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Guest editorial: Minimal access thyroid surgery - A new dawn?

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Rehan Kazi
Rehan Kazi
Rehan Kazi
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Rakesh Katna at Bombay Hospital & Medical Research Centre
Rakesh Katna
Raghav Dwivedi at University College London Hospitals NHS Foundation Trust
Raghav Dwivedi
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Ann R Coll Surg Engl 2010; 92: 361–362 361
Thyroid surgery has evolved considerably from the times of
Billroth and Kocher due to better understanding of the sur-
gical principles, better equipment and advanced surgical
techniques. Kocher, in 1909, pioneered what is today known
as the conventional thyroidectomy. It has remained the
standard approach to the thyroid gland and is still the most
widely used technique world-wide. A recent advance is
minimal access thyroid surgery (MITS). Though the con-
cept of minimal access surgery is not new and it has been
practiced in many other surgical specialties for over two
decades now,1its acceptance in head and neck surgery
remained rather slow. Since Gagner et al.2reported an
endoscopic approach to the parathyroid glands, various
techniques have been described and popularised for thyroid
surgery as well. Shifting focus of thyroid surgery towards
less invasive techniques for better aesthetic outcomes has
resulted in the emergence of minimally invasive approach-
es for the thyroid gland/compartment. The concept of MITS
is attractive because patients are concerned not only about
the results of treating their thyroid disease, but also out-
comes such as better cosmesis, reduced hospital stay and
decreased pain.
MITS has expanded in the last decade and is being con-
sidered as an alternative to conventional thyroidectomy
simply because it reduces tissue trauma and postoperative
pain, and provides excellent cosmetic results.3Many different
techniques have been developed for MITS over a short period;
these can be broadly classified into pure endoscopic tech-
niques, video-assisted techniques and minimally invasive
open surgery. In pure endoscopic techniques, the thyroid
compartment is approached using different routes with the
help of endoscopes with or without carbon dioxide gas insuf-
flation. The lateral neck,4axillary,5anterior chest 6and breast7
approaches have all been described. All these approaches
have in common the use of a 30º endoscope. They differ only
by the site of placement of the access cannulas. This tech-
nique avoids a visible neck scar, provides excellent cosmet-
ic results and allows early return to work.
Minimally invasive video-assisted thyroidectomy
(MIVAT) is the most widely used MITS technique. MIVAT
was first introduced and popularised by Miccoli et al.8in
Italy in the late 1990s. It has been extensively used in other
parts of the world and appears to be an excellent minimal-
ly invasive approach to the thyroid. A small incision
(1.5 cm) is made in the cervical skin crease and the opera-
tion is completed using a video-endoscope, except for the
final delivery of the gland, which is removed through the
original neck incision. Another less commonly used modifi-
cation of MIVAT technique is the video-assisted neck sur-
gery where an anterior neck flap is lifted without using gas
insufflation and a tent-like working space is created.9
Minimally invasive open surgery techniques are also
known as ‘small incision thyroidectomy’ and do not require
specialised instruments like endoscopes and video assis-
tance.10 Broadly speaking these techniques are similar to
conventional thyroidectomy but differ only in the length of
the incision.
Major advantages of MITS techniques include reduced
tissue trauma, shorter hospital stay, better cosmetic results,
minimal postoperative pain, reduced cost of healthcare and,
above all, patient comfort. Video-assisted endoscopic tech-
niques in addition offer a magnified, illuminated view of the
operating field. Miccoli et al.,8who have reported the
largest series of MIVAT, noted reduced postoperative pain,
better cosmetic results and short hospitalisation stay. In
another prospective study, the authors reported significant
reduction in postoperative pain and better cosmetic results
in the MIVAT group as compared to the conventional sur-
gery group.11
The main disadvantages of MITS procedures are the
longer duration of surgery, steep learning curve and
increased cost of surgery due to equipment usage. The
reported rate of important complications (like recurrent
laryngeal nerve palsy and hypoparathyroidism) are similar
to those seen in after conventional thyroid surgery. Miccoli
et al.8,11 reported rates of recurrent nerve palsy and
GUEST EDITORIAL
Ann R Coll Surg Engl 2010; 92: 361–362
doi 10.1308/003588410X12699663903755
Minimal access thyroid surgery – a new dawn?
REHAN KAZI1, RAKESH KATNA2, RAGHAV C DWIVEDI1
1Head and Neck Unit, Royal Marsden Hospital, London, UK
2Grant Medical College, Mumbai, India
CORRESPONDENCE TO
Rehan Kazi, Head and Neck Unit, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
E: drrehankazi@gmail.com
KAZI1 KATNA DWIVEDI MINIMAL ACCESS THYROID SURGERY – A NEW DAWN?
Ann R Coll Surg Engl 2010; 92: 361–362
362
hypoparathyroidism of 1.3% and 0.3%, respectively, in their
report of MIVAT.
There is an expanding role of MITS techniques for thy-
roid malignancies especially papillary thyroid carcinoma
(PTC). Malignancies of the thyroid were not considered
suitable for an endoscopic approach until 2002, when
Miccoli et al.12 reported a series of endoscopic surgery for
PTC. The authors found no significant statistical difference
between MIVAT and conventional thyroidectomy in these
patients, both in terms of iodine (131I) uptake and circulating
thyroglobulin (Tg) levels. It appears that MITS can be an
effective alternative to conventional thyroidectomy for
selected patients with well differentiated thyroid cancers,
especially PTC.
Judicious patient selection is the most important corner-
stone for the success of any MITS technique for both benign
and malignant thyroid swellings. At present, there are no
specific criteria laid down for deciding suitability of a par-
ticular candidate for MITS; however, there appears to be a
consensus on the size of tumour (< 35 mm for benign and
< 20 mm for malignant thyroid nodule/gland). Other com-
monly agreed indications for MITS are that there should be
no previous irradiation or surgery. Low-risk papillary carci-
noma without any sub-sternal extension and extrathyroidal
spread is the only malignant thyroid disease suitable at the
moment.
As technology continues to develop and impact on surgical
techniques, it is likely that these minimally invasive
approaches will become more widely used and easier to per-
form. As of now, MITS appears to be a useful addition to con-
ventional thyroid surgery. We need more long-term follow-up
and comparative trials to validate these interesting tech-
niques. There is a need to look into the expanding indica-
tions as well as the completeness of MITS procedures, espe-
cially in cases with malignant thyroid disease.
References
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... In the era of minimally invasive treatments, minimal access thyroid surgery (MATS) is gaining increasing popularity among patients and their treating surgeons. MATS, which is performed with energy-based devices, can be divided into three main categories: [1] nonendoscopic mini-incision thyroid surgery, [2] partly endoscopic surgery, and [3] purely endoscopic surgery [1,2]. By definition this latter is fully performed in endoscopy, with or without CO 2 insufflation, and the thyroid compartment is usually approached indirectly via an extracervical access. ...
... The thyroid compartment can be approached through different routes such as the axilla, the axilla and breast combined, or recently, through the oral vestibule [3,4]. These are considered remote-access procedures that allow thyroid operations to be performed free of a neck scar [1,3]. ...
... The thyroid compartment can be approached through different routes such as the axilla, the axilla and breast combined, or recently, through the oral vestibule [3,4]. These are considered remote-access procedures that allow thyroid operations to be performed free of a neck scar [1,3]. ...
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... In the era of minimally invasive treatments, minimal access thyroid surgery (MATS) is gaining increasing popularity among patients and their treating surgeons. MATS, which is performed with energy-based devices, can be divided into three main categories: [1] nonendoscopic mini-incision thyroid surgery, [2] partly endoscopic surgery, and [3] purely endoscopic surgery [1,2]. By definition this latter is fully performed in endoscopy, with or without CO 2 insufflation, and the thyroid compartment is usually approached indirectly via an extracervical access. ...
... The thyroid compartment can be approached through different routes such as the axilla, the axilla and breast combined, or recently, through the oral vestibule [3,4]. These are considered remote-access procedures that allow thyroid operations to be performed free of a neck scar [1,3]. ...
... The thyroid compartment can be approached through different routes such as the axilla, the axilla and breast combined, or recently, through the oral vestibule [3,4]. These are considered remote-access procedures that allow thyroid operations to be performed free of a neck scar [1,3]. ...
First report of benign track seeding after robot-assisted transaxillary thyroid surgery
Article
  • Oct 2020
Background: Robot-assisted transaxillary thyroidectomy is a well-established remote-access thyroid procedure that has been demonstrated to be as safe and effective as its time-honored conventional clamp-and-tie counterpart. However, it has been incriminated for a set of unprecedented complications that surgeons need to be aware of and deal with appropriately. Patient findings: The patient is a young woman who underwent robot-assisted thyroid lobectomy for a sizeable nodule that was reported as benign after fine-needle aspiration cytology. She presented 3 years later with subcutaneous nodules along the surgical track that were found to represent seeding of benign thyroid tissue. This is the first report of benign thyroid tissue seeding after a gasless transaxillary procedure. Summary: Seeding along the surgical track is a potential complication of gasless remote-access thyroid surgery, even in case of benign disease, that surgeons need to be acquainted with. Conclusions: Surgeons should be aware of the potential for benign seeding after remote-access thyroid procedures. Accordingly, adequate precautions should be taken, patients should be counseled in this regard, and alternative medical strategies to control local seeding of thyroid tissue could be suggested.
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... Thyroid surgery is the most common procedure done in the neck. Kocher in 1909, pioneered what is today known as the conventional thyroidectomy [1]. The goal for the surgeon is to remove the whole gland or its specific part, preserving inferior and superior laryngeal nerves and parathyroid glands, while achieving safe hemostasis mainly by ligating superior and inferior thyroid arteries [2]. ...
... Though there are no special criteria for MINET, volume of the gland and extent of its fixation to the surrounding structures are important factors to be considered. Minimal invasive thyroid surgery is usually done through a direct lateral mini-incision approach or a central mini-incision approach [1]. We report our experience using a mini -incision over the upper pole of thyroid swelling .and ...
... Thyroid surgery has evolved considerably from the times of Billroth and Kocher due to better understanding of the surgical principles, better equipment and advanced surgical techniques. Kocher, in 1909, pioneered what is today known as the conventional thyroidectomy [1]. It has remained the standard approach to the thyroid gland and is still the most widely used technique world-wide. ...
Minimally Invasive Hemithyroidectomy Using a Mini Incision over the Upper Pole of Thyroid Swelling
Article
Full-text available
  • May 2015
Minimally invasive thyroid surgery, using various techniques including endoscopic and video-assisted have been reported. Thyroid surgery using a mini-incision over the upper pole of the thyroid, as a new technique is presented here. Methods: The study group comprised of 52 patients undergoing minimally invasive thyroid surgery (MITS) by open method during the period May 2005-May 2013. Data regarding patient demographics, indication for surgery, operation performed, nodule size, final pathology, and complications were recorded. The operation was carried out through a 1.5-2-cm incision placed directly over the upper pole of the swelling, and deepening the incision to visualize the superior pedicle. After ligating the superior pedicle, the finger is passed over the gland and separated from all sides. Then the thyroid is pulled up and the inferior pedicle accessed and ligated. Any bleeding points were taken care of and the wound was closed without drain. Results: Fifty two patients underwent MITS, 38 women and fourteen men. All the patients underwent hemi -thyroidectomy. The average measured incision size was 2. cm at the end of the procedure. The average nodule size was 3.2 cm, and the average thyroid lobe resected measured 4.5 cm in maximal length. Final pathology revealed follicular adenoma in51 patients and one thyroid cancer (follicular). There was one wound infection and one patient had temporary recurrent laryngeal nerve neurapraxia. Conclusion: Minimally invasive thyroid surgery with a minimal incision over the upper pole of thyroid swelling as an alternative to open thyroid surgery, using a standard cervical collar incision, is safe and feasible.
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... The aesthetic outcome is Suture of Subcutaneous Tissue and Skin particularly relevant in thyroid surgery since patients are mostly women and young adults and since the incision is in a highly sensitive and in visible anatomic location. Cosmetic concern about the final scar appearance contributed to motivate the development of minimally invasive approaches for thyroid surgery and parathyroid surgery over the last decade [2][3][4][5][6][7][8][9][10][11][12][13]. In addition to MIT, methods of skin closure play a role in the cosmetic outcome of surgery. ...
... Development of minimally invasive approaches for thyroid surgery and parathyroid surgery over the last decade have been motivated by the cosmetic concern about the final appearance of the scar. [1][2][3]. Minimally invasive thyroid surgery techniques (MIT) are different but all share the same goals: reduction of tissue trauma, early hospital discharge, and better neck wound cosmetic appearance, while maintaining the same surgical outcome as traditional thyroidectomy [4]. ...
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... Recently, minimally invasive approaches to thyroidectomy have been increasingly adopted. These include minimal-incision open thyroidectomy, endoscopic, video-assisted, and robot-assisted techniques [16]. Compared to traditional open thyroid surgery, these approaches rely more on visual discrimination through the naked eye or monitor because it is difficult to palpate and magnify the tissue and nerves through surgical loupe due to the small incision [17]. ...
Intraoperative Nerve Monitoring in Thyroid Surgery: A Comprehensive Review of Technical Principles, Anesthetic Considerations, and Clinical Applications
Article
Full-text available
  • May 2025
Background: Intraoperative nerve monitoring (IONM) is increasingly recognized as an essential technique in thyroid surgery to preserve the integrity of the recurrent laryngeal nerve (RLN) and prevent postoperative complications. Although widely adopted, several technical and anesthetic factors can significantly affect the reliability and interpretation of electromyographic (EMG) signals. Methods: This narrative review summarizes the principles and methodologies of IONM in thyroid surgery, focusing on the mechanisms of RLN injury, the clinical benefits of IONM, and its limitations. Particular emphasis is placed on the anesthesiologic considerations, including the effects of neuromuscular blocking agents and anesthetic maintenance methods for EMG signal quality. Recent advances in alternative IONM techniques are also discussed. Results: IONM facilitates early detection of RLN injury and improves surgical outcomes. However, signal loss and technical errors occur in up to 23% of cases. Appropriate anesthetic management, such as the judicious use of neuromuscular blocking agents and the use of reversal agents like sugammadex, can significantly improve IONM accuracy. Alternative approaches, such as transcutaneous or thyroid cartilage electrode-based monitoring, show promise in overcoming current limitations. Conclusions: IONM is a valuable tool in modern thyroid surgery, aiding in the prevention of RLN injury. Anesthesiologists play a crucial role in optimizing IONM quality by managing factors that affect EMG signals. Ongoing research into novel monitoring techniques is expected to further enhance patient safety and surgical precision.
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... Non-endoscopic mini-incision thyroidectomy is identical to conventional thyroidectomy in all of its executional steps; however, it is performed through a smaller incision. Purely endoscopic procedures are completed totally endoscopically, with or without gas insufflation, via different routes: the axilla, breast, lateral neck, anterior chest and both the breast and axilla combined (1). Most of these procedures could be considered remote-access procedures that offer patients a thyroid surgery free of a neck scar. ...
Minimally Invasive Video-Assisted Thyroidectomy (MIVAT) in the Era of Minimal Access Thyroid Surgery
Article
Full-text available
  • Feb 2017
Background. In the era of minimal access thyroid surgery, the terms minimal access and minimally invasive are often used interchangeably and in most instances this is far from being accurate. The aim of this article is to examine the characteristics and potential of one of the first minimal access thyroid procedures described; minimally invasive video-assisted thyroidectomy (MIVAT). Methods. The purpose of this article was served by almost two decades of experience with the procedure at the authors’ center, and in light of the current available literature by conducting a PubMed search limited to articles originally written in English language between the years 1997 and 2016. The search was limited by using the terms: minimally invasive thyroid surgery, video-assisted, endoscopic, and robotic thyroidectomy. The procedure’s design, radicality and safety, learning curve, cost, advantages and disadvantages were addressed. MIVAT’s potential as a surgical tool for thyroid pathology was also addressed by evaluating its indications, contraindications, and limitations. Results. MIVAT is a gasless hybrid procedure that is comparable to conventional thyroidectomy (CT) in terms of radicality and safety, with the added advantage of reduced early postoperative voice and swallowing symptoms. MIVAT has a relatively rapid learning curve with an additional advantage over other minimal access procedures; the ability of being adopted by the low-volume surgeon at a cost and time comparable to CT, but with improved patient satisfaction. Furthermore, it is non-inferior to procedures free of a neck scar in terms of patient satisfaction. MIVAT’s main drawback is that it is limited by its strict selection criteria. It is a viable treatment option for all types of thyroid pathologies. However, its role in therapeutic neck dissection remains to be validated. Conclusion. MIVAT is a safe and effective procedure whose name truly describes its minimally invasive nature. It seems that in the era of innovative technologies and scarless-in-the neck thyroid surgery, MIVAT is here to stay.
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Surgery of the Thyroid Glands
Chapter
  • Feb 2016
In the fetus, at 3–4 weeks of gestation, the thyroid gland appears as an epithelial proliferation in the floor of the pharynx at the base of the tongue between the tuberculum impar and the copula linguae, at a point later indicated by the foramen cecum. The thyroid then descends in front of the pharyngeal gut as a bilobed diverticulum through the thyroglossal duct. Over the next few weeks, it migrates to the base of the neck. During migration, the thyroid remains connected to the tongue by a narrow canal, the thyroglossal duct.
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Benign thyroid lesions: Small incision hemithyroidectomy is a cosmetic alternative
Article
  • Jan 2014
Background: Hemithyrodectomy indicated for benign thyroid lesions. For thyroidectomy a collar incision is needed, which is extending from one sternocledomastoid to other side. We restricts lesion on contralertal side so that it results in smaller incision Study design: A prospective case study Methods: this study was conducted from June 2012 to June 2013, 17 patients admitted to our Center underwent surgical treatment for thyroidnodule with smaller incision. Results: Thyroid lobectomy was carried out in all 17 of patients with incision size 4.5 cm±1.99 (±2SD), while the surgical the mean surgical duration is 2.53±.45 (±2SD). Conclusions: Small incision thyroid Surgery should be advocated for the treatment of benign thyroid lesions, which results in better cosmetic outcome.
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Endoscopic thyroidectomy
Article
  • Jul 1999
Background: Endoscopic parathyroidectomy is a standard option for our patients with solitary adenoma. The magnified views of detailed neck anatomy prompted us to explore further territories of neck surgery under endoscopic guide. We performed our first successful endoscopic hemithyroidectomy in March 1997. Methods: Surgical emphysema is induced at the subplatysmal plane by low pressure CO2 insufflation. Dissection is analogous to retroperitoneal procedures. There are limited indications for the technically demanding operation, which leads to increased operation time and expenditure. At present, we are gathering experience from selected patients after full explanation of the procedure. Control trials will be carried after the detail technical aspects are defined and custom-made instruments are refined. Results: In 28 months, my team operated on 9 patients with 3 conversions to open surgery due to difficulties in dissection. There were no surgical complications like nerve damage or hemorrhage. All patients underwent a standard hemithyroidectomy with intact specimen retrieved. Conclusions: Endoscopic neck procedures are technically feasible and wait for further evaluation and refinements to establish its practicability.
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Minimally invasive thyroidectomy
Article
  • Feb 2009
  • Cas Lek Cesk
The past several decades have seen rapid developments in videolaparoscopic surgery. Minimally invasive methods can now be used even for endocrine surgeries. Minimally invasive thyroid procedures can be broken down into three groups: endoscopic access from a small lateral incision in the neck, video assisted methods using a central incision-MIVAT and a range of endoscopic methods. Indications for minimally invasive procedures are precisely defined and, MIVAT consequently represents a safe method that involve minimal tissue trauma, a short period of hospitalisation and that offers significant cosmetic benefits for the patient.
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Scarless Endoscopic Thyroidectomy: Breast Approach for Better Cosmesis
Article
  • Mar 2000
  • SURG LAPARO ENDO PER
An original technique for performing endoscopic thyroidectomy using a breast approach to avoid an operative scar in the neck was developed. The subcutaneous space in the breast area and the subplatysmal space in the neck were bluntly dissected through a 15-mm incision between the nipples, and CO2 was insufflated at 6 mm Hg to create the operative space. Three trocars were inserted at the breast, and dissection of the thyroid and division of the thyroid vessels and parenchyma were performed endoscopically using an ultrasonically activated scalpel. Four hemithyroidectomies and one partial resection of the thyroid for five female patients with thyroid adenomas 5 to 7 cm in diameter were successfully performed using this procedure. There were no conversions to open surgery or complications. No scars were apparent in the neck, and all patients were fully satisfied with the cosmetic results. Endoscopic thyroidectomy using a breast approach and low-pressure subcutaneous CO2 insufflation is a feasible and safe procedure, which results in satisfactory cosmetic results.
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Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: A prospective randomized study
Article
  • Feb 2002
  • SURGERY
Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated. Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated. MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 +/- 24 minutes for MIVAT and 45 +/- 15 minutes for CT (P = .001). Postoperative course was significantly less painful in the patients who underwent MIVAT (P = .003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT (P = .003 and P = .01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies. Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages.
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