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 • Shareholder, consultant 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 2 Unusual approaches to thyroidectomy 3/6/2015 Agenda History The phases of surgical innovation – an oversimplified model � History � First make it… safe � Definitions � Then make it… effective � How? � Then make it… smaller � Why? � “Surgical innovation” is often synonymized to “minimally invasive” 3 Unusual approaches to thyroidectomy 3/6/2015 4 Unusual approaches to thyroidectomy 3/6/2015 1 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
History History Surgical innovation = Smaller incision: The benefits of “smaller” – the underlying idea The minimally-invasive thyroidectomy edition � Minimize invasiveness of Open chole Lap chole Endoscopic lateral Mini-incision open dissection thyroidectomy thyroidectomy <1 cm x 3 Minimally invasive 2.5-4 cm video-assisted � Clinical benefits: thyroidectomy (MIVAT) 1.5-3 cm • Pain • Recovery/length of stay • Complications “Standard” open “Innovation” thyroidectomy 6-12 cm • Mortality “Historical” open thyroidectomy • Cosmesis 10-15 cm Time 5 Unusual approaches to thyroidectomy 3/6/2015 6 Unusual approaches to thyroidectomy 3/6/2015 History Definitions The “eras” of surgical innovation – an oversimplified model What constitutes an “unusual” approach to thyroidectomy? � First make it… safe � Things in common: � Then make it… effective • Location of incision - away from the anterior neck � Then make it… smaller ‒ Below vs above the neck � Now make it… “disappear” • Use of minimally-invasive technology • How? ‒ Endoscopic vs robotic • Why? • Addition of significant extracervical dissection and tunneling ‒ Gas insufflation vs gasless retraction ‒ “Remote-access thyroidectomy” 7 Unusual approaches to thyroidectomy 3/6/2015 8 Unusual approaches to thyroidectomy 3/6/2015 2 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
“Below-the-neck” approaches “Below-the-neck” approaches � Infra-clavicular (chest � Infra-clavicular (chest wall) wall) • Shimizu et al (1998) • Shimizu et al (1998) ‒ Unilateral lobectomy ‒ Two main infraclavicular incisions and small cervical incisions ‒ Endoscopic ‒ Gasless retraction � Use of Kirschner wires 9 Unusual approaches to thyroidectomy 3/6/2015 10 Unusual approaches to thyroidectomy 3/6/2015 “Below-the-neck” approaches “Below-the-neck” approaches � Transaxillary � Transaxillary • Options • Ikeda and Takami (2000) ‒ Endoscopic vs robotic ‒ Unilateral lobectomy ‒ Gas vs gasless ‒ 3-6 cm axillary incision • Robotic gasless transaxillary ‒ 3-4 endoscopic thyroidectomy probably the instruments placed in most well-known in US incision ‒ First described by Chung et ‒ Plane of dissection al (2007) above pectoralis and over clavicle ‒ Described in US by Landry et al (2010) ‒ Gas insufflation 11 Unusual approaches to thyroidectomy 3/6/2015 12 Unusual approaches to thyroidectomy 3/6/2015 3 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
“Below-the-neck” approaches “Below-the-neck” approaches � Transaxillary � Breast • Options • Ohgami et al (2000) ‒ Endoscopic vs robotic ‒ Also has an anterior chest incision ‒ Gas vs gasless � Breast-axillary hybrid • Robotic gasless transaxillary thyroidectomy probably the • Axillary-Bilateral Breast most well-known in US Approach (ABBA) ‒ First described by Chung et • Bilateral-Axillo-Breast al (2007) Approach (BABA) ‒ Described in US by Landry et al (2010) 13 Unusual approaches to thyroidectomy 3/6/2015 14 Unusual approaches to thyroidectomy 3/6/2015 “Below-the-neck” approaches “Below-the-neck” approaches � Breast � Breast � Breast-axillary hybrid � Breast-axillary hybrid • Axillary-Bilateral Breast • Axillary-Bilateral Breast Approach (ABBA) Approach (ABBA) ‒ Shimazu et al (2002) • Bilateral-Axillo-Breast Approach (BABA) • Bilateral-Axillo-Breast Approach (BABA) ‒ Choe et al (2007) ‒ Ability to perform bilateral dissection ‒ No anterior chest scar 15 Unusual approaches to thyroidectomy 3/6/2015 16 Unusual approaches to thyroidectomy 3/6/2015 4 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
“Above-the-neck” approaches “Above-the-neck” approaches � Retroauricular � Transoral (NOTES, TORS) • First successful • Pioneered by Terris et al endoscopic transoral (2011) thyroidectomy by Wilhelm & Metzig (2010) • Facelift-style incision • Incisions either… ‒ Sublingual (floor of mouth) ‒ Vestibulum with dissection over mandible � Nakajo et al (2013) • Largely still experimental (except in China) 17 Unusual approaches to thyroidectomy 3/6/2015 18 Unusual approaches to thyroidectomy 3/6/2015 Why? Why? ? ? � Safer? � Safer? ? � More effective? � More effective? � Less invasive/morbid? � Less invasive/morbid? � Improved cosmesis? � Improved cosmesis? • Patient selection very important � Incorporates new technology? � Incorporates new technology? • 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) 19 Unusual approaches to thyroidectomy 3/6/2015 20 Unusual approaches to thyroidectomy 3/6/2015 5 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Why? Why? ? • By definition, remote-access ? � Safer? � Safer? ✕ ✕ ? ? � More effective? approaches are more invasive � More effective? ✓ • Drains often necessary � Less invasive/morbid? � Less invasive/morbid? • Longer operative times � Improved cosmesis? � Improved cosmesis? • Longer LOS • Other complications: � Incorporates new technology? � Incorporates new technology? • Brachial plexus injury • Trachial/esophageal injury • Paresthesias 21 Unusual approaches to thyroidectomy 3/6/2015 22 Unusual approaches to thyroidectomy 3/6/2015 Why? Why? Culture and aesthetics: ? � Safer? Powerful drivers of behavior ✕ ? ✓ � More effective? ✓ � Less invasive/morbid? � Improved cosmesis? � Incorporates new technology? 23 Unusual approaches to thyroidectomy 3/6/2015 24 Unusual approaches to thyroidectomy 3/6/2015 6 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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? 25 Unusual approaches to thyroidectomy 3/6/2015 7 3/7/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Recommend
More recommend
