Junichi Takayama

Endoscopic thyroidectomy by the axillary approach

Neck surgery has recently become one of the newest fields for the application of endoscopic surgery because the resultant scar is small and inconspicuous. Still, some patients feel even a small scar on the neck is not cosmetically acceptable. We therefore have developed a new technique of endoscopic thyroidectomy by the axillary approach that leaves no scar on the neck at all. When this method is used, the small scar in the axilla is completely covered by the patients arm in a natural manner. The cosmetic result is excellent, and sensory loss in the neck is negligible because the area of surgical dissection is small. We believe that endoscopic thyroid surgery by the axillary approach will find a role in the treatment of thyroid disease.

Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: A preliminary report

Background: The use of endoscopic procedures leads to a reduction in the size of the surgical scar, making it more inconspicuous. In this paper, we evaluated the merits and limits of endoscopic neck surgery. Methods: Between August 1999 and July 2000, 102 patients underwent neck surgery in our department for thyroid or parathyroid disease. Twenty-eight of them were treated by the axillary. A 12-mm and two 5-mm trocars were inserted through the skin of the axilla. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedures were performed successfully in 26 cases (19 thyroidectomies and seven parathyroidectomies). There were two conversions to open procedures. The mean operating times for the thyroidectomies and parathyroidectomies were 212 and 171 min, respectively. No evidence of injury to the recurrent laryngeal nerve was observed in any of the cases. The postoperative cosmetic status of the patients was excellent. Conclusion: We believe that endoscopic thyroidectomy and parathyroidectomy by the axillary approach will find a role in the treatment of endocrine diseases in the neck.

Are There Significant Benefits of Minimally Invasive Endoscopic Thyroidectomy

Minimally invasive surgery using endoscopic vision is widely employed for the treatment of thyroid diseases. We have performed endoscopic thyroidectomy by the axillary approach (axillary approach) and video-assisted thyroidectomy via a 3 cm cervical incision (video-assisted approach). In this study, we evaluated the efficacy of these two procedures. Each procedure was performed in 20 consecutive consenting patients. The degree of invasiveness after surgery was compared using postoperative results. The amount of pain and satisfaction with surgery was evaluated by grade (1–5) using a patient questionnaire. All thyroidectomies were completed successfully. No recurrent laryngeal nerve palsies occurred. Operating time for the video-assisted approach was significantly shorter than that for the axillary approach (p < 0.01). The amount of pain for the axillary approach on 1, 3, and 5 days after operation, respectively, was graded 3.2 ± 0.7, 2.1 ± 0.6, and 1.6 ± 0.7 compared to 2.7 ± 1.1, 1.7 ± 0.7, and 1.1 ± 0.2 for the video-assisted approach. The postoperative course was significantly less painful in patients undergoing the video-assisted approach on postoperative days 3 and 5 (p < 0.01). The degrees of satisfaction for the axillary approach and the video-assisted procedure were 1.2 ± 0.4 and 2.4 ± 1.0, respectively (p < 0.01). The video-assisted approach is less “invasive” than the axillary approach, but the axillary approach may be indicated for patients who are anxious about the visible cosmetic results.

Endoscopic total parathyroidectomy by the anterior chest approach for renal hyperparathyroidism

Background: During the past 3 years, minimally invasive procedures have been adopted for the surgical treatment of primary hyperparathyroidism, and we have tried to perform endoscopic total parathyroidectomy for renal hyperparathyroidism. Methods: Five 5-mm trocars were inserted through the skin of the anterior chest under a general anesthesia. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedure was successfully performed in five patients. The mean duration of total parathyroidectomies was 236 min. No evidence of injury to the recurrent laryngeal nerve was observed in any cases. At follow-up, the serum calcium and parathyroid hormone levels had returned to within the normal range in all patients. Postoperative cosmetic status was excellent. Conclusion: We believe that endoscopic total parathyroidectomy by the anterior chest approach will find a role in the treatment of renal hyperparathyroidism.

Minimally invasive radioguided parathyroidectomy for hyperparathyroidism

Clinical or subclinical hyperparathyroidism (HPT) is one of the most common endocrine disorders. In patients with HPT who meet the indications for parathyroidectomy, complete surgical resection of all hyperfunctioning parathyroid tissue is essential for the curative treatment. The conventional surgical approach is bilateral neck exploration, whereas minimally invasive parathyroidectomy has been made possible by the introduction of 99mTc-sestamibi scintigraphy for preoperative localization of parathyroid adenomas. In minimally invasive surgery, the surgeon expects some modalities that predict complete resection of all hyperfunctioning parathyroid glands. The prevalence rate of 99mTc-sestamibi scanning for single parathyroid adenoma was widely accepted as 85–95%. Moreover, the recent developing technology of semiconductor electronics has produced useful portable γ-probes. Intraoperative navigation using these devices provides the possibility of easy and definitive identification of parathyroid nodules during the operation. In minimally invasive radioguided parathyroidectomy using γ-probe, different protocols are based on different timing and doses of tracer injected. Each procedure is technically easy, safe, with a low morbidity rate, and has better cosmetic results and lower overall cost than conventional bilateral neck exploration. We have applied this technique in selected patients and achieved success comparable to that achieved with contemporaneously performed standard neck exploration. In the hands of a competent surgeon, the use of sestamibi scanning and radioguided parathyroidectomy in appropriately selected patients is a useful technique.

Laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein

Background: We perform laparoscopic partial adrenalectomy without sectioning the adrenal central vein has been described because it is important to preserve this vein in the remnant adrenal gland in order to maintain its function. In this article, we describe our technique for laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein. Methods: The procedures were performed in four patients with aldosterone-producing adenomas (APA) and two patients with pheochromocytomas. Results: There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed that remnant adrenal function had been preserved in all cases. Conclusion: Since the vascular bed adjacent to the remnant adrenal gland is integral to the preservation of its function, it is important to perform procedures that do not separate the remnant adrenal gland from the retroperitonium space. Because the operative field is clearly visualized on the high-magnification video monitor, this delicate procedure can be performed with a high degree of accuracy via the laparoscopic approach. We consider this operative technique to be useful for selected cases.

Section 3. Adrenal: Laparoscopic partial adrenalectomy

Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the technique and results of these procedures. Laparoscopic partial or cortical-sparing adrenalectomy has been performed in 10 patients. Seven cases had an aldosterone-producing adenoma (APA) and three had a pheochromocytoma. Three cases with an APA and a case with a pheochromocytoma had tumors located far from the adrenal central vein, and the vein could be preserved. Four cases with an APA and two with a pheochromocytoma had tumors located close to the adrenal central vein, and it was necessary to section the central vein to resect them. All endoscopic procedures were performed successfully. There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed the preservation of remnant adrenal function in all patients. Laparoscopic partial or cortical-sparing adrenal surgery was safely performed, and adrenal function was preserved irrespective of whether the adrenal central vein could be preserved or not. We consider this to be a useful operative technique for selected cases.

Section 1. Parathyroid: Direct mini-incision parathyroidectomy

Abstract We describe our technique for performing a mini-incision parathyroidectomy in patients with hyperparathyroidism. Since our procedure differs from conventional parathyroidectomy in requiring a 2- or 3-cm skin incision and no raising of skin flap, this technique resulted in a good cosmetic status and less invasiveness. Hypesthesia or paresthesia in the neck and discomfort while swallowing related to a large skin incision and raising of skin flap are minimized. Although the cosmetic results of endoscopic techniques are better than those of our procedures, endoscopic instruments remain traumatic, can easily inflict iatrogenic lesions to parathyroid adenomas and enhance the risk of tumor cell exfoliation, especially if the parathyroid adenoma is manipulated by the instruments. Our surgical procedure can be less technically demanding and time-consuming. Although the number of patients whom we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for hyperparathyroidism.

Is laparoscopic partial or cortical-sparing adrenalectomy worthwhile?

SummaryBackground: Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the techniques and results of these procedures.Methods: Laparoscopic partial or cortical-sparing adrenalectomy was performed in nine patients. Six cases had an aldosterone-producing adenoma (APA) and three had a phaeochromocytoma. Two cases with an APA and one case with a phaeochromocytoma showed tumours located far from the adrenal central vein, and the vein could be preserved. Four cases with an APA and two with a phaeochromocytoma had tumours located close to the adrenal central vein, and it was necessary to section the central vein in order to resect them.Results: All endoscopic procedures were performed successfully. There were no postoperative complications. At follow-up, adrenal 131I-aldosterol scintigrams showed the preservation of remnant adrenal function in all patients.Conclusions: Laparoscopic partial or cortical-sparing adrenal surgery was safely performed, and adrenal function was preserved, irrespective of whether the adrenal central vein could be preserved or not. We consider this to be a useful operative technique in selected cases.ZusammenfassungGrundlagen: Da Kortikosteroide unerläßliche Hormone sind, kann eine partielle oder kortexsparende Adrenalektomie für die chirurgische Behandlung von Nebennierenkrankheiten eingesetzt werden. In diesem Artikel beschreiben wir die entsprechenden Techniken und die mit dieser Prozedur erhaltenen Ergebnisse.Methodik: Laparoskopische partielle oder kortexsparende Adrenalektomien wurden bei 9 Patienten durchgeführt. Sechs dieser Patienten hatten ein APA und drei ein Phäochromozytom. Bei zwei Patienten mit APA und einem Patienten mit Phäochromozytom lagen die Tumore weit entfernt von der zentralen Nebennierenvene, so daß die Vene erhalten werden konnte. Vier Patienten mit APA und zwei mit Phäochromozytom hatten Tumore, die sich dicht bei der zentralen Nebennierenvene befanden, so daß eine Sektion dieser Vene erforderlich war, um den Tumor zu entfernen.Ergebnisse: Alle endoskopischen Prozeduren wurden erfolgreich durchgeführt. Es gab keine postoperativen Komplikationen. Eine Folgeuntersuchung mit Hilfe von 131J-Aldosterol Szintigrammen zeigte bei allen Patienten eine Erhaltung der verbleibenden Nebennierenfunktion.Schlußfolgerungen: Partielle oder kortexsparende laparoskopische Adrenalektomie konnte sicher durchgeführt werden. Gleichzeitig konnte dabei die Nebennierenfunktion erhalten werden, unabhängig davon, ob die zentrale Nebennierenvene erhalten werden konnte oder nicht. Daher betrachten wir dies als eine nützliche operative Technik für ausgewählte Fälle.

Section 2. Thyroid: Direct mini-incision thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize surgical invasiveness and improve the cosmetic result. Our procedure differs from conventional thyroidectomy in requiring a 3-cm skin incision and no raising of the skin flap. Since this technique decreased tissue trauma by obviating unnecessary neck exploration, hypesthesia or paresthesia in the neck and discomfort while swallowing, related to a large skin incision and raising of the skin flap, are minimized. Since thyroidectomy is performed after delivering the thyroid gland through the small skin incision, sufficient exposure for dissection of the pretracheal and paratracheal space can be obtained. Therefore, injuring the recurrent laryngeal nerve and the parathyroid gland can be avoided. Although the number of patients that we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for patients with thyroid disease.