Abstract
Background
Translumenal endoscopic interventions via so-called natural orifices are gaining increasing interest because they allow surgical treatment without any incision of the skin. Moreover, minimally invasive procedures have found their way into thyroid and parathyroid surgery. Our goal was to develop a new access for thyroid and parathyroid resection via an entirely transoral approach.
Methods
We managed to find an entirely transoral sublingual access to the thyroid region in pigs and human cadavers. Using a modified rigid rectoscope (oraloscope) hemithyroidectomies as well as resection of parathyroid glands were performed via this new approach. Preparation and resection was performed using conventional laparoscopic instruments. In living pigs, integrity of the recurrent laryngeal nerve after resection could be documented by neuromonitoring. An absorbable suture was used to seal the mucosal incision.
Results
First, hemithyroidectomy was performed via the transoral access in 10 porcine cadavers, then in 10 living and orally intubated pigs, and finally in five human corpses. In humans, resection of parathyroid glands also was performed. We gained access to the thyroid region by blunt dissection of the layer behind the hyoid bone and the strap muscles of the neck. We did not observe any complication during the insertion, resection, and removal part of the new procedure.
Conclusions
Entirely transoral thyroid and parathyroid surgery via sublingual access seems to be feasible. However, further investigations are needed to evaluate the safety of the new technique, especially potential and clinically relevant contamination of the access route has to be excluded.
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References
Rattner D, Kalloo A (2006) ASGE/SAGES Working Group on natural orifice translumenal endoscopic surgery 2005. Surg Endosc 20:329–333
Gagner M (1996) Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 83:875
Yeung GH (1998) Endoscopic surgery of the neck: a new frontier. Surg Laparosc Endosc 8:227–232
Sebag F, Palazzo FF, Harding J, Sierra M, Ippolito G, Henry JF (2006) Endoscopic lateral approach thyroid lobectomy: safe evolution from endoscopic parathyroidectomy. World J Surg 30:802–805
Shimizu K (2001) Minimally invasive thyroid surgery. Best Pract Res Clin Endocrinol Metab 15:123–137
Takami H, Ikeda Y (2003) Total endoscopic thyroidectomy. Asian J Surg 26:82–85
Kitano H, Fujimura M, Kinoshita T, Kataoka H, Hirano M, Kitajima K (2002) Endoscopic thyroid resection using cutaneous elevation in lieu of insufflation. Surg Endosc 16:88–91
Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J (2002) Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: a preliminary report. Surg Endosc 16:92–95
Witzel K (2007) The axillary access in unilateral thyroid resection. Langenbecks Arch Surg 392:617–621
Shimizu K, Shiba E, Tamaki Y, Takiguchi S, Tanigushi E, Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillobilateral breast approach. Surg Laparosc Endosc Percutan Tech 13:196–201
Park YL, Han WK, Bae WG (2003) 100 cases of endoscopic thyroidectomy: breast approach. Surg Laparosc Endosc Percutan Tech 13:20–25
Ikeda Y, Takami H, Sasaki Y, Takayama J, Niimi M, Kan S (2003) Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 196:189–195
Cougard P, Osmak L, Esquis P, Ognois P (2005) Endoscopic thyroidectomy; a preliminary report including 40 patients. Ann Chir 130:81–85
Duh QY (2003) Minimally invasive endocrine surgery: standard of treatment or hype? Surgery 134:849–857
Witzel K, Rahden BHA, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endsoc 22:1871–1875
Akerström G, Malmaeus J, Bergström R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21
Langman J (1981) Medical embryology, 4th edn. Williams & Wilkins, Baltimore
Schiel R, Olthoff A, Kruse E (2005) Comparative anatomic conditions of the recurrent laryngeal nerve in humans and pigs; Vergleichende Anatomie des N. recurrens bei Mensch und Schwein. http://www.egms.de/en/meetings/dgpp2005/05dgpp098.shtml (German)
Salomon, Franz-Viktor, Geyer, Hans; Gilles, Uwe [Hrsg.] (2008) Anatomy in veterinary medicine (Anatomie für die Tiermedizin), Enkeverlag (German)
NOSCAR www.noscar.org
Wagh MS, Merrifield BF, Thompson CC (2006) Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model. Gastrointest Endosc 63:473–478
Kanstevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62:287–292
Merrifield BF, Wagh MS, Thompson CC (2006) Peroral transgastric organ resection; a feasibility study in pigs. Gastrointest Endosc 63:693–697
Della Flora E, Wilson TG, Martin IJ, O’Rourke NA, Maddern GJ (2008) A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery experimental models, techniques, and applicability to the clinical setting. Ann Surg 247:583–602
Bergenfelz A, Kanngiesser V, Zielke A, Nies C, Rothmund M (2005) Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism. Br J Surg 92:190–197
Miccoli P (2002) Minimally invasive surgery for thyroid and parathyroid diseases. Surg Endosc 16:3–6
Lorenz K, Miccoli P, Monchik JM, Düren M, Dralle H (2001) Minimally invasive video-assisted parathyroidectomy: multi-institutional study. World J Surg 25:704–707
Barczyński M, Cichoń S, Konturek A, Cichoń W (2006) Minimally invasive video-assisted parathyroidectomy versus open minimally invasive parathyroidectomy for a solitary parathyroid adenoma: a prospective, randomized, blinded trial. World J Surg 30:721–731
Rubello D, Mariani G, Pelizzo MR (2007) Italian Study Group of Radioguided Surgery and ImmunoScintigraphy. Minimally invasive radio-guided parathyroidectomy on a group of 452 primary hyperparathyroid patients: refinement of preoperative imaging and intraoperative procedure. Nuklearmedizin 46:85–92
Grant CS, Thompson G, Farley D, van Heerden J (2005) Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy: Mayo Clinic experience. Arch Surg 140:472–478
Berti P, Materazzi G, Picone A, Miccoli P (2003) Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 90:743–747
Irvin GL III, Solorzano CC, Carneiro DM (2004) Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg 28:1287–1292
Udelsman R, Donovan PI (2004) Open minimally invasive parathyroid surgery. World J Surg 28:1224–1226
Udelsman R, Donovan PI, Sokoll LJ (2000) One hundred consecutive minimally invasive parathyroid explorations. Ann Surg 232:331–339
Henry JF, Sebag F, Cherenko M, Ippolito G, Taieb D, Vaillant J (2008) Endoscopic parathyroidectomy: why and when? World J Surg 32:2509–2515
Disclosures
Drs. Elias Karakas, Thorsten Steinfeldt, Anja Kiefer, Thorsten Schlosshauer, Andreas Gockel, Reiner Westermann, and Detlef K. Bartsch have no conflicts of interest or financial ties to disclose.
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Karakas, E., Steinfeldt, T., Gockel, A. et al. Transoral thyroid and parathyroid surgery. Surg Endosc 24, 1261–1267 (2010). https://doi.org/10.1007/s00464-009-0757-z
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DOI: https://doi.org/10.1007/s00464-009-0757-z