Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon

Abstract

Objective

The objective of the study was to describe our experience with modifications of the Miccoli minimally invasive thyroidectomy.

Design

Planned analysis of a prospectively maintained database was undertaken after Institutional Review Board approval.

Methods

Demographic and surgical data were obtained and analyzed with attention to age, sex, pathology, incision lengths, and complications.

Results

From a single-surgeon series of 785 consecutive thyroidectomies, 178 patients were identified who underwent an endoscopic minimally invasive thyroidectomy. A series of modifications of the classic Miccoli technique evolved over a period of 4 years and include presurgical factors (patient marking in holding area, intubation with laryngeal EMG tube using videolaryngoscope, rotation of operating table away from anesthesia), intraoperative principles (use of operative loupes, slave monitor, laryngeal nerve monitoring, and novel instrumentation; identification of the medial cleft and ligation of superior pedicle bundle using ultrasonic technology; avoidance of clips), and postoperative techniques (deep extubation, laryngeal endoscopy, outpatient management, and oral calcium supplementation).

Conclusions

A minimally invasive endoscopic thyroidectomy is possible even in a practice with moderate surgical volumes by using several techniques that facilitate the performance of this procedure. A high success rate and low complication rate can be achieved, resulting in improved patient satisfaction.

Introduction

After nearly a hundred years of performing a thyroidectomy essentially the way it was described by Theodore Kocher [1] in the 19th century, the past decade has seen dramatic changes in modern surgical technique [2], [3]. Much of this change has been technologically driven, with the introduction of high-resolution endoscopy [4], [5]. advanced energy devices [6], [7], and the evolution of robust laryngeal nerve monitoring [8], [9]. In addition to a faster and probably safer thyroidectomy, the possibility of accomplishing this procedure through a smaller incision has been widely recognized and increasingly embraced [10], [11], [12].

Several teams of surgeons around the world led the search for a less invasive and more cosmetically appealing approach to a thyroidectomy [13], [14], [15]. Miccoli and his colleagues [16] in Pisa deserve the credit for advancing the most viable approach, which has ultimately been incorporated by a number of high-volume practices [17]. The essential features of this approach include a small cervical incision and a technique that is gasless and relies on conventional retraction, all of which are aided by the magnification afforded with a 5-mm angled laparoscope. The principal advantages are improved visualization, superior cosmetic outcome, and increased patient satisfaction. A downstream benefit that has been derived is the possibility of true outpatient surgery [18], particularly when combined with laryngeal nerve monitoring [9].

Because of the unusual nature of the endocrine practice in Pisa (surgical volumes exceeding 3000 cases per year), widespread application of this technique has been somewhat limited and, for practical purposes, has been confined to high-volume surgeons who have plentiful skilled assistants. We have introduced a number of modifications to this technique that serve to facilitate performance of the procedure and thereby potentially broaden its application beyond high-volume centers. These modifications are composed of preoperative, intraoperative, and postoperative interventions. Although these are particularly helpful for endoscopic and minimally invasive surgery, most of them also serve to make conventional thyroid surgery easier and more straightforward.