01 Nov 2010
Ms Jenny Poh Chew Hue had surgery in July to remove a lump in her neck, but she doesn’t need a scarf or necklace to cover any scars.
In fact, she has no scar at all on her neck, and the only evidence of her surgery and illness is a faint 6cm line hidden away in her armpit. Three months after surgery to remove her left thyroid gland, 55-year-old Ms Poh said: “I feel normal.
The neck area is still a bit numb, but I feel it only when I carry heavy things.”
Reduced risk of injury to nerve
Ms Poh, found to have a suspicious 3.5cm lump in her thyroid, was one of the first patients to undergo robot-assisted minimallyminimally invasive thyroidectomy, the latest surgical method available in Singapore to patients suffering from thyroid-related diseases such as thyroid nodules, goitre and thyroid cancer.
Apart from allowing surgery to be performed through the armpit, thus avoiding the need for a long horizontal incision on the neck like in traditional thyroid operations, robot-assisted thyroidectomy using the Da Vinci Surgical System is a very precise surgical method that lowers some risks associated with endoscopic thyroidectomy, a form of minimally invasive surgery where long, rigid instruments are used to operate through the armpit.
“In thyroid surgery, the paramount aim is to remove the tumour and thyroid without injuring the recurrent laryngeal (nerve that enters the lower part of the voice box and supplies the muscles of speech),” said Dr Tay Hin Ngan, Consultant, Department of Otolaryngology (Ear, Nose and Throat), Singapore General Hospital (SGH).
“Injury to one of the nerves will lead to paralysis of a vocal cord which causes the voice to be hoarse. If both nerves are injured, the patient may have difficulty breathing.
Conventional endoscopic thyroidectomy also avoids a scar on the neck, but protecting the nerve becomes more difficult than in open thyroidectomy.
This task is safer with the aid of the Da Vinci robot,” said Dr Tay.
In open thyroidectomy, a long horizontal incision is made across the base of the neck to allow surgeons access to the thyroid area. Opening up the neck allows the surgeon a clear view of the tumour and thyroid gland to be removed, and provides room for his hands to manoeuvre. Doing so, however, results in a long neck scar.
Faster recovery
In robot-assisted surgery, the incision is made in the armpit, avoiding scarring of the neck.
Removal of the tumour and gland is highly accurate with a high-definition camera that provides a three-dimensional view of the site under operation, helping to guide surgical instruments during the procedure. Two graspers and a Harmonic scalpel (used to cut tissue and stop bleeding) fitted to the tips of three arms of the robot perform the surgery.
The surgeon sits at a console, using his hands to control and remotely guide the arms of the robot.
“Robot-assisted surgery is more intuitive, allows for a very natural range of movements, and is easier to perform than endoscopic surgery. It is like having three hands operating inside the neck, bypassing the constraints of conventional endoscopic instruments caused by the collarbone and soft tissues,” said Dr Tay, one of the few surgeons in Singapore who is able to perform robot-assisted thyroidectomy.
Robot-assisted thyroidectomy, pioneered by South Korean surgeon Woong Youn Chung, Associate Professor of Yonsei University College of Medicine in Seoul, takes a shorter time – less than an hour of actual robotic operating time – to perform than endoscopic surgery, which can take several hours. The incision is also smaller, 5-6cm versus 8-10cm in conventional surgery. Pain and recovery are similar to open thyroidectomy. But some studies show that there are fewer swallowing problems after robotic or endoscopic thyroidectomy, where the incision is made in the armpit area, compared with the open procedure where the incision is in the neck.
“The next day (after surgery), I was up and about talking to the patient in the next ward. I did not take any painkillers at all,” said Ms Poh.
After surgery, patients often experience a numbness under the collarbone, but this is temporary and subsides gradually.
Cosmetic advantage important Opting for robot-assisted thyroidectomy to avoid a prominent neck scar may be vanity-driven, but in diseases of the thyroid, this is an important reason. Thyroid- related disorders appear to affect more women than men, and are more common in younger women between 30 and 50 years old.
Lumps found to be cancerous will need to be removed, but patients suffering from goitre may prefer to live with an enlarged thyroid gland, especially if the swelling is slight when it is in the early stages of the disease. The condition, which may be caused by iodine deficiency, is generally not lifethreatening, but creates symptoms such as discomfort when swallowing or breathing.
Because thyroid disorders tend to show up when the women are fairly young, “aesthetic concerns may deter the patient from agreeing to surgery even when it is necessary,” said Dr Tay. With this new treatment, women with thyroid disorders may feel less reluctant to agree to surgery.
Robot-assisted thyroidectomy, he said, can be performed on patients who are found to have single benign lumps of up to 5cm, or cancerous nodules of up to 2cm, and who have not undergone neck surgery before. Depending on the size of the gland, patients with multiple lumps may not be suitable for this procedure.
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Dept of Otolaryngology
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