Advantages of Endoscopic Neck Surgery

• Better visualization
• More precision
• Magnification
• Preservation of parathyroid & nerves
• Better compared to open surgery even in cancers
• No scar related issues
• Early recovery

Endoscopic Thyroidectomy

• Endoscopic Total Thyroidetomy.
  In Endoscopic Total Thyroidectomy the entire thyroid gland is removed endoscopically. Endoscopic Thyroidectomy is usually performed when there is suspicious thyroid nodules or in case of thyroid cancer or large goiter.
• Endoscopic Hemi Thyroidectomy.
  In Hemithyroidectomy, half of the thyroid gland is removed.

Endoscopic Parathyroid Surgery.

Parathyroid glands are four tiny glands that is located just behind the thyroid gland. They control the body’s calcium levels. Removal of parathyroid glands become necessary in case of parathyroid tumor or overactive parathyroid glands.

Endoscopic Neck dissection / Lymphadenectomy.

Lymphadenectomy is a surgical procedure to remove one or more lymph nodes.

Endoscopic Thyroglossal Cyst Excision.

Thyroglossal cyst is an irregular neck mass or a fluid filled pocket which lies in the front part of the neck, usually above the voice box.

Endoscopic Submandibular Salivary Gland Excision.

Salivary glands are endocrine glands that produce saliva. There are three major salivary glands that are paired, parotid, submandibular, and sublingual.

Endoscopic excision of Branchial Cyst.

Branchial cyst or branchial cleft cyst is a lump that develops on one or both sides of a child’s neck. It is a type of birth defect.

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Thyroid can enlarge during menarche (starting of menstrual cycle) and pregnancy which is called as physiological goiter, which will subside once the extra demand is over. Swelling (nodule) formation is a common problem. The nodule can be cancerous or noncancerous (benign). Thyroid tumours are common in women and they would like to have treatment options with a definite cosmetic appeal. Generally when someone is diagnosed with a single nodule or multiple nodules they need to be evaluated by ultrasound scan of neck and if needed fine needle aspiration cytology. The USG features or FNAC is suspicious of a malignancy then surgery is the solution, even at any size of the swelling. Even if the USG and FNAC suggest benign swelling the option of thyroidectomy needs to be sought if the nodule is more than 4 cm. Depending on the physical examination, USG and FNAC findings surgeon decides to offer a hemithyroidectomy (removal of full lobe on the side of lesion and isthmus) or total thyroidectomy.

Thyroid Surgery – Different Techniques

Open Thyroid Surgery/Thyroidectomy or Conventional Thyroidectomy

The surgical solution available in most of the places is open thyroidectomy, which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsighty scar which is not acceptable, especially for women. (Picture 1)

Lateral and Robotic Thyroidectomy

The lateral thyroidectomy by cutting on sides of neck for each side lobe removal – though better than full open surgery – is also not a desirable one.

Robotic surgery does not give any advantage on the cosmetic aspect of the thyroid surgery.

Endoscopic Thyroidectomy

Endoscopic thyroidectomy – the keyhole or minimally invasive technique is a very good alternative to other methods. It gives excellent cosmetic outcome especially when done by an axillary approach. It gives equal or even a better surgical outcome as far as the actual thyroid nodule management is considered. There are other less preferred endoscopic approaches like sternal and breast approach.

Endoscopic Thyroidectomy Procedure

The procedure of endoscopic thyroidectomy by axillary approach involves the following steps. A 10-mm trocar placement in the axilla towards neck for the telescope; which initially helps in creating the plane and visualization of structures with magnification, precision and clarity.

Then two 5-mm trocars are introduced in to the dissected space (subplatysmal) which are used as working ports. We use a less heat generating energy source the harmonic scalpel instead of cautery for tissue dissection.

Once space is created in the neck, the sternomastoids and strap muscles gets exposed. We can open the investing layer in midline and reach the thyroid gland. The gland is mobilized by blunt dissection and vital structures identified. The recurrent laryngeal nerve (important for respiration) the superior laryngeal nerve (for voice) and parathyroids (for calcium metabolism) with their blood supply will be preserved. The blood vessels are divided and gland detached from trachea. A specimen bag is used to place the thyroid and removed by dilating 10 mm trocar. For a total thyoidectomy one will have to put additional trocars on the opposite side and do the same steps on that side as well.

The investing layer is sutured back, drain is placed and the trocar sites closed. Patient is asked to be in the hospital for 24 hours only and can resume all kinds of activities in a few days.

Advantages of Endoscopic Thyroidectomy

These patients will have less wound related problem compared to open surgery group. The cosmetic outcome is such excellent that the small wounds in axilla heals with minimal scarring and gets covered with small inner-wears.

The earlier belief was that the endoscopic, no neck scar option for thyroid swellings are applicable to lesions of less than 4 cm size. But we have observed that swellings of size of even 12 – 15 cm can be tackled very successfully through this method. The only pre-requisite will be a surgeon with good experience, in both laparoscopic surgeries and thyroid surgeries.

The complications of this surgery are very similar to that of open surgery proving that it is a much desirable option. Any kind of pathologies like benign or cancerous nodules, thyoiditis can be safely tackled by endoscopic thyroidectomy. Completion of thyroidectomy is much more easier with this technique as one do not dissect the other side while performing the opposite side. Lymph node clearance when indicated can also be comfortably performed by this route.

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Endoscopic Thyroidectomy Videos

Endoscopic Thyroidectomy is a surgical procedure where thyroid surgery is carried out through a small incision at the axilla. This avoid a large cut at the neck and thus avoids scar to the neck.

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Three years old girl weighing only 10 kg was operated successfully through endoscopic method. Girl child hailing from Oman was suffering from a rare congenital condition called branchial cyst of second branchial cleft. The swelling had grown in such a size that she was finding it difficult to bend neck.

She was successfully treated by endoscopic surgery by a team led by Dr. R Padmakumar. The procedure was carried out through a 10 mm cut in the axilla (armpit) and nearby two 3 mm cuts. The entire swelling closely adherent to the main blood vessels (the carotid and jugular veins) and nerve to diaphragm was safely and completely removed. This kind of operation in the neck; that too for such young kid, was performed for the first time in the world. “The team’s expertise in doing endoscopic thyroidectomies for many patients really helped in successfully completing this unique procedure” said Dr. R. Padmakumar. As there is no cut in the neck child revived fast and could go back to Oman in three days time. Dr. Madhukara Pai, Dr. Mary Varghese, Dr. Shaji P.G and Dr. Sayooj Mukundan were part of this historic surgical procedure.

View publications in Journal of Pediatric Surgeryfor more details

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• Branchial cyst excision endoscopy.
• Axillary approach-no neck incision.
• First ever in a child.

Journal of Pediatric Surgery Case Reports

Abstract

This is the case report of a three-year-old female Arab child who presented with a neck swelling since one year of age. Physical examination was suggestive of a 6 × 4 cm swelling in the right lateral neck, which was dumbbell shaped, deep to sternocleidomastoid muscle on either side of the muscle. Ultrasound scan revealed a large cyst with internal echoes in the right carotid space anteriorly. The cyst was dissected endoscopically by an axillary approach and complete excision was achieved, thus avoiding the need for a large incision in the neck. No complications noted after treatment. The lowest age at which branchial cyst excision was carried out endoscopically was 18 years as per the available literature. Hence this case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group.

1. Introduction

A branchial cyst is a congenital epithelial cyst on the lateral aspect of the neck, due to failure of obliteration of branchial cleft during embryonic development. It is the most common congenital cause of a neck mass. Though congenital, it may present at a later date due to secondary infection. The definitive treatment is surgical excision of the entire cyst wall.

Presently, the principles of remote access and endoscopy are combined together and are used regularly for removal of thyroid masses[1]. In literature there is a case report of endoscopic branchial cyst excision in a patient aged 18 years [2]. We hereby report a case of endoscopic branchial cyst excision in a 3-year-old child via axillary approach without a neck incision. This case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group.

Read More on the Article in

Journal of Pediatric Surgery Case Reports

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