Novel Endoscopic Transaxillary Gas Insufflation Approach Thyroidectomy Procedure

Background: In the original axillary approach described by Ikeda et al. with three points incisions, they began by accessing the central neck region by dissecting the sternocleidomastoid muscle (SCM) off from the sternohyoid muscle. Later this approach was modified by utilizing a gasless approach that is popularized worldwide. The central neck region was accessed directly by dissociation of the sternal and clavicular heads of the SCM. However, this procedure required a 5–6 cm incision and also place a special static retractor. We modified the conventional gasless transaxillary thyroidectomy procedure to a transaxillary gas insufflation approach with shorter incisions, and a smaller flap creation area. This video is aimed to describe the step-by-step procedure of a case of modified endoscopic transaxillary gas insufflation thyroidectomy (ETGT). Case: A 43-year-old woman with a body mass index of 29.6 kg/m2 was found to have a thyroid nodule during physical examination and experienced no tracheal compression or voice changes. However, ultrasonography and CT scan revealed a 1.3 cm nodule in the left lobe of the thyroid, and several enlarged lymph nodes were also identified on the left side of the central neck region. A thyroid biopsy revealed papillary thyroid carcinoma with a mutation in the BRAF gene. Results of all routine preoperative examinations of the patient were within normal ranges. Surgery was indicated and endoscopic transaxillary thyroidectomy plus central neck dissection was chosen. The surgery began with making three incisions of endoscopic portals in the axillary region. After that, the working space was made using an ultrasonic scalpel while running CO2 insufflation. The central neck region was accessed by dissociating the sternal and clavicular heads of the SCM. The sternal heads of SCM, strap muscles, and thyroid gland were lifted by a suture that was retracted by ribbon. The vessels and the thyroid gland around the central neck region were dissociated, and the recurrent laryngeal nerve and the parathyroid glands were protected from injury. The specimen was released from the trap muscle and removed. Results: The technical aspect of the ETGT procedure with a step-by-step description is demonstrated in this video. Conclusions: Thyroidectomy is feasible to be done by this novel transaxillary thyroidectomy procedure with the advantages of shorter incisions and smaller flap creation area than the conventional gasless endoscopic thyroidectomy procedure. Authors' Contributions: Y.L. designed the procedure, conducted procedure, did the operations, and wrote the article. S.C. and J.W. conducted the procedure, acquired data, and edited the video. G.C. conducted the procedure, did the operations, and revised the article. All authors revised and approved the article for publication. Ethical Approval: The data and all the patient's information were anonymous, so the requirement for informed consent and ethical approvement was waived by the ethics committee of the Xi'an Jiaotong University. No competing financial interests exist. No funding was received for this article. Runtime of video: 9 mins 25 secs