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FIRST EXPERIENCE OF THYROID ENDOSURGICAL OPERATIONS:
LITERATURE REVIEW
Assistant
Khoshimov I. M.
Assistant
Akhmadjonov J.O.
Department of General Surgery and Transplantology
Annotation:
The aesthetic impact of standard thyroid gland (TG) surgery on the anterior
neck surface does not satisfy the ever-increasing demands of modern society. This situation
establishes the necessity of creating novel methods for carrying out TG surgery.
Key words:
Miniaturization, thyroid gland, methods, traditional thyroidectomy.
The history of minimally invasive surgery is inextricably linked to technological advances.
The combination of three factors of technological progress, a system of rod lenses,
miniaturization of image transmission systems and devices for gas insufflation in the div
cavity in order to create a working cavity allows performing minimally invasive operations
with less trauma compared to open surgery [1]. One of the most interesting potential
anatomical spaces for surgeons is the neck. The complexity of endoscopic operations on the
endocrine organs of the neck has been a challenge for many years for surgeons seeking to
widely introduce endosurgical technologies into thyroid surgery. According to the method of
performing thyroid surgery, they are divided into open (traditional) and endoscopic (fully
endoscopic and video-assisted). Many patients believe that endoscopic thyroid surgery is
always better than traditional, but this opinion cannot be considered correct. Endoscopic
surgeries have many advantages in the treatment of the chest and abdominal organs, but in
thyroid surgery, endoscopic surgeries have both advantages and disadvantages compared to
open ones.
One of the important advantages of endoscopic thyroid surgery is the movement of the
postoperative scar to an inconspicuous area (for example, to the armpit), or a decrease in the
size of the postoperative scar to 2-2.5 cm (with video-assisted surgery). At the same time,
with endoscopic removal of the thyroid gland from the armpit, it is necessary to create a
sufficiently deep tunnel in the subcutaneous tissue in order to get from the armpit to the
thyroid tissue - this increases the trauma of the operation and complicates the surgeon's work.
That is why endoscopic thyroidectomy should be performed only in specialized endocrine
surgery centers, where surgeons have significant experience in performing such operations.
Traditional thyroid surgeries can be performed in very different ways. A specialized
endocrine surgery clinic differs from a general center primarily in that during thyroid
surgery, endocrine surgeons do not cut the neck muscles, plan skin sutures along the natural
folds of the neck (which significantly improves the cosmetic result of the surgery), and
perform operations from a short access (usually the suture after traditional thyroid surgery in
a specialized center is about 4-5 cm long). If performed correctly, traditional surgeries can
be very minimally invasive — even less invasive than video-assisted surgeries.
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One of the ways to overcome these difficulties is to consider endoscopic operations on the
thyroid gland (TG)as surgical interventions performed in a potential working space.
Extracervical accesses include the following: transaxillary, retroauricular, axillary-mammary
(with or without access in the contralateral axillary region), thoracic, and transoral.
According to E. Berber et al. [2], the most common methods in 2015 were: endoscopic
thoracic access, endoscopic and robotic bilateral axillary-mammary access, endoscopic and
robotic transaxillary access. With the introduction of endoscopic and robotic technologies in
thyroid surgery, specific complications are described and studied, which include plexitis of
the brachial plexus, perforation of the separated skin flap, as well as sensory disorders in the
surgical area. An exceptional complication when performing thyroid surgery from a
transoral approach in the vestibule of the oral cavity is damage to the chin nerve. A specific
complication when using the post-auricular approach is damage to the marginal branch of
the facial nerve due to compression of the latter by trocars in a narrow surgical canal in the
post-auricular region. Currently, we have found three works in the world literature devoted
to the analysis of long-term cancer outcomes and the safety of performing robotic total
thyroidectomy compared to traditional thyroidectomy for papillary thyroid cancer [3-5].
All patients in three studies underwent prophylactic central neck lymph dissection. One of
the main criteria analyzed in all studies was the recurrence rate of the underlying disease. S.
Lee et al. [3] report the same tumor recurrence rate (1.2%) in both groups of patients (after
traditional access surgery and robotic surgery) with an average follow-up of 74 months. In T.
Sung et al. [4] with an average follow — up of 57.2 months, the recurrence rate after open
surgery was 1.5%, and after robotic thyroidectomy-2.7%. The lowest average follow-up
period was demonstrated in study K. Tae et al. [5] — 43.6 months — at the same time,
tumor recurrence was diagnosed in 1.1% of patients after traditional thyroidectomy and in
0.5% of cases after robotic thyroidectomy. In all studies, relapses were locoregional in
nature, and there was no long-term metastasis during follow-up. In conclusion, the authors
conclude that the cancer outcomes are statistically comparable and safe in the long-term
follow-up period, but conclude that further studies with a large number of patients and
follow-up periods are necessary. The use of minimally invasive technologies in Graves '
disease surgery requires separate consideration. The key limiting factor for the relatively
widespread use of minimally invasive technologies in the treatment of Graves ' disease is
increased thyroid vascularization, which causes technical difficulties of the operation in
conditions of intraoperative bleeding. In 2011, P. Alesina et al. [6] presented the results of
minimally invasive video-assisted thyroid surgery in 157 patients with Graves ' disease.
Among the technical features, the transition from the clipping technique for the treatment of
the upper thyroid artery and vein to the use of bipolar coagulation after performing the 91st
minimally invasive video-assisted operation is noteworthy. The main factor in selecting
patients with Graves ' disease for video-assisted surgery was the thyroid volume measured
using thyroid ultrasound and not exceeding 30 ml. According to the author, manipulations
on the thyroid gland with a fragile capsule in conditions of diffuse toxic goiter from
extracervical accesses may cause uncontrolled intraoperative bleeding. In this regard, the
author anticipates that the use of robotic technologies with all its advantages will reduce the
risk of intraoperative bleeding and will serve as an alternative to video-assisted thyroid
surgery for Graves ' disease, while demonstrating results comparable to video-assisted
surgery in terms of the radical nature of surgical intervention.
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The results of a meta-analysis comparing the immediate results of open and endoscopic
thyroidectomies for Graves ' disease revealed the advantages of endoscopic technologies in
terms of cosmetic effect and lower blood loss, while traditional surgery is associated with
shorter duration and costs for inpatient treatment [7]. Statistically comparable results for
both methods are shown by such criteria as the volume of discharge through drains, the
frequency of complications, including transient ULN paresis, transient hypocalcemia,
postoperative hypothyroidism, and recurrent thyrotoxicosis. An important point to clarify is
that in all the studies included in the meta-analysis, a feature of preoperative preparation of
patients for endoscopic thyroidectomy for Graves ' disease was the administration of Lugol's
solution.
Thus, endoscopic operations on the thyroid gland performed in a potential working space are
currently a dynamically developing area of surgery based on the introduction of modern
technological achievements and methodological developments. At the same time, further
analysis of the results of operations on the thyroid gland from remote accesses is required to
properly determine the indications and contraindications for such operations, as well as
further development of optimal aspects of surgical technique, which would expand the scope
of endosurgical technologies for the treatment of patients with thyroid diseases.
References
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https://doi.org/10.1136/adc.2004.062760
2.
Berber E, Bernet V, Fahey TJ 3rd, Kebebew E, Shaha A, Stack BC Jr, Stang M,
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3.
Lee SG, Lee J, Kim MJ, Choi JB, Kim TH, Ban EJ, Lee CR, Kang SW, Jeong JJ,
Nam KH, Jo YS, Chung WY. Long-term oncologic outcome of robotic versus open total
thyroidectomy in PTC: a casematched retrospective study. Surg Endoscopy.
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. Sung TY, Yoon JH, Han M, Lee YH, Lee Y, Song DE, Chung KW, Kim WB,
Shong YK, Hong SJ. Oncologic Safety of Robot Thyroid Surgery for Papillary Thyroid
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