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Rare keyhole thyroid surgery with no scars

The surgeon said the endoscopic thyroidectomy, or the minimally invasive technique, gives excellent cosmetic outcome if done by an axillary approach.

A visiting specialist surgeon has performed a rare keyhole surgery to remove entire cancerous thyroid from an expatriate patient, saving her the stigma of unsightly scars that a normal operation would have left around the neck.

The endoscopic thyroid surgery was performed by Dr R Padmakumar, a specialist surgeon at International Modern Hospital, Dubai, on a 40-year-old woman professional who had developed a disease and nodules affecting both sides of her thyroid.

As an ultrasound scan showed features suspicious of cancer, the doctor opted for surgical removal of the thyroid. She underwent a keyhole surgery through tiny cuts in the armpit and the entire thyroid was removed successfully.

Dr Padmakumar said that generally, the surgical solution available in most places across the globe is open thyroidectomy which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsightly scar which is not acceptable to patients, especially women.

“Working patients carry a stigma after any thyroid surgery as visible scars proclaim to the world they had undergone a procedure. My first patient in Dubai was concerned that a scar around the neck could make her redundant,” Dr Padmakumar told Khaleej Times on the phone from India.

He said endoscopic thyroid surgery, done only at a handful of hospitals in the world, is a boon for working professionals.

He says the feedback from insurance companies is that it’s so rare that they don’t even have a coding for it.

The surgeon said the endoscopic thyroidectomy, or the minimally invasive technique, gives excellent cosmetic outcome if done by an axillary approach. Compared to the sternal and breast approach, the axillary endoscopic approach produces a better surgical outcome as far as thyroid nodule management is considered, he added.

How it is done

Dr Padmakumar explained that endoscopic thyroidectomy by axillary approach involves the following steps — a 10mm trocar placement in the axilla towards the neck for the telescope, which initially helps in creating the plane and visualisation of structures with magnification, precision and clarity.

Two 5mm trocars are introduced into the dissected space, which are used as working ports. “We use a less heat generating energy source — the harmonic scalpel instead of cautery — for tissue dissection,” he said.

Once space is created in the neck, the sternomastoids and strap muscles get exposed. “We can open the investing layer in midline and reach the thyroid gland. The gland is mobilised by blunt dissection and vital structures identified.

The recurrent laryngeal nerve (important for respiration) the superior laryngeal nerve (for voice) and parathyroids (for calcium metabolism) with their blood supply can thus be preserved. The blood vessels are divided and gland detached from trachea. A specimen bag is used to place the thyroid and removed by dilating the 10mm trocar,” Dr Padmakumar explained, adding that for a total thyroidectomy, one will have to put additional trocars on the opposite side and repeat the same steps.

The investing layer is then sutured back, a drain placed and the trocar sites closed. Patients are only required to stay in the hospital for 24 hours and can resume normal activities in a few days as they will have less wound-related problem compared to the open surgery group, the surgeon said.

Dr Padmakumar rejected the myth that endoscopic surgery is an option for thyroid swellings of less than 4cm size.

He said swellings of even 12-15 cm can be tackled very successfully through this method, provided the surgeon has the technical skill and experience both in laparoscopic and thyroid surgeries.

An insurance professional, the second patient to undergo the operation here, told Khaleej Times she is extremely happy with the procedure done by Dr Padmakumar as it left no scarring around her neck and she could stay on in her career.

She said the specialist surgeon’s experience back home gave her immense faith in him despite the concern that her goitre was so big and whether he will be able to remove it through the keyhole procedure. “Luckily, the six-hour surgery went well and I am much better now,” she said.

Dr Padmakumar said while the surgery costs around Rs100,000 in India, in places like Dubai it costs 20-30 per cent more than the average charge of Dh30,000 which insurance companies sanction.

A sernior consultant surgeon and medical director of Sunrise Hospital, Cochin, Dr Padmakumar is also vice-president, Indian Hernia Society; founder member, Obesity and Metabolic Surgery Society Of India; founder member, Association of Minimal Access Surgeons of India; and International Faculty of IASGO on Hernia and Diabetic Surgery.

suresh@khaleejtimes.com