Endoscopic thyroidectomy (ET) techniques via various approaches have been touted for their cosmetic superiority. This is particularly true for those without any neck scars, such as the anterior chest approach, the breast approach, and the axillary approach. Recently, the Safe Introduction of New Procedures Committee of the Hospital Authority governing all of the 41 public hospitals in the Hong Kong Special Administrative Region of China has received submissions applying for permission to try the breast approach. Having been invited to chair the designated panel, I set out to search the English literature for clinical evidence; however, I could find only one comparative study without randomization (level 2 evidence) and four overlapping case series (level 3 evidence) [1–5]. The comparative study contained only 10–12 cases in each arm [5]. Also, three of these five publications came from the same university [3–5]. Given the paucity of published data, the jury seemed undecided about whether to allow its widespread adoption—until recently when I became acutely aware that ET is now commonplace in Mainland China. However, all relevant clinical reports have been written in Chinese. I feel compelled to unveil the current status of ET in China to the wider surgical fraternity based on my on-site observations and the data in the Manual of the 10th National Advanced Course in Endoscopic Thyroidectomy 2008—most aptly in Surgical Endoscopy, a specialty journal of international repute. An added impetus is that it was in the Journal that my first article on total video ET through three trocars in the neck appeared [6]. The year was 1997, during which the sovereignty of Hong Kong was reverted back to China. Unfortunately, the described technique rapidly fell into disfavor through lack of a high-sounding selling point. Zu and Wang were credited with being the first surgeons in Mainland China, successively performing an endoscopic thyroidectomy by the breast approach in 2001 and 2002, respectively, eliminating altogether the need for neck incisions [7]. Since then, an estimated 10,000 thyroidectomies have been performed under endoscopic vision in approximately 200 hospitals nationwide [7]. In 2006, a multicenter survey involving 26 hospitals from 13 provinces found a total of 1,327 cases of ET via breast approach, anterior chest approach, or axillary approach. Amongst the three approaches, the breast approach emerged as the clear favorite as evidenced by its exponential growth in number toward the mid 2000s (Fig. 1) [8]. This was simply because the disposition of trocars in the bilateral breast approach helps reap the dual benefits of excellent cosmesis and favorable ergonomics (visual axis between the working axes, 60 working angle and access to both lobes). The great majority of these 1,327 cases were benign solitary nodules, mainly adenomas, multinodular goiters, and sundry cystic lesions. Rarer pathologies were thyrotoxicosis (85 cases), thyroiditis (2 cases), and malignancy, mostly papillary microcarcinoma (31 cases). The overall incidence of early complications appeared to be acceptable (Table 1). The most common complication was related to the long subcutaneous path: collection or overlying skin bruising (1.28%). The second commonest complication was hoarseness of voice (0.6%). Notably, no major complications, including the most dreaded—tumor seeding in the access path—were experienced by these centers. It is tempting to extrapolate the present situation into the future: we can see a long-term trajectory of increased use of videoscopes for thyroidectomies because W. T. Ng (&) Department of Surgery, Yan Chai Hospital, 7-11 Yan Chai Street, Tsuen Wan, Hong Kong e-mail: houston_n@yahoo.com
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Aug 1, 2010
P R K Bhargav + 4
Open Access
