Rohaizak Muhammad

B.Sc, M.B.Ch.B, M.S, FRCS, FAMM

Breast and Endocrine Surgeon
UKM Medical Centre

24/8/2014

In the prehistoric era

division of the umbilical cord and

other minor procedures
human teeth and nails
Apocryphal tales suggest certain Rabbi used
sharpened thumbnails for circumcision of
the newborn
later with plant, animal and mineral

substitutes

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Introduction of haemostatic forceps by Spencer

Wells and Jules Pear (1874)

More meticulous and safe surgery

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Most commonly performed surgical procedures

worldwide

fundamental to surgical training

Extensive vascular network of the thyroid gland

Adequate haemostasis is very important

Identify important structure to avoid injury to important

structure
Minimal post-operative bleeding/haematoma can be lethal

Suture ligation with bipolar or monopolar

electrocoagulation for smaller vessels remains the
gold standard
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Electric monopolar coagulation

transmission of electric power
diffusion of heat to nearby tissue

Ligation and division of the thyroid vessels

time-consuming
sometimes difficult in small space

Upper pole vessel

Need assistant
Risk of knot slipping

Mechanical devices such as titanium clips would shorten

operative time
clip dislodge
Cost

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Electrothermal bipolar vessel sealing system and the

harmonic scalpel

Adequate haemostasis

Minimal thermal spread

Minimal tissue damage

No foreign bodies

Single-person operation (Hand-held or pedal control)

Faster surgery as doesnt need assistant

Safety and efficacy proven in laparoscopic and endoscopic surgery

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Harmonic scalpel (Focus)

Ligasure (Small Jaw)

Thunderbeat

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No conflict of interest

Both studies sponsored by the university and

approved by the UKM ethic committee

Do not receive any grant or contribution by any

pharmaceutical company

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Aim
To compare the operating time, length of hospital stay, overall drainage volume
as well as surgical complications between the two techniques.
To perform a cost-effectiveness analysis comparing both surgical techniques of
sutureless and conventional thyroidectomy by virtue of direct cost incurred
involving both techniques and surgical outcome measures like length of
hospital stay, seroma or haematoma complications and nerve injury

Method
Retrospective comparative study
Group A (2000 2006) ~ Conventional knot tying
Group B (2006 2011) ~ Harmonic Scalpel
66 patients were selected randomly from the available database by selecting 10
patients at a time

Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages

24/8/2014

All costs incurred were calculated

Preoperative

intraoperative
postoperative

include operating theatre cost, building costs, laboratory and investigation costs, building
costs, equipment costs and medication

Capital costs

preoperative assessment of thyroid function, thyroid antibodies, serum calcium, ultrasound

and computed tomography scanning of the neck where deemed necessary

include building, furniture and equipment costs.

All capital costs were discounted at the rate of 5% per annum.
The useful life of building is assumed to be 20 years while life span of furniture and
equipment was 5 years.
All equipment that cost above RM 500 were considered as capital (incl the
generators)

Recurrent costs

Personnel salary, consumables, laboratory investigations, drugs and maintenance of

equipment
Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages

24/8/2014

Individual costs
Calculations for each individual according to the laboratory,
investigations performed, the costs of analgesia required, the length of
hospital stay and the post-operative care rounds performed by
involved personals based on their salary and time spent.
Consumables include the number of gauze used, drains and blades

Disposable Harmonic Scalpel/Focus shear

Recycled up to 3 times (approved by the hospital management)

Sterilised using STERRAD
Price is 1/3 of purchasing price

Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages

24/8/2014

Techniques
Duration of Operation (mins)

Conventional
Sutureless

Length Of Stay (days)

Conventional
Sutureless

Weight of Thyroid Gland Removed (g)

Conventional
Sutureless

Volume of Gland (ml)

Conventional
Sutureless

Overall Drainage Volume( ml)

Conventional
Sutureless

N
33
33

Median
140.00
104.00

Range
(112.5-198)
(75-135)

P
0.001**

33

(2.5-5)

0.59

33

(3-4.5)

33

25.90

(11.1-82.4)

0.22

33
33
33

54.00
60.00
110.00

(18.1-92.0)
(17.30-189.37)
(31-248.87)

0.22

18

76

(36.25-128.75)

0.68

16

84

(59.50-121.75)

Median
(OT time)

range

Total thyroidectomy
(HS)

17

120.0

90.0-147.5

0.01

Total thyroidectomy
(C)

10

211.0

146.0- 255.0

Hemithyroidectomy
(HS)

16

90.0

60.0-122.0

Hemithyroidectomy
(C)

23

135.0

116.3-158.8

0.001

Nora, Rohaizak et al, M.S (gen Surg), UKM, 201324/8/2014

; 66 pages

Techniques
Complication-RLNinjury
ComplicationHaematoma
Complication-Seroma
Complication
Hypocalcaemia

Conventional
2 (6.0)

Sutureless
0

31 (94)

33 (100)

32 (97.0)

32 (97.0)

Yes

1 (3.0)

1 (3.0)

No
Yes

31 (93.9)

33 (100)

2 (6.1)

25 (75.8)

26 (78.8)

8 (24.2)

7 (21.2)

Yes
No
No

No
Yes

2.06

0.36

0.00

1.00

2.06

0.15

0.09

0.77

Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages

24/8/2014

Average
(RM)/patient
Total thyroidectomy
(HS)
Total thyroidectomy
(C)
Hemithyroidectomy
(HS)
Hemithyroidectomy
(C)

3888.11

Average
(RM)/patient
P= 0.244

4409.67
3108.79
3171.60

Recycle 3 times

P=0.543

Total thyroidectomy
(HS)
Total thyroidectomy
(C)
Hemithyroidectomy
(HS)
Hemithyroidectomy
(C)

5028.11

p=0.170

4409.67
4248.79

P=0.027

3171.60

Single use

By recycling the HS for 3 cycles, we found that there was a saving of RM521.56
(USD160) for each total thyroidectomy performed and a saving of RM62.81(USD20)
for each hemithyroidectomy performed using the sutureless method not significant
Despite significant reduction in operating time, the total cost using HS is
significantly higher if the instrument were used only once in hemithyroidectomy
(Total thyroid =RM618.44 and Hemithyroid =RM1077.19)

Nora, Rohaizak et al, M.S (gen Surg), UKM, 2013 ; 66 pages

24/8/2014

In 1935, The surprising voice is gone forever;

she had specter of a ghost replaced the velvet
softness
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Recurrent Laryngeal Nerve Paresis (RLNP) following

thyroid surgery

Lahey of Boston (1938) and Riddell of London(1956)

one of the leading reasons for medico-legal litigation against

surgeons

advocated routine identification and dissection of the RLN

Rare complication of thyroid surgery in expert hands

Permanent (0.33%)
Transient (38%)
Higher in
re-operative surgery (2-30%)
Extent of surgery (12.6 times greater risk (P = 0.01))
Less experienced
RLNP rates of 0.72% for surgeons performing greater than 45 NAR
procedures per year vs 1.06% in those with less than 45 NAR per year (P =
0.003)

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Technique/Tool that facilitate the identification,

preparation and preservation of important
structures

Subcapsular dissection

Magnifying glasses

Bipolar coagulation forceps

Ultrasonic shears

Ligasure

Intra-operative Nerve Monitoring (IONM)

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 Stay away from the nerve

if the nerve is seen, it is injured
Identify the nerve
Presuming the location;
know the anatomical landmarks and variations.
Limitations: - Nerve may not be identified even after thorough
searching.
Differentiate nerve from blood vessel or fibrous strands.
A structurally intact nerve does not mean a functioning nerve.
Identify the nerve and function
IONM, Intraoperative Nerve monitoring.
Identify the nerve even without seeing it.
Hear it, before see it

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Continuous IONM

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Started in August 2013

First hospital in Asia to use CIONM
(Continuous intra operative nerve monitoring)
Has performed more than 100 cases

Data to be audited

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One of the indication is cosmetic

Development of keloid or hypertrophied scar

Exposed part of the body

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Incisions in the neck (Cervical)

Smaller incision
Mini thyroidectomy
Minimally invasive video-assisted thyroidectomy

Incision in a not visible area(Extra-cervical) such as

Incisions outside the neck

the axilla
around the nipple

Endoscopic thyroidectomy via the chest

Axillary endoscopic thyroidectomy
Endoscopic thyroidectomy through the breast
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The usual indications:

Young patient
Patient under age of 45
Small and Benign lesions
Up to 5 cm

Yamamoto et al applied the endoscopic

thyroidectomy with breast approach to Graves
disease in 2001
In 2002, Miccoli et al. applied minimally invasive
video-assisted thyroidectomy to resection of a
papillary thyroid carcinoma
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Cervical
Extra-cervical

Axillary
Breast
Anterior chest wall
Axillo-bilateral-breast(ABBA)
Bilateral axillo-breast(BABA)
Shoulder Axillo Breast EndoThyroidectomy (SABET)

modifications to the technique

No consensus on which approach is the best
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Advantages

enables the surgeon to control the 3-dimensional highdefinition camera,

reducing physiological tremors
enabling free dexterity of movement using articulated
instruments
yield similar oncologic outcomes as conventional open
procedures
superior surgeon ergonomics

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SABET (Shoulder Axillo Breast

EndoThyroidectomy)

Gas insufflation of 12 mmHg

Dr Nguc Luong (Vietnam)

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Patient given option of

Performed by 3 endocrine surgeons

Open Mini thyroidectomy (3 cm incision)

Endoscopic thyroidectomy
All had experienced in laparoscopic surgery, sutureless
thyroidectomy and lateral approach

Routine ultrasound

Done by radiologist

Size less than 5 cm at its widest diameter

Not suspicious of malignancy

Routine FNAC

Malignancy excluded
Include indeterminate or inconclusive cytology
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3 ports technique

Axilla-Breast
Shoulder approach

CO2 at 12 mm Hg
Post-op

All patients had

drained

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Initial 19 patients from for analysis

2
8
11

17

Female
Male

Right
Left

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Converted

Second
Surgeon

200

180
160

Axis Title

140
120
100
80
60

Average : 116 min

40
20
0

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Operator
Surgeon 1
(Junior)

Surgeon 2
(Senior)

First 10 cases

Subsequent
cases

p-value

OT time (min)

214.054.2

163.052.5

0.046*

Size(cm)

3.17

2.99

0.25

Volume

10.77

8.79

0.08

Pain score

3.060.2

3.510.3

0.219

OT time (min)

156.037.6

100.4541.1

0.04*

Size(cm)

3.48

3.17

0.22

Volume

13.02

10.38

0.07

Pain score

3.190.32

2.930.66

0.148

24/8/2014
Nani, Rohaizak, Shahrun,
et al, 2014

Lateral approach

Endoscopic surgery

Open lateral and midline approach

Need to familiar with endoscopic/laparoscopic surgery

Sutureless thyroidectomy
? Surgeon performed ultrasonography
Not popular

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Size < 5 cm

Majority of thyroid in
UKMMC are huge goitre

Benign condition

Not keen for surgery

Opted for conservative
?? private

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?? Long neck
Culture/Religion

Covered by veil/hijab

Aesthetic clinic

Colourless scar

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New medical technologies implicated in the rising costs of health

care

Depends partly on our ability to control their use

Control technology diffusion
Staff need to perfect their skill at using the intervention, patient selection has to be refined
and patient numbers need to build up to economically viable levels

Conduct research to assess clinical and cost effectiveness

trials might either underestimate or overestimate clinical and cost effectiveness if
conducted too early

But control is difficult

Pressures
media

public demand
manufacturers
professional enthusiasm
provider competitiveness

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Advancement of technique/ technology in

thyroid surgery

vs clinical expertise/ infrastructure

vs Cost (incl OT/Staff/ hospital stay/morbidity)

vs Local Scenario/Culture/Religion

vs Patients convenience/Cosmesis

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