Colonic adenocarcinoma; Midline incision; Right Kocher’s incision; Right hemicolectomy
The duration of hospital stay, following surgical procedures, has undergone a significant reduction in recent years. However, there are some risks associated with short-stay thyroid surgery. An analysis has been made of data from patients who underwent short-stay thyroid surgery, analyzing the complications associated with this procedure. Overall 270 consecutive patients undergoing thyroidectomy in 2007 and 2008 were prospectively analyzed. Post-operative care included routine ward overnight observation. The discharge criteria were: stable vital signs; apyretic; no wound or airway problems; tolerating diet; and established autonomy at discharge. Data were collected regarding patients’ discharge criteria status, length of hospital stay and readmission, as well as morbidity (post-operative haemorrhage, recurrent laryngeal nerve injury and hypocalcaemia) and mortality. This series comprised 175 total thyroidectomies, 93 hemi-thyroidectomies and 2 isthmusectomies. No cases of death or post-operative haemorrhage occurred in any of these patients. Permanent unilateral recurrent laryngeal nerve injury was observed in 4 patients (1.48%). Transient post-operative hypocalcaemia occurred in 23 patients, whereas permanent post-operative hypocalcaemia was observed in 8 patients (2.96%); 4 patients were re-admitted and required early calcium supplementation. Five patients failed to tolerate the diet during the immediate post-operative period. The average duration of hospital stay was 1.02 days. Considering the 4 patients who required re-admission due to hypocalcaemia, the total length of hospital stay was 1.05 days. In conclusion, the one-day surgery model is safe and effective in patients undergoing surgery for thyroid disorders.
Thyroidectomy; Lenght of hospital stay; Post-operative complications; Post-operative haemorrhage; Hypocalcaemia; Post-operative pain
Many low-risk patients with solitary papillary thyroid cancer located in one lobe had undergone surgery that was less extensive than hemithyroidectomy in China. An acceptable completion surgery regimen was suggested for these patients based on our experience. A total of 117 enrolled patients underwent completion surgery. Thirty-two patients had prior tumor resection, 46 patients had prior partial thyroidectomy and 39 patients had prior subtotal thyroidectomy. No neck dissection was performed. Reoperation was scheduled a median of 1.2 months (range, 3 days–6.5 months) after primary surgery for papillary thyroid cancer (PTC). Among the 117 patients, residual tumor was pathologically confirmed in 60 patients, with a residual rate of 51.28%. Among these 60 patients, residual tumor was identified in the thyroid bed alone in 18 patients and in compartment VI alone in 28 patients, while 14 patients exhibited residual tumor in both of these regions. Lymph node metastasis was observed in compartment VI in 42 patients (35.90%), and an average of 6.5 nodes were removed (range, 2–14 nodes for each patient). Additionally, 3.14 positive lymph nodes were removed on average from each of the 42 patients. We conclude that the completion regimen, including the ipsilateral residual lobe, the isthmus and ipsilateral compartment VI (prelaryngeal, pretracheal and paratracheal lymph nodes), is reasonable and acceptable for low-risk patients undergoing surgery that is less extensive than hemithyroidectomy.
papillary thyroid cancer; central compartment; lobectomy
BACKGROUND: Many authorities advocate draining the neck routinely after thyroid and parathyroid surgery with no scientific evidence to support this practice. We aimed to establish if the routine use of drains following thyroid/parathyroid surgery is of any value. METHOD: Medical records of patients who underwent thyroidectomy or parathyroidectomy under the care of a single endocrine surgeon (GP) over a 14-year period were reviewed. For the first 6 years, the neck was routinely drained (drain group) and for the subsequent 8 years the neck was only drained if the surgeon felt it necessary according to the operative situation (selective group). RESULTS: A total of 606 procedures (425 thyroidectomy and 181 parathyroidectomy) were performed on 582 patients. Drains were routinely used in 134 (22%) procedures (drain group) and were selectively used in 472 (78%) (selective group) of which 191 (40%) were drained. In all patients, there was a significant increase in the rate of postoperative bleeding/haematoma in patients with a drain (8/314 versus 1/282, Fisher's exact, P < 0.05). Wound infection occurred only in the patients with a drain. There was no difference in the incidence of postoperative bleeding and airways obstruction between the drain and selective groups. CONCLUSION: We conclude that the routine use of neck drains is unnecessary and may indeed be harmful, drain insertion being associated with an increased incidence of wound infection. Drains should, therefore, be used selectively after thyroidectomy and parathyroidectomy.