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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• He has got the World record – Branchial Cyst Endoscopic removal in the youngest age (Omani Child of 3 years)
• Endoscopic Excision of Thyroglossal Cyst – First of its kind in Kerala

Dr. R. Padmakumar was invited by the Government Hospital in Dubai for endoscopic thyroid surgeries. Generally, these invitations as International visiting doctors to operate in Dubai Hospital is extended to reputed surgeons from US, UK, Germany, etc, but usually inviting doctors from India is very rare. Dr. Padmakumar was invited directly by Dubai Health Authority.

Dr. R. Padmakumar specializes in three approaches to performing thyroidectomy:

• Endoscopic Thyroidectomy (Scarless Thyroid Surgery)
• Robotic Thyroidectomy (Scarless Thyroid Surgery)
• Open Thyroidectomy

Endoscopic Thyroidectomy

Dr. R. Padmakumar is one of the few surgeons in the world doing Endoscopic Thyroidectomy. In Endoscopic Thyroidectomy the surgeon removes the thyroid through small skin incisions made at the axilla. An endoscope with a video camera at the tip is inserted via the axilla allowing the surgeon to get a magnified view of the internal structures. The main advantage of performing thyroidectomy endoscopically is that it avoids a large cut to the neck.

Dr. Padmakumar performing Endoscopic Thyroidectomy

Endoscopic Thyroidectomy can be used for both Total Thyroidectomy and Hemithyroidectomy.

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

Robotic Thyroidectomy

Robotic Thyroidectomy is also a scarless thyroidectomy procedure and focuses on the axillary approach with small incisions made near the axilla. Robotic Thyroidectomy differs from endoscopic thyroidectomy in that Robotic Thyroidectomy involves the use of a robot to assist in the thyroidectomy procedure.

Image showing Robotic Surgery performed by Dr. R. Padmakumar and Team. Robotic Surgery makes use of Robot in assisting the thyroidectomy procedure. Small incisions are made and the internal structures are visualized on a monitor as shown in the above image.

Open Thyroidectomy

For patients in whom endoscopic thyroidectomy or Robotic Thyroidectomy is not possible, Open Thyroidectomy will be performed. In open thyroidectomy, the thyroid surgery is performed in the traditional way by making an incision at the neck through which the thyroid is removed.

Endoscopic Neck Surgeries.

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 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 Neck Lipoma Excision.
Lipomas are lumps under the skin that occurs because of overgrowth of fat cells. These are usually considered benign tumors. It becomes necessary to remove lipomas in case it causes pain or other complications or symptoms.

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.

Endoscopic assisted excision of Ectopic Goiter.

Dr. R. Padmakumar as the best thyroid surgeon in Kerala is presently the Head of the Department of Minimally Invasive Surgery at VPS Lakeshore Hospital situated in Kochi and today it is the best hospital for thyroid surgery in India. He is the Chairman and Managing Director of Keyhole Clinic, best center for outpatient thyroid surgery consultations in Kerala.

Dr. Padmakumar at Dubai Hospital for Endoscopic Thyroid Surgery

Dr. Padmakumar visits Sultan Qaboos University in Oman as faculty for Endoscopic Thyroid Surgery

Thyroid Surgery Cost in Kerala

Thyroid Surgery cost in Kerala is less compared to other parts of India. The cost of Endoscopic Thyroidectomy is bit higher than the cost of open thyroidectomy, but patients normally chose to go ahead with Endoscopic Thyroidectomy as it offers the benefit of no scar on the neck, minimal hospital stay required than open thyroidectomy, and faster healing.

Thyroidectomy cost in India is also less compared to other parts of the world. Lot of patients suffering from Thyroid Cancer from outside India visit Kerala for having thyroidectomy done, especially endoscopic thyroidectomy, as they would like to get the procedure done under the expertise of top thyroid cancer surgeons. Dr. R. Padmakumar is one of the best surgeons for thyroid cancer.

The post Thyroid Surgeon India appeared first on Dr. R. Padmakumar.

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.

The post Endoscopic Thyroidectomy Videos – Talks by Dr. R. Padmakumar appeared first on Dr. R. Padmakumar.

Thyroglossal cyst is a congenital cyst with upper attachment to root of tongue and lower attachment to thyroid gland. It is situated above the thyroid cartilage (the Adam’s apple). Generally, it is removed by a large cut in the neck which leads to an unsightly scar which is uncomfortable for the individual. 

Thyroglossal Cyst Excision

Endoscopic Excision of Thyroglossal Cyst – First of its kind in Kerala

A team of Surgeons in the Dept of Minimally Invasive Surgery at VPS Lakeshore Hospital, Kochi, has successfully removed a cyst from inside the upper neck without any cut on the neck. This was a Thyroglossal cyst. Its a very rare keyhole surgery of its kind – first time in the state of Kerala was performed on a 30-year-old person from Wayanad.

The team led by Dr R Padmakumar performed the procedure by an axillo-breast approach without making any scar in the neck. 

Endoscopic method involves tiny cuts in the armpit area and uses the laparoscopic equipment to complete the procedure in a keyhole manner. 

Others in the team who performed this procedure included Dr Madhukara Pai, Dr Beena K Nair, Dr Kevin Chiramel and Dr Aravind Balakrishnan.

The excellent facilities at VPS Lakeshore Hospital and our experience in Keyhole Thyroid Surgeries helped us in performing this rare surgery – opined Dr Padmakumar.

Read more on Endoscopic or Keyhole Neck Surgeries

1. Endoscopic Thyroidectomy
2. Scarless Solutions for Thyroid Tumors

Important Terms

Thyroid Gland: The Thyroid is an endocrine gland. It is a butterfly-shaped organ and is located in front of the neck and below the Adam’s apple. It is composed of the left lobe and the right lobe. The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyroninine (T3). These hormones are necessary for the body to function normally.

Adam’s Apple: Adam’s apple is a protrusion or a lump, typically larger in males, that is formed by the angle of the thyroid cartilage surrounding the larynx. It is usually clearly visible in males.

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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

The post Rare Keyhole Neck Surgery For 3 Year Old Girl appeared first on Dr. R. Padmakumar.

• 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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