The number of surgical interventions in endocrinology is steadily increasing. There are a large number of thyroid diseases, some of which require surgery. Surgical interventions in this area requires a high level of professionalism and the availability of modern equipment. In addition, given the complex anatomy in the area of thyroid and parathyroid glands, it requires perfection of surgical techniques.
Treatment in Germany, in Munich, various medical centers are developing new methods of surgical treatment of thyroid diseases. Such methods include minimally invasive technologies, which allow to avoid drains and accelerate the process of healing and recovery after surgery. Also, endoscopic technologies are used, when using which the suture is cosmetic, it improves the quality of life of the patient. In addition, gaining momentum application of technologies with the help of robot, it improves visualization during surgery, as well as they allow to remove pathological structures of small volume without affecting healthy tissues.
1. In the area of the thyroid gland tissues are hypervascularized, i.e. they have a large number of blood supplying vessels. Therefore, when performing any, even seemingly the simplest operations in this area, specialists have to face a large number of bleeding, which is quite difficult to stop. To reduce the number of such complications in German clinics use laser technology, clipping, as well as performing diathermocoagulation or deep tissue heating with LigaSure. In addition, many German operating rooms, particularly in Munich, use ultrasound technology.
Each of the above methods have both advantages and disadvantages. Two devices are the most popular and have the maximum number of advantages: the bipolar energy sealing system and ultrasonic coagulation.
— LigaSure is a bipolar diathermy system that seals vessels with little thermal exposure of the surrounding tissue. The device has been successfully used in abdominal surgery and was introduced as a new method of hemostasis during thyroidectomy. The LigaSure diathermy system provides simultaneous selective sealing and vessel separation without energy dissipation and with less heat generation. Also, the application of this method allowed to change the surgical technique itself, to reduce the duration of head rotation, to shorten the operation time and to reduce the operative access.
2. A relatively recent invention is the harmonic scalpel. It uses high-frequency mechanical energy to simultaneously incise and coagulate tissue and is also used in otorhinolaryngologic, cardiac, gastrointestinal, vascular, laparoscopic, obstetric and gynecologic surgery. The main advantages of ultrasonic coagulation/dissection systems over the standard electrosurgical device are represented by minimal heat damage to surrounding tissues. There is less smoke produced, no neuromuscular stimulation, and no effect of electrical energy on the patient.
3. The main goal of all endoscopic approaches is to improve the cosmetic results of conventional surgery. Endoscopic thyroidectomy has been categorized into two types: video-assisted and total endoscopic. Also, endoscopic methods of surgical treatment with and without CO2 insufflation are distinguished.
4. Minimally invasive video-assisted thyroidectomy (MIVAT) is characterized by a single 1.5 cm access in the mid-neck region, approximately 1-2 cm above the level of the sternum; tissue dissection is performed using tiny spatulas to separate the muscle from the overlying thyroid lobe in the muscle bed. From this point, the procedure is performed endoscopically without the use of CO2 with external retraction. A 5 mm diameter laparoscope is used with this technique. After insertion of the laparoscope through the skin incision, the fascia is completely dissected using laparoscopic instruments with a diameter of 2 mm. The use of optical magnification allows excellent observation of both the external branch of the superior laryngeal nerve as well as the recurrent nerve, which are isolated along with the upper part of the parathyroid gland. During the operation, the recurrent laryngeal nerve is checked, and after the final check of the nerve operation, the final stages of the operation are performed. When using endoscopic techniques, the muscles under the superficial layer of tissue are not separated or pulled away, this results in less tissue swelling. Clinical studies conducted with MIVAT on the benefits of this procedure have shown a better cosmetic effect and less postoperative pain compared to other surgical techniques.
When developing the endoscopic lateral access used for hemithyroidectomy, endoscopic instruments specifically designed for this procedure are used. An additional advantage of this method compared to classical methods is the absence of the need for additional assistants to hold retractors.
Total endoscopic thyroidectomy is a more sophisticated variation of the minimally invasive technique of thyroid removal. Using specialized instruments and techniques, part or all of the thyroid gland can be removed through a small incision, avoiding additional damage to the neck. To achieve this goal, various accesses have been developed and refined, mainly the commonly used: cervical, anterior, axillary, and thoracic accesses. However, none of these accesses is exclusively advantageous or universally accepted. Cervical and axillary accesses are minimally invasive but cosmetically not superior. Axillary and thoracic accesses are no longer minimally invasive enough to achieve the desired beneficial effect. Furthermore, axillary approaches are not suitable for bilateral manipulations and are even more technically challenging. Thus, based on all the advantages and disadvantages of the above-mentioned accesses, the axillary-bilateral access (ABBA) was developed, which is actually a combination of the others. The axillary-mammary access (BABA) was introduced later and was also claimed to be easily applicable for thyroid cancer removal. While the applicability of the endoscopic approach is limited by the size of the gland, researchers noted that this limitation does not exist for BABA as even large glands are easily extracted through axillary access. This method is now even being improved with the Da Vinci robotic system.
Endoscopic thyroidectomy includes a requirement for additional equipment, namely high-resolution endoscopes and monitors for video-enhanced techniques.
5. Robotic surgery
Robots began to be used in the operating room about 15 years ago, but their use in assisting in laparoscopic endocrine surgery is very new. Due to improvements in technology, easier set up, better image quality, and smaller robotic systems, there has been interest in using a robot for thyroid surgery. Thyroid surgery is an excellent target for robotic equipment compared to conventional endoscopic techniques because it requires work to be performed in a small space, which greatly limits the type of equipment that can be used. Robotic technology seems to overcome the limitations of conventional laparoscopic technology in thyroid surgery.
The Da Vinci Surgical System consists of a «surgical console» and a «surgical arm cart». The surgical cart holds the robotic instruments and the endoscopic camera. The endoscope for the Da Vinci system is a specially designed 12mm dual camera endoscope that is capable of sending 3D images to a specialized viewing screen in the console called the InSite Vision System. By examining this 3D imaging system, which eliminates all superfluous images other than those on the screen, the surgeon is immersed in the operative area. The camera and instruments are controlled by joysticks on the console. To alternate back-and-forth digital handle control between camera control and instrument control, the surgeon presses a foot pedal at the base of the console. There are currently 18 different robotic instruments in the Da Vinci system.
Once immersed in the Da Vinci virtual field, the surgeon inserts fingers into the handles, sits in an ergonomically correct position and then maneuvers the instruments: side by side, step (up/down), insert, grasp and others. In fact, maneuvering the Da Vinci instruments is like miniaturizing your hands and wrists and placing them in cavities they normally can’t be immersed in, allowing for fine, precise dissection and suturing in the smallest cavity possible — through small skin incisions. Once the system was introduced it continued to be refined, and the second generation, the da Vinci S, was released in 2006. The latest version, da Vinci Si, was released in April 2009 with an improved full HD camera system, improved ergonomic features and, most importantly, the ability to use two consoles for surgery.
The Zeus robotic surgical system also has two components: a console for the surgeon and robotic instruments connected by a computer interface that can filter tremor and adjust the motion and rotational scale of the instruments. Unlike the Da Vinci system, the Zeus robots are not on a cart, but instead can be attached directly to a work table. The second difference between Zeus and Da Vinci is that Zeus uses an activation camera control system called the AESOP Robotic Endoscope Positioner. Instead of requiring a specialized 12mm endoscope like the Da Vinci, Zeus allows the use of routine 5mm or 10mm endoscopes with the AESOP arm. With this system, the surgeon can continuously maneuver the camera position with simple voice commands. The next difference between the two robotic surgical systems is that the Zeus system currently uses robotic laparoscopic instruments that do not have the additional degrees of freedom that would result from an instrumented «endoscopist» handpiece designed to mimic the human hand. Like standard laparoscopic instruments, these advanced Zeus instruments have only 5 degrees of freedom.
As robotic technology rapidly advances, Zeus is already in its third stage of design and is now available with tools called «Microwrist Technology». These new tools have cues that mimic the movements of the human wrist.
Filtering hand tremor, providing fine movements, ensuring minute and precise tissue manipulation, and an ergonomic console help surgeons experience less fatigue.
6. Prevention of postoperative laryngeal nerve palsy: neuromonitoring
Technological advances now allow accurate, non-invasive monitoring of the development of laryngeal nerve palsy during thyroidectomy. Experts note that nerve injury during thyroidectomy can be caused by stretching, pressure, crushing, electrical damage, ligature, and ischemia. In these cases, the injured nerve may appear intact to the surgeon’s eyes. Thus, monitoring nerve function represents a complement and extension of the usual visual identification of the nerve during surgery.
Thus, the availability of new technologies in thyroid surgery expands the scope for improving surgical techniques and outcomes.
Clinics in Germany utilize all of the above advanced technologies and accesses for thyroid surgery. This improves clinical outcomes and reduces the risks of various complications. In addition, hospitalization and recovery times after such surgeries are much shorter in German clinics compared to other countries.