Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

The five steps approach of GETTA is easy to learn and can be adapted for dissecting both benign and malignant thyroid and parathyroid diseases. This technique offers significantly improved cosmetical results. It eliminates the carbon dioxide gas insufflation, and preserves the function of the anterior cervical region.

It is a viable and safe technique for patients with early low risk papillary thyroid carcinoma who wish to avoid a cervical scar. To begin, place the anesthetized patient in a supine position and abduct the upper limb on the affected side to a 60 to 90 degree angle. Then, make a primary incision of approximately four to six centimeters in length using a scalpel.

Next, create a secondary incision of about 0.5 centimeters using a surgical scalpel for the trocar. Locate the gap between the sternal head of the sternal cleo mastoid muscle and the clavicle head. Using the mini button of the ultrasonic scalpel, coagulate the small blood vessels within the gap.

Employ dissecting forceps in the ultrasonic scalpel to dissect the anatomical space between the sternothyroid muscle and the internal jugular vein. Dissect the natural space between the thyroid and sternothyroid muscle. Position the retractors within the space, and complete the creation of the surgical cavities.

Locate the recurrent laryngeal nerve around the bifurcation of the inferior thyroid artery using a nerve monitoring probe. Dissect the area around the inferior thyroid artery while protecting and coagulating the inferior thyroid blood vessels to expose the trachea. After coagulating and cutting off the branches of the inferior thyroid artery, follow the nerve pathway to the larynx, ensuring its protection during the dissection process.

Perform a central neck dissection method, like open surgery, and remove lymph nodes from the central compartment of the neck based on the extent of the patient's disease. After separating the upper pole of the thyroid gland, continue the separation process along the cricothyroid space to expose the blood vessels of the upper thyroid pole. Using the mini button of the ultrasonic scalpel, coagulate and carefully cut off the blood vessels of the upper pole of the thyroid gland.

Fully dissociate the gap between the upper pole of the thyroid gland and the cricothyroid muscle. Utilize an ultrasonic scalpel to coagulate small blood vessels. Then remove both the thyroid isthmus and the lymph nodes located in the central area alongside the thyroid gland.

Collect the specimen in the specimen bag. Using a laparoscopic aspirator, flush the operating cavity with warm sterile saline. Then position a drainage tube near the trachea and use dissecting forceps to guide the tube out from the axilla.

Close the axillary incision with a 30 centimeter interrupted absorbable 4.0 suture. In this study, a cohort of 200 female patients with a mean age of 36 years underwent the gasless endoscopic thyroidectomy trans axillary approach. Five patients experienced temporary recurrent laryngeal nerve signal weakening, post surgery, which resolved after a month.

No cases of permanent recurrent laryngeal nerve injuries were observed. However, three patients required conversion to open surgery due to intraoperative bleeding. It is crucial to recognize and protect the recurrent laryngeal nerve before any surgical intervention involving coagulation or cutting.

Following this procedure, parathyroidectomy and the lateral lymph node dissection can concurrently be executed with a procedure. Upon further refinement, this technique can facilitate total thyroidectomy, parathyroidectomy, and the lateral lymph node dissections, in addition to being adaptable for endoscopic breast surgeries.