David J. Terris and Michael C. Singer (eds.)Minimally Invasive and Robotic Thyroid and Parathyroid Surgery201410.1007/978-1-4614-9011-1_19
© Springer Science+Business Media New York 2014
19. Thyroid Surgery 2020
(1)
Department of Surgery, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4052, Chicago, IL 60637, USA
(2)
Endocrine Surgery Research Program, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
Abstract
In the past few decades, thyroid surgery has changed by increasing use of outpatient surgery, neuromonitoring of the recurrent laryngeal nerve, and numerous small incision or remote incision approaches to thyroidectomy. Since innovation in surgery is driven by the belief that something could be done better, the future of thyroid surgery will only change if surgeons believe that there is a need to make improvements. We suggest that future developments in thyroidectomy should focus on reducing the incidence of nerve and parathyroid injuries, better identification of residual thyroid tissue in the neck and thyroid cancer in lymph nodes, and reducing the need for thyroidectomy if nodules can be definitively proven to be benign preoperatively.
Prediction is very difficult, especially about the future.
Niels Bohr, Winner of Nobel Prize in Physics, 1922
Introduction
An invitation to write a chapter predicting future developments in any field is a double-edged sword. At the time that the predictions are made, they can never be wrong since the future is unknown. At the point that they can be proven wrong, they are rarely reviewed since few in the future care what was predicted in the past. Writing a chapter about the future also has the benefit of being inherently subjective since, by definition, predictions can never be evidence based. Given the restrictions noted above, we will, in the upcoming paragraphs, consider some of the innovations that have characterized thyroid surgery in the last few decades and suggest possible directions for future development.
Innovation in surgery has largely been characterized by surgeons creatively attempting to solve intraoperative problems for their patients. As such, the drive to innovate (i.e., to make changes for the good) is grounded in the belief that something should be able to be done better. Although determining whether a new approach is actually beneficial for patients requires a scientific approach and the accumulation of data, the actual drive to try a new approach, is often based on the serendipity of adapting a technique or technology to solve a specific clinical problem. For this reason, innovation generally requires the belief that a problem exists.
A Look Back
In order to thoughtfully consider the potential changes in thyroidectomy in the future, it is helpful to look at the recent past. In the last few decades, thyroid surgery has become increasingly common as rates of papillary thyroid cancer have risen worldwide. A number of changes have occurred with the operation over that time: (1) performing thyroid surgery as an outpatient procedure; (2) neuromonitoring of the recurrent laryngeal nerve during thyroid surgery; and (3) making the scar smaller or moving it to a location away from the neck. We will consider these changes and what has driven their development as a tool to help predict future changes.
Although a small number of surgeons have performed outpatient thyroidectomies for many years, in the last decade, the numbers of patients treated this way have significantly increased. The move to outpatient surgery has been an innovation that is primarily driven by surgeons rather than by patients. Although many patients are happy not to spend a night in the hospital, the economic incentives for discharge are primarily for the insurance company or the hospital. Thus, the push for outpatient surgery has largely been reflective of the more general shift to outpatient surgery in order to save money.
In recent years, neuromonitoring technologies have been increasingly used as a way to try to reduce the risks of recurrent laryngeal nerve (RLN) injury during thyroidectomy. Many studies have looked at how neuromonitoring affects the actual risks of nerve injury, yet only one has shown a statistically significant improvement in RLN injury rates with use of neuromonitoring. Barczynski and colleagues showed a statistically significant reduction in rates of transient RLN injury (but not in permanent RLN injury) with use of neuromonitoring. When looking to determine what has driven the move toward increasing use of neuromonitoring technology in recent years, a number of important factors can be identified. RLN injuries, although not common after thyroidectomy, remain a problem in a small number of patients and an ongoing source of worry for patients and surgeons. The morbidity of a RLN injury can be significant and a complication that all surgeons try to avoid for their patients’ benefit. In addition, RLN injuries are a common cause of malpractice claims against surgeons and, as such, a clear source of added concern to thyroid surgeons.
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