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ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 128-133

Comparative study on endoscopic versus open thyroidectomy


1 Department of General Surgery, Rangaraya Medical College, Kakinada, Andhra Pradesh, India
2 Department of Medical Student, Rangaraya Medical College, Kakinada, Andhra Pradesh, India

Date of Submission06-Oct-2020
Date of Acceptance10-Dec-2020
Date of Web Publication20-Jan-2021

Correspondence Address:
Mr. Tarun Kumar Suvvari
Rangaraya Medical College, Kakinada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/trp.trp_66_20

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  Abstract 


Background: In recent times, the demand for endoscopic techniques for thyroid tumors has been increased, and the aim of this study is to compare conventional open thyroidectomy (ConT) with endoscopic thyroidectomy (ET) in terms of duration of the procedure, blood loss during surgery, postoperative discomfort or pain, antibiotics, and analgesics requirement and other associated factors.
Materials and Methods: The study was a prospective study carried out among 90 patients who were undergone endoscopic or open thyroidectomy at the government general hospital, Kakinada, between August 2017 and August 2019. Fifty-two patients have undergone ConT, and 32 patients have undergone ET. The Microsoft Excel 2016 and SPSS Version 20 were used for statistical analysis. A Chi-square test was performed to analyze surgical outcomes, and P < 0.05 was taken as statistically significant.
Results: The majority of the study participants was females and belongs to the age group in between 31 and 40 years. The mean duration of surgery for ConT and ET is 79.13 and 135.15 min and has statistical significance (P < 0.01). The mean period of hospitalization was 2.1 days for ET, which was lesser than 4.21 for ConT The Wound Infection was found more in people who undergone ConT, and the postsurgery patient satisfaction was more among people who undergone ET.
Conclusion: ET approach has several potential weaknesses in terms of operative time, cost factor, and invasiveness and In favor of shorter hospital stay, less postoperative pain, and excellent cosmetic results, especially in young women.

Keywords: Conventional open thyroidectomy, endoscopic thyroidectomy, thyroid tumors, Wong–Bakes FACES pain rating scale


How to cite this article:
Ponnada P, Nudurupati RR, Suvvari TK. Comparative study on endoscopic versus open thyroidectomy. Thyroid Res Pract 2020;17:128-33

How to cite this URL:
Ponnada P, Nudurupati RR, Suvvari TK. Comparative study on endoscopic versus open thyroidectomy. Thyroid Res Pract [serial online] 2020 [cited 2021 Jun 22];17:128-33. Available from: https://www.thetrp.net/text.asp?2020/17/3/128/307560




  Introduction Top


The prevalence of benign and malignant thyroid tumors has experienced a significant rise in the past 20 years due to an increase in people's awareness, utilization of diagnostic tools, and routine physical examinations. Conventional thyroidectomy through a skin-crease incision in the anterior neck has been the proven, efficient surgical method for treating various thyroid tumors for the few previous 10–20 years.

Conventional thyroidectomy requires a cervical collar incision, leaving an unsightly scar. However, numerous patients with thyroid tumors who require surgery are younger women, and they are worried about the cosmetic appearance of the scar. Consequently, in the present day, the demand for surgical procedures that avoid visible scars, with optimal functional and ideal cosmetic results is increasing. The goals of endoscopic thyroidectomy (ET) are to limit external scarring and improve the cosmoses to reduce postoperative pain, to enhance early postoperative recovery, and to achieve these ends without compromising treatment efficacy.

Huscher et al.[1] described ET in the year 1997. Most of the earlier endoscopic approaches to the thyroid gland employed small cervical incisions in the midline or laterally. To avoid a visible scar in the neck, noncervical methods to the thyroid gland have been applied. The most commonly used noncervical approaches are the axillary,[2] the breast,[3] the lateral,[4] and also certain hybrid approaches, such as the axillary-bilateral breast approach, the bilateral axillary-breast approach, the unilateral axillary-breast approach, and the postauricular and axillary approach. Among these, the breast approach has emerged as the clear favorite, evidenced by its exponential growth thin number. The latest method, the transoral endoscopic technique, an adaptation of the concept of natural orifice transluminal endoscopic surgery to the neck, is a technique that promises to improve the esthetic aspect by offering a scar less operation while retaining the advantages of minimally invasive surgery.[5]

It may be due to the culture that avoidance of a cervical neck scar justifies the expense of technological investment combined with a lengthy procedure to approach the thyroid compartment remotely, which has promoted the widespread application of ET. The preponderance of females among patients requiring thyroid surgery has probably been another influence in the development and patient acceptance of ET.

The aims and objectives of the present study are to compare conventional thyroidectomy with ET in terms of duration of the procedure, blood loss during surgery, postoperative discomfort or pain, antibiotics, and analgesics requirement, complications encountered, duration of hospitalization, the cost factor, and patient satisfaction.


  Materials and Methods Top


The study was a prospective study carried out in 90 patients at the government general hospital Kakinada between august 2017 and august 2019. The inclusion criteria were no suspicion of malignancy, fine-needle aspiration cytology report of a benign thyroid lesion, thyroid goiter or nodules <5 cm diameter, thyroid gland volume <25 ml. The exclusion criteria were history of thyroiditis, history of hyperthyroidism, previous neck surgery, and irradiation. The patients were randomly assigned to open or endoscopic surgery and they have undergone for the surgery.

Preevaluation was done before the selection of the type of surgery they have to undergo. Preoperative imaging was used to screen all patients. The tumor size, lesions, metastasis of lymphatics, and people thought to be low risk were undergone ET. Patients with an invasion of extra thyroid tumor, distant metastasis, peri-nodal infiltration of lymph nodes, and multiple lateral neck metastases. Patient's preferences were also considered for the selection of the type of surgery.

The informed consent was taken from all the patients and this study was approved by the Institutional ethical committee of Rangaraya Medical College, Kakinada.

Statistical analysis

The data were entered into Microsoft Excel 2016, count and percentages were tabulated. IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA) was used for statistical analysis. Significance between demographic profile surgical outcomes was analyzed using the Chi-square test, and P < 0.05 was considered as statistically significant.


  Results Top


A total of 90 patients had undergone thyroidectomy in this study. Fifty-two patients have undergone conventional open thyroidectomy (ConT), and 32 participants have undergone ET. The major proportion of study participants were females, i.e., 94.4%, and the remaining 5.6% were male. The distribution of the study population was mostly concentrated in the age group of 31–40 years, with a percentage of 37.7, followed by 21–30 years age group with 32.2%. There was no statistical significance found between different age groups and gender (P = 0.33). Based on fine-needle aspiration cytology (FNAC) findings, 31.11% (28) of the study population found to have a nodular goiter, followed by follicular neoplasm and colloid goiter occupying 23.22% (21) and 22.22% (20). The remaining 14.44% (13) of the population has multinodular goiter, and 8.89% (8) have cysts.

According to FNAC findings and procedure type [Table 1], 57.8% of the study participants have undergone conventional thyroidectomy, and the remaining 42.2% had ET. Among the study participants who had chosen conventional thyroidectomy majority (32.69%) have nodular goiter and are similar among ET participants with 28.94%.
Table 1: Distribution of the study population according to surgical outcomes (n=90)

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The meantime duration taken for undergoing surgery among the different findings by FNAC is mentioned in [Table 2]. The highest mean duration of 113 min with standard deviation of 32.91 was observed in the cyst, followed by colloid goiter and nodular goiter having a similar mean duration of 102 min. There is a statistical significance between the two surgical procedures performed on the study subjects with respect to the time duration of the procedures [Table 2].
Table 2: Association between duration of surgery/surgical outcomes and types of procedures/fine.needle aspiration cytology findings (n=90)

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There was no significant association found between the conventional thyroidectomy and different FNAC diagnosis (P = 0.824). A similar insignificant association was also found between ET and different FNAC Diagnosis (P = 0.824) [Table 2].

Based on Wong-Baker FACES pain rating scale. About 42.2% belong to Grade 2, 37.8% belong to Grade 3, and 20% belong to Grade 4 on rating using the above-mentioned scale. No one had experienced Grade 1 Pain. All the study participants who had undergone a conventional type of thyroidectomy belong to Grade 3 and Grade 4 of the pain rating scale. Moreover, the study participants who had chosen ET belong to Grade 2 [Table 1]. It is clear that there is a statistically significant association between the duration of antibiotic use and the type of surgical procedure done with a P < 0.001. The mean duration of antibiotics for conventional thyroidectomy was found to be 4.44 ± 0.95, and for ET was 3.13 ± 0.34 [Table 2].

16.67% (15) of the study participants had a hoarse voice after surgery, and among those, 66.67% (10) of the study participants had undergone conventional thyroidectomy [Table 1]. There was no statistically significant association found (P = 0.447). Only 5.56% (5) of the study population had transient recurrent laryngeal nerve (TRLN) palsy, and only 2.2% (2) had TRLN hypocalcemia as complications. No statistically significant association found between the type of procedure undergone and TRLN palsy and hypocalcemia (P > 0.05) [Table 1]. 16.67% (15) of the study, participants had wound infection after surgery, and among those, 66.67% (10) of study participants had undergone conventional thyroidectomy. There was no statistically significant association found (P = 0.447). It was clear that none of the study population had permanent recurrent laryngeal nerve (PRLN) palsy, and only 1.11% (1) had TRLN hypocalcemia as complications. No statistically significant association found between the type of procedure undergone and PRLN palsy and hypocalcemia (P > 0.05) [Table 1].

It is clear that there is a statistically significant association between the duration of hospitalization and the type of surgical procedure done with a P < 0.001 [Table 2]. The mean duration of hospital stay for conventional thyroidectomy was found to be 4.21 ± 0.53, and for ET was 2.10 ± 0.31. There is a statistically significant association between the type of surgical procedure done and the cost factor with a P < 0.001. The mean cost for conventional thyroidectomy was found to be 36846.15 ± 2803.25, and for ET was 77473.68 ± 3493.13 [Table 2]. About 80.76% of the study population who had undergone conventional thyroidectomy was not satisfied, and among the study population who had undergone ET, 89.47% of them were satisfied with the procedure that was performed on them. A statistically significant association was found between patient satisfaction with respect to the type of procedure performed (with a P < 0.001) [Table 2].


  Discussion Top


The present study includes 90 patients of thyroid swelling who were treated at Government General Hospital, Kakinada, from august 2017 to august 2019. Comparison of age group with Johri et al.[6] He took the study population from 16 to 70 years. Most of them were at the mean range of 32–41 years. Majority of patients in this study, along with to age group 31–40 years at a cumulative frequency of 37.7%. The youngest was 16 years, and the oldest was 60 years old.

In another study, Cao et al.[7] have quoted 35–48 years, and Wang et al. study show the age group 32–46 years. The present study is found to be similar to Felin Coa, Gyan Chand, SK Mishra's, and other studies by Wang et al.[8] distribution of the study population based on FNAC finding. The present study composed of endoscopic thyroid surgery for clinically euthyroid benign goiter; out of 90 patient's majority is STN. Hence that capsular dissection identification of parathyroid and recurrent laryngeal nerve (RLN) during surgery can be performed safely.

Duration of surgery in endoscopic thyroidectomy and open thyroidectomy

The mean operative time of ET in our series was 135.15 min, and conventional thyroidectomy was 79.13 min. The operative time achieved was due to short learning arrive with a good surgical view, magnification of surgical field, and excellent instruction and breast approach to the thyroid gland. In Cao et al.[7] study, the total operative time for conventional thyroidectomy 50.4 ± 11.90 and for endoscopy thyroidectomy 90 ± 14.60. Operative time is the only significant factor in our study that did not compare favorably to the open surgical procedure. However, the longer operative time compared to the open surgery group could possibly be reduced through the further accumulation of experience. In the study by Jeong et al., the operative time was 138.5 min for ET and 105.5 min for ConT.[9] In another study by Chung et al., the mean total operative time was 152 ± 48 min, with a mean endoscopic procedure time of 58 ± 18 min.[10] The present study results were similar to the results of Cao et al.[7]

Pain

The usage of minimally invasive techniques in elective surgeries is associated with a reduced inflammatory stress response with improved pulmonary function and hypoxia. The Wong-Bakers face scale was significantly less for the endoscopic group, i.e., is Grade2. In a conventional thyroidectomy, it is Grade 3 and Grade 4.

Distribution of study population according to the grade of pain and two different procedures

Wong bakes face were used to rate pain, i.e., no pain, mild pain, moderative pain, and severe pain [Figure 1]. The study compared with Cao et al.[7] in their study, pain grading with endoscopy is less when compared to conventional thyroidectomy.
Figure 1: Wong-Baker FACES Pain Rating Scale

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Distribution of study population according to the use of analgesics

In Wang et al.,[8] the study duration of analgesic usage is 3.1 ± 0.6 in ET and open conventional thyroidectomy 5.29 ± 0.92. In my present study, the mean use of analgesics is 4.44 ± 0.95 in conventional thyroidectomy and 3.13 ± 0.34 in ET. The study was comparable with the Zong-Linwang and Zong-Lian Pan.

Complications encountered

The common complications of ET were TRLN palsy or PRLN palsy.

Transient hypocalcemia (or) permanent hypocalcemia

By the lateral view of the thyroid gland and paratracheal region, we early identified and preserved the RLN and parathyroid gland while performing the ET in most of the case.

Hoarseness of voice

It is comparable with the Cao et al. study.[7] Voice changes after thyroid surgery are usually due to injury to the RLN. In this present era, identification and preservation of laryngeal nerves are widely practiced. Intraoperative neuromonitoring and RLN Visualization alone are the two methods usually used for the identification of RLN nerves. RLN visualization alone is considered a gold standard for the presentation of nerve injury during surgery.

Voice changes are frequent but usually transient, and sometimes, permanent recovery of transient voice change is quite good, but voice change due to RLN palsy was statistically significant in patients in which completion thyroidectomies were performed. Furthermore, studies are required to evaluate the impact of thyroidectomy and the effects of factors such as patient age, sex, operation time and type, surgeon's experience, orotracheal intubation on the voice of patients undergoing thyroidectomy. In this study, we have experienced a lower incidence of transient hypocalcemia. In the endoscopic T group than previous reports. All patients with transient hypocalcemia recovered within 1 month after the surgery.

Period of hospitalization

In Cao et al. study,[7] the lesser hospital stays in ET is due to less rate of wound infection, reduced size of the incision, and minimal pain after ET. Distribution of the study population according to wound infection. The wound infection rate in this study was found to be less in the endoscopic group being 16%. For this, antibiotics usage and analgesic used in endoscopic was median 3.13 Days and opened 4–5 days P < 0.001. And also significantly less in the endoscopic patient.

Similar results were observed in Cao et al.[7] Study where they observed a15% rate of wound infection from this study. The other factors are the rate of conversion to open has been reported to 0.13%; the major reason for conversion to open surgery is hemorrhage, difficult dissection, and nodule size. In the present study, five patients were required conversion to open because of bleeding from the surface of the nodule and superior thyroid vessels.

Other factors

There are the chances of potential adverse effects due to CO2 insufflation in surgical working space with some reports of subcutaneous emphysema—Park et al. Concern about scar around the nipple, especially in Western women.[11] Therefore, surgeons from Western countries favor endoscopic neck surgery through the trans axillary approach. However, trans axillary has several drawbacks including, a lateral approach to thyroid, narrow working space, a long scar in the axilla, and contralateral lobectomy requires an ipsilateral approach.[12] In our series, most of our patients were satisfied with their nipple scar.

However, no adverse effect has been reported in our series with using CO2 at low pressure (7 mm) with high flowrate (7 l/min), this high flow helps us in maintaining the working space during CO2 gas loss, either due to frequent use of suction to clear smoky field produced by electric cautery. Cost factors it is obviously high in ET than conventional thyroidectomy as it needs high equipment.

Our ET approach has several potential weaknesses in terms of operative time, cost factor, and invasiveness and In favor of shorter hospital stay, less postoperative pain, and excellent cosmetic results, especially in young women.


  Conclusion Top


ET by the breast and axillary approaching selected patients with benign thyroid disease is an effective procedure and allows excellent cosmetic results. This method is a valid option to the selected group of patients who do not want visible scar in the neck.

In addition to improved cosmesis, numerous patients experience decreased pain and faster recovery and are at no increased risk for complications. ET is associated with fewer chances of wound infection, and there is no risk of wound dehiscence. The analgesic usage in ET is comparatively lesser than that of con T. The degree of postoperative pain and its duration is less when compared. The amount of analgesic requirement is less in ET. ET patients had tolerated oral feeds earlier and are mobilized faster. The duration of hospital stay is less, and patients can be discharged quickly from the hospital. Patients of the ET group can resume their work earlier. The cosmetic advantage in ET is distinct. The only disadvantage of ET over the open procedure is the cost factor and the duration of operating time, which is significantly longer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Huscheret CS, Chionidid S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.  Back to cited text no. 1
    
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Cho YU, Park IJ, Choi KH, Kim SJ, Choi SK, Hur YS, et al. Gasless endoscopic thyroidectomy via an anterior chest wall approach using a flap-lifting system. Yonsei Med J 2007;48:480-7.  Back to cited text no. 3
    
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Camenzuli C, Schembri Wismayer P, Calleja Agius J. Transoral endoscopic thyroidectomy: A systematic review of the practice so far. JSLS 2018; 22(3):e2018.00026. doi: 10.4293/JSLS.2018.00026.  Back to cited text no. 5
    
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Johri G, Chand G, Gupta N, Sonthineni C, Mishra A, Agarwal G, et al. Feasibility of endoscopic thyroidectomy via axilla and breast approaches for larger goiters: Widening the horizons. J Thyroid Res 2018;2018:4057542.  Back to cited text no. 6
    
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Cao F, Xie B, Cui B, Xu D. Endoscopic vs. Conventional thyroidectomy for the treatment of benign thyroid tumors: A retrospective study of a 4-year experience. Exp Ther Med 2011;2:661-6.  Back to cited text no. 7
    
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Wang ZL, Pan ZL, Rao SR, Lin Z, Yu J. Endoscopic thyroidectomy through improved breast areola approach in males. Biomed Res 2017;28:247-50.  Back to cited text no. 8
    
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Jeong JJ, Kang SW, Yun JS, Sung TY, Lee SC, Lee YS, et al. Comparative study of endoscopic thyroidectomy versus conventional open thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients. J Surg Oncol 2009;100:477-80.  Back to cited text no. 9
    
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Chung EJ, Park MW, Cho JG, Baek SK, Kwon SY, Woo JS, et al. A prospective 1-year comparative study of endoscopic thyroidectomy via a retro auricular approach versus conventional open thyroidectomy at a single institution. Ann Surg Oncol 2015;22:3014-21.  Back to cited text no. 10
    
11.
Park YL, Han WK, Bae WG. 100 cases of endoscopic thyroidectomy: Breast approach. Surg Laparosc Endosc Percutan Tech 2003;13:20-5.  Back to cited text no. 11
    
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Sasaki A, Nakajima J, Ikeda K, Otsuka K, Koeda K, Wakabayashi G. Endoscopic thyroidectomy by the breast approach: A single institution's 9-year experience. World J Surg 2008;32:381-5.  Back to cited text no. 12
    


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