Minimally invasive approach to removing diseased thyroids

An incision about half the length used for traditional surgery works just as well in removing diseased thyroids, researchers have found.

This minimally invasive approach is safe, likely speeds wound healing and has a superior cosmetic result, according to findings published in the June issue of Laryngoscope.

The study looked at 44 patients with cancerous or benign thyroid disease who had surgery between September 2003 and May 2004 at Medical College of Georgia Medical Center or the Veterans Affairs Medical Center in Augusta.

"This is a very straightforward approach in skilled hands that allows us to use smaller incisions while still safely identifying important structures in the area, which are the nerves to the voice box and the parathyroid glands," says Dr. David J. Terris, Porubsky Professor and chair of the MCG Department of Otolaryngology - Head and Neck Surgery and lead author on the study.

This approach incorporates various techniques to reduce the typical incision size across the base of the neck – from about three to four inches to one to two inches – while still enabling removal of all or part of the peach-sized gland that controls metabolism. Growths on this gland can cause jitters and weight loss.

"We use retractors to get exposure and use telescopes and other laparoscopic instruments that can fit through a small incision then we work off the video screen," says Dr. Terris. "I send many patients home the day of surgery because it's so much less invasive."

To access the thyroid, most otolaryngologists make a horizontal incision at the base of neck, called a transverse cervical collar incision, move the muscles and dissect out the thyroid. This approach remains the best option for some patients who have had previous surgery or have an extremely enlarged thyroid.

But most patients – 65 percent of the 44 patients in the study – likely can benefit from a smaller, more direct approach, Dr. Terris says. He notes that working through the smaller space increases surgery time about 20-30 percent, but that has not been a deterrent for his patients.

The minimally invasive approach includes a smaller incision, ligating blood vessels as needed, then cutting through the strap muscles – called the Sofferman technique – to directly access the thyroid. Surgeons use tiny video cameras and endoscopes to work through the incision. Afterward, the strap muscles are repaired and the incision closed with medical-grade glue. Reduced tissue trauma means less chance of postoperative drainage from the site. Patients may go home the same day or spend one night in the hospital compared to two to three days with the older technique.

None of the patients selected for the minimally invasive approach had to be converted to conventional thyroidectomy. One of the minimally invasive patients developed a mildly thick scar that responded to treatment.

"It works great," says Dr. Terris. "It's really revolutionized how we manage these patients. The biggest thing is that we are doing this typically on young women. They tend to care the most about what their incision is going to look like." Women are more likely than men to develop nodules and thyroid cancer; 31 of the 44 study patients were women, Dr. Terris says.

That reality helped inspire his pursuit of less invasive options.

"This approach is evolving but is an appropriate addition to the practice of the modern endocrine surgeon," Dr. Terris and his colleagues write.