Robotic thyroid surgery for nodule/lump in the thyroid gland
A new option for thyroid surgery that doesn’t leave a neck scar
The worry of the person having lump in the thyroid is this a cancer or not a cancer. Which can known to some extent by performing needle test( FNAC) done by expert pathology doctor .
The treatment of cancer or when diagnosis is not clear by FNAC test is surgery. The surgery entails removal of effected lobe of thyroid gland with or without removal of lymph nodes. Traditionally
A cut is made of 4-6cm length in front of neck ,3-4cm below “Adams apple” then the surgeon would expose the thyroid gland so that he or she could directly see the gland ,preserve recurrent laryngeal nerve which controls the voice and parathyroid glands -calcium controlling glands . This would leave a scar in the front of neck which would heal perfectly in some and some scar is ugly because of scarring tendency is different in every person.
There’s a new treatment option for patients who need to have thyroid surgery: robotic thyroidectomy.
No, that doesn’t mean that a robot is doing your surgery.
Robotic thyroidectomy does mean that you won’t have a scar on your neck, and for many people, that’s reason enough to try this recently-developed surgical technique.
Robotic thyroidectomy—a minimally invasive surgical technique to remove all or part of the thyroid—was developed by doctors in South Korea, Seoul.
Robotic thyroidectomy is, in fact, a major step in thyroid surgery. As Dr. Mudit says, “This made sense that robotic thyroidectomy would be the next step in thyroid surgery, especially for those who don’t want a neck scar.”
How It Works ?
Robotic thyroidectomy eliminates the visible neck scar by accessing the thyroid gland through an incision behind the earlobe . This is called an retroauricular approach. That incision is 5-7cm long, but it’s hidden in the hairline. This technique has been adopted from plastic surgeon performing facelift procedure for cosmetic enhancement.
Robotic thyroidectomy is done using the daVinci Surgical System, a system that’s been used in many other robot-assisted surgeries with much success. The daVinci system has:
- Four robotic hands: These are called EndoWrist instruments, and they do work just like hands. They can grab things, twist, and turn—and they’re incredibly small. The robotic hands allow the surgeon to make very precise movements.
- 3D camera: This is a high-definition camera that gives the surgeon a 3D image of the thyroid. He or she can zoom in and get an even more detailed look; the camera includes magnification of 10x.
- Console: The surgeon sits at the console, where he or she controls the four robotic hands and sees images from the 3D camera.
The four robotic hands and the 3D camera are inserted through the incisions. The surgeon can then accurately remove part or all of the thyroid, depending on what the patient needs.
As a reassurance, the daVinci robot is completely under the control of the surgeon. The robotic hands cannot move on their own; they must be told what to do by the surgeon. The daVinci Surgery System also cannot be programmed; the surgeon must be there giving input and making decisions during the surgery.
Advantages of Robotic Thyroidectomy
Dr. Mudit, who was trained in robotic thyroidectomy by the surgeons who developed the technique in South Korea, explains the advantages of robotic thyroidectomy over traditional open operation:
- No incision in the neck
- Better identification of critical structures: Due to the magnified 3D view, it is easier to identify critical structures, such as the recurrent laryngeal nerve (the nerve that goes to your voice box) and parathyroid glands.
The recovery time for robotic thyroidectomy is almost about the same as it is for open —a patient usually spends one-3 day in the hospital following the surgery.
Disadvantages of Robotic Thyroidectomy
The only disadvantages sees in robotic thyroidectomy right now is that it can’t be used on every patient.
Who Can Have a Robotic Thyroidectomy?
Right now, robotic thryoidectomies work best for patients who:
- Have not undergone previous neck surgery
- Have nodules less than 5cm
- Have nodules on just one side of the thyroid gland
The biggest benefit is, of course, the lack of a scar on the neck. . Cosmetically speaking, a robotic thyroidectomy is a huge step forward in thyroid surgery.
And beyond the cosmetic benefits, robotic thyroidectomy is a fascinating advance in how surgeons can treat thyroid patients. It enables surgeons to do endoscopic procedures with more precision because the robotic hands have dexterity similar to, if not better than, human hands.
Chemotherapy and its Role in Head Neck Cancer
Good health is one of the biggest assets of life and everybody has a deep longing for it but with changing lifestyle, being healthy has become a strenuous task. Ailments like Cancer leave patients highly despondent and their families distressed.
Timely detection of Cancer can improve the cure and survival rates for patients. Treatment options depend on the type of cancer and how advanced it is. Apart from surgery and radiotherapy, Chemotherapy is used to treat many types of cancer. For some people, chemotherapy may be the only treatment you receive. But most often, one will have chemotherapy and other cancer treatments, depending on the type of cancer you have, if it has spread and where, and if you have other health problems.Chemotherapy can be indicated as the standard therapy for a very limited range of advanced head and neck cancers.
What is Chemotherapy?
Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to kill cancer cells.Chemotherapy is used to treat cancer and lessen the chance for cancer to return, or stop or slow its growth. It also eases the cancer symptoms by shrinking the tumors that are causing pain and other problems.
Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly.
Chemotherapy can be employed with other treatment methods:
- Make a tumor smaller before surgery or radiation therapy. This is called neoadjuvant
- Destroy cancer cells that may remain after treatment with surgery or radiation therapy. This is called adjuvant Adjuvant chemotherapy is most useful in patients who have a high risk of relapse.
WHEN CHEMOTHERAPY IS USED?
For oral or mouth cancer ,induction chemotherapy is used for locally advanced disease which cannot be considered for surgery to shrink the tumor and then perform surgery.
Concurrent chemotherapy and radiation therapy treatment means radiation therapy is given along with weekly chemotherapy. This used for locally advanced stage III &IVa oropharynx cancer (tonsil and base of tongue) and stage 3 larynx or voice box cancer and for cancer of nasopharynx( area behind nose)
and first-, second-, and third-line chemotherapy is used for metastatic (already spread to lungs, bone etc.)or recurrent disease which cannot be operated.
- INDUCTION (neoadjuvant) CHEMOTHERAPY:
It is typically given to patients with stage III-IVB disease in order to shrink a primary tumor to reduce its bulkiness in preparation for future surgery or radiation therapy. Decision to treat the patient with induction chemotherapy rather than concurrent chemo-radiation or surgery, radiation, or chemotherapy alone is made by our multidisciplinary tumor board ( A radiation therapist, an ENT surgeon along with best head and neck surgeon in India- Dr. Mudit Aggarwal).
- FIRST-LINE CHEMOTHERAPY:
- It is practised for metastatic or recurrent disease (oral cavity, pharyngeal, and laryngeal cancers) with cancer of Stage IV. It includes the use of single-agent or combination chemotherapy.
- Platinum-based chemotherapy regimens are preferred if these agents can be tolerated by the patient; if they cannot be tolerated, single agents have been used.
- SECOND- AND THIRD-LINE CHEMOTHERAPY
- It is for metastatic or recurrent disease (oral cavity, pharyngeal, and laryngeal cancers) with Stage IV cancer.
- Second-line chemotherapy is given after disease progression or recurrence following completion of first-line therapy
- Third-line therapies are given after disease progression or recurrence following completion of first-line and second-line therapies
- Second- and third-line regimens are similar to regimens used as first-line therapy but usually offer lower response rates and survival benefits
- Patients should be treated with platinum-based chemotherapy regimens if they have not previously received a platinum-based drug
METHODS FOR GIVING CHEMOTHERAPY:
Chemotherapy is often given through a thin needle that is placed in a vein on your hand or lower arm. Your nurse will put the needle in at the start of each treatment and remove it when treatment is over
Some other common ways include:
The chemotherapy comes in pills, capsules, or liquids that you swallow
- Intravenous (IV)
The chemotherapy goes directly into a vein
The chemotherapy is given by a shot in a muscle in your arm, thigh, or hip, or right under the skin in the fatty part of your arm, leg, or belly
The chemotherapy is injected into the space between the layers of tissue that cover the brain and spinal cord
- Intraperitoneal (IP)
The chemotherapy goes directly into the peritoneal cavity, which is the area in your body that contains organs such as your intestines, stomach, and liver
- Intra-arterial (IA)
The chemotherapy is injected directly into the artery that leads to the cancer
The chemotherapy comes in a cream that you rub onto your skin
WHICH CHEMOTHERAPY DRUGS TO BE GIVEN?
There are many different chemotherapy drugs. Dr. Mudit Agarwal carefully decides which to be included in your treatment plan depends on the basis:
- The type of cancer you have and how advanced it is
- Whether you have had chemotherapy before
- Whether you have other health problems, such as diabetes or heart disease
SIDE-EFFECTS OF CHEMOTHERAPY:
Chemotherapy not only kills fast-growing cancer cells, but also kills or slows the growth of healthy cells that grow and divide quickly. Examples are cells that line your mouth and intestines and those that cause your hair to grow. Damage to healthy cells may cause side effects, such as mouth sores, nausea, and hair loss. Side effects often get better or go away after you have finished chemotherapy.
The most common side effect is fatigue, which is feeling exhausted and worn out.
It’s a long-lasting disease that affects your mouth. It doesn’t go away, but you can keep it under control.
Anybody can get it. Women are more likely to have it than men. It’s most common in people older than 40. But kids and young adults can also get it.
What Causes It?
- We aren’t sure what causes oral lichen planus. It may run in your family.
- It is autoimmune disease.
- With oral lichen planus, immune fighter cells get confused and attack the lining of your mouth.
- Other possible triggers include medicines like painkillers, high blood pressure treatments, diabetes drugs, and malaria medications.
- It may also be a reaction to metal, such as dental fillings. It could be triggered by other mouth problems such as having a rough crown or a habit of biting your cheeks or tongue.
- oral lichen planus isn’t contagious
What Are the Symptoms?
Symptoms can come on slowly or start all at once.
- You may start out with dryness or a metallic, burning taste in your mouth.
- Then you’ll see white patches on your tongue, cheeks, and gums. They can be tiny dots or lines that make a lace-like pattern. You may also have redness and swelling. Sometimes, there’s peeling or blistering.
THESE PATCHES CAN produce burning and painful. They’ll likely hurt the most when you eat or drink foods that are spicy, salty, acidic (orange juice, tomatoes), or alcoholic.
Diagnosis : history,clinical examination and biopsy(removing small piece of affected area)
- How Is It Treated?
If you only feel a slight roughness in your mouth, you may not need treatment. If pain or ulcer present then local corticosteroid cream may be applied and if not subsiding then oral steroids tablets may be used.
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What is Oral Submucous Fibrosis (OSF) ?
It is condition which affects people who chew tobacco like Gutka,Paan masala,Areca nut or Supari. It is characteristed by inability to open the mouth completely. This happens due progressive fibrosis of submucosal tissues and juxta-epithelial inflammatory reactions. It means inner cheek lining which is usually red or pink and stretchable turns into thick white hard like a parchment and become un-stretchable . In advanced stages there are fibrotic bands are formed which does not allow the mouth to open.
DISADVANTAGES : 1) Inability to eat normally as mouth does not open, there may be burning sensation in the mouth also. 2) It is precancerous condition i.e. This lining has tendency to turn into cancer, symptoms one should be watchful of any ulcer which is to healing, pain during opening the mouth, pain in the ear or during eating. White or red patch can also develop.
TREATMENT 1) Stop tobacco– most important in early stages as changes can halt and might revert back, in other stages a least it will not further progress. 2) Injection of local steroid with mouth opening exercise. 3) if these do not work then surgery has to be done,Co2 LASER incision followed by mouth opening exercise, or putting a flap or piece of skin taken after the excision
WHY IS THIS TREATMENT IMPORTANT ? If mouth opening is not good then, no examination inside mouth is not possible to look for any changes for cancer happening inside.
These tumors arise from chemoreceptor zone present at the division of carotid artery ( supplying arterial blood to face – external carotid artery and brain- internal carotid artery) into external and internal carotid artery as shown in the figure.
PRESENTATION : usually presents as a painless neck mass, but larger tumors may affect cranial nerve , usually of the vagus nerve (leading to change or heaviness of voice) and hypoglossal (tilting or deviation of tongue towards the side of tumor) nerve. These are highly vascular tumors means have many small blood vessels around it.
INHERITANCE : 3 different types
The sporadic (does not genetic link) form is the most common type, representing approximately 85% of carotid body tumors . The familial(have genetic link) type (10-50%) is more common in younger patients. The hyperplastic form is very common in patients living at a high altitude (> 5000 feet above sea level) due to decrease level of oxygen .
About 5% of carotid body tumors are present on both sides of neck and 5-10% can be cancerous also, but these rates are much higher in patients with inherited disease.
Individuals with malignant (cancerous) carotid body tumors may have higher blood pressure .
DIAGNOSIS : The test performed are ultrasonography with color Doppler, CT scanning of the head and neck with contrast or CT Angiography ,is also helpful and typically reveals a hypervascular tumor located between the external and internal carotid arteries.
MRI imaging may also be considered to be the criterion standard of carotid body tumors, and the tumor has a characteristic salt and pepper appearance on T1-weighted image.
TREATMENT is surgical excision taking care of nearby vital structures and to take care internal carotid is preserved through out.patient can be discharged in 1-2 days.
SCARLESS OR MINIMALLY INVASIVE THYROIDECTOMY
This procedure is meant to perform half or total removal of thyroid gland by a technique which causes less scar in the neck or no visible scar in the neck.
Indications: are no previous surgeries in the same area of neck with nodule or thyroid size <=5cm, larger thyroid can be removed with no visible scar but with combined approach (placing incision in the skin behind the ear and in the armpit) Technique : Retroauricular approach (FIGURE 1): incision is placed in area behind the ear and in the hairline so it is not visible, tunnel is created upto thyroid lobe which is to be removed. The skin flap is held up with Chung’s retractor. Endoscope is introduced with for magnified view, specialised instruments are used to perform thyroidectomy (half or total removal of thyroid gland). Incision on other side may be required for removal of opposite thyroid. Special care is taken during surgery for identification of recurrent laryngeal nerve (figure 2), and its preservation, so that injury to this nerve is avoided. Parathyroid glands (figure 2)which are situated on the backside of thyroid lobe ,these glands control level of calcium in the body. These glands needs to be preserved so that calcium levels are maintained in normal . By this approach we do by ROBOTIC SURGERY (DAVINCI – XI ) or by ENDOSCOPIC SURGERY. It depends on the surgical expertise of the surgeon which surgery he is going to perform. Endoscopic surgery has the advantage of same approach with much decreased cost . Admission in the hospital is for 1-2 days. Recovery time is 2weeks.
Parotid glands are salivary glands which are situated in the area in front of ear . It produces saliva to keep our mouth wet , if you see or think about delicious food it starts producing saliva and opens in the mouth via a duct, adjacent to upper 2 molar tooth or upper 2 nd last tooth.
Parotid gland can get affected by tumor’s or lump which in 80% times is not cancerous most common of which is Pleomorphic adenoma. They will usually been seen as swelling which keeps on growing with time slowly and will usually not cause any pain. If there is pain or recently it has rapidly increased in size suggests cancerous conversion. To diagnose it one needle test is done called FNAC by which it is confirmed that swelling is cancerous or not cancerous. Surgeon will require CT scan or MRI for looking inside the nature of lump and likely any extension.
Surgery is challenging as there is nerve called Facial nerve which runs deep to the tumor so this nerve and its branches needs to be preserved. This nerve controls the facial expressions . Its damage during surgery leads to inability to close the eyelid and deviation or mouth to while smiling. Surgery is the only successful way by which it can be removed . Surgeon’s experience and use of adjunctive instruments like nerve stimulator to help in identifying the finer branches with large tumours. In good hands facial nerve is preserved with full function most of the times if temporary weakness of the nerve occurs it usually recovers within 6 months.
BECAUSE INCISION IN THE NECK GIVES A SCAR WHICH IS SEEN, TECHNOLOGICAL ADVANCEMENT HAS LEAD TO PLACING THE INCISION BEHIND THE EAR AND ALONG THE HAIRLINE (RETROAURICULAR) . THROUGH THIS INCISION ENDOSCOPIC CAMERA AND INSTRUMENT ARE PUT , SURGERY IS PERFORMED AND THEN INCISION IS SUTURED. THESE OPERATION IS PERFORMED FOR DOING THYROIDECTOMY (THYROID REMOVAL OPERATION), PARATHYROIDECTOMY (PARATHYROID GLAND ADENOMA REMOVAL) AND NECK DISSECTIONS FOR HEAD NECK CANCER. THE COSMETIC OUTCOME IS VERY GOOD WITH SURGICAL REMOVAL OF THE TUMOR.