FEATURE SURGERY
«Thyroid carcinomas comprise approximately 1 to 1.5% of all malignant tumours»
INDICATIONS FOR THYROIDECTOMY Indications for thyroidectomy are numerous, and the most common include suspected or proven cancer of the thyroid gland, overproduction of the thyroid hormone that can not be controlled by conservative means, and a large mass in the thyroid gland that can cause difficulties with breathing and/or swallowing. Thyroid carcinomas comprise approximately 1-1.5% of all malignant tumours. Of these, 60 to 70% are papillary carcinomas, 20 to 30% are follicular carcinomas, 5 to 10% are medullary carcinomas, and – luckily – there are less than 1% of anaplastic carcinomas that yield horrendous prognosis. However, it is important to mention that the total number of thyroid procedures performed for benign disorders is significantly higher than the number of thyroidectomies performed for a proven cancer. Data shows that the most common indication for thyroidectomy (50% of cases) in the United States is the presence of a solitary thyroid nodule. While palpable solitary nodules may occur in up to 4% of the population, with ultrasonography (US) nodules can be found in up to 50% of individuals over 50 years of age. The evaluation of patients with
suspected thyroid disorder should generally include an assessment of serum thyroid hormone levels, and US exam. Furthermore, laryngeal motor function, radioactive iodide uptake, and scintiscan can also be performed. Today it is known that certain sonographic characteristics of a
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Arab Health Congress 2012 is introducing the newly reformatted surgery conference as an innovative four days educational event. The 11th Middle East Surgery Conference aims to become the most important surgical educational event in the Middle East by introducing workshops, master classes and surgery video competitions into the conference agenda. To register to attend, visit the Al Wasl foyer between halls 4 and 5 at Arab Health.
thyroid nodule are associated with a higher likelihood of malignancy. These include nodule hypoechogenicity compared to the normal thyroid parenchyma, increased intranodular vascularity, irregular infiltrative margins, presence of microcalcifications, an absent halo, and a shape taller than the width measured in the transverse dimension. For all suspicious thyroid nodules, fine-needle aspiration biopsy (FNAB) has become the diagnostic study of choice that can safely be performed as an office-based procedure. FNAB is today considered the most accurate and cost- effective method for evaluating thyroid nodules. In the hands of an experienced practitioner FNAB is a very reliable method, with a false-negative rate of less than 2% and a false-positive rate of less than 3%. If proven to be benign, most thyroid nodules can be followed with serial US examinations 6-12 months after the initial FNAB. If nodule size is stable, the interval before the next follow-up US examination may even be longer. In a case of proven malignancy, primary
treatment is surgical excision whenever possible. Differentiated thyroid cancer - comprising papillary and follicular histology - accounts for the vast majority (more than 90%) of thyroid cancers. Total thyroidectomy has been the mainstay for treating well-differentiated thyroid carcinoma. In this procedure, all apparent thyroid tissue is surgically removed. After total thyroidectomy, some patients can undergo radioiodine scanning to detect regional or distant metastatic disease, followed by radioablation of any residual disease found. With a timely and proper treatment, well-differentiated thyroid carcinomas are carrying excellent prognosis. Overall, papillary carcinoma is associated a 30-year cancer-related death rate of 6%, while follicular carcinoma has a 30-year cancer-related death rate of 15%.
NOVEL TECHNOLOGIES IN THYROID SURGERY Technological advancements have allowed thyroid surgeons to develop novel approaches to the treatment of thyroid disorders, which has driven a trend toward minimally invasive methods, bloodless and drainless surgery, and outpatient management. Among these technologies are new devices for achieving hemostasis, reliable laryngeal nerve monitoring (LNM),
and minimally-invasive surgery. Recurrent laryngeal nerve (RLN) is extremely important anatomical structure that is in close vicinity to the thyroid gland, and therefore may be injured over the course of thyroidectomy. RLN innervates all of the intrinsic muscles of the larynx (with the exception of the cricothyroid muscle) and the consequence of an RLN injury
FIGS 1,2,3 1
1A
2
3
Figure 1: Laryngeal nerve monitoring. By using an EMG endotracheal tube, which contains tracing electrodes and is connected to an EMG monitor, surgeon is in able to continuously monitor the laryngeal recurrent nerve during thyroidectomy. Figure 2: Intaoperative view of the harmonic scalpel hand piece during thyroid surgery. The generator of the harmonic system produces an acoustic wave that is transmitted down the shaft of the scalpel to the active blade, causing it to vibrate at the frequency of 55 kHz. Figure 3: Minimally invasive video- assisted thyroidectomy (MIVAT), intraoperative view. This endoscopically- based surgical technique allows operations to be performed successfully through small incisions and with less dissection. They carry the benefits of improved cosmesis, less postoperative morbidity, and reduced hospital stay.
Arab Health Show Issue 2012 121
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