Minimally invasive surgery by Dr. Simon Wright
Some disorders of the head and neck have traditionally required large incisions. Examples of this include thyroid surgery for benign nodules, parathyroid surgery, lymph node biopsy and vagal nerve stimulator (VNS) implantation.
In those cases, disfiguring incisions were made in visible areas of the neck simply for surgical access. In response to this problem, less invasive techniques have been developed and are now in practice around the globe. |
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Dr. Wright has been performing video-assisted, minimally invasive procedures since 2002. He performs most thyroid and Parathyroid surgeries using this technology, greatly minimizing the length of surgical scars.
Additionally, some thyroid patients are candidates for a scarless, totally endoscopic procedure which involves no visible incision. Dr. Wright has also developed a scarless, minimally invasive technique for placement of vagel nerve stimulator —an anti-seizure implant similar to a pacemaker. This eliminates any scar on the neck.
Background of minimally invasive thyroid and parathyroid surgery.
Since the early 1980’s, minimally invasive surgery has revolutionized the surgical management of conditions in the chest and abdomen, drastically reducing recovery from invasive procedures and expanding the range of therapeutic interventions.
Some disorders of the head and neck have traditionally required large incisions to gain access to small areas or structures. Examples of this include thyroid surgery for benign nodules, parathyroid surgery, lymph node biopsy, and Vagal Nerve Stimulator (VNS) implantation. In these cases, disfiguring incisions are made in visible areas of the neck simply for surgical access. In response to this problem, less invasive techniques have been developed and are now in practice around the globe.
Minimally invasive surgery of the neck was first developed for management of thyroid and parathyroid disorders. Since that time, a variety of minimal-access techniques have been developed which accomplish the desired surgical goal. These techniques are currently practiced worldwide, and multiple clinical trials confirming the safety and benefit of these procedures have been performed.
Dr. Wright has been performing video-assisted procedures since 2002. He performs most thyroid and parathyroid surgeries using this technology, minimizing the length of surgical scars. Some thyroid and parathyroid patients are candidates for a scarless totally endoscopic procedure, which involves the creation of no visible incision. In addition, Dr. Wright has developed a “scarless” minimally invasive technique for placement of the vagal nerve stimulator, an anti-seizure implant similar to a pacemaker; this eliminates any scar on the neck.
Minimally Invasive Thyroid Surgery
Thyroid cancer is an uncommon disease. However, many common thyroid disorders simulate thyroid cancer, and surgical excision of portions of the thyroid gland is frequently necessary for diagnosis. This means that many people undergo surgery for a benign problem and acquire a disfiguring visible scar as a result. Techniques now exist to minimize the length of incisions for most thyroid surgeries.
Videoassisted Thyroidectomy
The video-assisted surgical technique represents the first innovation in thyroid surgery in the past 100 years. This technique markedly shortens incision length, reduces post-operative pain, and speeds return to normal function. The pioneering work of surgeons in Italy demonstrated the safety and feasibility of the video-assisted thyroidectomy. This is conceptually a fairly minor modification – the basic sequence of steps in the procedure are nearly identical to a conventional open thyroidectomy – however, the incision is generally confined to 2-3 cm in length, recovery is reduced, and less pain is experienced postoperatively. This technique simply involves making a much smaller incision, using retractors to create a working space around the gland, and supervising the thyroid procedure using endoscopes, much like laparoscopic procedures of the abdomen.
This technique has been performed thousands of times around the world with consistently safe results comparable to the conventional technique. It does not increase operative time, and incurs no increased risk. The only reproducible difference is a much smaller incision, shorter recovery time, and less pain. Only recently has this technique begun to be taught in the United States. A handful of surgeons in this country have been doing this technique for a number of years, including Dr. Wright. Dr. Wright is one of the most experienced surgeons in the United States with this technique. Parathyroid surgery can and is performed in a similar fashion.
Totally endoscopic thyroidectomy
A second, more sophisticated variation of minimally invasive thyroid may be an option for some patients. Using special instrumentation and techniques, part or all of the thyroid gland can be removed through small puncture sites in the armpit, avoiding any incision on the neck whatsoever. In this technique, the skin overlying the collarbone is lifted from the underlying muscle and laparoscopic techniques are used to create a working space. The muscles of the neck are identified, and the thyroid procedure is performed exactly as it would be in an open procedure. The surgeon operates using laparoscopic instruments and supervises the case through endoscope cameras under high magnification. In many cases, the surgeon can see better in this technique than in a conventional open procedure. Only selected patients are suitable for this operative approach.
Video-assisted technique
- Ideal for thyroid procedures.
- Mini-incision (typically 2-3 cm).
- An Endoscope provides excellent lighting and magnification.
- Band-aid dressing, often with no need for a post operative drain.
- Operative times are comparable to conventional techniques.
- Easier recovery.
Totally endoscopic approach
- Appropriate for some candidates.
- Avoids any neck incision with no visible scar on the neck.
- Entire surgery is performed through small incisions away from neck.
- Recovery is typically significantly easier than conventional techniques.
- Minimal pain.
Minimally Invasive Parathyroid Surgery
To make an appointment
Dr. Wright practices at the ENT Clinic of Iowa, where he provides minimally invasive surgery services.
Call 1-800-267-1800 or e-mail Dr. Wright’s nurse at thyroidectomy@entclinicofiowa.com
At present, Dr. Wright practices in Des Moines, Iowa at the ENT Clinic of Iowa, where he provides minimally invasive and robotic head and neck services. He operates at the major hospitals in town and trains medical students and surgical residents.
Minimally Invasive Parathyroidectomy
Hyperparathyroidism typically involves a single parathyroid gland which overproduces parathyroid hormone (PTH), causing elevated calcium and a variety of systemic side effects. Most people have four small parathyroid glands in the region of the thyroid gland. The conventional procedure involves a lower neck incision with sequential identification of each gland until the enlarged gland is encountered. Once found, the abnormal gland is removed.
Video-assisted technique
- A mini-incision (typically less than 2 cm)
- An endoscope and specialized instruments provide excellent lighting and magnification for removal of the parathyroid gland
- An intraoperative blood test confirms removal of the overactive parathyroid gland (PTH level falls immediately after removal of abnormal gland)
- Band-Aid dressing
Vagal Nerve Stimulator Implantation
The vagal nerve stimulator (VNS) is a medical device used to treat epilepsy or depression. It involves two components: a battery pack similar to a pacemaker and a nerve lead, which attaches to the vagal nerve in the neck for pacing.
Conventional placement involves a two-inch incision in the left mid-neck for lead placement on the nerve, in addition to a second two-inch incision in the left armpit to place the battery.
Because the neck incision is high in the neck, it is difficult to hide with clothing. In addition, the scar can be recognized as a VNS procedure, revealing one’s private health problem of depression or epilepsy. The minimally invasive approach eliminates the neck incision entirely, using endoscopes and specialized instruments to access the neck and place the nerve leads.
Minimally invasive approach
- No scar
- Avoids any neck incision
- Armpit incisions are virtually invisible
- Easier recovery
- Operative times comparable to open technique
- Band-Aid or skin glue dressings
What if I live out of state?
Arrangements can be made to accommodate out-of-state patients when preliminary studies such as ultrasound reports and pathology reports are made available. Most patients recover suitably for travel within 24 hours of surgery.
Recovery
Recovery from thyroid or parathyroid depends primarily on the extent of surgery. Parathyroidectomy for single adenoma or partial thyroidectomy typical involves a very brief recovery with minimal pain. Total thyroidectomy or extensive parathyroid exploration will incur a greater recovery. Generally speaking, the recovery from conventional thyroid and parathyroid surgery is not severe. Most patients return to non-strenuous activity in 7-14 days. This recovery time can be approximately reduced by half with minimally invasive approaches.
Which surgical approach is right for you.
The fact is, most surgical incisions for thyroidectomy heal relatively well and are fairly inconspicuous. There are many surgeons in the country who can provide conventional thyroid surgery safely. For some people, however, the standard 10 cm incision is undesirable. This is particularly true for children or young women, but depending on a person’s individual point of view, anyone may prefer to have a smaller incision or to shorten their recovery period.
Not everyone is a candidate for a small incision. Previously operated patients, those with aggressive cancer or very large tumors may not be candidates. It is always possible that a small incision will have to be made larger for safety of the procedure. Visiting with your minimally invasive surgeon should address all of these issues. The video-assisted approach is applicable to nearly every situation; not every patient is a candidate for a “scarless” transaxillary approach. The safety of minimally invasive surgery has been confirmed in large studies performed in Europe and Asia, where these procedures were initially developed.
At present, very few thyroid surgeons are trained to perform minimally invasive video-assisted thyroid and parathyroid surgery. Dr. Wright has been doing this procedure since 2002, and is the most-experienced video-assist surgeon in the region, and one of the most experienced minimally invasive head and neck surgeons. Many of his patients are children or young adults. He is one of a few surgeons in the nation who is experienced in performing transaxillary head and neck surgery. He is one of the most experienced robotic neck surgeons in the country, and the most experienced for the transaxillary approach. He developed other transaxillary surgical approaches to the neck, and is actively developing new applications for less invasive surgery of the head and neck region.
Dr. Simon Wright
More on Thyroidectomy & Parathyroidectomy
Pediatric Thyroidectomy & Parathyroidectomy
Thyroidectomy.com
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