Despite the additional trauma resulting from the flap formation, the application of the trans-axillary approach is of some value in suitable circumstances. https://emedicine.medscape.com/article/2051665-overview. AN INCISION (CUT) THAT WILL REQUIRE SPECIAL CARE. Patients who are asked to stay overnight generally have very large goiters, advanced cancer, bleeding disorders, a history of taking anticoagulation, or have a personal preference to spend the night. endstream endobj startxref Thyroid nodules and cancer management guidelines: comparisons and controversies. ~ x>$;oz5/^xJqE_CqK.mu,;L.&?-Y-NM>FyZ-;,pCpfC !DC),!S?Iy,`SDt As the sternal head of the SCM was elevated by the retractor during the procedure, the decreased VRSs may be partly due to the shorter surgical time and improved surgical techniques. A P value < 0.05 was considered as statistically significant. volume20, Articlenumber:9 (2022) Permanent nerve damage occurs in approximately 1% of cases performed by a skilled surgeon. Routine level 2b dissection may be recommended only in N1b papillary thyroid carcinoma with three- or four-level lateral lymph node metastasis. Huang Z, Qin H, Liao J, Meng L, Qin Y, Li B, et al. 0 Patients now expect a more measured approach to their care, which sometimes includes quite small incisions (Figure 42-5). The parathyroid glands control calcium homeostasis within the body. Liang J, Zhan L, Xuan M, Zhao Q, Chen L, Yan J, Kuang J, Tan J, Qiu W. Thyroidectomy for thyroid cancer via transareola single-site endoscopic approach: results of a case-match study with large-scale population. Gasless single incision trans-axillary thyroidectomy: the feasibility and safety of a hypo-morbid endoscopic thyroidectomy technique. In addition to the complications of standard thyroid surgeries listed below, there are several complications specific to this operation. A portion of the enlarged thyroid (if possible) or the entire thyroid gland may need to be removed. MedicineNet does not provide medical advice, diagnosis or treatment. As the scar heals, it will appear to be part of the crease and thus camouflage it. This suggests that discomfort in the anterior neck area and SCM is obvious shortly after surgery and is relieved over time in most cases. Prior to the operation, patients will need certain pre-operative testing to make sure that they are healthy enough and properly prepared for an operation. The suit covers the incision and prevents your dog from licking or chewing the incision. Jsls. Thyroidectomy for substernal usually includes goiters with minimal extension in the thoracic cavity and those that are present in the mediastinum (the area surrounding the chest cavity ). 2016;23:694700. Surgery is the most commonly used technique in treating thyroid diseases. All cases of this complication reported to date have been temporarily, and is related to compression of the brachial plexus from arm positioning during surgery. This approach involves making an incision in the center of your neck to directly access your thyroid gland. Seromas happen rarely and usually disappear within a few weeks. Short and long-term cosmesis of cervical thyroidectomy scars The risk of a substernal goiter is higher in people who: 1996-2023 MedicineNet, Inc. An Internet Brands company. XYL and HOY analyzed the data. The best way to identify the proper crease and overall location is with the patient sitting upright in the preoperative holding area rather than waiting until the patient is lying supine on an operating table (Figure 42-6). 2009;56:3619. 87 Xiangya Road, Changsha, 410008, China, Rong Cong,Xinying Li,Hui Ouyang,Wenbo Xue,Zeyu Zhang&Fada Xia, You can also search for this author in The sensory change and paralysis results from this technique and patients satisfaction with the cosmesis were also studied. From July 2020 to March 2021, 51 patients (49 females and 2 males) underwent operations by gasless, endoscopic trans-axillary approaches, with one patient whose operation was converted to open surgery because of internal jugular vein injury. hXms8+/3@6]H1|p@/IBd`zc[Vx}iJL8t3\bDgX&#&'8N,0f2Pq6PbYD\f(6uiMlJt]#aZal14t FlJNlCO} In the hands of Columbia Thyroid Center surgeons, the risk of having a temporarily low blood calcium level is about 5% and the risk of having a permanently low blood calcium level is less than 1%. Compared with conventional approach, it holds the advantages of comparative extensive indications and similar complication rate but achieving a better cosmetic result. This study kept the confidentiality of patient data and strictly complied with the Declaration of Helsinki and its later amendments or comparable ethical standards. The mean number of lymph nodes removed by unilateral CND was 3.15 3.2 (range 212) in PTC patients. This study was approved by the Institutional Ethics Committee of Xiangya Hospital, Central South University (No.202011960). hbbd``b`$M .$A "H$&X@2`b AzU R\bitiL #3=|` h Total thyroidectomy (sometimes called near-total thyroidectomy) is the surgical removal of the entire thyroid gland. Comparison of learning curves for retroauricular and transaxillary endoscopic hemithyroidectomy. Patients with other significant medical issues may be asked to visit with their medical team to obtain a letter of medical clearance. Patients will receive general anesthesia. The decision as to which thyroid operation to perform depends on a number of factors including the type of disease and the patient's preferences. (PDF) Comparison of Supraclavicular Oblique Incision - ResearchGate A number of surgical procedures and surgical approaches have been developed and the terminology can be confusing. Surg Endosc. 2017;24:R1326. Patients diagnosed with thyroid cancer and thyroid nodules with diameters > 4 cm who underwent trans-axillary thyroid surgery from July 2020 to March 2021 in Xiangya Hospital were retrospectively enrolled. Although the numbers of identified parathyroid glands have not been calculated, we considered that the recognition and protection of the parathyroid gland would get improvement with the growing experience. Second, we divided the area between the sternal and clavicular head of the SCM, up to the annular cartilage and down to the clavicle. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Patients who spend the night in the hospital are typically discharged by 10AM the next morning. Next, an endoscope with two cameras that produce three-dimensional viewing is inserted into the incision, and three robotic arms are inserted into the incision. Modern thyroid surgery found its origins in the late 19th century in the work of Billroth and Kocher.7 Although Billroth is credited with first systematically pursuing thyroidectomy in a deliberate fashion, it was Kocher who developed a safe and reproducible technique for accomplishing a therapeutic thyroidectomy. Temporary numbness of the anterior chest is very common after this operation, and can last for several months. This can also happen after parathyroid surgery. Both lobes of the thyroid were noted to be enlarged. A more in-depth study of the learning curve of the procedure via the TA approach is urgently needed. There is no clear definition of what minimally invasive means, and surgical incisions as large as 6 cm. PDF Creative Commons License [CC BY-NC-ND 4.0] 2022 The Author(s Our study suggested that the lateral supraclavicular incision is a safe and practical approach for thyroidectomy. Clinical findings and postoperative complications of patients who had undergone trans-axillary thyroid surgery due to thyroid cancer and thyroid nodules were retrospectively studied. The sternal head of the SCM was subsequently retracted to expose the strap muscles. The size of the incision is dictated by surgeon preference and need for adequate exposure to remove the tumor. Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, et al. Gasless endoscopic thyroidectomy using trans-axillary approach; surgical outcome of 581 patients. The CAT scan will also allow the surgeon to see if the trachea is being moved to one side or the other and if it is being narrowed by the thyroid. As the radical operations of the 1960s and 1970s gave way to the more selective operations of the 1980s and 1990s, neck incisions for thyroid and neck dissection evolved. Thyroid Nodules Diagnosis and Treatment , Follicular Thyroid Cancer/ Hurthle Cell Carcinoma. Acceptable wound cosmetology has become a focus for thyroid surgeons. However, the risk of damage to this nerve must be understood prior to surgery. Correspondence to Consideration should be given to breast size, especially in younger women, as over time the incision will be pulled downward if the breasts are large and pendulous. The patient may be positioned with special pillows under the neck to tilt the head back. Endoscopic minimally invasive thyroidectomy: first clinical - Springer In the past decade, advancements in A c c e p t e d . Typically, patients will be given prescriptions for the following medications after the operation: Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. Collar incision was made about 2 1/2cm above the inner ends of the clavicle, through the platysmal muscle. Figure 42-1 The Lahey incision (A) affords wide access to the lateral neck, but it is associated with a trifurcation, which is subject to necrosis. Poor cosmetic result from scarring of the neck or axillary incision may occur and require secondary scar management. Due to the working space needed for the flap formation and division of the SCM during an axillary approach, this technique is more time-consuming. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be as small as possible, as big as necessary, therefore perhaps qualifying him as the first minimally invasive surgeon. The internal jugular vein was injured in two of the patients during the making of working space, one patients operation was converted to open surgery. Most patients may need to take thyroid hormone pills (thyroid hormone replacement) for the rest of their lives when the whole thyroid gland is removed. 3). This chapter presents historical discussions followed by a series of important guiding principles that serve as fundamental reference points during thyroid and parathyroid surgery incisional design. First, we dissected the tunnel to the anterior neck area with exposure of the sternocleidomastoid muscle (SCM). Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. The surgical drain was removed 2 days after surgery in all cases. Another variation of the minimally invasive thyroidectomy is the minimally invasive video-assisted thyroid surgery (MIVAT). Endoscopic thyroidectomy. Symptoms of hypocalcemia include numbness and tingling in your hands, soles of your feet and around your lips. Eur Arch Otorhinolaryngol. A comparison of postoperative pain after conventional open thyroidectomy and single-incision, gasless, endoscopic transaxillary thyroidectomy: a single institute prospective study. It is often possible for your surgeon to place the incision in an existing skin crease. The stiffness and paraesthesia of the SCM resulting from the division of the SCM are also relieved over time. The thyroidectomy (near or total), as we know it today, began in the 1860s with the help of Billroth [ 5 ]. 2013;22:113. Is Substernal Goiter Surgery Safe? - MedicineNet The collodion will turn white and start curling up at the edges in about 5 to 7 days. The average drainage volume was 48.0 24.4 ml (20100 ml) on day one and 13.7 5.6 ml (1030 ml) on day two. The PSSs were 1 (very satisfied), 2 (satisfied), 3 (unsatisfied), or 4 (very unsatisfied) [13]. And their results showed this procedure was feasible with an acceptable safety profile where the need of conversion to conventional thyroidectomy was found in only 2 (0.45%) cases. If the patient was taking thyroid hormone before the operation, they should continue taking the same dose unless it was changed by the surgeon. Classically 8-12 cm (3-5 inch) incisions were performed. Anaesthesia for thyroid and parathyroid surgery | BJA Education You might notice bruising around your incision or upper chest and slight swelling above the scar when you are upright. The primary advantage of this surgical procedure is avoidance of an incision on the neck. Examples of the so-called necklace neck incision associated with a classical thyroidectomy through an open approach (, Delivery of a thyroid lobe through a minimal access incision. It is critical to work with a team of thyroid specialists to choose the right operation for each individual patient. 4). A concept that has gained traction in recent years is the customization of both the incision and the surgery to the patient and the disease characteristics, rather than a one size fits all approach. low collar incision Most patients (97%) will not notice any change in their voice after the operation. This surgical procedure is known as athyroidectomy. Surg Today. All data generated or analyzed during this study are included in this published article. We have been using this approach since 1999. J Laparoendosc Adv Surg Tech A. Most people will not be able to notice the incision once the redness fades away. Rarely, nerve injury to the arm can occur, resulting in impaired arm and/or hand function. 82073262) and the Hunan Province Natural Science Foundation (grant number 2021JJ41033 and 2019JJ40475). The primary endpoint was the cosmesis of the collar scar six weeks after surgery assessed using the patient and observer scar assessment scale (POSAS). World Journal of Surgical Oncology E, F Step three, the strap muscles were dissected laterally and the retractor was placed beneath the straps muscle to expose the thyroid lobe. Skin flaps were created deep to the platysma up to the hyoid bone and down to the suprastemal notch. The dissected area is marked in green. that the dissected flap width in trans-axillary approach is significantly wider than conventional thyroidectomy, causing greater trauma, and potentially more severe pain [20]. We make every effort to eliminate the use of 4 4 gauze sponges during the operation, as the material is abrasive and behaves like sandpaper when it is placed into and retrieved from small incisions. also reported a study concerning the gasless trans-axillary thyroidectomy with the assistance of robots. The middle thyroid vein was then ligated. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000 tablets and if the symptoms do not go away after 30 minutes, call your doctor. Figure 42-5 Delivery of a thyroid lobe through a minimal access incision (A), which is just big enough to admit the gland. The 27-year . A number of technological advances such as advanced energy devices for hemostasis,1 high-resolution endoscopes for improved visualization,2 and laryngeal nerve monitoring3 have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions.4 Also emerging are techniques for remote access thyroid and parathyroid surgery.5,6 Conventional surgery remains necessary in many circumstances, such as for large substernal goiters or advanced malignancy, and will remain in the endocrine surgeons armamentarium. This work was supported by the National Natural Science Foundation of China (grant No. The patients were placed in a supine position while the lesion side limb was extended 90 degrees after general anesthesia. Thyroid cancer can also spread to the lateral neck. If the recurrent laryngeal nerve is damaged, patients may have vocal cord weakness or paralysis, causing either hoarseness or a weak, breathy voice, and in severe cases of bilateral paralysis, respiratory distress. During the 1850s, operations on the thyroid gland were undertaken via longitudinal, oblique, or vertical neck incisions. . Surgery is typically recommended for goiters that are causing symptoms. When a large thyroid lobe is delivered through small incisions, it is not uncommon to observe evidence of an ischemic or traumatized skin edge, Technological Innovations in Thyroid and Parathyroid Surgery, Approach to the Mediastinum: Transcervical, Transsternal, and Video-Assisted, Non-Neural Complications of Thyroid and Parathyroid Surgery, Surgery for Locally Advanced Thyroid Cancer: Larynx, Principles in Surgical Management of Primary Hyperparathyroidism, Surgery of the Thyroid and Parathyroid Glands Expert Consult Pre. reported the endoscopic trans-axillary technique. 2017;92:914. California Privacy Statement, At the Columbia Thyroid Center, 95% of our patients are able to go home after a 4 hour observation period in the recovery room. The final pathology is ready approximately1 week after the operation. Endoscopic versus conventional thyroid surgery: a comparison of quality of life, cosmetic outcomes and overall patient satisfaction with treatment. Department of General Surgery, Xiangya Hospital, Central South University, No. In any case, the incision should be parallel to relaxed skin tension lines, following classic cosmetic principles. Terms and Conditions, The surgeon has excellent magnified visualization, can manipulate the camera to customize the view of the field, and works with surgical instruments that are more maneuverable than the human wrist and hand. The patient is usually given general anesthesia to numb the. revealed that trans-axillary thyroidectomy was associated with a better cosmetic index, however, it was also associated with a longer operation time, aggravated voice changes, paresthesia, and changes in swallowing function [18]. CAT scan of the chest: This test allows the surgeon to evaluate if the thyroid disease is growing down into the chest and if so, how it is affecting the structures in the chest. Traditionally, parathyroidectomy involved a collar incision, bilateral exploration of the neck, identification of all four glands, and removal of the diseased gland or glands. The Advantages of Robotic Over Open Thyroidectomy in Thyroid - PubMed Patients may also be given a prescription for thyroid hormone medication (Levothyroxine or Synthroid). 202011960). Acceptable wound cosmetology has . Indications for this procedure include unilateral goiter and unilateral benign thyroid nodules. C and D, Both the right and the left neck may be thoroughly dissected with appropriate retraction assistance. Compared to two-dimensional endoscopic thyroidectomy, three-dimensional endoscopic thyroidectomy is an efficient, safe, and reliable method with better depth perception and stereoscopic vision, and an equally satisfactory outcome [23]. Provided by the Springer Nature SharedIt content-sharing initiative. The average blood loss for this operation is less than a tablespoon and the chance of needing a blood transfusion is extremely rare. Figure 42-4 Examples of the so-called necklace neck incision associated with a classical thyroidectomy through an open approach (A and B). World J Surg Oncol. In general, patients should be eating, drinking, walking around, and doing their normal activities the night of the operation. See additional information. Single-incision, gasless, endoscopic trans-axillary total thyroidectomy: a feasible and oncologic safe surgery in patients with papillary thyroid carcinoma. h. Continuous variables are presented as the mean SD and the mean (range). The risk of having any of these complications depends on the experience of the surgeon. Other risks of thyroid surgery include wound infections and seromas. Introduction: The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. This approach accesses the thyroid through an incision inside the mouth. We divided the patients into two groups in surgical order to compare the VRSs regarding paralysis of the SCM. In cases of indeterminate lesions, some surgeons refer to a thyroid lobectomy as a diagnostic lobectomy because the main purpose of the operation is to make a diagnosis cancer or benign thyroid disease. Introduction The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. 2021;19:23. Chapter 42 Incisions in Thyroid and Parathyroid Surgery. Most thyroid nodules are small, and performing a full collar incision is not necessary to provide needed surgical exposure to safely remove the thyroid lobe. They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement. 2020;34:1891903. Thyroid Surgery Recovery, Side Effects, and Complications - Verywell Health The traditional "Kocher incision", an 8-10 cm collar incision, is regarded as the conventional appropriate incision for thyroidectomy.2 However, many new approaches for thyroid surgery were developed in order to further minimize the size of the surgical incision.3 Post-thyroidectomy scars have a negative effect on quality of life. Surg Endosc. The complications, including hypoparathyroidism, tracheal injury, esophageal injury, or surgical site infection did not occur. Surg Endosc. In this study, we reported our initial experiences with 51 patients who underwent gasless endoscopic trans-axillary thyroid surgery performed by a single experienced surgeon. The exceptions are blood thinners, aspirin, Plavix, and anti-thyroid medications like PTU and Methimazole. Trans-axillary robotically assisted approaches were first reported by Lobe et al. Once at home, patients and their friends/family should watch for signs such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. XYL, HOY, WBX, and ZYZ performed the study, collected the data, and contributed to the design of the study. Temporary or sometimes permanent hypoparathyroidism (low blood calcium levels). Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000 tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. The typical incision made for thyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collar bone. Kim SK, Park I, Hur N, Lee JH, Choe JH, Kim JH, et al. Jantharapattana K, Maethasith J. Transaxillary gasless endoscopic thyroidectomy versus conventional open thyroidectomy: a randomized study. Cong, R., Li, X., Ouyang, H. et al. This procedure may also be appropriate for small, non-aggressive thyroid carcinomas less than 1cm. The total mean operative time of working space make was 44 12.8 min (range 20120 min). Jules Boeckel of Strasbourg introduced the collar incision to thyroid. No internal jugular vein injury was reported [19]. D Thyroid isthmus was dissected. 2006;10:20611. Medication to normalize abnormal thyroid hormone levels may help decrease the size of goiters. The muscles around the thyroid gland are retracted to expose the thyroid gland. The Procedure of Traditional Low Collar Incision Thyroidectomy The patient was placed in the supine position neck hyperextension. J Minim Access Surg. Call (212) 305-0444 for appointments. For example, a gentleman with a 26-inch neck (Figure 42-2, A) and a large goiter (Figure 42-2, B) is not a good candidate for any type of minimally invasive approach. The dissected area is marked in blue, The procedure of thyroidectomy and central neck dissection (CND). The trans-axillary approach (TA) can hardly locate the contralateral thyroid lobe, causing the limitation of TA in bilateral thyroidectomy. Thyroid cancer often spreads to lymph nodes in the neck. 2011;25:161723. Risks of the thyroid surgery include the risks common to all surgeries including risks associated with administration of general anesthesia, bleeding, and infection. Supraclavicular lateral collar incision versus conventional approach 4 Also emerging are techniques for remote access thyroid and This study was reviewed and approved by the Ethics Committee of Xiangya Hospital, Central South University (No. Only two patients developed temporary vocal cord paralysis and no patient developed permanent vocal cord paralysis. Hoarseness generally improves within the first 3 to 4 weeks after the operation but it may take up to 6 months. This nonobese gentleman who has a 26-inch neck circumference and a large goiter would not be a candidate for any minimally invasive approach. 2013;9:11621. However, the da Vinci system is blamed for a prolonged surgery duration and a significantly higher economic cost. 2016;23:40238. Surg Endosc. 2005;15:64752. Approximately 70% of patients who have half of a normal thyroid gland left in place will not require thyroid hormone replacement pills. Solved Preop Dx: Cold thyroid nodule Postop Dx: Multinodular - Chegg 4 Technologic If you experience itching once the collodion is off, you may apply lotion to the scar. Surgery. As the working space is crucial to the surgery, we have summarized this process in three standard steps. They have a higher death rate due to postoperative complications. Moreover, the patients arm is raised during the entire operation time which might cause pain in the axilla [20, 21]. https://doi.org/10.1186/s12957-021-02484-z, DOI: https://doi.org/10.1186/s12957-021-02484-z. Thyroid hormone levels will then be measured about every 2 months until the hormone levels are stable (levels generally stabilize in 4 to 5 months). Your incision will be located on the front of your neck. Endoscopic and robotic thyroidectomy for cancer. C, D Step two, sternocleidomastoid muscle (SCM) was dissected longitudinally and the sternal head of SCM was elevated by the retractor to expose the strap muscles. This technique can be performed on incisions as small as 2.0 cm (0.8 inches), and generally has excellent healing and cosmetic result. After a total thyroidectomy, patients will need to take thyroid hormone replacement pills (one pill a day for the rest of their lives). Wound infections happen in about 1 out of 2000 operations (far less than 1%) and because of this low risk, the routine use of antibiotics is not needed. The optimal position in which to mark the anticipated thyroid incision is with the patient seated upright in the holding area. A concept that has gained traction in recent years is the customization of both the incision and the surgery to the patient and the disease characteristics, rather than a one size fits all approach.9 Historically, surgeons proposing to accomplish a thyroidectomy would make a standard length incision in a routine location and accomplish an identical operation for each patient.
collar incision for thyroidectomy
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