Fig. 3.1
Paolo Miccoli and his colleagues in Pisa developed a minimally invasive cervical approach that relies on endoscopic assistance to achieve and incision as small as ¾ in., with excellent visualization of the critical structures, such as the recurrent laryngeal nerve and parathyroid glands, as shown. Importantly, their innovations helped to demonstrate that the conventional approaches (and incision sizes) were no longer necessary for many patients (Reprinted with permission from Miccoli P, Berti P, Ambrosini CE. Perspectives and lessons learned after a decade of minimally invasive video-assisted thyroidectomy. ORL J Otorhinolaryngol Relat Spec. 2008;70(5):282–6)
Substantial modifications to the Miccoli technique were described by our group in an effort to facilitate its performance by lower-volume surgeons. The very first difference is that the location of the incision is identified with the patient sitting upright in the holding area in order to be certain the incision is in the proper location for when the patient is upright and in public. Some of the technical changes included the utilization of nerve monitoring as an additional safety measure, implementation of a slave monitor to improve the ergonomics especially for the camera assistant, and bundle ligation of the superior pedicle (Fig. 3.2) which reduces the time required to mobilize the superior pole. Patients are uniformly managed without a drain and on an outpatient basis. For those undergoing total thyroid surgery, routine calcium supplementation is provided to obviate the need for blood tests and to minimize the likelihood of symptomatic hypocalcemia.
Fig. 3.2
An important modification of the Miccoli minimally invasive thyroidectomy was the application of bundle ligation of the superior vascular pedicle, which is faster and easier in the confined space of the upper pole of the thyroid gland. After the upper pole is fully mobilized (a), and advanced energy device is used to ligate the entire upper pedicle (b) in a single bundle (Reprinted with permission from Terris DJ, Seybt MW. Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon. Am J Otolaryngol. 2011;32(5):392–7)
An intermediate approach to minimally invasive surgery was also described in which a small incision is used but without the need for endoscopic assistance. The incision size for these procedures is generally between 25 and 40 mm, and the patients benefit from all of the same procedural innovations, although with a slightly longer incision.
Remote Access and Robotic Thyroid and Parathyroid Surgery
In the inexorable movement toward smaller and more easily hidden scars, and especially in cultures where a neck scar is particularly undesirable (including a number of Asian countries), Yoshifumi Ikeda from Japan made substantial contributions by innovating and refining a totally endoscopic insufflation-based axillary thyroidectomy. Although this technique is lengthy and challenging for even very skilled laparoscopic and endocrine surgeons, it paved the way for future creative surgeons who modified this approach in a number of different ways and with a number of different portals.
By 2013, the most popular technique that has emerged has been a gasless axillary approach which was refined by several different South Korean groups. Deserving of much credit in advancing this field, Woong Youn Chung merged robotic technology with remote access principles (Fig. 3.3) and was able to substantially shorten the duration of axillary thyroidectomy. This group has quickly accumulated a vast experience with this approach and proven its safety and completeness, at least in a South Korean population. A more extensive bilateral axillary and breast approach has also proven to be popular in the South Korean patient environment. Because of challenges in extrapolating these approaches to a North American population, an alternative approach that uses a facelift incision has recently been described (Fig. 3.4).
Fig. 3.3
Particularly in many Asian countries where the skin type predisposes to hypertrophic scarring and there is a cultural aversion to neck scars, remote access surgery has been extraordinarily popular. Woong Youn Chung made substantial contributions by innovating a gasless transaxillary approach that is retractor based and eventually incorporated the use of the robot (Reprinted with permission from Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, Nam KH, Chang HS, Chung WY, Park CS. Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients. Surg Endosc. 2009;23(11):2399–406)
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