Endoscopic neck surgery

especially due to cosmetic benefits. The primary target organs have been the parathyroid and the Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar thyroid glands, [2-9] although few studies have reported surgical technique was used for performing on its application to other cervical structures, such thyroidectomy the following year. Most commonly as the sub-mandibular gland and cervical spine. reported endoscopic neck surgery studies in Furthermore the approaches may be classified into literature have been on thyroid and parathyroid total (pure) endoscopic (CO glands.The approaches are divided into two types 2 assisted endoscopic and minimally invasive mini i.e., the total endoscopic approach using CO insufflation and the video-assisted approach without 2 incision approaches. [15-18] insufflation. The latter approach has been approach has been further sub-classified into a reported more often. The surgical access (port supraclavicular, anterior chest wall, axillary, and placements) may vary-the common sites are the periareolar breast approach. The latter three have also neck, anterior chest wall, axilla, and periareolar been attempted in the video assisted endoscopic region.The limiting factors are the size of the gland and malignancy. Few reports are available on approach. endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic ENDOSCOPIC PARATHYROIDECTOMY neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and Reported in 1996 by Gagner, the parathyroid glands feasible in suitable patients with thyroid and parathyroid pathologies. Application of this especially due to their size are amenable to the technique for approaching other cervical organs endoscopic approach. The drawback is their variable such as the submandibular gland and carotid artery position. Minimally invasive parathyroidectomy has are still in the early experimental phase. evolved due to a parallel progress in imaging and localizing techniques making a targeted approach


INTRODUCTION
The cervical region comprises a plethora of welldefined anatomical structures systematically arranged in layers with minimal or negligible vascular overlap these well-defined layers form the vascular anatomical planes, which have been exploited by the endoscopic surgeon to create a working space for surgical manipulation.Reported initially in 1996, [1] endoscopic neck surgery has evolved in its application [21][22][23][24] A combination of the sestamibi scan along with a radiological investigation has been described as equivalent to an open conventional bilateral exploration of the neck for localizing the parathyroid lesion.High-resolution cervical ultrasonography alone has reported a high success rate of 94% for pre operative specific side localization of the parathyroid lesion. [20]The sensitivity was reported as 89% with a 98% positive predictive value.The most popular minimally invasive approach for performing parathyroidectomy is the focused minimally invasive mini incision approach. [25,26]Few reports are available for total endoscopic parathyroidectomy, reporting on limited number of patients.Currently just below 50% of all parathyroidectomies are being performed by the minimal access approach popularly known as minimally invasive parathyroidectomy (MIP). [27]estrictions in its applicability are selection criteria such as unilateral disease, (preferably a single adenoma), absence of thyromegaly, no previous neck agnosed to have parathyroid hyperplasia.Ten pro cedures (7 procedures with CO 2 insufflation and three procedures video-assisted) were performed by a supraclavicular approach, four by an anterior chest wall approach, and four by a periareolar breast approach.Carbon dioxide insufflation was maintained at 10 mm of Hg.Post-operative monitoring of S Ca ++ and S PTH levels were done to confirm complete removal of all hyper functioning parathyroid tissue.There was one conversion due to non-localization of the parathyroid adenoma.The tumor was identified in the tracheo -esophageal surgery and no previous history of irradiation to the groove.30] experience is small, the results conform to those reported in literature in terms of safety and Techniques to ensure complete removal of the hyper feasibility.functioning parathyroid tissue in MIP reported are intra-operative rapid parathormone assays, [29,[31][32][33][34] Our progress from a supraclavicular approach to a frozen section and good clinical judgment followed periareolar approach is strongly driven by superior by post-operative S.Ca ++ and PTH level monitoring.cosmetic results, as the dissection involved in this Several studies have also reported day care MIP usapproach is much more than a focused mini-incision ing local/regional anesthesia. [26]Such centers apply approach.techniques, such as chemilumiscent assay for intact PTH level (quick PTH) giving a success rate of 95-98%

ENDOSCOPIC THYROIDECTOMY
37][38] However, these results are best observed in patients Unlike parathyroidectomy, endoscopic thyroidecto with uniglandular disease.Provided a careful preop-my has progressed toward more remote sites of ac erative patient selection is performed, an MIP will cess to improve cosmesis and provide patients with cure the patient whether or not an intra operative a scar less neck.This has been more on patient de-QPTH assay is done [Table 1]. [25]and as thyroid disease predominantly affects wom en.Endoscopic thyroidectomy was first reported in Carbon dioxide embolization, a potential life 1997 [2] since then several reports have been published threatening complication has so far not been reported.
describing novel ways (neck, chest wall, axilla, and breast) [2][3][4]6,8,40,41] of access to this gland. Indication Our own experience spans 8 years with 18 patients for endoscopic thyroidectomy in various studies of primary hyperparathyroidism (PHPT) subjected to include solitary, benign thyroid nodules, follicular total endoscopic parathyroidectomy.About 17 of these patients were diagnosed with a single parathyroid adenoma on 99 TC sestamibi scan corroborated by an ultrasonography neck or an mag netic resonance imaging scan.One patient was di-  [39] Recurrent laryngeal nerve palsy Failed surgery (persistent -hyper calcemia/increase PTH) Hemorrhage Seroma Hypocalcemia and oxyphilic cell tumors, papillary micro carcinomas (<1 cm in size and no evidence of clinical or radiological lymphadenopathy) and Grave's disease.[3,13,42] The latter has been reported only sporadically [Table 2].However, few reports describing the video assisted approach have reported removing tumor up to 74 mm in size.[12] The aim of most studies apart from being cosmetically superior has been to be minimally invasive offering all associated advantages such as minimal post operative pain, rapid recovery, and low analgesic requirement.[51][52][53] In terms of invasiveness none of the distant sites of access prove to be truly minimally invasive as extent thyroidectomy, the latter results due to CO 2 insufflation.Studies comparing intra operative pain and speed of recovery (return to normal activity) have all reported results in favor of the endoscopic approach [6,11,45,62] reaching statistical significance although analgesic requirement was not different.[52] Both video-assisted and total endoscopic approaches have been reported for operating on thyroid cancer.The prerequisite are papillary tumors <1 cm in size with a negative clinical and radiological lymph node status.[11,12,45,55] Overall about 8% patients undergoing of invasion is much more compared to a focused, endoscopic thyroid surgery had papillary carcinoma.direct approach.The popularity has however persisted Patients of follicular carcinoma less than 5 cm may and increased due to improvement in cosmesis.
undergo endoscopic thyroidectomy.This surgery may also be recommended as a prophylaxis [63] to patients The supraclavicular approach has other advantages of multiple endocrine neoplasia with medullary such as rapid access to thyroid (in the event of a carcinoma.vascular mishap), the advantage of applying external pressure for hemostasis. [54]The video-assisted focused Our experience comprises 25 patients operated since approach using conventional instruments has a 1997.57][58] and four patients had small multi-nodular goiter.In three patients a supraclavicular approach was The size of the thyroid lobe removed has varied adopted and 22 patients were operated by a peri between 20-80 mm and the volume where recorded areolar approach.The surgery in one of the three has ranged 15-73 grams in most studies. [16,42,58,59]A patients of the supraclavicular approach was thyroid size beyond 70 mm or 70 grams becomes converted to a conventional exploration due to too voluminous to provide an adequate safe working abnormally high vascularity of the gland, which turned out to be a multi-centric papillary carcinoma on histopathology.The patient subsequently Studies reporting total endoscopic thyroidectomy under went a completion thyroidectomy.Three with carbon dioxide insufflation have reported using patients developed subcutaneous emphysema which ultrasonic shears for dissection and excision of the resolved over 24 hours and five patients showed specimen. [5,6,40,58]The size and volume of tissue bruising in the presternal region which resolved in removed by either method is similar.The use of 2 weeks.There were no other complications.It was harmonic scalpel has been shown to reduce operative easier operating from the periareolar approach as a space.
time in thyroid surgery [Table 3]. [60]l complications save the last have been reported with both video assisted and total endoscopic larger working space was available.In 21 patients of solitary thyroid nodule a hemi thyroidectomy was performed and in three patients of multinodular goiter the excision extended to a little more than half the opposite lobe.The size of the resected specimen varied from 2 x 2.4 cm 2 to 5 x 4.1 cm 2 (the specimen were not weighed).
The sub-mandibular gland and other structures A few reports have been published over the past 2 years about an endoscopic approach to the sub- ) .
mandibular gland. [62,63]It has been demonstrated in cadaveric models to be possible. [64]Initial attempts, reported injury to facial artery and lingual nerve.Video-assisted approach deploying the harmonic scal pel has also been reported with a 15-20 mm skin incision.Endoscopic sentinel lymph node biopsy in oral malignancy is another area where this potential is being explored. [65]These reports are all in the very early phase and may at the most be described as experimental.The cervical spine is another region where endoscopy is being commonly practiced, but since it involves a specialty branch that is neuro increasing skill and patient demand, this surgery is focused, scan guided parathyroidectomy-experience from the first going to be performed in more centers.However mandibular gland is as yet in the experimental stage.) .
l i c a t i o n s ( w w w .m e d k n o w .c o m et al.: Endoscopic neck surger y et al.: Endoscopic neck surger y l i c a t i o n s ( w w w .m e d k n o w .c o m 100 cases.Harefuah 2003;142:242-5,320.careful patient selection is advocated.Though few 20.Gilat H, Cohen M, Feinmessr R, Benzion J, Shvero J, Segal K, et al.Minimally invasive procedure for resection of a parathyroid centers are reporting good results in thyroid adenoma: The role of malignancy, the role of endoscopy in thyroid ultrasonography.J Clin Ultrasound 2005;33:283-7.malignancy is as yet controversial.Endoscopic 21.Yamashita H, Noguchi S. Recent advances in the diagnosis and treatment of primary hyperparathyroidism.Nippon Geka Gakkai approach to other neck structures such as the sub-Zasshi [Japanese] 2005;106:468-71.

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22. Fuchs SP, Smits AB, de Hooge P, Muller AF, Gelissen JP, van Dalen T Minimally invasive parathyroidectomy: A good operative procedure for primary hyperparathyroidism even without the CMYK7 l i c a t i o n s ( w w w .m e d k n o w .c o m