Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

Summary

Here, we present a protocol for retrosternal thyroid goiter resection using a thoracoscopic-assisted transcervical approach.

Abstract

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure.

The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection.

To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day.

Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter's size and mediastinal positioning.

Introduction

A retrosternal goiter represents an entity of abnormal thyroid enlargement, with its largest mass extending through the thoracic inlet into the intrathoracic space¹. Therefore, retrosternal goiters differ from nodular goiters anatomically rather than physiopathologically. Triggered by environmental and genetic factors, goiter development is also associated with iodine deficiency, thyroid nodules, Hashimoto's thyroiditis, and Graves' disease. The prevalence of retrosternal goiters varies greatly by region, from 0.02% to 30% and adopted definitions^1,2,....

Protocol

The protocol follows the guidelines of Bern University Hospital's human research ethics committee. The patient provided both written and oral consent for the anonymous use of his surgical images.

1. Surgery Part I: Transcervical resection

NOTE: The first step of this procedure involves a thyroidectomy performed in a standard fashion with a transcervical approach. Since the carcinoma is located on the left side, it is common practice to begin on th.......

Discussion

The great majority of retrosternal goiters can be resected with a transcervical approach¹³. However, if this is not feasible or in the eventuality of a complication, such as uncontrolled bleeding, the surgeon must be prepared for a bail-out procedure to access the retrosternal part of the goiter. Usually, a thoracotomy or thoracoscopy is used for a retrosternal goiter located in the posterior mediastinum, and a sternotomy is performed for goiter in the anterior mediastinum. Risk factors for thorac.......

Materials

Name	Company	Catalog Number	Comments
12 mm Balloon Trocar	N/A	N/A	Thoracoscopic part
Bipolar Forceps	Symmetry Surgical	https://www.aspensurgical.com/Catalog/Products/open-surgery-instruments	Cervical part
Laparoscopic grasper			Thoracoscopic part
Laparoscopy tower	Karl Storz	https://www.karlstorz.com/us/en/category.htm?cat=1000113577	Thoracoscopic part
LigaSure Impact Open Instrument	Medtronic	https://www.medtronic.com/covidien/en-us/support/products/vessel-sealing/ligasure-impact-sealer-divider.html	Cervical part
NIM 3.0 Systems	Medtronic	https://www.medtronic.com/us-en/healthcare-professionals/products/ear-nose-throat/neuromonitoring/nerve-integrity-monitor-3.html	Neuromonitoring
Surgical instruments and draping for open surgery	N/A	N/A	Cervical part