Video-assisted neck surgery (VANS) technique in Graves' disease

Video-assisted neck surgery (VANS) technique in Graves' disease

Yasser M Hamza,a MD; PhD; FRCS; Waleed AH Abul-Waja,a MD; PhD;

Rafik Khalil,a MD; Kazuo Shimizu,b MD

a) Department of Surgery, University of Alexandria, Egypt. b) Department of Surgery, Nippon Medical School, Japan.

Co"espondence:e-mail: hamzay3@hotmail.com

Abstract

Background: The introduction of Video assisted neck surgery (VANS) technique for treatment of thyroid diseases was established by K.Shimizu in 1998.Since that time, the indications of this procedure  are expanding  as regarding  the size of the thyroid tumors and the type of thyroid pathology.

Results: Twelve patients with small diffuse primary thyrotoxicosis underwent video-assisted thyroidectomy. The estimated thyroid weight of the study patients ranged from 18.2 to 57 with a mean of32.5 grams. Three ofthefirst seven patients had recurrent hyperthyroidism. This was due to poor visualization and subsequently inadequate excision of the thyroid lobe away from the   camera. A  modification  was   made  thereafter that  corrected this  defect.

Conclusion: Video-assisted near total thyroidectomy for Graves' disease is considered to be safe, effective. It gives excellent cosmetic results.

Introduction:

The introduction of video  assisted neck surgery (VANS) technique  for treatment of thyroid diseases was established  by Shimizu in 1998.1 VANS was first used to excise discrete thyroid nodules.ISince that time, the indications of this procedure are expanding as regarding the size of the goiter amenable for resection as well as the underlying thyroid pathology.24 Compared to the total endoscopic approach using C02 insuffiation, the video­ assisted approach without C02 insufflation has been reported more often.5

Indications  for endoscopic thyroidectomy in  various  studies include  solitary, benign thyroid nodules, follicular and oxyphilic cell tumors  and papillary micro  carcinomas.6-8

The aim of most studies apart from being cosmetically superior has been to be minimally invasive  offering  all associated advantages such as minimal  post-operative pain,  rapid recovery, and low analgesic requirement.9,10

Interms of invasiveness none of the distant sites of access prove to be truly minimally invasive  as the extent of dissection  is much

more compared to a focused, direct approach. Their popularity has however persisted and increased  for   the   sake  of   cosmesis.

VANS would be very suitable for Grave's disease which usually affects young females and is typically  associated with small  sized goiter.6 Concerns have, however, been raised regarding  the feasibility of the technique  in view of the high vascularity of the gland and its efficacy in controlling the hyperthyroidism.

Aim of the study:

The aim of the study is the assessment  of the feasibility, safety and efficiency ofVANS in the treatment of Grave's disease of thyroid gland.

Patients and methods:

Study  design: This is a prospective  non­ randomized clinical trial with informed written consent signed by all patients.

Study population: The study included 12

patients with Grave's disease presenting to the Department of Surgery  II, Nippon  Medical School, Tokyo, Japan and to the Head & Neck

& Endocrine Surgical Unit, Department  of General Surgery, Alexandria Main University Hospital, Egypt. The patients were selected following the following  inclusion  criteria:

- Thyroid lobes with maximum diameter of 55

mm.

-No history of neck surgery or neck irradiation.

- Absence of thyroiditis.

All patients underwent complete medical history and clinical examination.

Investigation  included hematological

analysis, thyroid hormone assay, ultrasound of the neck  and laryngoscopy. Detailed operative data, postoperative course and complications were collected. Cosmetic result and  patient   satisfaction were  recorded.

Statistical analysis:

All data were analyzed by using the Statistical  Package for the Social Sciences Version 13 software (SPSS Inc, Chicago, IL). Quantitative values are expressed as means± standard deviation (SD).

Results:

All patients  were females.  Age ranged

between 20 and 42 years with a mean of 28.1 years. None of the studied patients suffered

Table (1): The  operative data of the 12 patients.

from  associated  medical  conditions.

Patients had video assisted thyroidectomy

using the infraclavicular approach and gasless skin lifting  technique.ISeven patients had subtotal thyroidectomy and five had near total thyroidectomy.

There was high incidence  of recurrence among the first seven cases (317, 42.9%), due to poor visualization and subsequently inadequate excision of the thyroid lobe away from the camera. A modification was made thereafter which corrected this defect: The camera was moved to a second port on the other side while excising the corresponding lobe. No patient developed recurrent hyperthyroidism after introduction  of this modification to the technique.

Table(l) summarizes the data of the study patients. The average estimated weight of the thyroid was 32.5 grams. The average amount removed by VANS was 30.4 grams. The average estimated weight left was 2 grams. Operative time ranged from 43 to 196 minutes with a mean of 67±34.32

There was no permanent nerve injury inthe study group. Three patients suffered from transient vocal cord paralysis. No patient suffered from hypocalcemia postoperatively.