Total endoscopic thyroidectomy.

We have developed endoscopic thyroidectomy procedures using anterior chest and axillary approaches. Both of our procedures differ significantly from the usual thyroidectomy, which involves lifting both the platysma and the sternohyoid muscle. Because only the platysma is lifted during our procedures, a CO(2) insufflation pressure of less than 4 mmHg is sufficient. While the sternohyoid muscle is transected to obtain greater exposure of the thyroid gland in minimally invasive procedures in the neck, we do not divide it so as to prevent adhesions to the platysma, unless the nodule is large. As we accumulated experience with these procedures in 58 patients, typical operation time decreased to less than 120 minutes for the anterior approach and to less than 150 minutes for the axillary approach. Large follicular tumours can be extracted using the axillary approach, with all of its cosmetic advantages, whereas the anterior chest approach is advocated for removal of bilateral multinodular goitres and parathyroid lesions. Both approaches result in minimal postoperative hypoaesthesia, paraesthesia, and discomfort during swallowing. We conclude that endoscopic neck surgery is the procedure of choice in carefully selected patients with thyroid disease.