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Endoscopic Right Lobectomy Axillary-breast Approach: Report of Two Cases

Miccoli introduced this technique as a three-part procedure 188 minutes, mean blood loss was 53 ml and mean hospital
starting with an open technique followed by endoscopic stay was 3.3 days. BABA (bilateral-axillary-breast approach)
component and then completed in an open fashion. According was introduced later and claimed to be easily applied for
to some data in the literature, any surgeon approaching the thyroid cancer as well. 3,5-7,9 This technique is now even
MIVAT technique must carefully consider that at the improved by using da vinci robotic system by Eun Lee et
beginning of his or her experience, the procedure will be al , which is useful in identification of anatomy and
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significantly longer than the standard operation. From then, dissection during surgery. The function of EndoWrist
endoscopic thyroidectomy can be divided in two types with instrument is beneficial in doing complex tasks in difficult
CO insufflation or gasless. Others classified as video- areas with limited access. The mean operating time without
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assisted and total endoscopic. 1,7,8 robotic was 165 minutes and with robotic was 218.3 minutes,
Total endoscopic thyroidectomy is a more sophisticated but there is a tendency of decrease in operation time. They
variation of minimally invasive thyroid. Using special also perform central node dissection and limited lateral node
instrument and technique, part or all of the thyroid gland picking. Tran Ngoc Luong in 2004 modified the technique
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can be removed through small puncture site avoiding any by using axillary-breast-shoulder approach. Using this
incision on the neck whatsoever. In this technique, the skin technique, they can do total and other bilateral procedures,
overlying the collarbone is lifted from the underlying muscle including central neck dissection. The first operating time
and laparoscopic techniques are used to create a working was 420 minutes and significantly reduced mean time for
space. 8
Various approaches have been devised and improved lobectomy is 15 minutes and total is 30 minutes now.
further to fulfill this goal, mainly including the cervical The first endoscopic surgery, performed transcervically,
approach, anterior chest approach, axillary and breast was employed to treat a 3 mm moderately differentiated
approach. However, none of these approaches is exclusively papillary microcarcinoma with focal capsular invasion in
advantageous and universally accepted. The cervical 1997. The use of a transcervical approach results in small
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approach and anterior chest approach are minimally invasive operative scars in the neck. After this attempt, Ohgami
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but not cosmetically excellent. The axillary and breast et al performed endoscopy via breast approach for thyroid
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approaches have maximized cosmesis, but meanwhile cause adenoma 5 to 7 cm in diameter. Yamamoto et al applied
much invasiveness. Furthermore, the axillary approaches endoscopy via breast approach for Graves’ disease patients.
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are not suitable for bilateral manipulation and even more Ikeda at al applied anterior chest and axillary approach for
technically challenging with abnormal anatomic vision. follicular tumors, Graves' disease and papillary micro-
Therefore, an axillary-bilateral-breast approach (ABBA) has carcinoma.
been developed, which is actually a combination of the Generally, endoscopic thyroid surgery has been thought
procedure. In comparison, ABBA permits bilateral exploration to be appropriate for benign thyroid disease. First, it was
more space for instrument use and the removal of larger indicated for nodule not more than 3 cm, benign or low
nodule. With this technique, the mean surgical time was grade follicular lesion and papillary carcinoma. Contra-
indications were previous neck surgery, large goiter, locally
metastasis, previous neck irradiation, thyroiditis and
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hyperthyroidism. These indications then slightly change
during the development of the technique. Some can even
perform for nodule more than 5 cm for Graves’ and
thyroiditis. 4,10 The role of endoscopy for carcinoma is still
in debate. In other areas of oncologic surgery, such as for
gastric or colorectal carcinoma, minimally invasive
laparoscopic surgery has been established through clinical
experience and technical development. Similarly, endoscopic
thyroid surgery can be used for malignant thyroid disease.
BABA and axillary-breast approach similar to Tran Ngoc
Luong technique can be used as an appropriate method for
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treating thyroid malignancies. 4,6,10 Kitano et al reported
the treatment of thyroid cancer with anterior chest approach
Fig. 3: Postoperative appearance endoscopic surgery. The indications are as follow: Age

World Journal of Laparoscopic Surgery, September-December 2010;3(3):109-112 111