in past three decades , minimal access and minimally invasive techniques have been firmly established in the field of surgery .
though , initially it was restricted to abdominal and gynaecological surgeries , minimal access techniques have been employed in sub specialities in the latter period . similarly , thyroidectomy is not an exclusion to these minimally invasive approaches .
various endoscopic thyroidectomy ( et ) techniques ranging from totally endoscopic , video- assisted , trans - axillary , chest wall approaches have been reported .
the gas dependent techniques also lead to complications such as hypercarbia , subcutaneous emphysema , mediastinal emphysema , cardiac arrythmias etc . in few cases . in this context
, we evaluated our technique of a safer et through trans - axillary route for its feasibility and safety .
this is a retrospective study conducted in endocrine and metabolic surgery department of a tertiary care teaching hospital in southern india .
this study complied with the international ethical norms according to helsinki declaration - ethical principles for medical research involving human subjects .
the details of operative technique were documented and recorded in all the cases . only cases with benign thyroid nodules were included .
exclusion criteria were diffuse toxic goitres ( graves disease ) , thyroid cancer , > 6 cm nodules , recurrent goitres and patients with shoulder joint pathology .
all the cases were performed by the operative team -the primary operating surgeon ( os ) and two assisting surgeons ( as ) .
the ipsilateral arm was abducted to 90 and elbow flexed such that hand stays besides the head .
the surface markings of relevant anatomical landmarks such as clavicle , anterior axillary line ( aal ) , sternocleidomastoid ( scm ) and jugular notch were made [ figure 1 ] . surface markings for surgical procedure - axillary incision ( vertical arrow ) ; anatomical landmarks ( trasverse arrows ) a 4 - 5 cm long skin incision was used 1 cm posterior and parallel to aal . skin incision was deepened up to pectoral fascia .
pectoral fascia was incised in the same line and sub - fascial dissection was performed by blunt digital and sharp instrumental dissection to create operative space .
after initial dissection , subsequent dissection was done under telescopic guidance placed through the same incision and held by camera assistant ( ca ) .
thus , dissection for operative space was done both under synergistic view of naked eye and monitor .
the operating surgeon ( os ) and as stand on ipsilateral side of goitre to visualize the operative field through the axillary incision .
thyroid bed was entered through the distal avascular area between the two heads of scm [ figure 2 ] .
the sternal head of scm and strap muscles are retracted by as to the opposite side . while managing the clavicular head of scm , os retracts carotid sheath and superior vascular pedicle is ligated with conventional knotting or clipping individual vessels [ figure 3 ]
. further medial mobilization of helps in visualizing and securing the recurrent laryngeal nerve ( rln ) and superior parathyroid gland ( ptg ) .
ipsilateral goitre was resected after incising the isthmus , which was sutured in conventional way .
a 14 fr suction catheter is placed in to thyroid bed and operative space through a separate stab wound in axilla .
it was retained in situ till the drain output was less than 20 ml on two consecutive days with no erythema or bogginess in dissected area .
intraoperative view i - approach to thyroid through sternomastoid muscle - sternal head ( white arrow ) ; clavicular head ( black arrow ) intraoperative view ii - clipping of superior pole vessels ( white arrow ) ; superior parathyroid ( black arrow ) ; retracted strap muscles ( hollow arrow over goiter ) intraoperative view iii - recurrent laryngeal nerve ( black arrow ) ; superior parathyroid ( lower end of double headed arrow ) ; suture being threaded to tie a branch of inferior thyroid artery ( hollow arrow ) post - operative period was uneventful in all the cases .
the ipsilateral arm was abducted to 90 and elbow flexed such that hand stays besides the head .
the surface markings of relevant anatomical landmarks such as clavicle , anterior axillary line ( aal ) , sternocleidomastoid ( scm ) and jugular notch were made [ figure 1 ] . surface markings for surgical procedure - axillary incision ( vertical arrow ) ; anatomical landmarks ( trasverse arrows ) a 4 - 5 cm long skin incision was used 1 cm posterior and parallel to aal . skin incision was deepened up to pectoral fascia .
pectoral fascia was incised in the same line and sub - fascial dissection was performed by blunt digital and sharp instrumental dissection to create operative space .
after initial dissection , subsequent dissection was done under telescopic guidance placed through the same incision and held by camera assistant ( ca ) .
thus , dissection for operative space was done both under synergistic view of naked eye and monitor . the operating surgeon ( os ) and as stand on ipsilateral side of goitre to visualize the operative field through the axillary incision .
thyroid bed was entered through the distal avascular area between the two heads of scm [ figure 2 ] .
the sternal head of scm and strap muscles are retracted by as to the opposite side . while managing the clavicular head of scm , os retracts carotid sheath and superior vascular pedicle is ligated with conventional knotting or clipping individual vessels [ figure 3 ] .
further medial mobilization of helps in visualizing and securing the recurrent laryngeal nerve ( rln ) and superior parathyroid gland ( ptg ) .
a 14 fr suction catheter is placed in to thyroid bed and operative space through a separate stab wound in axilla .
it was retained in situ till the drain output was less than 20 ml on two consecutive days with no erythema or bogginess in dissected area .
intraoperative view i - approach to thyroid through sternomastoid muscle - sternal head ( white arrow ) ; clavicular head ( black arrow ) intraoperative view ii - clipping of superior pole vessels ( white arrow ) ; superior parathyroid ( black arrow ) ; retracted strap muscles ( hollow arrow over goiter ) intraoperative view iii - recurrent laryngeal nerve ( black arrow ) ; superior parathyroid ( lower end of double headed arrow ) ; suture being threaded to tie a branch of inferior thyroid artery ( hollow arrow ) post - operative period was uneventful in all the cases .
6/15 patients had compensated comorbidities such as diabetes , hypertension , chronic airway disease . at the time of surgery , all the patients were rendered euthyroid .
demographic and clinical profile operative , postoperative morbidity and histopathology details are shown in table 2 .
the only specific complications were induration in the infraclavicular area between axillary incision and thyroid region , prolonged wound drainage and stiffness in lower 3 of sternocleidomastoid .
induration of infraclavicular area resolved at a mean of 20.7 ( 15 - 35 ) days and sternocleidomastoid induration at a mean of 36.5 ( 22 - 50 ) days in all the cases .
all the patients had excellent cosmetic outcome with a hidden surgical scar in axilla [ figure 5 ] .
surgical and post - operative details 12th post - operative day clinical photograph - no cervical scar ( white arrow ) ; axillary incision to be hidden by clothes ( lower black arrow ) ; induration in ipsilateral dissected area ( vertical arrow )
a glance at the history of thyroidectomy reveals how it was developed by pioneer endocrine and thyroid surgeons through various stages till the present era of minimal access surgery .
though , open conventional thyroidectomy is still the favored approach worldwide , a plethora of endoscopic thyroidectomy ( et ) techniques ranging from totally endoscopic , video - assisted , trans - axillary , chest - wall approaches have been already employed . even novel approaches such as thoracoscopic , robotic , trans - oral , post - auricular routes have been explored .
though none of them are validated universally , chest - wall and trans - axillary approaches are favoured by the majority .
the objectives of any et technique are better cosmesis , lesser pain , lower morbidity and feasibility in patients with co - morbidities .
most of available et techniques fulfill cosmetic and pain aspects , but fail to address the latter two aspects . based on use of gas ( co2 ) , et may be broadly divided in to gas dependent and gasless techniques .
the gas dependent techniques can cause serious hypercarbia associated complications such as subcutaneous emphysema , mediastinal emphysema , cardiac arrhythmias and even death in few cases . especially , patients with comorbid conditions such as hypertension , diabetes and chronic obstructive airway disease are susceptible to the complications .
these complications are related to co2 insufflation pressures , length of surgery , susceptibility and comorbid conditions of the patient .
lower co2 insufflation pressures , intensive end tidal co2 monitoring ( etco2 ) , intra - operative arterial blood gas analysis ( abg ) , intermittent desufflation , shorter operative times , proper patient selection have been recommended to counter these gas related complications . on the contrary ,
gasless techniques are very safe as it nullifies the whole gamut of gas related morbidity .
thus , even patients with well to moderately controlled comorbidities can be taken up for surgery and allows longer operative times with extra safety .
it also reduces the cost of intensive etco2 and abg monitoring used for gas dependent techniques .
the only practical disadvantage of gasless over gas dependent technique is inadequate operative space , which can be compensated by proper retraction by as and synergistic naked eye and camera vision of thyroid area . in conventional open approach
, the gland is reached through a range of variably sized collar neck incisions in the neck , which can result in scar with hyperesthesia , paraesthesia and increased patient self - awareness .
furthermore , keloid or hypertrophic scar worsens the cosmetic outcome , especially in dark skinned individuals .
total et has reduced the level of surgical invasiveness with extra - cervical short incisions with superior cosmetic outcome , but is a gas dependent technique with its associated risk .
the trans - axillary approach utilizes an access through the axilla , thus avoiding a cervical or chest wall incision .
this is especially applicable in modern times , due to increasing use of low neck tops exposing the upper anterior chest wall , which is the surgical access area for et through chest wall .
the position of the patient has great importance , as abduction of the arm and flexion of the elbow reduces the distance between the aal and the thyroid bed by almost 4 - 6 cm , ensuring easier accessibility of thyroid through axilla .
pre - operative surface marking was very much useful in limiting dissection during creation of the space .
the plane of dissection was confined below the pectoral fascia , which reduces the chances of skin burns due to electro - cautery and subcutaneous ecchymosis .
the development of this natural plane was easier compared to traumatic dissection of subcutaneous space and beyond clavicle ; it was continued in to sub - platysmal plane .
the use of telescope with magnified view on monitor with synergistic naked eye vision has a practical advantage ( vide infra ) .
both steps are complementary , especially for identification and preservation of critical structures like rln and ptg .
the entry in to the thyroid bed was through the two heads of scm which is a relatively avascular plane in the lower 1/3 .
further , it reduces the morbidity related to strap muscle division . throughout the procedure it requires efficient retraction of the sternal head of scm along with strap muscles the as
. thus it does not require co2 gas to maintain the working space for dissection and thus precludes its related morbidity .
the dissection performed utilizes both open as well as laparoscopic instruments and the combines the advantages of both the techniques .
maneuvering in the depth to ligate the superior pole by open knotting technique is one of the disadvantages for the surgeons with shorter fingers . in such situations ,
all the haemostatic techniques such as direct knotting , diathermy , clips can be used complementarily and interchangeably as per surgeon 's experience .
the sternohyoid muscle to create a good visual space even for the contralateral lobe dissection has been described , but has disadvantage of prolonged operative time and post - operative neck pain with discomfort while swallowing .
to counterbalance this situation , we employed a similar procedure on contralateral side through its corresponding axilla for total thyroidectomy .
this bilateral axillary approach for total thyroidectomy was not associated with any extra morbidity compared to unilateral approach and ensures better identification of rln and ptg on both sides .
kang et al . , described a similar technique , but employed a subcutaneous route with an additional 5 mm chest wall port .
holsinger et al . and landry et al . , described a robotic technique with similar approach , but are feasible in very few centers in near future .
though , it increases the area of dissection in infra - clavicular region , it compensates with better post - operative cosmetic result .
comparision between various studies of trans - axillary thyroidectomy the three notable morbidities , we observed with this technique are prolonged drainage ( mean : 5.4 days ) , induration of lower part of scm and induration of infraclavicular area .
infraclavicular induration is evidently due to larger area of dissection compared to conventional thyroidectomy , through neck and lymphatic plexuses in subpectoral mammary area . in our experience , with conventional thyroidectomy
though , we did not perform formal analysis of this variable in the present study , this observation is significant enough to investigate further as it prolongs hospital stay .
the increased seroma rates in other studies might be due to earlier drain removal or understatement , as we found wound drainage lasted for longer duration than the hospital stay in those studies .
induration of lower 1/3 of scm is probably due to splitting and dissection between its two heads .
though , it was self - limiting , it appears to be a unique complication specific to gstat .
induration of ipsilateral infraclavicular area corresponded to the dissected area between axillary incision and thyroid bed .
similar to scm induration , this was self - limiting and unique to gstat , although of shorter duration than the former . in an effort to obviate the adverse aesthetic and morbid effects of conventional open surgical technique and gas dependent et techniques
, we employed this gasless single incision trans - axillary thyroidectomy ( g - stat ) .
the basic sequence of steps in the procedure is nearly identical to a conventional open thyroidectomy .
an endoscope provides excellent lighting and magnification , thus the entire surgical team can see the structures and procedure better than in a conventional open procedure .
thus , this technique combines the magnification of endoscopy and tactile sensation of open surgery .
this study demonstrates the feasibility and safety of gasless trans - axillary endoscopic thyroidectomy technique for nodular goitres with usual general surgical risk .
 introduction : a range of minimally invasive endoscopic techniques ( gas dependent and gasless ) have been attempted for thyroidectomy in the past two decades . in this context 
 , we evaluated the feasibility and safety of our technique of a gasless trans - axillary thyroidectomy.material and methods : this retrospective study from the department of endocrine and metabolic surgery in southern india included 15 cases . 
 the details of operative technique , intra and postoperative data were documented in all the cases . only cases with benign thyroid nodules were included . 
 exclusion criteria were diffuse toxic goiters ( graves disease ) , thyroid cancer , > 6 cm nodules , recurrent goitres and patients with shoulder joint pathology . 
 statistical analysis was done with spss software 12.0 version.results:f:m -14:2 . 
 mean age of the patient group was 26.4 years ( 15 - 52 ) . 
 mean operative time was 123.4 ( 82 - 206 ) minutes . 
 the only specific complications were induration in the infraclavicular area between axillary incision and thyroid region , prolonged wound drainage and stiffness in lower 3rd of sternocleidomastoid . 
 wound drainage lasted for 5.4 days ( 4 -8 ) . 
 there was no significant operative morbidity.conclusion:this gasless trans - axillary technique for nodular goitres is safe and effective in the hands of an experienced thyroid surgeon . 
INTRODUCTION
MATERIAL AND METHODS
Description of Operative Technique
RESULTS
DISCUSSION
CONCLUSION