In recent years, with the ‘inert’ characteristic of DTC and the improvement in operation skills, thyroidectomy for DTC has resulted in a good prognosis. However, due to the anatomical position of the thyroid gland, a 6–10 cm surgical scar is usually left in the cervical area after COA thyroid surgery, seriously affecting the cosmetic appearance of the neck. In our study, the BAA approach obtained better cosmetic satisfaction than the COA approach. To meet the cosmetic requirements of the majority of patients, various methods are adopted (e.g., several kinds of concealed incisions and small incisions). Under the guidance of aesthetic principles with the assistance of energy instruments, we improved the cosmetic outcomes by using a shorter collar incision between 3.5 and 4.0 cm long. Even so, a slight scar could be observed on the anterior neck.10
Bilateral areolar endoscopic thyroidectomy could be an ideal approach for thyroid surgery. However, the advantages and benefits of endoscopic thyroid surgery have been controversial because this procedure needs dissection of a large area of subcutaneous tissues, and some new complications may appear, such as bleeding in the tunnel and hypercapnia. The endoscopic apparatus needs a large operating space to reach the thyroid region, which determines the surgical time and surgical injury severity.
Here, we report a simple and easy method to establish the operating space. First, we adopted a low concentration of epinephrine inflation fluid (500 ml of normal saline + 0.5 mg of epinephrine). Generally, the epinephrine concentration is twice as high.10 In fact, epinephrine inflation fluid at a low concentration may not only shrink the subcutaneous vessel but also avoid subsequent withdrawal bleeding. In our research, no tunnel bleeding was observed with the BAA. Therefore, we recommend this concentration of epinephrine inflation fluid. Then, no more than 40 milliliters of inflation fluid was injected into each surgical tunnel, as too much fluid may incur excessive smog when a subsequent energy apparatus is used in the narrow tunnel. After the three incisions were made, we used 14 cm curved Mayo dissecting scissors to establish the operating space.
The fascia pectoralis divides into two layers to envelop the pectoralis major, and its superficial layer goes beyond the sternum to continue with the contralateral fascia pectoralis. The superficial pectoral fascia (SPF) is easily undermined and separated with a Mayo dissecting scissor. We used a gentle pushing force by the scissor. It was very easy to stretch the SPF in a nonvisual situation. We cut the fiber connective tissue when meeting resistance. The posterior layer of the SPF was dense and difficult to penetrate. We used the other hand to locate the position of the scissor tip to ensure that the scissor was in the correct layer. The time of establishing the operating space in the chest (OSC) was only 3–4 minutes, much less than that with any traditional method. The overall operation time is greatly shortened. We established a small operating space just enough to accommodate the trocar. It was not necessary to dissect the chest flap extensively, so the technique is minimally invasive.
Usually, surgeons utilize a visible flap dissection stick to establish the operating space.11 This is a blunt separation process that leads to trauma and rupture of fat cells. Moreover, it needs a long time and a large space, resulting in an extended total operation time and significant surgical injury. Subcutaneous emphysema, fat liquefaction and tunnel bleeding are common complications associated with the BAA but did not occur in our study.
As shown in our results, compared with the COA, the operating time of the BAA was longer. This result is not difficult to comprehend because it is easier to operate in an open incision. However, we thought it was worthwhile for aesthetic purposes at a cost of approximately 30 minutes per operation. We believed we could shorten the operation time with the improvement in skill and accumulation of experience. The number of lymph nodes dissected, postoperative hospitalization time and incidence of postoperative complications were not significantly different between the two groups. The results showed that the BAA technique was safe and reliable. The reduced intraoperative bleeding associated with the BAA also showed the superiority of this technique. In some cases, we were able to finish the operation without any hemostatic gauze.
Furthermore, the BAA group reported lower pain scores than the COA group. Some researchers believe that this could be because the BAA exploits only the subcutaneous tunnels and the neck platysma does not need to be removed. The skin and subcutaneous tissue were well combined when the trocar was extracted. However, in the COA, the neck platysma needs to be removed to expose the thyroid bed. Therefore, the COA was associated with higher pain scores.
Of note, patients in the BAA group reported significantly higher cosmetic satisfaction scores (with a shorter incision length) than patients in the COA group. These data indicate that BAA thyroidectomy is a highly feasible and safe surgical procedure, especially for young female patients.12 Nevertheless, our current study had some limitations, such as a small sample size, and all patients were derived from a single center. Thus, a large-scale, prospective, multicenter clinical study should be conducted to validate these findings.