Endoscopic Hemithyroidectomy: Surgery, Procedure, Risks and Benefits

Endoscopic hemithyroidectomy, or minimally invasive video-assisted thyroidectomy, is frequently used to treat thyroid conditions. Women are more likely than men to suffer from thyroid diseases, and many find these scars painful and unattractive. Endoscopic hemithyroidectomy enables the surgeon to do thyroid surgery through a tiny skin incision. In the axilla (armpit), small incisions are created for endoscopic hemithyroidectomy. The structures may be seen more clearly and dissected comfortably with a video camera.

Anatomy and physiology of thyroid glands

The thyroid gland is a butterfly-shaped endocrine gland situated in the neck. It has two lobes that are connected with a tissue called the isthmus. The thyroid gland secretes the hormones thyroxine (T4) and triiodothyronine (T3) that regulate the body's metabolism. The thyroid hormones perform several functions. They control the metabolism of carbohydrates, regulate energy levels, weight, hair, skin and nail growth, and affect heart rate and contraction.  In hyperthyroidism, the thyroid gland secretes excessive thyroxine (T4) and triiodothyronine (T3). In contrast, in patients with hypothyroidism, the thyroid gland does not secrete sufficient thyroxine (T4) and triiodothyronine (T3).

Generally, endoscopic hemithyroidectomy is done by a doctor to help diagnose or treat thyroid conditions. Below mentioned are some of the common conditions that are treated using endoscopic hemithyroidectomy:

1. Thyroid cancer: When the thyroid cancer is restricted to only one lobe of the thyroid gland, the doctor advises the patient to undergo hemithyroidectomy.
2. Non-cancerous enlargement of the thyroid gland: The thyroid gland may be enlarged, as in the case of goitre. It compresses the other nearby organs, such as the trachea or oesophagus. In such cases, hemithyroidectomy removes a part of the thyroid gland. In some cases, it is also performed for cosmetic purposes, as people do not find it comfortable to have a bulging neck. 
3. Overactive thyroid: In patients with an overactive thyroid gland, which results in hyperthyroidism, the doctor may suggest undergoing hemithyroidectomy. 

The doctor may recommend an endoscopic hemithyroidectomy procedure if a person has thyroid disorders. These include cancer, a noncancerous enlargement of the thyroid (goitre) and overactive thyroid (hyperthyroidism). Endoscopic hemithyroidectomy may also be an option if someone doesn’t get relief from non-surgical treatments.

A smaller axillary (armpit) incision is used during the minimally invasive endoscopic thyroidectomy surgery. The incisions are used to insert surgical instruments and a video camera. Throughout the surgery, the camera directs the surgeon. The surgeon performs the surgery through the following steps:

1. The patient lies on the operation table on his back.
2. The anesthesiologist administers general anaesthesia to the patient.
3. Through an IV line, the doctor may infuse the painkillers, antibiotics or other drugs during or after the surgery.
4. A scope with tools is introduced at the axilla using a keyhole (laparoscopic surgery techniques) to remove part of your thyroid gland.
5. The camera lets the surgeon see the thyroid gland on a monitor with magnification, accuracy, and clarity.
6. The thyroid gland is separated from the trachea (windpipe).
7. The surgeon sutures the incisions made during the procedure.

Prior to the endoscopic hemithyroidectomy, the doctor or the surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Endoscopic Hemithyroidectomy

1. The patient undergoes a pre-anaesthesia check-up before the surgery. It helps the surgeon to determine if the patient can tolerate the anaesthesia administered during the surgery.
2. The surgeon also comprehensively analyses the medical history of the patient. If the patient has uncontrolled diabetes, blood pressure or any cardiovascular disease, the doctor may postpone the surgery until the underlying conditions are under control.
3. Once the results of all the examinations, including the pre-anaesthesia check-up, are satisfactory, the doctor may provide a date of surgery to the patient.
4. As there may be blood loss during the surgery due to incision and thyroid removal, the surgeon advises the patient to avoid taking blood thinners, such as aspirin or other blood thinners, a few days before the surgery.
5. The patient is also advised to avoid eating or drinking at least from midnight before the day of surgery.
6. The surgeon explains the procedure, the associated risk, the time of surgery, and the cost involved. The hospital staff will also help the patient in completing the insurance formalities. 

On the day of Endoscopic Hemithyroidectomy

The patient may expect the following on the day of surgery:

1. The patient should reach the hospital an hour before the surgery to complete the formalities. 
2. A family member may accompany the patient to complete the formalities on his behalf.
3. The staff asks the patient to sign a consent form indicating the patient's consent to undergo surgery.
4. The hospital administration also requests the patient to deposit the surgery fees.
5. The patient is advised to leave the jewellery or other valuable items home before visiting the hospital.
6. The paramedical staffs perform the patient's medical examination and record the vital signs, such as oxygen levels, heart rate and blood pressure.
7. Once the test results are normal, the patient is asked to change the clothes and wear a hospital gown.
8. The patient is then shifted to the operating room for Endoscopic Hemithyroidectomy.

The following things can be expected after the endoscopic thyroidectomy procedure:

The recovery process at the hospital

1. Once the surgery is completed, the staff shifts the patient to the ICU.
2. In the ICU, the vitals of the patient is continuously monitored. 
3. The patient gains consciousness while recovering in the ICU. 
4. When all the vitals are stabilised and the patient feels comfortable, the staff shifts the patient to a normal ward. 
5. The doctor may also give certain medications, such as anti-inflammatory and analgesics, to relieve the pain and inflammation and antibiotics to reduce the risk of infection. 
6. The patient is discharged from the hospital within 2-3 days after the surgery, depending upon the recovery and presence of other complications. 

Recovery process/expectation after hospital discharge

1. The patient should take adequate care of their wound by keeping it dry, not scrubbing, and changing the dressing as advised by the doctor. 
2. The patient may resume most routine activities within 1-2 weeks after the surgery. However, the patient should avoid driving or lifting heavy objects before recovery.
3. Two weeks off from work or school helps increase the rate of recovery.
4. Some patients prefer to initiate with a liquid diet. However, there are no dietary restrictions after the surgery. 
5. The patient should drink adequate fluids to clear the throat as they may experience hoarseness after the surgery. 
6. The patients should take medicine as prescribed. They should not withdraw any medications without consulting the doctor.

First follow-up appointment

1. The doctor provides the complete follow-up schedule plan for the patient during the time of discharge. However, the procedure may be changed depending on the patient's recovery and surgical complications.
2. The first follow-up visit is usually one week after the surgery. 
3. The doctor examines the wound and looks for any surgical complications.
4. The doctor, through the blood tests, determines the alteration in the levels of the hormone before and after the surgery.
5. The patient may also undergo imaging tests in the first or subsequent follow-up visits to determine cancer recurrence in case of thyroid cancer.

The advantage of endoscopic hemithyroidectomy is that it uses a minimally invasive technique (i.e., the surgery is performed through a keyhole incision). Other benefits include precision and safety. The most significant advantage is that the neck is left scar-free when the thyroidectomy is done endoscopically through axillary incisions. The little scars left behind at the axilla are concealed by inner clothing. It provides an excellent cosmetic benefit. There are several benefits of endoscopic hemithyroidectomy over conventional surgery. These are:

1. Less tissue damage
2. No scar in the neck 
3. Low blood loss
4. Less pain after surgery, thereby requiring less dose/less frequent analgesic administration.
5. Fewer complications 
6. Short recovery time
7. Less stay at the hospital

Like any other surgery, the endoscopic hemithyroidectomy procedure also has some potential risks and complications, such as:

1. Bleeding
2. Infection
3. Vocal cord alterations
4. Hematoma (pooling of blood under the skin)
5. Nerve damage
6. Vocal cord paralysis (in rare cases)

When is consultation with the doctor needed?

The patients should not wait for the follow-up visit schedule if they experience any concerning symptoms. Symptoms that require immediate medical attention are:

1. Skin discolouration that may indicate tissue necrosis
2. Pain not relieved with medications
3. Fever
4. Increased swelling in the neck
5. Discharge from the incision
6. Redness and inflammation around the incision

If the surgery is delayed, the patient may experience any of the following complications, depending upon the reason for undergoing surgery:

1. Complications of hyperthyroidism: Thyroid surgery is done for the overactive thyroid gland (hyperthyroidism) and enlarged thyroid (goitre). If the surgery is delayed, the high levels of thyroxine hormone in the blood for a prolonged period may result in certain complications. It results in weight loss and irregular or rapid heart rate. The patients may also experience brittle bones, swelling in the skin, eye problems, and thyrotoxic crises.  
2. Progression of cancer: Hemithyroidectomy is also done to remove the cancerous lobe of the thyroid. However, if the surgery is delayed, cancer may spread to the entire thyroid gland and other body parts. It is complicated to manage cancer and will require advanced and aggressive treatment. 

The cost of Endoscopic Hemithyroidectomy ranges from ₹96,200 to ₹2,00,000. The cost varies based on the following factors:

1. Type of endoscopic hemithyroidectomy surgery
2. Age of the patient
3. The medical condition of the patient
4. The type of hospital facility availed - individual room or shared.