Total thyroidectomy with a modified Miccoli's approach for treatment of Graves' disease--feasibility and its applying techniques / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To assess the feasibility and relevant applying techniques of total thyroidectomy for Graves' disease with a modified Miccoli's approach.</p><p><b>METHODS</b>Forty-two patients with Graves' disease consecutively received the radical operation from June 2002 to December 2004.The modification includes: (1) Incision extending according to the degree of lobe enlargement (3-6 cm, average 4 cm); (2) A space maintain-regulating device was used to change dimensionally the volume of working space (mainly height) when specific manipulation needed; (3) A volume-reducing resection step was performed for the gland with degree III hyperplasia by cutting off the middle-inferior part of the lobe prior to endoscopic lobectomy. The approach was designed to mainly use ultrasonically-activated scalpels, with suction-dissector or others as supplementary instruments. During the operations, a method of "sequenced dissect-coagulate-cut" was employed to directly divide all branches of thyroid vessels without ligation or application of hemoclips.</p><p><b>RESULTS</b>All procedures were completed successfully. None of them were converted to open surgery due to uncontrolled bleeding or severe postoperative hematoma. No severe complications occurred, except 2 cases who suffered from temporary hoarseness.</p><p><b>CONCLUSION</b>Total thyroidectomy for Graves' disease can be safely performed with the modified Miccoli's approach by using ultrasonic scalpel and the space maintain-regulating device. Application of these adaptive reforms can obviously reduce the difficulties in manipulation, and thus, make the usage of this minimally invasive design also clinically possible for even radical treatment of the gland.</p>

Endoscope-assisted parotidectomy for benign tumors via a short hidden auricular incision / 中华整形外科杂志

<p><b>OBJECTIVE</b>To evaluate a technique of endoscope-assisted parotidectomy for benign tumor via a short hidden auricular incision.</p><p><b>METHODS</b>Twenty-six volunteer patients were selected for the new approach, 16 with mixed tumor, 9 Warthin's tumor and 1 lymphoepithelial cyst. The tumor size was 1.6 approximately 3 cm (average 2.2 cm) and the incision ranged 3.5 approximately 5.5 cm(average 4.5cm) divided into two parts: 1) basic segment--started from anterio-superior crease of tragus, went downward along tragal margin and pre-earlobial fold,and stopped at earlobe root; 2) extended segment--went from earlobe root, curved down posterio-inferiorly. The length of the latter was generally not beyond 1 cm. The procedure began with raising the myo-cutaneous flap and dissecting the whole posterior portion of the gland. Thus, two working spaces needed for endoscopic manipulation could be artificially created with suitable retracting instruments. Endoscopic view was then established, and the surgeons operated continuously in the later steps. Modified techniques, such as the antegrade facial nerve dissection, retrograde great auricular nerve dissection and direct coagulate-cut method with ultrasonically activated scalpel, were employed to archive the goals of endoscopical nerve preservation and tissue resection.</p><p><b>RESULTS</b>All tumors were entirely removed. No postoperative paralysis occurred, excepting 1 case who suffered from an temporary paralysis for two months. The appearance was good due to overlapping the short scar onto the irregular line of auricular contour and hiding its lowest part in the earlobe shadow.</p><p><b>CONCLUSIONS</b>Parotidectomy for benign tumors could be safely done via a much-shortened incision, assisted by an endoscope. The postoperative stress of patients can be obviously reduced with the minimally invasive manipulation and the good appearance.</p>

Using ultrasonically activated scalpels as major instrument for vessel dividing and bleeding control in minimally invasive video-assisted thyroidectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To establish new techniques on the control of vessel dividing and bleeding in minimally invasive video-assisted thyroid surgeries.</p><p><b>METHODS</b>One hundred and seventy volunteer patients with nodular goiter, adenoma and Graves' disease consecutively received the endoscopic thyroid operation according to Miccoli's mode from April 2002 to June 2003. The approach was designed to use ultrasonically activated scalpels [Harmonic Scalpel (R), Johnson & Johnson, USA] as a major, suction-dissector or others as supplementary instruments during the whole process. During the operations, two methods, "sequenced dissect-coagulate-cut" and "pre-coagulation + interlaced cut-suck-coagulate-dissect", were employed and separately evaluated for their safety or efficacy.</p><p><b>RESULTS</b>All of the procedures, except that 2 (their lesions were proven to be "cancer" by frozen section and need different treatment), were successfully completed. None of them were interrupted and converted to open surgery due to uncontrolled bleeding or severe postoperative hematoma. Branches of major thyroid vessels can be directly divided by ultrasonic scalpel without ligation or using hemoclips, supposing the technique of "sequenced dissect-coagulate-cut" method was strictly used. Bleeding during intra-gland dissection can be effectively controlled by the combined techniques of precoagulation of the vessels and the capsule vessel network near and around the incision, and then, by coordinating manipulation with a special multiple functional ultrasonic scalpel and a suction-dissector, supposing the technique of "interlaced cut-suck-coagulate-dissect" was properly employed.</p><p><b>CONCLUSIONS</b>Using ultrasonic scalpels as major, suction-dissector or others as supplementary instruments, manipulating cooperatively during the whole process, can be an ideal fashion in the site of a narrow gasless working space via a small single incision in anterio-inferior neck. And this may dramatically simplify the manipulation, and hence greatly reduce the operative difficulty. The reforms resolved two key technique problems in Miccoli's endoscopic operation: vessel-dividing and bleeding-control, therefore, laying a sound basis for the clinical application of this special approach.</p>