How to Do It Endoscopic Thyroidectomy and Sentinel ... - Springer Link

Surg Today (2009) 39:178–181 DOI 10.1007/s00595-008-3840-5

How to Do It Endoscopic Thyroidectomy and Sentinel Lymph Node Biopsy Via an Anterior Chest Approach for Papillary Thyroid Cancer JA SEONG BAE, WOO CHAN PARK, BYUNG JOO SONG, SANG SEOL JUNG, and JEONG SOO KIM Department of Surgery, The Catholic University of Korea, Seoul, South Korea

Abstract The clinical role of endoscopic thyroidectomy and sentinel lymph node biopsy (SLNB) for differentiated thyroid cancer remains open to debate. Conventional thyroidectomy requires a cervical incision and often leaves an unsightly scar on the anterior neck. Endoscopic thyroidectomy is technically feasible and safe, with much better cosmetic results. The prognostic importance of lymph node metastasis in thyroid cancer makes central lymph node dissection a crucial option in thyroid cancer surgery. However, it is associated with an increased risk of complications such as recurrent laryngeal nerve injury or hypoparathyroidism, even in expert hands. Thus, the feasibility and future role of SLNB in thyroid cancer remains controversial. We describe our technique of performing endoscopic thyroidectomy with SLNB and central lymph node dissection via a gasless anterior chest approach for thyroid cancer.

indications for endoscopic thyroidectomy to include thyroid cancer. The sentinel lymph node (SLN) is defined as the first lymph node draining into a lymphatic basin. It is well known that sentinel lymph node biopsy (SLNB) for thyroid cancer is technically feasible and safe. Satisfactory SLN identification rates have been reported, with prediction of the disease status of the neck,4,5 although skip metastases of thyroid cancer can be encountered.6 Thus, the clinical role of SLNB in thyroid cancer patients remains controversial. We performed successful endoscopic thyroidectomy, including SLNB central compartment lymph node dissection, to treat papillary carcinoma, and describe the operative procedure herein.

Key words Sentinel lymph node · Thyroid cancer · Endoscopic thyroidectomy

We performed gasless endoscopic thyroidectomy with SLNB, using a retractor system and an ultrasonic coagulator, on 11 patients with papillary thyroid cancer at the Department of Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, Catholic University of Korea. Preoperatively, all patients underwent ultrasonographic examination of the neck and fine-needle aspiration biopsy. All tumors were diagnosed as papillary thyroid cancer, pathologically. Patients with clinically negative lymph node were included in this series.

Introduction Conventional thyroidectomy is widely accepted as the most effective treatment for patients with thyroid nodules. However, this leaves a scar on the anterior neck. For improved cosmesis, thyroid tumors have recently been removed endoscopically.1–3 With improvements in surgical techniques and endoscopic instruments, many surgeons are trying to expand the Reprint requests to: J.S. Kim, Uijeongbu St. Mary’s Hospital, 65-1 Kumoh-dong, Uijeongbu, Kyunggi-do 480-130, South Korea Received: May 7, 2008 / Accepted: June 26, 2008

Patients and Methods Patients

Surgical Procedure and SLNB The gasless endoscopic thyroidectomy procedure was performed with the patient under general anesthesia and in the supine position with the neck extended by using a shoulder pillow. Approximately 500 ml of diluted epinephrine solution (1 : 500 000) was infused via a 16gauge long needle into the subcutaneous space in the

J.S. Bae et al.: Endoscopic Thyroidectomy and SLNB

anterior chest wall and the subplatysmal space in the anterior neck to prevent bleeding and to make dissection easier. A 10-mm skin incision was made two-thirds of the way down from the clavicle to the nipple in a midclavicular line on the anterior chest wall. These areas were then dissected bluntly and gently through a 10-mm skin incision, with a 46-cm acrylic bar. Meticulous care was taken when the bar was introduced over the clavicle, because of the risk that it could be introduced incorrectly under the clavicle. A 10-mm trocar was inserted, through which carbon dioxide was insufflated at a pressure of 6 mmHg. A 5-mm trocar was inserted in the other midclavicular line, and another 5mm trocar was introduced into the parasternal border between the first two trocar sites to minimize the development of a keloid scar. A 30°, 5-mm endoscope was inserted through the 5-mm port in the parasternal border. Any remaining connective tissue in the space was dissected with endoscopic scissors and electrocauterization. The operative space was created from the anterior chest to the thyroid cartilage level of the upper neck, above the strap muscle, to the lateral border of the sternocleidomastoideus muscle laterally. A prototype gasless retractor system shaped like a question mark was assembled and introduced through the 10-mm port wound site. The skin flap was elevated by a retractor system (Fig. 1). After securing the operative space, intermittent suction was applied through a suction tube connected to a 5-mm port to evacuate the fumes of electrocauterization and to improve visibility. The strap muscle was dissected at the avascular midline with an L-shaped hook and an ultrasonically activated scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, New Brunswick, NJ, USA). It was then retracted laterally through the skin flap with 3-0 Vicryl, which was tied around the retractor system to secure the retraction. Next, we injected 0.5 ml of 2% methylene blue into the primary

Fig. 1. Gasless endoscopic thyroidectomy via anterior chest approach

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tumor and surrounding parenchyma with a 25-gauge long needle, taking care not to stain the surrounding tissue (Fig. 2). Within seconds, staining of one or more lymphatic channels became apparent. The lymph node that was stained first by the methylene blue dye was defined as the SLN (Fig. 3). The harvested SLN was sent for frozen section and endoscopic thyroidectomy was continued. The thyroid mass was revealed and dissected from the lower pole with division of the inferior thyroid veins with the ultrasonically activated scalpel, proceeding to the posterior and lateral aspects of the gland while the tumor was elevated and retracted with 5-mm toothed grasping forceps from the other 5-mm port. The inferior thyroid artery and the middle thyroid vein were skeletonized and divided with the ultrasonically activated scalpel, and the thyroid was separated from the trachea. The thyroid tumor mass involving parenchyma was divided at the isthmus. The superior

Fig. 2. Injection of methylene blue

Fig. 3. Identification of sentinel lymph node

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Table 1. Clinical characteristics of the 11 patients who underwent endoscopic sentinel lymph node biopsy Patient no. 1 2 3 4 5 6 7 8 9 10 11

Age (years)/Sex

Tumor size (mm)

Procedure

Sentinel LNs

Total LNs

Operating time (min)

41/F 22/F 46/F 36/F 33/F 32/F 42/F 43/F 40/F 39/F 36/F

8 15 10 15 10 10 26 6 8 15 6

Hemithyroidectomy+CCND TT+CCND TT+CCND NTT+CCND TT+CCND TT+CCND NTT+CCND NTT+CCND NTT+CCND TT+CCND TT+CCND

0/1 1/1 0/2 1/1 0/2 2/2 1/1 1/1 0/1 0/0 0/0

0/9 6/6 0/15 6/14 0/20 3/3 5/26 2/7 3/9 1/4 2/8

135 125 160 195 180 230 260 180 220 180 240

LN, lymph node; TT, total thyroidectomy; NTT, near total thyroidectomy; CCND, central compartment node dissection

thyroid artery and vein were identified and divided last. During the procedure, all the central lymph nodes and paratracheal nodes were dissected with the ultrasonic scalpel and the parathyroid glands and recurrent laryngeal nerve were identified and preserved. After the thyroidectomy, the specimen was retrieved through the 10-mm port wound, in a bag. When the frozen section confirmed malignancy in ten patients, total or near total thyroidectomy was performed. After complete hemostasis, the strap muscles were sutured with 3-0 Vicryl. A 5-mm closed suction drain was inserted and placed in the lower part of the operative space. The port wounds were closed with double-layer sutures.

Results The characteristics of the 11 patients with papillary carcinoma treated by the endoscopic thyroidectomy are summarized in Table 1. One patient underwent hemithyroidectomy and the others underwent total or near-total thyroidectomy. There was no conversion to conventional thyroidectomy. The pathologic diagnosis was well-differentiated papillary carcinoma in all patients. The reliability of SLNB by frozen section was examined in all patients with identified SLNs. The rate of identification of SLNs was 81.8%. There were five patients with positive SLNs and four patients with negative SLNs in frozen sections. Among the four patients with negative SLNs, three had negative non-SLNs and one had a positive non-SLN. The diagnostic accuracy was 88.9%, and the sensitivity and specificity were 83.3% and 100%, respectively. The positive predictive value and negative predictive value were 100% and 75%, respectively. The mean operative time was 191 ± 42.8 min. Postoperatively, there were no complications such as hypoparathyroidism, hemorrhage, or recurrent laryngeal nerve injury.

Discussion Endoscopic thyroid surgery has evolved in recent years. The major advantage of endoscopic thyroidectomy over conventional thyroidectomy is improved cosmesis; however, for oncological or technical reasons, the indications for endoscopic thyroid surgery have mainly been limited to benign nodules. Few reports describe endoscopic thyroid surgery for malignant thyroid nodules.7,8 The primary treatment for papillary thyroid cancer is surgery, although there is controversy about whether prophylactic lymph node dissection improves the prognosis of thyroid cancer patients. Central neck nodes adjacent to the thyroid nodule are usually involved first.9,10 However, routine lymph node dissection of the central compartment can cause complications such as recurrent laryngeal nerve injury and permanent hypoparathyroidism and is unnecessary in patients with negative lymph nodes. Moreover, the lymph node metastasis rate is lower in papillary microcarcinomas than in tumors larger than 1 cm, having been reported to range from 3.1% to 18.2%.11,12 Sentinel LNB may allow us to distinguish thyroid cancer patients with positive lymph nodes from true lymph node-negative patients. By using blue dye, Kelemen et al. first noted the feasibility of SLNB in thyroid surgery.13 Various methods have been used for SLNB in thyroid cancer, namely the blue dye technique, radiotracer techniques, and the combined method. Although the blue dye and radiotracer techniques each have their own advantages and disadvantages, SLNB for thyroid cancer seems to be technically feasible. In the present group of patients, the operations we performed using gasless endoscopic thyroidectomy via an anterior chest approach resulted in a better cosmetic outcome than conventional thyroid surgery. Therapeutically, the mean number of retrieved lymph nodes and


SLNs were 10.8 and 1.3. There was concordance between the SLN status and the status of nonsentinel lymph nodes in all except one patient, and the intraoperative pathologic diagnosis was confirmed by final pathologic examination. In conclusion, we demonstrated the safety and feasibility of endoscopic total thyroidectomy including SLNB and central compartment lymph node dissection using a gasless anterior chest approach for papillary carcinoma. Sentinel LNB may be helpful not only for assisting in the diagnosis of metastasis and avoiding unnecessary lymph node dissection, but also for reducing the risk of complications of thyroid surgery such as recurrent laryngeal nerve injury and hypoparathyroidism. Not least, gasless endoscopic thyroidectomy via a chest approach results in a better cosmetic result than conventional neck surgery, with comparable therapeutic effects. Therefore we think that this surgical technique is a valid option for selected patients with papillary carcinoma.

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