Primum non nocere, deinde philosophare

Abstract

We read with interest the article entitled Retroauricular Video-Assisted ‘‘Gasless’’ Thyroidectomy: Feasibility Study in Human Cadavers [1]. This article describes a new ‘‘distant access’’ minimally invasive surgical approach to the thyroid gland. The article presents for the first time the retroauricular hairline incision approach to the thyroid gland using the endoscopic assistance gasless technique. The proposed technique allowed hemithyroidectomy to be performed through an 11.8 ± 1.2-cm incision [2] in six human cadavers. In our opinion, the surgical technique described by the authors is limited to hemithyroidectomy. Total thyroidectomy could be performed through a bilateral retroauricular access. We think the 11.8 ± 1.2-cm incision is quite large for a video-assisted approach to the thyroid gland and that a double-size incision due to the bilateral approach is not justified for a total thyroidectomy. This extensive access is not justified for either minimally invasive surgery or open surgery. Kocher’s cervicotomy, video-assisted thyroidectomy (VAT), and minimally invasive video-assisted thyroidectomy (MIVAT) remain the best options for thyroidectomy or parathyroidectomy. A surgical access far from the targeted organ can increase the risk of infection and can damage important structures not identified in reaching the thyroid gland. The described procedures entail an increased risk of damage to the great auricular nerve, lesser occipital nerve, facial nerve, accessory nerve, hypoglossal nerve, digastrics muscle, styloyoid muscle, internal jugular vein, external carotid artery, phrenic nerve, and vagus nerve. The risk of infection also is increased due to the proximity of the incision to less clean areas of the body (ear and hair). Because of the high increased risks added with this procedure, we think the most important thing in surgery is primum non nocere, deinde philosophare (do not harm first, philosophize later). The authors mention that the end point of the study was to achieve gland resection with identification and preservation of the recurrent laryngeal nerve. Because the study was conducted with human cadavers, preservation of the nerve could not be identified with certainty. The authors have recorded 100% success in a cold, bloodless setting, but we know that every time the camera is moved, the risk of causing damage to important anatomic structures is increased [3], especially with the gasless technique. The authors mention two added complications: dysthesia of the earlobe and alopecia at the incision site. These complications preclude the good cosmetic results they mention as an end point desired by the patient. To achieve good cosmetic results, plastic surgery after a classic Kocher’s cervicotomy would be more appropriate. In fact, the authors have written that ‘‘overall patient satisfaction with the resultant scar on a visual analogue scale was significantly higher in patients in the retroauricular cohort as compared with patients having a traditional cervical incision’’ [2]. This underscores the importance of the cosmetic result for the patient, but the citation is incorrect because in the mentioned study, the authors compare a lateral neck upper incision with retroauricular access. Therefore, it is not possible to know whether the patient prefers a classic G. Galata (&) M. Mulla Department of Surgery, King’s College Hospital, NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK e-mail: g.galata@libero.it