"Stealing" the thyroid gland

Here's a story about a technique of thyroid surgery that is no longer being done

During one summer of my college years in the mid-1960s, I worked as an orderly at a community hospital in my hometown. There are no orderlies anymore. I guess the closest thing would be a "patient care technician." Orderlies used to push patients around on gurneys, help the nurses change beds, clean up poop, run errands, and do whatever no one else wanted to do. It was common for premed students to do at least one summer of orderly work to demonstrate their commitment to becoming a doctor. I suppose it's analogous to today's premed students' doing a summer of research cleaning test tubes.

Anyway, back to the story. A woman was admitted with thyrotoxicosis, a hyperactive thyroid gland resistant to whatever medications were being used to suppress thyroid function at the time.

She was scheduled for a total thyroidectomy, but the stress of anesthesia and surgery was known to induce a potentially fatal condition called a "thyroid storm." A thyroid storm can still occasionally occur in patients with untreated hyperthyroidism. Some symptoms of thyroid storm are fever, rapid heart rate, agitation, delirium, tremor, and low blood pressure, among others.

In the early 1900s, the threat of this problem prompted a famous early thyroid surgeon, George Crile, to devise a plan for "stealing" the gland.

Following Crile's script, what we did with our hyperthyroid lady was to visit her every day dressed in our surgical scrubs. The anesthesiologist would fiddle with her IV and talk to her. The OR nurse and I would chat with her too. All of this was done so that she could become accustomed to our presence. The idea was to one day anesthetize the patient in her bed and take her to the operating room for her thyroidectomy. Since the patient did not know on which day her surgery would occur, she was not so anxious.

A few days went by. One day we were told, "Today's the day." When we went into the room, the anesthesiologist, instead of just fiddling with the IV, injected some sodium pentothal, and the patient fell asleep. Off we went to the OR, and the operation was done.

These days, it's a good thing that hyperthyroidism can be treated with more effective medication. I doubt that insurance companies would pay for a three or four day preoperative hospital stay so that the thyroid gland could be stolen.

Whatever happened to robotic thyroidectomy?

In case you missed it, there was a brief romance between thyroid surgeons and robots. Thyroid surgeons, itching to join the crowds migrating to robot-assisted surgery, came up with the idea to use the robot to perform thyroidectomies.

It appears that the push began in Korea, and to add some pizzazz to the mix, a trans-axillary approach to avoid a scar in the neck was incorporated. As is often the case, the initial results were favorable.

Then reality set in.

The early euphoria gave way to the revelation that American patients were larger and more difficult to operate on than patients in Korea. But randomized trials of selected patients were suggested.

A paper from Wayne State in Detroit found complications in 4 (22%) of 18 cases—3 temporary vocal cord pareses and a post-operative hematoma that required re-operation. Hospital stay was a median of 2 days.

More than 90% of conventional thyroidectomy patients are done as same day surgeries.

After receiving 13 reports of complications, Intuitive Surgical, the company that manufactures the robot, decided it could no longer support the use of its robot for thyroid surgery.

At this point, a surgeon from the MD Anderson Cancer Center took the unprecedented step of publicly renouncing her previous stand on robotic-assisted thyroid surgery (RATS).

In an editorial in the December 2012 issue of the journal Surgery, she said, "After performing nearly 40 RATS procedures, we came to the conclusion that the main benefit of RATS—translocation of the surgical incision to the axilla—did not offset the risks and liability of performing an operation that was not supported by the equipment manufacturer, took twice as many resources to perform as open surgery, and faces complex legal hurdles beyond our control that currently prevent implementation of telerobotic/distant access surgery across the United States. Justifying the expense in a time when demands outweigh resources obligated us to focus on outcomes. When we did that, we proved that we could perform RATS, but not that we should."

Here's a link to a series of photos showing exactly how robot-assisted thyroidectomy was done. It looks like one trades a thin scar in the neck for an ugly scar in front of the armpit.

There are still hospital websites that say they offer the procedure. Here is one. Google "robotic thyroidectomy" and you will see. 

Maybe they didn't get the memo.