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Comparison of conventional thyroidectomy and horizontal lateral incision thyroidectomy.

BACKGROUND

Thyroid surgery has followed all the steps of evolution to reach the time of endoscopic surgery. Thyroidectomy is one of the common surgical interventions for thyroid disease. Modern thyroid surgery owes much to one man called Theodor Kocher, Professor of Surgery at Berne, Switzerland. He can be called Father of thyroid surgery.

In conventional thyroidectomy incision should be almost exactly transverse, extending well on to the borders of the sternocleidomastoid muscles (Kocher's neck collar incision), made about two fingers above the sternal notch. This millennium is of minimally invasive techniques. Patients are much more concerned about cosmesis. So surgeons are obliged to do cosmetic approach for every surgery. Horizontal incision thyroidectomy scar from 4.5 cm at lower crease extending from posterior (Lateral) border of sternocleidomastoid posterolaterally. Scar will be assessed at 4 weeks, 8 weeks and after 6 months.

Aims of the study are to compare the results of conventional thyroidectomy and horizontal lateral incision thyroidectomy in terms of cosmesis (Scar assessment score) and complications (hypocalcaemia, recurrent laryngeal nerve palsy).

Ethical Considerations

Study has been conducted after getting approval from Institutional Ethical Committee. A written informed consent has been taken from all the patients included in the study. Patients participating in the study did not have to incur any expenses. The anonymity of each individual has been maintained.

MATERIALS AND METHODS

Study Design

This is a prospective observational study.

Study Period and Duration

Study was conducted over a period of one and a half years from January 2015 to June 2016.

Study Setting

Study was conducted on patients with thyroid swelling who underwent thyroidectomy in general surgery ward, Government T. D. Medical College and Hospital, Vandanam, Kerala.

Sample Size

This study was carried out as a part of fulfilment of PG course and hence had to be completed within one and a half years. Sample was selected on the basis of number of elective thyroidectomies to be done by a particular surgical unit from January 2015 to June 2016. As there is only one theatre day per week for a unit in our department, assuming one thyroidectomy per week, the maximum number of possible cases which can be done is 40. So, sample size was taken as 40.

Method of Allocation of Group

Patients admitted in surgical ward in our unit are counselled about the two types of surgical methods. Those who wish to undergo the particular procedure are selected after obtaining informed consent.

Group 1

Horizontal lateral incision thyroidectomy-40 patients.

Group 2

Conventional large incision thyroidectomy-40 patients.

Study Population

Inclusion Criteria

1. Solitary nodule thyroid.

2. Multinodular thyroid.

Exclusion Criteria

1. Malignancy.

2. Large retrosternal thyroid.

3. Thyroiditis.

Study Procedure

Protocol was initiated after obtaining Institutional Ethical Committee. After getting informed consent, patients were interviewed based on an appropriate semi-structured questionnaire and they were followed up after surgery.

Study Variables

The variables studied were age of the patient, gender, diagnosis, type of incision, type of surgery, complications (Hypocalcaemia, Recurrent laryngeal nerve palsy) and scar assessment scale- OSAS (Observer Scar Assessment Scale) and PSAS (Patient Scar Assessment Scale).

Data Analysis

Statistical Method- Mann-Whitney U Test.

All the analysis was done using qualitative variables in Statistical Package for Social Sciences (SPSS) version 16.

RESULTS

1. Age

Most of the patients in the study were in the age group 30-50 yrs., with that is 68.8% that is 30 patients in 40-50 and 25 in 30-40 years' group.

2. Gender

In the study population, the percentage of female patients was 61% and the percentage of male was 19%.

4. Diagnosis

In the study population, 55% that is 44 patients were diagnosed as SNT and 45% that is 36 patients were diagnosed as MNG.

5. Surgery

In the study population 42.5% i.e. 34 patients underwent hemithyroidectomy and 57.5% i.e. 46 underwent total thyroidectomy.

6. Incision

7. Association of Complications with Incision

Occurrences of hypocaicaemia in both groups were analysed; 27.5% of patients in lateral incision group developed transient hypocalcaemia and 7.5% were permanent; 22.5% of patients in conventional thyroidectomy group developed transient hypocalcaemia and 5% developed permanent hypocalcaemia. There is no statistically significant difference between the two groups with regard to occurrence of post-op hypocalcaemia [p value- 0.459].

8. Comparison of Incision based on Recurrent Laryngeal Nerve Palsy

Occurrences of RLN palsy in both groups were analysed; 22.5% patients had RLN apraxia in lateral incision group and 5% had RLN palsy; 27.5% patients in conventional thyroidectomy developed RLN apraxia and 2.5% had palsy. There is no statistically significant difference between two groups with regard to occurrence of RLN injury [p value0.869].

9. Comparison of OSAS based on Incision

There is statistically significant difference between the two groups with regards to the outcome of the scar in OSAS. The scar was significantly better in thyroidectomy done through lateral incision thyroidectomy [p value- 0.003].

10. Comparison of PSAS based on Incision

There is statistically significant difference between the two groups with regards to the outcome of the scar in PSAS. The scar was significantly better in thyroidectomy done through lateral incision [p value- 0.000].

DISCUSSION

Age

Most of the patients in the study were in the age group 30 50 yrs., with that is 68.8% that is 30 patients in 40 - 50 and 25 in 30-40 years' group.

Sex

In the study population, the percentage of female patients was 61% and the percentage of male was 19%. In the study population 12 male patients included in age group 30-40 and 50-60, but in female patients 42.6% that is 26 patients included in age group 40-50. This finding was in concordance with the findings in the previous studies of horizontal lateral incision thyroidectomy by Thomas Varghese. [1]

Diagnosis

In the study population, 55% that is 44 patients were diagnosed as SNT and 45% that is 36 patients were diagnosed as MNG.

Surgery

In the study population 42.5% i.e. 34 patients underwent hemithyroidectomy, 57.5% i.e. 46 underwent total thyroidectomy.

Complications

* Hypocalcaemia- Occurrences of hypocalcaemia [2] in both groups were analysed; 27.5% of patients in lateral incision group developed transient hypocalcaemia and 7.5% were permanent; 22.5% of patients in conventional thyroidectomy group developed transient hypocalcaemia and 5% developed permanent hypocalcaemia. [2] There is no statistically significant difference between the two groups with regard to occurrence of post-op hypocalcaemia [p value- 0.459]. In Thomas Varghese [1] study of horizontal lateral incision thyroidectomy, parathyroid deficiency was reported in 10/283 that is 0.035% only.

* Recurrent Laryngeal Nerve Palsy- Occurrences of RLN palsy [3,4] in both groups were analysed; 22.5% patients had RLN apraxia in lateral incision group and 5% had RLN palsy; 27.5% patients in conventional thyroidectomy developed RLN apraxia and 2.5% had palsy. There is no statistically significant difference between two groups with regard to occurrence of RLN injury [p value- 0.869]. There were no nerve injury reported in horizontal lateral incision thyroidectomy according to Thomas Varghese. [1]

* Cosmesis- Post-op scar was assessed based on the Patient's and Observer's point of view Observer scar assessment scale. [5,6,7] There is statistically significant difference between the two groups with regards to the outcome of the scar in OSAS. The scar was significantly better in thyroidectomy done through lateral incision thyroidectomy [p value- 0.003].

This finding was in concordance with the previous studies of horizontal lateral incision thyroidectomy by Thomas Varghese, [1] Zhi Giang Chen, [8] Lei Wang, Tao Li et al and Terris et al, patient's scar assessment scale. There is statistically significant difference between the two groups with regards to the outcome of the scar in PSAS. [5,6,7] The scar was significantly better in thyroidectomy done through lateral incision [p value- 0.000].

This finding was in concordance with the previous studies of horizontal lateral incision thyroidectomy by Thomas Varghese [1], Zhi Giang Chen, [8] Lei Wang, Tao Li et al and Terris et al. The scar in lateral incision thyroidectomy was cosmetically far better compared to the conventional incision thyroidectomy.

CONCLUSION

Lateral or horizontal incision thyroidectomy is analogous and feasible alternative to conventional thyroidectomy in selected cases. The advantage of this technique was an enhanced aesthetic result. This technique is not recommended in huge thyroid, retrosternal thyroid, thyroiditis and malignancy, so it cannot be recommended as a standard therapy. Study on a large number of patients, preferably randomised double-blinded studies with longer followup periods is recommended.

ACKNOWLEDGEMENTS

I am grateful to Dr. A. Abdul Latheef A, Professor and Head of the Department of General Surgery, T. D. Medical College, Alappuzha for his great help, expert guidance, suggestions, his valuable guidance, his constant help and support extended towards me.

I am sincerely grateful to Dr. I. J. Jinu, Assistant Professor, Department of General Surgery, Govt. T. D. Medical College, Alappuzha, advice and encouragement, he showed to me to get through this study.

I am thankful to the Principal and all the staff members of the Department of General Surgery, T. D. Medical College, Alappuzha for their valuable encouragement and support.

I thank all my co-PG's for their constructive criticism, constant help and encouragement during my study.

I also acknowledge my patients along with their attenders, who formed the base of my study and without their cooperation this work would not have been possible.

I also acknowledge Kerala University of Health Sciences for the support they have shown to me. In all those times when I needed a hand to seek support, I always found my family close by, let every opportunity to express my gratitude towards them be fruitful. Above all my deepest gratitude to the almighty for enabling me to complete the work.

REFERENCES

[1] Varghese T. 538. Horizontal lateral thyroidectomythomas' technique--a novel anatomical approach based on 3D interactive digital anatomy for superior results. Feasibility Study. Eur J Surg Oncol 2012; 38(9):886-7.

[2] Noureldine SI, Genther DJ, Lopez M, et al. Early predictors of hypocalcemia after total thyroidectomy: an analysis of 304 patients using a short-stay monitoring protocol. JAMA Otolaryngol Head and Neck Surg 2014; 140(11):1006-13.

[3] Zakaria HM, Al Awad NA, Al Kreedes AS, et al. Recurrent laryngeal nerve injury in thyroid surgery. Oman Med J 2011; 26(1):34-8.

[4] Lo CY, Kwok KF, Yuen PW. A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy. Arch Surg 2000; 135(2):204-7.

[5] Draaijers LJ, Tempelman FRH, Botman YAM, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg 2004; 113(7):1960-5.

[6] Fearmonti RM, Bond JE, Erdmann D, et al. The modified Patient and Observer Scar Assessment Scale: a novel approach to defining pathologic and nonpathologic scarring. Plast Reconstr Surg 2011; 127(1):242-7.

[7] van de Kar AL, Corion LUM, Smeulders MJC, et al. Reliable and feasible evaluation of linear scars by the Patient and Observer Scar Assessment Scale. Plast Reconstr Surg 2005; 116(2):514-22.

[8] Chen ZQ, Wang L, Li T, et al. Supraclavicular lateral collar incision versus conventional approach for thyroidectomy: supplement for minimally invasive techniques with extended indications. J Laparoendosc Adv Surg Tech A 2011; 21(1):45-50.

Dimmy Harold (1), Abdul Latheef A (2), I. J Jinu (3)

(1) Junior Resident, Department of General Surgery, TD Medical College, Alappuzha.

(2) Professor and HOD, Department of General Surgery, TD Medical College, Alappuzha.

(3) Assistant Professor, Department of General Surgery, TD Medical College, Alappuzha.

Financial or Other, Competing Interest: None.

Submission 27-02-2017, Peer Review 23-03-2017,

Acceptance 30-03-2017, Published 06-04-2017.

Corresponding Author:

Dr. Dimmy Harold, Mannamkery, South Gate P. O, Vaikom, Kottayam-686141, Kerala, India

E-mail: dimmyharold@gmail.com, drlatheef62@gmail.com

DOI: 10.14260/jem ds/2017/492

Caption: Figure 1

Caption: Figure 2

Caption: Figure 3
Table 1. Percentage Distribution of
the Sample, According to Age

Age     Count   Percent

< 30     10      12.5
30-40    25      31.3
40-50    30      37.5
50-60    10      12.5
> 60      5       6.3

Table 2. Percentage Distribution
of the Sample, According to Gender

Gender   Count   Percent

Male      19      23.8
Female    61      76.3

Table 3. Distribution of Age and Gender

Age     Male              Female
        Count   Percent   Count    Percent

< 30      1       5.3       9       14.8
30-40     6      31.6       19      31.1
40-50     4      21.1       26      42.6
50-60     6      31.6       4        6.6
> 60      2      10.5       3        4.9

Table 4. Percentage Distribution
of the Sample, According to Diagnosis

Diagnosis                 Count   Percent

Solitary nodule thyroid    44      55.0
Multinodular thyroid       36      45.0

Table 5. Percentage Distribution
of the Sample, According to Surgery

Surgery               Count   Percent

Hemithyroidectomy      34      42.5
Total thyroidectomy    46      57.5

Table 6. Percentage Distribution
of the Sample, According to Incision

Incision                          Count   Percent

Lateral incision thyroidectomy     40      50.0
Conventional thyroidectomy         40      50.0

Table 7. Comparison of Incision based on Hypocalcaemia

Incision                                 Hypocalcaemia
                                  No                Transient
                                  Count   Percent   Count

Lateral incision thyroidectomy    26      65.0      11
Conventional thyroidectomy        29      72.5      9

Incision                                     Hypocalcaemia        Z *
                                            Permanent
                                  Percent   Count       Percent

Lateral incision thyroidectomy    27.5      3           7.5       0.74
Conventional thyroidectomy        22.5      2           5.0

Incision                          P

Lateral incision thyroidectomy    0.459
Conventional thyroidectomy

* Mann-Whitney U Test

Table 8. Comparison of Incision based on Recurrent Laryngeal Nerve
Paisy

                     Recurrent Laryngeal Nerve Palsy
Incision                  No               Apraxia
                   Count   Percent    Count    Percent
Lateral incision    29      72.5        9       22.5
thyroidectomy

Conventional        28      70.0       11       27.5
thyroidectomy

                   Recurrent Laryngeal
                      Nerve Palsy
Incision                Palsy         Z *       p
                   Count   Percent
Lateral incision     2       5.0      0.16    0.869
thyroidectomy

Conventional         1       2.5
thyroidectomy

*Mann-Whitney U Test

Table 9. Comparison of OSAS based on Incision

        Incision
OSAS    Lateral Incision  Conventional      Z *          P
        Thyroidectomy     Thyroidectomy
        Count   Percent   Count   Percent

< 15     33      82.5      21      52.5
15-34     7      17.5      15      37.5     2.98   0.003[dagger]
34-50     0       0.0       4      10.0

* Mann-Whitney U Test [dagger] Significant at 0.01 level.

Table 10. Comparison of PSAS based on Incision

        Incision
PSAS    Lateral Incision  Conventional      Z *          P
        Thyroidectomy     Thyroidectomy
        Count   Percent   Count   Percent

< 15     35      87.5      19      47.5     3.87   0.000 [dagger]
15-39     5      12.5      17      42.5
40-50     0       0.0       4      10.0

* Mann-Whitney U Test [dagger] Significant at 0.01 level.

Graph 1. Percentage Distribution
of the Sample, According to Age

        Percentage

<30     12.5
30-40   31.3
40-50   37.5
50-50   12.5
>60     6.3

Note: Table made from bar graph.

Graph 2. Percentage Distribution
of the Sample, According to Gender

         Percentage

Male     23.8

Female   76.3

Note: Table made from bar graph.

Graph 3. Distribution of Age and Gender

           Percentage
          Male   Female

<30       5.3    14.3
30-40     31.6   31.1
40-50     21.1   42.6
50-60     31.6   16.6
>60       10.5   4.9

Note: Table made from bar graph.

Graph 4. Percentage Distribution
of the Sample, According to Diagnosis

                  Percentage

Solitary nodule   55.0
thyroid

Multinodular      45.0
thyroid

Note: Table made from bar graph.

Graph 5. Percentage Distribution
of the Sample, According to Surgery

                      Percentage

Hemithyroidectomy     42.5
Total thyroidectomy   57.5

Note: Table made from bar graph.

Graph 6. Percentage Distribution
of the Sample, According to Incision

                   Percentage

Lateral incision   50.0
thyroidectomy

Conventional       50.0
thyroidectomy

Note: Table made from bar graph.

Graph 7. Comparison of Incision based on Hypocaicaemia

                           Percentage
                   No     Transient   Permanent

Lateral incision   65.0   27.5        7.50
thyroidectomy

Conventional       72.5   22.5        5.00
thy roidectomy

Note: Table made from bar graph.

Graph 8. Comparison of Incision based
on Recurrent Laryngeal Nerve Paisy

                        Percentage
                   No     Apraxia   Palsy

Lateral incision   72.5   22.5      5.0
thyroidectomy

Conventional       70.0   27.5      2.5
thyroidectomy

Note: Table made from bar graph.

Graph 9. Comparison of OSAS based on Incision

                Percentage

        Percentage      Conventional
        Lateral         thyroidectomy
        incision
        thyroidectomy

<15     82.5            52.5
15-34   17.5            37.5
34-50   0.0             10.0

Note: Table made from bar graph.

Graph 10. Comparison of PSAS based on Incision

                  Percentage

          Lateral         Conventional
          Incision        thyroidectomy
          thyroidectomy

<15       87.5            47.5
15-39     12.5            42.5
40-50     0.0             10.0

Note: Table made from bar graph.
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Article Details
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Title Annotation:Original Research Article
Author:Harold, Dimmy; A, Abdul Latheef; Jinu, I.J.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Apr 6, 2017
Words:2699
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