Dr.

Devby Ulfandi
Dr. Arief, Sp.B
Prof. dr. H. Muchlis Ramli, SpB(K)Onk
 THYROIDECTOMY
Conventional Open (COT) versus Endoscopic (ET)
COT leaves a conspicuous scar on the anterior
neck
ET leaves no scar on the neck and has catered for
the esthetic need of women
ET can benefit patients by providing superior
cosmetic appearance, less postoperative pain, and
a better surgical view with magnification
compared with COT
 Methods
Between March 2001 and November 2014,
224 patients underwent ET via the breast
approach and 218 patients (control group)
underwent COT in West China Hospital,
Sichuan University.
Clinicopathological characteristics and
surgical outcomes were retrospectively
compared.
 Inclusion
Thyroid nodule with a maximum diameter of less than
5 cm estimated by preoperative ultrasonography

Exclusion
Nodules greater than 5 cm in diameter;
Graves disease;
Nodules with an atypical, highly suggestive for
malignancy;
Patients with a history of prior neck surgery,
irradiation, mediastinal goiter, and severe
coagulation disorders
All the patients were evaluated preoperatively
using ultrasonography and received laboratory
examination for thyroid function, parathyroid
hormone, and serum calcium levels.
Ultrasonography-guided fine needle aspiration
biopsy (FNA) was performed in 315 of 442 patients.
All the operations were performed by one surgeon.
Permanent hypocalcemia was defined as any decrease in
laboratory calcium levels below the normal limit at 6 months
postoperatively.
Permanent recurrent laryngeal nerve (RLN) palsy was defined as
non-normalization of voice change within 6 months.
The examination of RLN function was evaluated by direct
laryngoscopy at 1 and 6 months postoperatively, respectively.
Postoperative pain and cosmetic results were analyzed using a
questionnaire (Fig. 1).
Postoperative pain ranged from 1 to 5 (1, no pain; 2, mild; 3,
moderate; 4, severe; 5, very severe).
Cosmetic results were evaluated by the patients 6 months after the
operation using a verbal response with 2 possible responses:
satisfied and dissatisfied.
Questionnaire after operation
Clinicopathologic Characteristic of patient in the 2 groups
 DISCUSSION
In modern society, more and more patients pursue
not only for the treatment of the disease, but also
for the postoperative quality of life, especially
cosmetic result.
The diameter of nodule greater than 5 cm is
considered to be an contraindication, due to a
limited space for the operation.
With the accumulation of surgical skills, ET has
been gradually extended to some selected thyroid
cancer with a low risk.
DISCUSSION
We found that ET was superior to COT with
regard to intraoperative blood loss, amount of
drainage, duration of drainage, and cosmetic
satisfaction, although the ET group had a longer
operation time.
There was no significant difference between the 2
groups with respect to hospital stay and
postoperative complications.
Many previously published studies reported that ET was
more time consuming than COT. We also observed a
similar result.
Cao et al, reported that the mean operative time of ET for
benign thyroid tumors via the breast approach was 89.9
minutes.
This difference may be attributable to the early phase of
learning curve for ET.
We believe that operative time will gradually decrease
with accumulated experience and improvement of
endoscopic apparatus.
 The invasion of ET remains controversial.
Some researchers reported that ET is more invasive than
the COT, due to an extensive dissected area from the
anterior chest to the thyroid cartilage, higher pain, and
larger amount of drainage.
Lombardi et al, reported that the patients undergoing
ET suffered less pain and took less analgesic.
Tae et al, reported that there was not significant
difference in terms of postoperative pain in the neck and
anterior chest between the ET group and the COT group.
DISCUSSION
With regard to the complications of ET, transient /
permanent RLN palsy and transient / permanent
hypocalcemia were regarded as the major complications.
Cao et al, reported that the incidence of transient /
permanent RLN palsy was 3.2% and 0% in the ET group,
respectively. Transient hypocalcemia / permanent
hypocalcemia was occurred in 1.4% and 0% of the ET
group.
Chung et al, reported an incidence of transient RLN
palsy of 2.5%and transient hypocalcemia of 17.7% after
ET. Similar results were observed in our study
 The cosmetic result is another noteworthy aspect
of ET. However, it is difficult to evaluate at present,
due to the subjective judgment of the patients.
Our results showed that the ET group was
associated with a significantly higher cosmetic
satisfaction 6 months after surgery, which were
consistent with previous studies.
Three patients (1.4%) in the ET group were
dissatisfied with their cosmetic results due to the
hypertrophic scarring.
 LIMITATIONS
First, our study was nonrandomized, retrospective trials,
which inevitably add a degree of selection bias to the
results. The patients choice of surgical procedure would
lead to patient selection bias.
Second, a relatively small number of patients were
included in our study and the follow up period was
short.
Accordingly, well-designed randomized controlled trials
with larger volume and longer follow-up are needed to
confirm important outcomes of ET for the patients with
benign thyroid nodules compared with COT.
 Conclusion
ET via breast approach with CO2 insufflation is a
feasible and safe technique for benign thyroid
nodules.
Even though ET requires a longer operative time, it
provides excellent cosmetic outcomes and similar
surgical outcomes compared with COT.
Further prospective randomized controlled trials
with longer follow-up are needed to confirm our
findings.