With the incidence of thyroid cancer on the rise, the number of thyroidectomies performed in the United States has increased over the last decade as well. Much of this growth in procedures is attributed to early detection of thyroid cancers under 2 cm in size.
At Memorial Sloan Kettering, surgeons have introduced several minimally invasive techniques that are well suited to patients with these small thyroid cancers or benign thyroid diseases.
In most cases, the thyroid glands are amenable to minimal access thyroid surgery, either in the standard open fashion through 3- to 4-cm incisions, or through even smaller 1.5-cm incisions using a minimally invasive video-assisted thyroidectomy procedure known as MIVAT.
Experience with MIVAT
The advent of MIVAT in the late 1990s made possible even smaller incisions than what was achieved previously using the minimally invasive access surgery with short skin incisions. In a MIVAT procedure, surgeons operate through the 1.5 cm incision using a 30-degree endoscope, specialized small retractors, and the harmonic scalpel.
The operation is ideally suited to patients with small thyroid nodules or cancers, such as those with thyroid nodules less than 2 cm in size in thyroid glands less than 25 cubic cm in volume. Additionally, the eligible patients have thyroid malignancies that are intraglandular, with no evidence of capsule invasion on preoperative ultrasound or the presence of central compartment lymph nodes.
Individuals with follicular lesions of undetermined significance and small multinodular goiters are also often candidates for MIVAT, as are those with parathyroid adenomas in the presence of hyperparathyroidism (in which case only a 1.0-cm incision is used).
In contrast to traditional surgery, MIVAT procedures also require significantly less soft tissue dissection, as they are aided by use of the endoscope.
At Memorial Sloan Kettering, head and neck surgeons such as Ian Ganly offer MIVAT to select patients with thyroid nodules or thyroid cancer. The surgical group as a whole described their initial experience with the procedure in 2010 — in what was the first report from a dedicated cancer center.(1)
In contrast to most hospitals doing MIVAT surgery, where only a small percentage of patients had thyroid cancer, 74 percent of patients undergoing MIVAT at Memorial Sloan Kettering had this malignancy.
And while many patients traditionally have not been considered candidates for MIVAT due to the presence of Hashimoto’s thyroiditis, large thyroid glands, or large thyroid cancers, the 2010 report demonstrated no elevated complications rates for MIVAT surgery in patients with thyroiditis, glands greater than 25 cc in size, or nodules greater than 2 cm in size.
These results encouraged us to consider offering MIVAT surgery to a wider cohort of patients than what traditional guidelines dictate. “Many patients aren’t overly concerned with the length or appearance of their thyroidectomy scar. But many patients are thrilled with the size of their incisions,” Dr. Ganly says.
“The short scars are tiny, compared to the longer scars associated with traditional thyroid surgery. But, beyond the scar, we have found that recovery is much faster after MIVAT. Because there is less dissection, patients tend to experience very little discomfort after surgery, and are back at their daily activities the next day.” “It’s important that not all thyroid surgeries are appropriate for MIVAT,” Dr. Ganly cautions. “But for those patients who are good candidates, we are pleased to offer this procedure at Memorial Sloan Kettering.”