Feasibility of thoracoscopic approach for retrosternal goitre (posterior mediastinal goitre): Personal experiences of 11 cases

Abstract

Introduction: Posterior mediastinal goitres constitute of a unique surgical thyroid disorder that requires expert management. Occasionally, they require thoracic approach for the completion of thyroidectomy. In this paper, we describe the feasibility and utility of a novel thoracoscopic approach for such goitres.

Materials and methods: This is a retrospective study conducted at a tertiary care endocrine surgery department in South India over a period of 5 years from January 2010 to December 2014. We developed a novel thoracoscopic technique for posterior mediastinal goitres instead of a more morbid thoracotomy or sternotomy. All the clinical, investigative, operative, pathological and follow-up data were collected from our prospectively filled database. Statistical analysis was done with SPSS 15.0 version. Descriptive analysis was done. Operative Technique of Thoracoscopic Thyroidectomy: Single lumen endotracheal tube (SLETT) was used of anaesthetic intubation and general inhalational anaesthesia. Operative decubitus was supine with extension and abduction of the ipsilateral arm. Access to mediastinum was obtained by two working ports in the third and fifth intercostal spaces. Mediastinal extension was dissected thoracoscopically and delivered cervically.

Results: Out of 1,446 surgical goitres operated during the study period, 72 (5%) had retrosternal goitre. Also, 27/72 (37.5%) cases had posterior mediastinal extension (PME), out of which 11 cases required thoracic approach. We utilised thoracoscopic technique for these 11 cases. The post-operative course was uneventful with no major morbidity. There was one case of recurrent laryngeal nerve (RLN) injury and hoarseness of voice in the third case. Histopathologies in 10 cases were benign, out of which two had subclinical hyperthyroidism. One case had multifocal papillary microcarcinoma.

Conclusions: We opine that novel thoracoscopic technique is a feasibly optimal approach for posterior mediastinal goitre, especially for benign and non-invasive malignant goitres.

Figure 1

Axial CT image of the chest (left) showing right PME; failed intraoperative attempt to deliver PME with finger dissection through the neck (right)

Figure 2

Operative decubitus and port placements - clinical image (left); schematic diagram (right)

Figure 3

Intraoperative thoracoscopic views – operative (left); schematic (right) showing A: SVC, B: Phrenic nerve, C: Azygos vein, D: Collapsed upper lobe of the right lung, E: PME of goitre

Figure 4

Gross ex vivo specimen – arrows pointing to PME into the chest after total thyroidectomy