Thyroid Surgery

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Repdsesstuinas

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Does anyone have input on who typically does most thyroid surgery (between general surgerons who have done an endocrine fellowship vs ENTs)? Also, do many generalist ENTs do much thyroid surgery or is that more limited to the H&N fellows?

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At the medical center it really depends on the referral patterns. Whoever is in best with the local endocrinologists gets the business.

In practice, I don't get the sense that a lot of general surgeons do thyroids, it seems to be a mainly ENT procedure (though I am in ENT so likely a bit biased in what I see and hear about). And it's definitely done by ENT generalists, you don't need head and neck training to do a thyroid (generally speaking, with some exceptions).
 
Thanks for the input. Thyroid/parathyroid pathology is one of the main reasons I became interested in ENT. Appreciate the input.
 
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In my main facility, my group (3 ENT's) does 90+% of the thyroids. There are a total of 7 ENT's that have privileges in this facility and 5 general surgeons. At our secondary hospital, it's about 95% with only 3 general surgeons. We've worked hard to build our thyroid practice, although I'm starting to question why as the reimbursement on thyroids has significantly decreased relative to the B&B of tubes and tonsils. We make the smallest incisions when doing non-endoscopic (3cm incisions for lesions up to about 5.5cm). We make 1.5cm incisions when doing endoscopic. We don't have the DaVinci so we don't do transaxillary approaches here. I think our small incisions and good outcomes are what have sold our practice to the endocrinologists.

The parathyroid market is more evenly split. We do about 70% of those. Mostly because we just don't do many and building that reputation has taken longer, although about a year and a half ago I'd say it was closer to 50%, so again, our small incisions and good outcomes have made a tremendous impact on referral patterns.

None of us are fellowship-trained.
 
We make the smallest incisions when doing non-endoscopic (3cm incisions for lesions up to about 5.5cm). We make 1.5cm incisions when doing endoscopic.

Wow. That is small. What retractor system do you use? I don't think an Army-Navy or a Langenback would even fit in a 3cm incision. How many people do you need helping you with retraction/exposure when you do these?
 
Wow. That is small. What retractor system do you use? I don't think an Army-Navy or a Langenback would even fit in a 3cm incision. How many people do you need helping you with retraction/exposure when you do these?

I use the Alexis retractor system. Extra small version which can accomodate incisions from 2-5cm. It's awesome and protects the skin well when using the Ligasure or Harmonic. I use one scrub and one assist--either my partner or another scrub to do these cases. The nice thing is the assist can usually hold just 1 army navy to retract the straps and it's plenty because the alexis does the rest.

When I do an endoscopic one, I use 1 scrub and 1 assist and no retractors (except sometimes a freer)--the assist mostly holds the scope. I don't particularly see a huge benefit from the endoscopic approach over the 3cm version in terms of long term healing. The scar is much less visible sooner, but in a year, you can barely see either.
 
Similar here - we do most of the thyroids at two hospitals and ~50% at another. Incisions are usually 2.5-4 cm. Have tried them endoscopically on small nodules < 2 cm (both in residency and now that I am out), but adds more time to the case and the endoscopic incisions look similar to the smaller incisions in time. Rarely use drains except on the big ones (we did a 11.5 cm nodule the other day). Have been looking at the data for outpatient thyroidectomies (postop PTH, etc), but am a little to nervous to try it. Agree with the reimbursement thing, too. Especially when compared with other procedures (septoplasty + SMR turbs, for example).

What is challenging is taking residents through a thyroid with a small incision. There has to be a lot of trust in the resident as it is difficult to see exactly what they are clipping/cutting/harmonic.
 
I use the Alexis retractor system. Extra small version which can accomodate incisions from 2-5cm. It's awesome and protects the skin well when using the Ligasure or Harmonic. I use one scrub and one assist--either my partner or another scrub to do these cases. The nice thing is the assist can usually hold just 1 army navy to retract the straps and it's plenty because the alexis does the rest.

When I do an endoscopic one, I use 1 scrub and 1 assist and no retractors (except sometimes a freer)--the assist mostly holds the scope. I don't particularly see a huge benefit from the endoscopic approach over the 3cm version in terms of long term healing. The scar is much less visible sooner, but in a year, you can barely see either.

Nice. I should try it. The Alexis looks like one of those female condoms that were on the market years ago. Is it easy to use or should I have rep come in to teach me how to use it?
 
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Nice. I should try it. The Alexis looks like one of those female condoms that were on the market years ago. Is it easy to use or should I have rep come in to teach me how to use it?

The only thing that's tricky is making sure that you undermine wide enough for the inner green ring to fit. Once you get that down, it's a piece of cake to use. It wouldn't hurt for the rep to come in, but it's certainly just a matter of fiddling with it until you get it. For the XS size, you'll need your subplatysmal flap to be 5cm which seems huge when you've made a 3cm incision.

Like you, LeForte, I haven't placed a drain in over 5 years now and have done so without a hiccup so I agree with your post-op management. I haven't sent any hemithyroids or totals home yet despite the literature because I'm not receiving any pressure to do so from insurance or patients. I suppose I will when that pressure comes since we do have rapid PTH, but I sleep better knowing that there is close supervision that first night.
 
The only thing that's tricky is making sure that you undermine wide enough for the inner green ring to fit. Once you get that down, it's a piece of cake to use. It wouldn't hurt for the rep to come in, but it's certainly just a matter of fiddling with it until you get it. For the XS size, you'll need your subplatysmal flap to be 5cm which seems huge when you've made a 3cm incision.

OK. Just so I understand...does a 5cm subplatysmal flap mean you undermine 5cm superior, inferior, and bilaterally? Do you only use the XS size or do you use the next size up occasionally for a larger incision?

Also, are you also doing a level VI neck dissection through that incision? Do you use bipolar? Harmonic?
 
OK. Just so I understand...does a 5cm subplatysmal flap mean you undermine 5cm superior, inferior, and bilaterally? Do you only use the XS size or do you use the next size up occasionally for a larger incision?

Also, are you also doing a level VI neck dissection through that incision? Do you use bipolar? Harmonic?

No just 5cm diameter under the flap to accommodate the 5cm ring. I use the XS because it will allow for up to a 5cm incision. I have used a small Alexis when I helped a general surgeon do a total thyroid and he made a 5.5cm incision and I swear we could have done a heart transplant through it. I suppose you could use the larger Alexis's for gigantic goiters--I took out a 12cm gland last year, but didn't use the Alexis for it.

It's very easy to do a central neck dissection through the XS Alexis once the thyroid is out. I prefer the Ligasure to the Harmonic because it is smaller. The drawback is that once the vessel is sealed it takes an extra step to use Metz to divide. However, I like that because I can visually confirm the ligation prior to division (my own anality on that). My partner prefers the harmonic to avoid the extra step. I will have a bipolar available but use it only for surface bleeders on the thyroid more than anything--just the pesky suckers that bleed on a hashimoto's gland and stuff like that.
 
Using the da Vinci to do transaxillary thyroid surgery has got to be the most vain application of that device I could have ever conceived. Ridiculous.

Of course, using it for a tonsillectomy is pretty ridiculous as well.

Frankly, the whole thing is pretty stupid at this stage.
 
Fah-Q...you're reaching your "tin" anniversary. I just noticed.
 
Neutropeniaboy, I would agree transax seems a little much. Some other interesting approaches are coming out in the literature - transoral robotic as well as via face lift approach (I believe David Terris is the one behind this). I've started doing robotic cases as an extension of transoral laser resections and I think the exposure and tissue manipulation is excellent. I agree I would not use it for simple tonsillectomy. The technology there is only getting better so it will be interesting where it will be in 5 years.
 
Does anyone have input on who typically does most thyroid surgery (between general surgerons who have done an endocrine fellowship vs ENTs)? Also, do many generalist ENTs do much thyroid surgery or is that more limited to the H&N fellows?

At the hospital where I'm doing my residency (in ENT), we do virtually all of them. As far as I know, I've only seen one or two thyroidectomies that were performed by a general surgeon. I'm sure it varies from place to place and depending on the training and interests of the surgeons on staff. Still, though, I can't see why anyone would not want to send these cases to us. Nobody is as comfortable with the head and neck as we are.
 
Generally speaking you are correct. However, a well trained or seasoned endocrine surgeon can do these very well too. Honestly, it's not that technically challenging of a surgery (usually).
 
Skull base. Skull base. Skull base.

Gamma Knife, Gamma Knife, Gamma Knife?

Its eating into acoustic neuroma volume and I've heard its making major inroads in skull base as well.
 
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