Scarless thyroid surgery

A presentation on the latest technique to remove the thyroid gland; via the transoral route. This novel technique is a form natural orifice trans-endoscopic surgery (NOTES) and is truly scarless. Comparisons with the traditional open and other remote endoscopic techniques are explored.

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

18. ?

19. Conclusion Goitre s 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?