Scarless thyroid surgery

1. Scarless Thyroid Surgery Chea Chan Hooi MD, MS, FMAS, DMAS, CMIA, AMM Borneo Medical Centre (Miri)

2. Content • Anatomy • Function • Clinical features • Investigations • Treatment options • Medicine • Surgery • Radioiodine • Q&A

3. Anatomy • Butterfly shaped • 30 - 50% of population have pyramidal lobe • Goitre = enlarged thyroid gland

4. Function • Cardiac • Increase heart rate • Increase cardiac output • Respiratory • Increase respiration rate • Biochemical • Increase basal metabolic rate • Increase protein and carbohydrate metabolism • Nervous system • Potentiates brain development • Increase sympathetic activity • Reproductive • Increase endometrial thickness

5. Classification of thyroid disorders • Anatomical • Solitary nodule • Dominant nodule of MNG • Multinodular goitre (MNG) • Diffuse goitre • Functional • Hyperthyroidism (↑) • Hypothyroidism (↓)

6. History • Compressive symptoms • Malignancy component • Risk factors • Red flags • Cancer spread symptoms • Thyroid status • Hyper or hypothyroidism symptoms • Past thyroid or neck surgery

7. Graves eye signs NO SPECS Class 0 None Class 1 Only signs (lid retraction ± lag) Class 2 Soft tissue (conjunctival & lids edema, injection) Class 3 Proptosis Class 4 Extraocular muscles involvement Class 5 Corneal involvement Class 6 Sight loss (usually CNII)

8. Tests • TFT • TSH • T4 • T3 • Antibodies • Anti-TPO • Anti-Tg • Thyroglobulin • ECG • CXR • CT scan

9. Treatment options • Cancer • Surgery • Radioiodine • Hyperthyroidism • Medical • Radioiodine • Surgery • Thyroiditis • Medical • Less is more

10. Thyroidectomy - removal of thyroid • By extent Hemithyroidectomy

11. • Open • Via collarneck incision • Endoscopic •Facelift incision approach •Breast-axillary approach •Transoral

12. Facelift approach

13. Breast approach

14. Transoral thyroidectomy

15. Possible complications General • Bleeding • Infection • Hoarseness of voice • Surrounding organ injury Specific • Chin numbness • Lip asymmetry

16. Advantages • No visible scar • Minimal skin area dissected, less bleeding, less infection, less thickening Disadvantages • New technique • Not for huge goitres • Potential contamination by oral cavity bacteria • Numbness at chin

17. Patients who are not suitable • Previous radiotherapy to neck • Previous neck surgery • Goitre extends into chest • Goitre stuck to other organs • Needs extensive lymph node dissection • Nodule > 6cm

19. Conclusion • Goitres are common • Beware of red flag symptoms that suggest malignancy • Surgery had always been a main treatment option for goitres • Transoral thyroidectomy avoids a visible neck scar • Transoral thyroidectomy is the next frontier in thyroid surgery

20. TQ! Q&A?