Unusual approaches to Consultant thyroidectomy Prescient Surgical - - PowerPoint PPT Presentation

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Unusual approaches to Consultant thyroidectomy Prescient Surgical - - PowerPoint PPT Presentation

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Disclosures UCSF School Department of Section of of Medicine Surgery Endocrine Surgery Intuitive Surgical Research grant support Grand Rounds Unusual approaches to Consultant thyroidectomy Prescient Surgical

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 1

UCSF School

  • f Medicine

Department of Surgery Section of Endocrine Surgery

Insoo Suh, MD Assistant Professor, Endocrine Surgery Section UCSF Department of Surgery Staff Surgeon, Endocrine & General Surgery San Francisco VA Medical Center 3/6/2015

Unusual approaches to thyroidectomy

Disclosures

Intuitive Surgical

  • Research grant support

Grand Rounds

  • Consultant

Prescient Surgical

  • Shareholder, consultant

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Agenda

History Definitions How? Why?

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First make it… safe Then make it… effective Then make it… smaller “Surgical innovation” is often synonymized to “minimally invasive”

History

4

The phases of surgical innovation – an oversimplified model

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 2

History

Minimize invasiveness of dissection Clinical benefits:

  • Pain
  • Recovery/length of stay
  • Complications
  • Mortality
  • Cosmesis

The benefits of “smaller” – the underlying idea

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Open chole Lap chole

3/6/2015

History

Surgical innovation = Smaller incision: The minimally-invasive thyroidectomy edition

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Time “Innovation”

3/6/2015 Unusual approaches to thyroidectomy “Historical” open thyroidectomy 10-15 cm “Standard” open thyroidectomy 6-12 cm Mini-incision open thyroidectomy 2.5-4 cm Minimally invasive video-assisted thyroidectomy (MIVAT) 1.5-3 cm Endoscopic lateral thyroidectomy <1 cm x 3

History

First make it… safe Then make it… effective Then make it… smaller Now make it… “disappear”

  • How?
  • Why?

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The “eras” of surgical innovation – an oversimplified model

Definitions

Things in common:

  • Location of incision - away from the anterior neck

‒ Below vs above the neck

  • Use of minimally-invasive technology

‒ Endoscopic vs robotic

  • Addition of significant extracervical dissection and tunneling

‒ Gas insufflation vs gasless retraction ‒ “Remote-access thyroidectomy” What constitutes an “unusual” approach to thyroidectomy?

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 3

“Below-the-neck” approaches

Infra-clavicular (chest wall)

  • Shimizu et al (1998)

‒ Unilateral lobectomy ‒ Two main infraclavicular incisions and small cervical incisions ‒ Endoscopic ‒ Gasless retraction Use of Kirschner wires

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“Below-the-neck” approaches

Infra-clavicular (chest wall)

  • Shimizu et al (1998)

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“Below-the-neck” approaches

Transaxillary

  • Ikeda and Takami (2000)

‒ Unilateral lobectomy ‒ 3-6 cm axillary incision ‒ 3-4 endoscopic instruments placed in incision ‒ Plane of dissection above pectoralis and

  • ver clavicle

‒ Gas insufflation

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“Below-the-neck” approaches

Transaxillary

  • Options

‒ Endoscopic vs robotic ‒ Gas vs gasless

  • Robotic gasless transaxillary

thyroidectomy probably the most well-known in US ‒ First described by Chung et al (2007) ‒ Described in US by Landry et al (2010)

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 4

“Below-the-neck” approaches

Transaxillary

  • Options

‒ Endoscopic vs robotic ‒ Gas vs gasless

  • Robotic gasless transaxillary

thyroidectomy probably the most well-known in US ‒ First described by Chung et al (2007) ‒ Described in US by Landry et al (2010)

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“Below-the-neck” approaches

Breast

  • Ohgami et al (2000)

‒ Also has an anterior chest incision Breast-axillary hybrid

  • Axillary-Bilateral Breast

Approach (ABBA)

  • Bilateral-Axillo-Breast

Approach (BABA)

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“Below-the-neck” approaches

Breast Breast-axillary hybrid

  • Axillary-Bilateral Breast

Approach (ABBA) ‒ Shimazu et al (2002)

  • Bilateral-Axillo-Breast

Approach (BABA)

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“Below-the-neck” approaches

Breast Breast-axillary hybrid

  • Axillary-Bilateral Breast

Approach (ABBA)

  • Bilateral-Axillo-Breast

Approach (BABA) ‒ Choe et al (2007) ‒ Ability to perform bilateral dissection ‒ No anterior chest scar

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 5

“Above-the-neck” approaches

Retroauricular

  • Pioneered by Terris et al

(2011)

  • Facelift-style incision

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“Above-the-neck” approaches

Transoral (NOTES, TORS)

  • First successful

endoscopic transoral thyroidectomy by Wilhelm & Metzig (2010)

  • Incisions either…

‒ Sublingual (floor of mouth) ‒ Vestibulum with dissection over mandible Nakajo et al (2013)

  • Largely still experimental

(except in China)

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Why?

Safer? More effective? Less invasive/morbid? Improved cosmesis? Incorporates new technology?

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?

  • Patient selection very important
  • Contraindicated in:
  • Larger glands
  • Significant substernal extension
  • Cancers with preoperatively suspected

difficulties related to size, lymph node mets, local invasion

  • Scarring in the area of dissection (e.g.

from prior surgery/radiation)

Why?

Safer? More effective? Less invasive/morbid? Improved cosmesis? Incorporates new technology?

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? ?

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 6

Why?

Safer? More effective? Less invasive/morbid? Improved cosmesis? Incorporates new technology?

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? ? ✕

  • By definition, remote-access

approaches are more invasive

  • Drains often necessary
  • Longer operative times
  • Longer LOS
  • Other complications:
  • Brachial plexus injury
  • Trachial/esophageal

injury

  • Paresthesias

Why?

Safer? More effective? Less invasive/morbid? Improved cosmesis? Incorporates new technology?

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✓

? ? ✕

Why?

Safer? More effective? Less invasive/morbid? Improved cosmesis? Incorporates new technology?

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✓

? ? ✕

✓

Why?

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Culture and aesthetics: Powerful drivers of behavior

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 3/7/2015 7

Conclusions: “Neat…” but at what price?

Cost considerations

  • Robot can add up to 1.5-8x the cost (Cabot et al 2012, Yoo et

al 2012) Ethical considerations

  • Individual implications: What is the absence of scar worth?
  • Societal implications: Should society pay for the extra cost?

Should surgeons be expected to train more for this?

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