Is there a minimally invasive method of thyroidectomy without leaving a scar when a patient has a hyperactive thyroid?

by jodiles (student)

University Degree Medicine and Dentistry

Grave’s Disease

Is there a minimally invasive method of thyroidectomy without leaving a scar when a patient has a hyperactive thyroid?

The Problem

Graves’s disease is a disease which very often leads to hyperthyroidism, a condition affecting the thyroid. The thyroid is an endocrine gland and so produces hormones. The main function is to help with metabolism (gaining energy from food) and uses the hormones triiodothyronine (T3) and thyroxine (T4). The hyperthyroidism that grave’s disease leads to means that the body uses energy quicker than it should and too much of the hormones are secreted. Figure 1 shows an image of a normal thyroid in someone without the disease (the pink section), compared to a swollen thyroid as found in someone with grave’s disease (the blue section).

The higher level of hormone means that the rate at which energy is gained from food increases and this can affect physical appearances as well as moods. The disease is unlikely to be fatal. Symptoms can include brittle hair, thin skin, becoming nervous or weakening of the muscles.1 The disease affects 2-3% of the population, although some people do not recognise the symptoms and so have not been diagnosed and it is ten times more common in women than men. It is a disease that most commonly takes place during middle age although can affect people of other age groups.2 It is an autoimmune disease and so it occurs when the body reacts against a healthy substance in the body as if it was toxic.4

One way of treating hyperthyroidism is to remove the whole or part of the thyroid to try and regulate hormone levels. This is done in a total or subtotal thyroidectomy and the results are permanent. The usual option is a subtotal thyroidectomy as it carries fewer complications and only 5 in 100 people still suffer from a hyperactive thyroid after the surgery.

There are five main reasons why the surgery is chosen. These are:

A thyroid nodule is present during diagnosis of Grave’s disease and so cancer is suspected

The quickest method of treatment is needed

The patient has a fear of been exposed to radiation and so cannot be treated with radioiodine treatment

The patient is allergic to antithyroid pills

The thyroid is largely swollen3

Occasionally too much of the thyroid can be removed, leaving the patient with an under active thyroid and so medication would have to be taken to replace the missing thyroxine.5

Unfortunately, many women are put off the surgery due to the unsightly scar left on the neck. A solution has been found in using a robotic thyroidectomy, a technique which is not minimally invasive and possibly more invasive due to the distance needed from the incision to the thyroid, but the surgery enables the patient to have a much more subtle scar.7

The Solution

A robotic thyroidectomy creates an incision under the arm instead of across the neck, meaning that any scarring is hidden and not obvious. This method was initiated by Dr. Woong Youn Chung of Yonsei University College of Medicine, Seoul, South Korea. A study was carried out by Dr Kasperbauer and his colleagues at the Mayo clinic in Minnesota. He has said, "Early experience with lobectomy and near-total thyroidectomy with central compartment dissection in our patients has been rewarding without permanent hypocalcemia or vocal cord paralysis." This is stating that early studies have shown the surgery to be largely successful.7

The surgery is done by making an incision under the arm which can range between 5cm and 7cm, which although will create a long scar, it is hidden under the arm, unlike the conventional method which resulted in a 4 – 6cm scar across the middle of the neck. As well as the large cut made under the arm, there is a smaller 5mm incision made in the chest. Having a cut made under the arm rather than across the neck is called an axillary approach.8 Figure 2 shows the location of the incision made under the arm and also shows the relative distance to the thyroid. This incision is where two of the robotic arms would be inserted as well as the camera.

To do the surgery, four small robotic arms are used, each one being able to hold on to things as well as being able to turn and rotate. Along with the arms there is a 3D camera with up to ten times zoom, giving the surgeon a high-definition view of inside the patient’s body so that the arms can be used to make precise movements. To control each of these there is a remote control and so the surgeon is always in control and can accurately remove the thyroid. The robot can also currently not be programmed to do the ...

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At the moment there are 300 robots in Europe and 1,300 in the USA and so 200,000 procedures are being done every year using the robots.9

The reason of why this method is appropriate for solving the problem is because creating an incision under the arm means that the scar created is hidden from view compared to the scarring of the conventional method of thyroidectomy. Figure 3 shows the scar made by open surgery compared to the location of the scars made in a robotic thyroidectomy. The red lines on the image show the scars made by each method, with the scars made by the robotic thyroidectomy being much more discrete than the scar of the open method.

A study has been done by Jae Hyun Park et al at Yonsei University, Korea, into whether a robotic thyroidectomy really does give better results than an open thyroidectomy. This study used 165 patients, of which they were all similar ages, 56 of these underwent the robotic thyroidectomy and the other 109 underwent open surgery. The patients were all suffering from cancer of the thyroid rather than hyperthyroidism although the procedure is very similar and the results of the study can be directly compared. The participants in the study needed lymph nodes (the location of the cancer) removed. The patients were assessed on factors such as hospital stay, complications, operation length and the number of lymph nodes removed.

The results of this study showed that, although the average operating time for the robotic surgery was significantly longer than the open surgery with robotic surgery taking an average of 4 hours and 37 minutes and open surgery taking an average of 3 hours and 38 minutes. The average number of lymph nodes removed was 39.4 for open compared to 37.3 for robotic. After the operation, the average stay in hospital for the patients who underwent the robotic surgery was just 6 days whereas the stay for those who underwent the open surgery was 8 days. After the surgery, 72.5% of the open surgery group suffered complications whereas 72.2% of the robotic group suffered complications, showing that there is very little difference between the two methods. Neither of the surgery options gave any indication of the cancer returning.

It was concluded that the robotic thyroidectomy is a safe procedure and so is an acceptable alternative to open neck surgery. It was also concluded that a large advantage of the robotic thyroidectomy was the cosmetic results of the scar being under the arm rather than across the neck.13

Figure shows the post-operation pain score on a scale of 1 to 10, with the red line representing the robotic surgery and the blue line representing the open surgery. Each of the points shown on the graph represent the pain score from the day of the operation up until the third day after the operation.

Implications

One social implication is that the surgery is limited to a certain type of person and so, for example, obese patients cannot have the surgery done through robotics currently. This means that at the moment, a robotic thyroidectomy is only used on patients who strongly wish to avoid obvious scarring on the neck for cosmetic reasons. As confidence in the surgery grows, the currently limited criteria will also grow and so the numbers of eligible patients will increase. At the moment, a robotic thyroidectomy is limited to patients with smaller thyroids of a diameter of 4cm or less.7 Patients must also only have nodules on one side of the gland for the surgery to work at its best.8

One economic implication is that each robot costs over $2.5 million and so they are only available to specialist clinics. Also, specialist training is needed for each new surgeon who is going to use the robot, which again will cost the facility for the training. This means that the machines can only be purchased at specialist hospitals and cannot be used by everyone as it will no doubt be expensive to use the procedure. This means that only a selective group can use this method of surgery until it becomes more widely used.9

Risks/disadvantages

One risk of having a thyroidectomy is the general anaesthetic. Within this are several risks, ranging from very common to very rare. The very common risks have a one in ten chance of happening and the common risks have a one in 100 chance. These are:

Feeling sick/vomiting

Sore throat

Dizziness

Blurred vision/headaches

Itching

Aches

Pains/backache

Bruising and soreness around the area of injection

Confusion/memory loss

The uncommon risks are at a chance of one in 1,000, these are:

Chest infections

Bladder problems

Muscle pains

Slow breathing

Damage to tongue and lips

Experiencing a medical condition worsening

Waking up and becoming conscious during the surgery

The rare and very rare risks are a chance of one in 10,000 or 1 in 100,000, these are:

Death

Equipment failure

Nerve damage

Responding with a serious allergy to the drugs used

Damage to eyes10

Wider Benefits

A wider benefit is that, when operating, the high-definition 3D camera gives a much more accurate image of the gland and surgeons can see nerves surrounding the thyroid. This is compared to looking at the thyroid from above as is done in open surgery. The camera also enables surgeons to zoom in on the thyroid, giving a clearer view of important structures around the thyroid gland such as the nerve leading to the voice box (the laryngeal nerve) and the parathyroid glands. The ability of the robotic arms to rotate means that surgeons have increased accessibility to the thyroid gland compared to in open surgery, meaning that a thyroidectomy becomes more accurate and precise in the amount of thyroid removed.8 Another benefit is that patients do not suffer from difficulty swallowing food as the incision is made away from neck and so the post-operative pain is largely reduced (as shown in figure 4).9

Two alternative solutions

An alternative solution to the hyperthyroidism caused by Grave’s disease is the use of antithyroid drugs, the most common of these being carbimazole. These work by reducing the amount of thyroxine, although they cannot affect the amount of hormone which has already been made and stored by the thyroid. This means that drugs can take between 4 and 8 weeks to take effect and reduce hormone levels.11

There are two ways to reach the correct dosage of the drugs. The first of these is to take the first dose much higher than a normal dose so as to regulate the amount of thyroxine in the blood. The same dose will then have to be taken for the initial 4 to 8 weeks before the drugs can properly take effect in the thyroid. The high dose is gradually decreased to the amount which is right for the patient. Judging the dosage needed by individual patients is difficult as each one will produce different amounts of thyroxine and so will needed different amounts of the medicine. To make sure that this dose is correct, the patients are monitored with a blood test every month. This ensures that the patient’s thyroxine levels are regulated properly by the drugs. This method of treatment is called ‘titration’.

The second method of prescribing the medicine is for the patient to take a high dose of carbimazole every day which prevents the thyroid gland from producing any hormones and so must be balanced by a prescription of thyroxine. This is effectively doing the job of the thyroid. This method is called ‘block and replace’ and is the more commonly chosen of the two drugs methods.

Within six months of taking the medicines, 50% of patients who use the ‘block and replace’ method get better whereas it takes 18 – 24 months for this to happen using the ‘titration’ method.

Like any drugs there are side effects. These include rashes, headaches, sore throat or mouth ulcers.11

Radioactive iodine treatment (RAI) is a type of radiotherapy which implants radioactive iodine into the thyroid. This then builds up within the thyroid and causes it to decrease in size which then decreases the amount of thyroxine made. This can be done either in a drink or in a pill but neither of these methods contain harmful amounts of radioactivity. There are limitations in that the treatment is unsuitable during pregnancy and if the patient has eye problems.5

RAI is often given in doses which are too large; leading to hypothyroidism due to the difficulty in controlling how much is needed. There has recently been work to try and make this a more efficient cure although it is challenging and currently, 20% of all patients suffer from hypothyroidism in the first year after treatment and another 3-5% more every year following. This shows it to have a low total success rate. 6

In conclusion, you can see that this is not a minimally invasive procedure due to the distance needed to reach the thyroid from under the arm, although it does not leave a scar and so is a suitable method to be used on patients who are worried about the cosmetic look of the scarring.

Bibliography

1 Sagmiller. G. J. (2011) All about Thyroid Disease, Grave’s disease, Hyperthyroidism and Hypothyroidism, The Gifted Learning Project

2Grave’s disease and thyroid foundation, 2012, available at: (accessed 10/03/12)

3Grave’s disease and thyroid foundation, Thyroidectomy, authors: Robert F. Dons, M.D., Ph.D.; Angelita Ramos-Gabatin, M.D. and Jon B. Getz, M.D., 2012, available at:

(accessed 10/03/12)

4NHS: Thyroid, overactive, Causes, last reviewed 2010, available at: (accessed 11/03/12) This source is reliable as the NHS aims to help with health problems and has pages specifically for a range of health problems. The page I have used is for the causes of Grave’s disease and the NHS is a respectable group and will not gain anything from people following information on the site.

5 NHS, Thyroid, overactive treatments, last reviewed 2010, available at: (accessed 11/03/12)

6 BBC health: Grave’s disease, last reviewed by Dr Trisha Macnair, 2009, available at:

(accessed 11/03/12) The BBC is a respectable media source and is unbiased towards anyone. This article has also been reviewed by Dr Trisha Macnair, a PHD student in medicine, meaning that it is more reliable than it would have been otherwise and the article has been agreed with. It is also reliable because I have found similar or the same information on other websites and so this shows that it has been backed up. Dr Trisha Macnair graduated from Bristol University and is now a Speciality Doctor in Medicine for the Elderly at Milford Hospital, near Gilford in the UK. In 2001, Dr Trisha Macnair, won an award from The Medical Journalists Association for her article on Genetics for the BBC health website and has an MA in Medical Ethics and Medical Law, from Kings College, University of London as well as being a member of the British Medical Association.

7Mayo clinic, available at: (accessed 11/03/12)

8Endocrine web, Robotic thyroidectomy, written by Kamiah A. Walker, last reviewed by , 2010, available at: (accessed 11/03/12) This source is a website specialised for endocrine disorders and the article I have used was written by Kamiah A. Walker who is a Senior Medical writer in Illinois and works closely with the editors of the site to ensure that all information posted is trustworthy. She is also a Doctor of Medicine or an MD. The article has also been reviewed by Brendan C. Stack Jr. MD, FACS, FACE who is a professor and Chair in Otolaryngology-Head and Neck surgery at the University of Arkansas for Medical Sciences. He has written 150 articles which have then been peer-reviewed and has presented at over 200 meetings and conferences. Having the article reviewed by Brendan C. Stack Jr. MD, FACS, FACE increases the reliability of the article as it shows that it has been supported by a nationally known professor in the USA. The source is also reliable as I have found the same information on a second website. ()

9Thyroid gland surgery, Dr. Patrick Aiden, 2011, available at: (accessed 11/03/12)

10Patient information, NHS, published 2008, reviewed 2010, available at: (accessed 11/03/12)

11Patient, diseases and conditions, antithyroid medicines, written by Jenny Whitehall and peer reviewed by Dr. Tim Kenny, last reviewed Jan 2012, available at: (accessed 12/03/12)

12, , , , and (2010), Surgical Endoscpy, Volume 24, number 12; difference in postoperative outcomes, function, and comesis: open versus robotic thyroidectomy, Springer New York

13Global Robotics Institute, 2011, available at (slide 52 – 58): (accessed 29/03/12)

Figure 1, an image of the thyroid gland, thyroid gland – grave’s disease, available at: (accessed 11/03/12)

Figure 2, an image of where the incision is made compared to the location of the thyroid gland, mayo clinic – robotic thyroidectomy, 2001 – 2012, available at: (accessed 11/03/12)

Figure 3, a comparison of the scars made by each method, thyroid gland surgery, Dr. Patrick Aiden, 2011, available at: (accessed 11/03/12)

Figure 4, a graph to show the post-operation pain score, Global Robotics Institute, 2011, available at: (accessed 29/03/12)

Figure 1: the thyroid gland

Figure 2: where the incision is made compared to the location of the thyroid

Figure 4: A graph to show the post-operation pain score

Figure 3: a comparison of the scars made by each method

Is there a minimally invasive method of thyroidectomy without leaving a scar when a patient has a hyperactive thyroid?

Grave’s Disease

Is there a minimally invasive method of thyroidectomy without leaving a scar when a patient has a hyperactive thyroid?

This is a preview of the whole essay

3Grave’s disease and thyroid foundation, Thyroidectomy, authors: Robert F. Dons, M.D., Ph.D.; Angelita Ramos-Gabatin, M.D. and Jon B. Getz, M.D., 2012, available at:

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