Transcript Benign Thyroid Disease

CASE
 Patient particulars
 Patient name- Rajni devi
 Age/sex- 35 year/ female
 Residence- Dhaulpur
 Occupation- House wife
 Religion- Hindu
 DOA- 09/07/16
Chief complaints
 Swelling in front of neck for 6 months.
 Difficulty in swallowing for 1 month.
History of present illness
 Swelling in front of neck
1) She noticed the swelling 6 months ago.
2) Insidious onset.
3) Gradually increased in size to attain the present
size.
4) No history of pain over the swelling.
5) Not associated with difficulty in breathing, no
change in voice during this period.
 Appetite is normal.
 Bowel and bladder habits are normal.
 There are no symptoms pertaining to respiratory,
cardiac and nervous system.
 No menstrual problems.
Past and Family history
 No h/o any major ailment in past
 No h/o prior irradiation in the neck.
 No other in the family has similar swelling in the
neck
Personal History
 Married
 Vegetarian
 Non smoker
 Non alcoholic
 No history of weight loss
 Menstrual cycle normal
 Obstetrical status P3L3 A0
Drug history
 No h/o drug allergy
 No h/o any drug treatment (antithyroid , thyroxin etc)
General examination
 Conscious and oriented to time place and person.
 Average built and nourished, afebrile.
 Pulse-88/min regular, normal volume
 BP- 124/80, Right arm supine.
 No pallor, clubbing, cyanosis, icterus, pedal edema
 No Lymphadenopathy.
Local examination
 A 4x3 cm swelling in front of neck in the thyroid
region moves up and down with deglutition , not
moves up with tongue protrusion
1) Globular in shape
2) Smooth surface
3)Rounded margin
4) Firm in consistency
5) Free from skin and underlying structures
 Non tender
 Carotid pulse is palpable in normal position on both
sides
 Cervical lymph nodes are not palpable
 No toxic signs (eye signs, tachycardia, tremor) found
on examination and no clinical evidence of retro-
sternal prolongation
Provisional diagnosis
 Colloid nodule
 Follicular adenoma
 Carcinoma thyroid
 Thyroid cyst
Work up
 Blood investigations: CBC,LFT,RFT were normal
 T3,T4 and TSH were normal.
 Ultrasound shows complex echogenecity nodule with
solid and cystic component is seen in left lobe of thyroid
measures 41×30 mm. left lobe of thyroid is not separate
from the SOL.
FNAC of the swelling was suggestive of colloid nodule.
 The patient underwent
transoral endoscopic
thyroid surgery .
 The procedure lasted
for 1 hr 30 mins.
DISCUSSION
MINIMALLY INVASIVE PROCEDURE
TOTALLY ENDOSCOPIC APPROACH
1.AXILLARY
2.ANTERIOR CHEST
3.BREAST APPROACH
4 ROBOTIC
5. TRANS ORAL
MINIMALLY INVASIVE VIDEO – ASSISTED /
MINI INCISION APPROACH
History
 Huschner in 1997 successfully applied 1st endoscopic
thyroidectomy for benign thyroid tumor.
Advantages of minimal invasive
thyroid surgery
1) smaller incision
2) better cosmesis
3) less pain
4) early discharge
AXILLARY (IKEDA ) APPROACH –
 A 30 mm skin incision in axilla and lower layer of
platysma was exposed through the upper portion of
pectoralis major muscle.
 10 mm & 5 mm trocars are inserted via this incision.
 CO2 insufflated upto 6 mm of hg.
 An additional 5 mm trocar is inserted adjacent to
incision in anterior axillary line.
 A subcutaneous plane is created – anterior to
pectoralis – b/w the heads of SCM & deep to strap
muscles.
 Specimen extracted through 30 mm skin incision.
 A drain is placed under platysma on the site of 5 mm
trocar.
ANTERIOR CHEST APPROACH –
 A 10 mm skin incision – made on chest over sternum
about 10 cm from suprasternal notch.
 CO2 insufflation done upto 8 to 10 mm of Hg
pressure.
 Blunt dissection done for development of
subplatysmal space.
 A 5 mm incision is made on the left side under
clavicle at midclavicular point and trocar and cannula
passed over the surface of the clavicle anterior to
SCM muscle.
 On right side another 5 mm trocar and cannula
inserted in same position.
 Strap muscles separated in midline and retracted
laterally to deliver the gland into the operative space.
PORT POSITIONS
ADVANTAGE
 It avoids cervical incision and there are no visible
scars outside.
 It also allows bilateral neck dissection so we can
perform total thyroidectomy with central
compartment clearance for pappilary ca and near
total thyroidectomy for MNG.
BREAST APPROACH
 OHGAMI M introduced endoscopic thyroidectomy
using the breast approach in 2000.
PORT POSITIONS AND TECHNIQUE
 A 10 mm port on upper edge of areola on right side
 5 mm port on upper edge of areola on left side
 Another 5 mm inserted on right parasternal region
 A 3mm incision made in right axillary area
 Co2 insufflation done upto 6 mm of Hg and dissection
performed with hooks and endoscopic shears .
 Inferior thyroid pedicle divided
 RLN and parathyroids identified and preserved.
 Superior pole dissected
 Thyroid separated from trachea .
AXILLARY AND BREAST APPROACH
 Also called as hybrid approach
1) ABBA APPROACH ( axillo bilateral breast approach )
PORT POSITION
 Two 5 mm ports on bilateral areolar margins
 A 5 mm port in right axilla
 After dissection specimen removed by widening of axillary
incision.
2) BABA APPROACH (bilateral axillo breast
approach)
 A modification of ABBA approach.
 An extra axillary incision is added on opposite side
also.
 Better visualisation of thyroid gland obtained.
MINIMAL INVASIVE VIDEO ASSISTED
THYROIDECTOMY (MIVAT)
 It is a type of key hole surgery that enables the
surgeon to remove a part or all of the gland.
 With traditional open surgery incision is about 8 to
10 cm but with MIVAT it is about 1.5 to 2 cm.
MIVAT – 5 steps
1) incision and access to the operative space
2) section of the upper pedicle
3) identification of RLN and parathyroids
4) resection and extraction of lobes
5) closure
TECHNIQUE
 A 1.5 to 2 cm horizontal incision made in central neck
1.5 cm above the sternal notch.
 The dissection is performed as a conventional skill under
endoscopic vision using 5 mm 30 degree scope and
haemostasis achieved via harmonic scalpel.
 Applied generally for small well diff.ca
MIVAT
Comparision with traditional thyroidectomy
 magnified images of gland and nerves
 cosmatically better – smaller scar
 operative time – similar but is learning curve
 complication are same as the traditional method.
 post op course – better than conventional
Indications of MIVAT
 A thyroid nodule size less than or equal to 30 mm in
diameter
 Stage T1 or small T2 PCT
 Total thyroid volume less than 30 ml
 No history of thyroiditis or neck radiation
MIVAT - Contraindications
ABSOLUTE
 1) large goitres
 2) previous neck surgery
 3) thyroiditis
 4) presence of suspicious lymph nodes
 5) locally advanced carcinoma
RELATIVE
1) previous neck irradiation
2) graves disease
3) short neck in obese patients
 With MIVAT it is easy to convert to conventional
surgery in cases of massive bleeding or other
emergency by enlarging the cervical incision.
TRANS ORAL APPROACH
 Trans oral endoscopic thyroidectomy is one
such novel procedure that is based on the
principle of NOTES (natural orifice
transluminal endoscopic sugery ) and allows
for a truly scar free surgery with minimal
dissection.
Operative technique
 Pre op preparation
Pt was asked to gargle with chlorhexidine mouthwash
bd for 3 to 4 days
 Body position
Pt was placed in supine position with her neck
extended using a sand bag below her shoulders and
head supported by a head ring
PROCEDURE
 oral cavity washed with saline and betadine.
 packed with betadine soaked gauge packs.
 Endotracheal intubation was done through nasal route.
 1:500 adr saline was injected in subplatysmal plane vertically
in the neck and also in vestibular side of the lip and whole the
skin in chin.
 The approach was through the inferior vestibule of the oral
cavity where the ports were placed and included one midline
10 mm camera port and two lateral 5 mm working ports.
 The operative field was insufflated with with carbon
dioxide.
 The subplatysmal plane was entered and dissected.
 The deep fascia was opened in midline and strap muscles
retracted.
 The superior and inferior pedicles on the left side were
identified and divided by ultra scission.
 Recurrent laryngeal nerve was identified and preserved.
 Hemostasis was secured
 The nodule was brought out through the oral cavity
through widened 5 mm port.
 The deep fascia was closed using absorbable sutures.
 The vestibular port sites were closed in layers using
absorbable sutures.