title: Subxyphoid thyroidectomy: a feasibility study.
abstract: OBJECTIVE
  The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance.
  
  
  METHODS
  This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform's 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction.
  
  
  RESULTS
  The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient.
  
  
  CONCLUSIONS
  Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.
authors.affiliation: 1Oregon Clinic, GMIS Division, Portland, OR, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Sharata
authors.forename: Shaghayegh
authors.initials: S
authors.lastname: Aliabadi-Wahle
authors.forename: Neil H
authors.initials: NH
authors.lastname: Bhayani
authors.forename: Ashwin A
authors.initials: AA
authors.lastname: Kurian
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Reavis
authors.forename: Christy M
authors.initials: CM
authors.lastname: Dunst
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanstrom
mesh_terms: D004724:Endoscopy / Q000295:instrumentation / Q000379:methods; D005240:Feasibility Studies; D006801:Humans; D013965:Thyroidectomy / Q000295:instrumentation* / Q000379:methods*; D014989:Xiphoid Bone / Q000601:surgery
keywords: SILS/single site surgery; endocrine surgery; flexible endoscopy; image-guided surgery; thyroid surgery