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Welcome to the First Issue of
Our "Spotlight Feature"Series in which we highlight Endocrine Surgery, with the emphasis on Robotic Thyroid Surgery and one of the pioneers of Robotic Thyroidectomy Dr.Emad Kandil, MD, FACS, Edward G. Schlieder Chair in Surgical Oncology Assistant Professor of Surgery, Otolarygology and Medicine Chief, Endocrine Surgery Section Department of Surgery, Tulane University School of Medicine
New Orleans, LA
Dr. Emad Kandil, MD, FACS.
Robotic Endocrine Surgery at Tulane University School of Medicine
What is Endocrine Surgery?
Endocrine surgery involves procedures upon the glandular system of the human body (thyroid, parathyroid, adrenal, and endocrine pancreas). Diseases in this category range from common conditions like goiter, thyroid and pancreatic cancer to unusual problems such as Cushing's disease, Conn's Syndrome and the Multiple Endocrine Neoplasia Syndrome.
The American Association of Endocrine Surgeons recognizes surgeons “who have a major interest and devote significant portions of their practice or research to endocrine surgery, and who are certified by the American Board of Surgery”.
The Section of Endocrine Surgery at Tulane University Medical Center provides cutting-edge surgical care to patients with complex endocrine problems. Minimally invasive surgery can dramatically diminish – or in some cases, eliminate altogether – scars that typically result from surgical incisions.
Dr. Emad Kandil, Assistant Professor of Surgery and Chief of the Endocrine Surgery Section at Tulane, is a leader in minimally invasive surgery for endocrine conditions. He runs an annual course to teach other surgeons across the country how to perform these minimally invasive procedures. Why Should You Have a Specialized Endocrine surgeon?
In this Issue we will focus on Robotic Thyroid Surgery
Thyroid issues can affect both men and women. The effects of the disorders differ in men and women. There are tests your doctor can do to see if your thyroid is functioning normally. Once tests are done you can work with your doctor to find the proper way to treat your condition.
Thyroid Issues in Men
Having hypothyroidism can cause lethargy and depression in men as well as a decreased libido. It may also cause your muscles to be weaker than they appear. Hyperthyroidism can lead to muscle wasting and weakness, especially in thighs and upper arms. It can also upset the balance between testosterone and the female sex hormone, estradiol, in the body. Some men experience breast tenderness or enlargement and difficulty with erections. Thyroid cancer is rare but if there are nodules in the thyroid gland, in men they are more likely to be cancerous. If you are experiencing any of these problems have your doctor examine your thyroid and check your TSH levels with a blood test.
Thyroid Problems in Women
More women than men suffer from hypothyroidism, and many more women than men with thyroid issues have problems with weight gain. Women experience low thyroid and weight gain primarily because:
Women spend much of their lives dieting, usually in a yo-yo cycle of feasting and then fasting. This undermines your metabolism and decreases your metabolic rate, a compounding factor for the thyroid, especially during perimenopause.
Women tend to internalize stress, which affects their adrenal, brain, and thyroid function, resulting in increased cravings for sweets and simple carbs to provide instant energy and feel-good hormones.
Women experience monthly hormonal fluctuations that affect their biochemistry.
Hyperthyroidism can occur at any age but it is more likely to occur after the age of 15, and more so to those in their 30's and 40's. Although the exact cause is not known it is believed that your immune system does not work properly and the body produces a substance that makes more hormone than it needs. Instead of protecting the body's tissue, antibodies produced in the body's immune system attack tissue and as a result cause the thyroid gland to overproduce
The application of endoscopic visualization to thyroid surgery has allowed surgeons to perform thyroidectomy through incisions far smaller and less visible than the conventional Kocher’s incision—the so-called “less is more.” In general, these endoscopic techniques attempt to minimizing the extent of dissection, improving cosmesis, reducing postoperative pain, shortening hospital stay, and enhancing postoperative recovery. Michel Gagner was the first to apply endoscopic technique to neck surgery when he reported a totally endoscopic subtotal parathyroidectomy for a 37-year-old man suffering from familial hyperparathyroidism.
The application and feasibility of the endoscopic approach was given a further boost with the availability of various robotic systems such as the da Vinci system (Intuitive Surgical, Sunnyvale, California). Unlike other cancers such as prostate cancer, the initial enthusiasm of using the robot in thyroid cancers was not great because of its relatively high cost, bulkiness of the robotic arm, and long operating time. However, since the publication of two large surgical series demonstrating the feasibility and safety of robotic-assisted thyroidectomy in differentiated thyroid carcinoma, an increasing number of specialized surgical centers worldwide are beginning to accept and perform this procedure.
The theoretical advantages of using the robot over the endoscopic approach include the three-dimensional view offer to the operating surgeon, the flexible robotic instruments with seven degree of freedom and 90° articulation, the increased tactile sensation, and the ability to filter any hand tremors....for complete story Click here
"No Neck Scar" Robot Assisted Thyroid Surgery
Development of Robotic Gasless Transaxillary Thyroid Surgery
Robotic gasless transaxillary thyroidectomy is a newly developed minimally invasive surgical technique to remove all or part of the thyroid. This was developed by Dr. Chung in South Korea. With this new technique, a small incision is made under the arm.
Before its development there were different options for thyroid surgery: conventional open surgery, endoscopic surgery or transaxillary approach with gas insufflation.
• Conventional open surgery involves a scar on the neck. • Endoscopic or videoscopic techniques are done using a small camera, however, this still involves a neck scar. The neck scar is shorter in these approaches, but still there is an incison in the neck. • With the new method, Robotic gasless transaxillary thyroidectomy, there is no scar on the neck whatsoever.
Dr. Chung set out to find a way to perform thyroidectomy without causing the four-inch horizontal neck scar typical of traditional thyroid surgery. “Many Asian people, especially young women, don’t want to have a neck scar after surgery, because a hypertrophic scar is more frequent in Asian people,” Dr. Chung said in an e-mail.
How does Robotic Gasless Transaxillary Thyroidectomy work?
Robotic gasless transaxillary thyroidectomy eliminates the neck scar by accessing the thyroid gland through a hidden incision under the arm. The special designed robotic arms allow the surgeon to operate with very precise movements. Robotic instruments do work just like hands. However, they are amazingly small. The robot is completely under the control of the surgeon. The robotic system also proides 3D visualization, with a special designed high-definition camera with an excellent magnification of 10x.
This technique is not only about avoiding an incision and a scar on the neck. From a surgical standpoint, safely performing these procedures depends on clear visualization of important nearby structures, including nerves and parathyroid glands.
Initially, robotic approach was done with gas insufflation to the neck area, however this gas can be retained, which can cause retained pneumomediastinum or subcutaneous air with uncomfortable crepitations. The patient may experience significant metablic problems with CO2 retention. The gas eventually will be absorbed, but it can cause siginificant discomfort until this completely absorbes. These patients needed to stay hospitalized longer than they used to with conventional surgery for observation. With this new approach, gas insufflations is avoided, so Co2 retention complications are also avoided.
This procedure was recently approved by FDA and is is proven to be a safe approach. However, special training and experience with robotic surgery is a must to proceed. With more experience, more patients can be offered this approach. Large thyroid nodules over 4cm were initially not candidates for this procedure, however, now the surgery is able to be offered to these patients with an excellent outcome.
Dr. Emad Kandil of Tulane University School of Medicine is one of the first in the country to perform this new form of endoscopic surgery that uses a small incision under the arm to remove all or a portion of the thyroid or parathyroid glands without leaving a scar on the neck. Not only is Dr. Kandil one of the few surgeons in the US trained to perform the surgery, but he chairs an annual symposium at Tulane to teach surgeons how to perform minimally invasive thyroid surgery and will be teaching the technique to doctors from across the country.
One of the Pioneers of Robot Assisted Thyroid Surgery is Emad Kandil, MD, FACS, Chief of Endocrine Surgery at Tulane University School of Medicine.
To read more about Emad Kandil, M.D., FACS click on Image
Emad Kandil, M.D.,
is Assistant Professor of Surgery, Otolarygology and Medicine, Edward G. Schlieder Chair in Surgical Oncology and Chief Endocrine Surgery Section Department of Surgery at Tulane University School of Medicine
Prior to coming to Tulane, Dr. Kandil was a Neuroendocrine research fellow at New York University and completed his training with a clinical fellowship in Surgical Endocrinology and Oncology at Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Kandil received his general surgery residency training at the State University of New York (SUNY) Health Sciences Center at Brooklyn, New York.
He had two research fellowships at New York University Medical Center and the State University of New York Health Sciences Center. He is full-time academic faculty at Tulane University School of Medicine.
His clinical interests include all aspects of endocrine and oncological surgery. He has a special interest in robotic and minimally invasive surgery. He is a fellow of the American College of Surgeons and a member of many prestigious societies as listed in his CV below.
Dr. Kandil is on the advisory board and editorial board for prestigious journals including, but not limited to, the American Journal of Translational Research and the International Journal of Clinical and Experimental Medicine. Dr. Kandil received multiple prestigious research awards for his major contributions to the endocrine surgery field.
He was one of the first surgeons to perform robotic endoscopic transaxillary gasless thyroid surgery in the country and is the only endocrine surgeon in the country. Since robotic thyroid surgery is relatively new and many head and neck surgeons in the country are still learning robotic surgery, Dr. Kandil has been committed to educational excellence and was selected to chair a symposium in 2010 to teach surgeon across the country this novel surgical technique.
Dr. Kandil acts as a proctor for robotic surgery and has traveled all over the country to present papers and teach robotic surgery. He has also been featured on PBS and on multiple local television stations in New Orleans regarding scarless neck surgery.
For more information about Robotic Thyroid Surgery and Scarless Thyroid Surgery at Tulane University Medical Center Click here
Dr. Emad Kandil and Tulane University School of Medicine now perform Same Day Robotic Scarless Neck Surgery • Read Dr.Celine Lemieux's testimonial below
Dr. Celine Lemieux writes:
To the Director of Surgery at Tulane
I wanted to take this opportunity to express my most sincere thanks and appreciation for the excellent medical treatment that I received at Tulane University and especially the care that was provided to me by your staff and in particularly Dr. Emad Kandil.
I was referred to Dr. Kandil by my Endocrinologist Dr. Talik Mallik. As part of an examination for an unrelated issue, nodules were found in my thyroid on an MRI. I received my initial work-up including FNAB and blood work from Dr. Mallik. The pathology report seemed somewhat ominous that perhaps there was a malignancy so he referred me to Dr. Kandil.
Dr. Kandils' staff and clinic director were most helpful in getting an appointment for me quickly. Dr. Kandil reviewed the pathology slides that were previously obtained, performed an additional biopsy and enhanced ultrasound.
When my husband and I returned for the results, Dr. Kandil was very informative, discussing the possibilities of a malignancy, but he had a intentioned plan to save half of my thyroid in the event there was no malignancy.
He suggested the daVinci robotic method, his treatment plan was intentioned, intelligent and sensitive to my needs for care. As well he was very comforting, confident and concerned about my outcome since I am a health care provider as well. My duties as a Chiropractor require me to be able to use my upper body strength and that I not be absent from my practice for an extended period of time.
My procedure was scheduled for Tuesday, April 26, 2011. There was no malignancy and I still have half of a functioning thyroid.
Dr. Kandils' surgical approach left me with no scar on my neck and no complications what so ever. In fact, the procedure was "Same Day" surgery. I was in my home relaxing by one o'clock in the afternoon that very day. Today is the two week mark since my surgery and I have been back at work since Monday, what a wonderful thing!
I would highly recommend Tulane University, Dr Kandil, The daVinci technique which allows for minimum hospital stay and of course the wonderful medical staff. There's no place like home when you have something like this do deal with. If one should consider this method, have a trusted friend or family member there to help you out for the first day or two.
I am very pleased with my rapid recovery and I am very happy to have met Dr. Kandil and his kind staff. My referral list for my own patients will definitely include him and your Medical Center.
Celine Lemieux, D.C.
•Please Click Here for more of Dr. Kandils' Patients Testimonials
Thyroid Surgery Without a Neck Scar
Same Day Robotic Scarless Neck Surgery at Tulane University Medical Center
Exploring Scarless Transaxillary Robotic Thyroid Surgery with Dr. Emad Kandil
One of the lasting effects of thyroid surgery - known as thyroidectomy - is the scar left behind by the incision. The best thyroid surgeons have expertise at carefully positioning the incision so the scar is hidden in a neck crease. In recent years, incisions have gotten smaller, thanks to video assisted surgery techniques. The visual appearance of thyroid scars have certainly improved to a large extent, but thyroidectomy with a neck incision still leaves a visible scar.
Some surgeons are now performing thyroid and neck surgery with robotic assistance, placing the incision in the underarm (axilla) area. This is known as "transaxillary robotic" surgery. The FDA approved this procedure in 2009. Only about 35 medical centers nationwide offer such minimally invasive robotic thyroidectomies
In addition to the cosmetic benefit of having the only scar in the underarm area - rather than on the neck -- the underarm area has fewer nerve endings per square inch than the throat area, so healing is less painful and with good care, the incision will heal faster than in the neck area.
Emad Kandil, MD, FACS, is Chief of Endocrine Surgery at Tulane University School of Medicine. Dr. Kandil has helped revolutionize and develop transaxillary robotic neck surgery techniques, using "intraoperative nerve monitoring" to protect the laryngeal (voice box) nerve.
Thyroid and Parathyroid Surgery Without a Neck Scar
Transaxillary robotic-assisted thyroid and parathyroid surgery utilizes the latest da Vinci® Si High Definition minimally invasive robotic surgical system to make a two inch incision below the armpit. This allows Dr. Kandil to maneuver a small camera and specially designed surgical and nerve monitoring instruments between the muscles of the neck to access the thyroid or parathyroid gland; diseased tissue can be removed through this incision, eliminating the prominent neck scar that is a byproduct of the traditional surgical approach, and reducing the risk of injury to the nearby glands and nerves.
The da Vinci® Si High Definition minimally invasive robotic surgical system allows for an enhanced view of the patient’s anatomy and greater surgical precision than the traditional open or endoscopic surgical method. Dr. Emad Kandil of the Tulane Thyroid Center is the only endocrine surgeon in the country that is qualified to perform robotic-assisted thyroid and parathyroid surgery; he has successfully treated patients who were previously considered not to be candidates for this surgical approach.
Armed with new tech, local doctor performs thyroid surgeries without scars; By Meg Farris / Eyewitness News
Dr. Kandil and his partner, Plastic Surgeon Dr. Thomas Moulthrop, now perform "Robotic Neck Lift Surgery"
Emad Kandil, MD, FACS
This new "twist" to robotic thyroidectomy,
which by itself is already a wonderful procedure eliminating the visible scare in the front of the neck left behind after a "traditional open thyroidectomy", now allows for the surgeon to go in from the back of the neck.
After Dr. Kandil finishes the robotic thyroidectomy, his partner Dr. Thomas Moulthrop, is then able to take over and perform the face lift from the same surgical incision site, hiding the scar underneath the hair.
As soon as we find out more about this exciting new procedure we will let you know.
In the mean time please read the testimonial from J.L
J.L. tells her story;
I found a big lump on my neck during my physical check on September 2012 and it turned out to be a 3.2 cm thyroid nodule. I was blessed to find Dr Kandil and he is the best doctor I have ever encountered. He was very sweet and treated me like his family. I am from China and most my family members are living in China now. They encouraged me to go back China and have the surgery done there. But I chose to do the surgery in the United States instead, the reason is simple--
If I chose to do the surgery in China, I will have a visible scar on my neck, but Dr Kandil with his Robotic Technology can help me avoid the ugly scar. Dr Kandil has many years experience in Robotic Surgery and he can do the surgery through axilla area instead of directly on the neck, Dr Kandil convinced me that he could even do it from the back of my neck using advanced robotic technology called "Facelift Technology" and the scar will be hidden by my hair.
The result of my surgery turns out a big success. I was able to talk normally immediately after surgery, and I didn't even need any pain medicine during my recovery period. I was able to go to the mall shopping one week after the surgery, go back to work two weeks later without anybody in my work place noticing that I had a major surgery, and go to the gym exercising after three weeks.
I feel that I have been blessed to meet Dr Kandil and I definitely will recommend him to anyone who also has to go through thyroid surgery and wishes to have a beautiful neck after the surgery.
Publications co-authored by Emad Kandil MD, FACS
Jackson N, Yao L, Tufano RP, Kandil E, Head & Neck - HED-11-1069 (Safety of robotic thyroidectomy approaches: Meta-analysis and systematic review (Head and Neck, 2013 Mar 8, doi: 10.1002/hed.23223. [Epub ahead of print, PMID: 23471784].
Kandil EH, Noureldine SI, Yao L, Slakey DP. “Robotic transaxillary thyroidectomy: an examination of the first one hundred cases” J Am Coll Surg. 2012 Apr; 214(4): 558-64. Epub 2012 Feb 22. PMID: 22360981
Li X, Massasati SA, Kandil E. Robotic clipless transperitoneal adrenalectomy. Gland Surg 2012 Oct 27. DOI: 10.3978/j.issn.2227-684X.2012.10.08
Kandil E, Malazai AJ, Alrasheedi S, Tufano RP. Minimally invasive/focused parathyroidectomy in patients with negative sestamibi scan results. Arch Otolaryngol Head Neck Surg. 2012 Mar;138(3):223-5. Epub 2012 Feb 20. PMID: 22351855
Kandil E, Abdelghani S, Noureldine SI, Friedlander P, Abdel Khalek M, Bellows CF, Slakey D. Transaxillary gasless robotic thyroidectomy: a single surgeon’s experience in North America. Arch Otolaryngol Head Neck Surg. 2012 Feb;138(2):113-7. PMID: 22351858
Richmon JD, Holsinger FC, Kandil E, Moore MW, Garcia JA, Tufano RP. Transoral robotic-assisted thyroidectomy with central neck dissection: preclinical cadaver feasibilitystudy and proposed surgical technique. J Robot Surg. 2011 Dec;5(4):279-282. Epub 2011 Jun 15. PMID: 22162981
Massasati S, Noureldine S, Aslam R, Kandil E. Robotic Transaxillary Thyroid Lobectomy of a Follicular Neoplasm. Ann Surg Oncol. 2012 Mar 10. PMID: 22407311
Kandil E, Noureldine S, Khalek MA, Aslam R, Ekaidi I, Steiner R, Holsinger FC. Robotic transaxillary thyroidectomy with gasless approach in a girl with goitre. Int J Med Robot. 2012 Jun;8(2): 210-4.PMID: 22454366
Kandil E, Noureldine S, Abdel Khalek M, Alrasheedi S, Aslam R, Friedlander P, Holsinger FC, Bellows CF. “Initial experience using robot-assisted transaxillary thyroidectomy for Graves’ disease,” J Visc Surg, 2011 Dec; 148(6):e447-51. Epub 2011 Nov 25. PMID 22118896
Winters R, Friedlander P, Noureldine S, Ekaidi I, Moroz K andKandil E. “Preoperative parathyroid needle localization: A minimally invasive novel technique in reoperative settings,” Minim Invasive Surg, 2011; 2011:487076. Epub 2011 Aug 13. PMID 22091358
Abdel Khalek M, Joshi V, Kandil E. “Robotic-assisted laparoscopic wedge resection of a gastric leiomyoma with intraoperative ultrasound localization,” Minim Invasive Ther Allied Technol, 2011 Dec; 20(6):360-4. Epub 2011 Sep 16. PMID 21919811
Kandil E, Abdel Khalek M, Thomas M, Bellows CF. “Are bilateral axillary incisions needed or is just a single unilateral incisionsufficient for robotic-assisted total thyroidectomy?” Arch Surg, 2011 Feb; 146(2):240-1. PMID 21339443
Katz L, Abdel Khalek M, Crawford B, Kandil E. “Robotic-assisted transaxillary parathyroidectomy of an atypical adenoma,” Minim Invasive Ther Allied Technol, 2011 May 4. PMID 21542724
Kandil E, Winters R, Aslam R, Friedlander P, Bellows C. “Transaxillary gasless robotic thyroid surgery with nerve monitoring: Initial experience in a North American center,” Minim Invasive Ther Allied Technol, 2011 Mar 14. PMID 21395464
Kandil E, Wassef SN, Alabbas H, Freidlander PL. “Minimally invasive video-assisted thyroidectomy and parathyroidectomy with intraoperative recurrent laryngeal nerve monitoring,” Int J Otolaryngol. 2009; 2009:739798. Epub 2010 Feb 8. PMID 20169134
*Dr Kandil has also co-authored many non robotic surgery related papers
Kandil E “Less Invasive approaches to the Thyroid and Parathyroid Glands” Mastery of Endoscopic and Laparoscopic Surgery, Editors: Lee Swanstrom and Nat Soper. Publisher, Lippincott Williams and Wilkins, Chapter 42, 4th edition. (In press)
Kandil E, Zeiger MA and Tufano RP. Solitary Thyroid Nodule. In Early Diagnosis and Treatment of Cancer: Head and Neck Cancer. 1st edition. Chapter 12, (page 223-236). Edited by W Koch and S Yang.
Kandil E, Noureldine S, Tufano R. Extensive Surgery for Thyroid Cancer: Central Neck Dissection. 1st edition. Thyroid Surgery: Managing Complications and Best Practice, edited by Paolo Miccoli, David Terris, Michele Minuto, and Melanie Seybt. 2012 John Wiley & Sons, Ltd. DOI: 10.1002/9781118444832. Chapter 8 (Page 67-77).
Felger E and Kandil E. Surgical Management of Parathyroid Disease. In Otolaryngology Clinics. Edited by Ralph P. Tufano. (PP 417-432). Published by Elsevier.
Kandil E, Invited Commentary, Atlas of Head and Neck Surgery, Chapter 49 “ Robotic Thyroidectomy: Surgical Technique for lobectomy via axillary incision without carbone dioxide insufflation” PP 488-498. Edited by Gary Clayman.
Kandil E, Noureldine S and Tufano RP. Surgical treatment of well differentiated thyroid cancer in childhood and adolescence. Brazilian Book of Endocrine Surgery. Published by Guanabara Koogan, AC Farmaceutica LTDA. Cirurgia da Tireoide e da Paratireoide 2013. (in press)
Kandil E, Robotic Transaxillary Parathyroidectomy: Surgical Technique and Pearls. Operative Techniques in Otolaryngology-Head and NeckSurgery. (In press).
Presentations by Emad Kandil MD, FACS
Invited Speaker, “Robotic Thyroid Surgery: Is it ready for Prime time?” 129th German Surgical Society Annual meeting, Berlin, Germany, 2012 April 27th.
Invited Speaker, “ Robotic Thyroid Surgery: an Update” Hellios Klinikum Berlin-Buch, Berlin, Germany, 2012 April 26th.
Invited Speaker, “Chasing the recurrent laryngeal nerve branching with nerve monitoring”, University of Halle-Wittenberg, Halle-Saale, Germany, 2012 April 30th.
Invited Speaker, “ Robotic Thyroid Surgery: Tips and Tricks” Klinik fur Chirurgie and Zentrum fur Minimally Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany, 2012 April 19th.
Invited Speaker, Grand Rounds, Cleveland Clinic, Cleveland, OH “ Update on Robotic Thyroid and Parathyrid Surgery” Dec 14th, 2012.
Chairman, Robotic thyroid surgery with live surgery, Yonsei Severance Robotic Symposium, Live/Advanced course at Severance Robot & MIS Center, Seoul, S. Korea, 2011 Aug 26th.
Invited Speaker, “Robotic Transaxillary Thyroid Surgery: Update on North American Experience” Yonsei Severance Robotic Symposium, Live/Advanced course at Severance Robot & MIS Center, Seoul, S. Korea, 2011 Aug 26th.
Chairman, “State of the art robotic thyroid and modified radical neck dissection” Yonsei Severance Robotic Symposium, Live/Advanced course at Severance Robot & MIS Center, Seoul, S. Korea, 2011 Aug 25-27.
Invited Speaker, “Robotic Thyroid Surgery” and “ Current management of medullary thyroid cancer”: 10th Thyroid Symposium Annual meeting, Medical College of Georgia, Augusta, GA, Oct 19-20, 2012.
Invited speaker and committee member, “Robotic Thyroid Surgery: State of the Art” Robotic Assisted Microsurgical & Endoscopic Society Annual meeting, Orlando, FL, 2011 Nov 4-6.
Invited Speaker, “Robotic thyroid surgery” 81st Annual American Thyroid Association Meeting. Indian Wells, CA, 2011 Oct 26-30
and many more.......
Oral Presentations on Robotic Thyroidectomy by Emad Kandil MD, FACS
At The Academic Surgical Congress 8th Annual meeting, New Orleans, LA.
“Automatic Nerve Stimulation Monitor Application During Thyroid Surgery” February 5th, 2013
“Is Robotic Hemithyroidectomy Superior To Its Conventional Counterpart?” February 5th, 2013
“Optimal Timing For Repeat Thyroid Biopsy” February 6th, 2013
“Simultaneous Suppression Of The MAP Kinase And PI3K/AKT Pathways In Aggressive Thyroid Cancer” February 7th, 2013
“CD146-Latexin Cross-Talk And Their Potential Role In Thyroid Tumorgenesis” February 7th, 2013
“Examining the Bethesda criteria in the Diagnosis Of Thyroid Nodules” February 7th, 2013
“Nampt Expression Is Upregulated In Well-differentiated Thyroid Carcinoma, February 7th, 2013
•“A Comparative North American Experience of Robotic Thyroidectomy in a Papillary Thyroid Cancer Population” July 23rd, 2012, The 8th International Conference on Head & Neck Cancer. Toronto, Canada.
•“Robotic thyroid surgery” Thyroid and Parathyroid Diseases: Current Trends and Controversies, 4th Annual Symposium, Tulane University School ofMedicine, New Orleans, LA. June 2012.
•“Outpatient thyroid surgery” Thyroid and Parathyroid Diseases: Current Trends and Controversies, 4th Annual Symposium, Tulane University School ofMedicine, New Orleans, LA. June 2012.
•“Intraoperative Adjuncts in parathyroid surgery” Thyroid and Parathyroid Diseases: Current Trends and Controversies, 4th Annual Symposium, Tulane University School of Medicine, New Orleans, LA. June 2012.
For a complete list of publications and presentations contact us
Ask Dr. Kandil about Transaxillary Robotic Thyroid Surgery
Emad Kandil, M.D., FACS
Question: The transaxillary robotic neck surgery is considered an advancement beyond the video-assisted endoscopic surgery that has been increasingly used for thyroid and neck surgery, and endoscopic surgery is considered more state-of-the-art than traditional surgery. Can you tell about these forms of surgery? Dr. Kandil: Traditional thyroid surgery usually involves a fairly long incision at the base of the neck. A permanent visible scar is possible. More recently, the video-assisted endoscopic surgery of the thyroid and neck has come into use. This surgery is done with a smaller neck incision, using endoscopic visualization with a small camera. This procedure was pioneered in Italy by Dr. Paolo Miccolli and gained popularity in the United States after Dr. David Terris adopted this procedure. I have been offering this procedure to my patients with the addition of a nerve monitoring system - as well as training other surgeons in this technique -- over the last two years. This technique does, however, still result in a scar on the neck.
Question: What is transaxillary robotic assisted thyroid surgery and how is it performed? Dr. Kandil: Dr. Woong Youn Chung in Seoul, Korea, developed the technique of scarless neck surgery with robotic assistance.
Initially, the robotic neck surgery approach was done with carbon dioxide (CO2) gas insufflation (introduction of gas into the surgical area) to the neck area. The use of gas has the potential to cause some post-surgical side effects, however, as patients can experience pain due to retained gas in the tissues surrounding the lungs (a condition known as pneumomediastinum) or subcutaneous air with crepitations. The pain and discomfort can remain until the gas is eventually absorbed.
Robotic, gasless, transaxillary thyroidectomy is a newly developed, minimally-invasive surgical technique to remove all or part of the thyroid. Gas insufflation is avoided, so problems related to retention of the gas are also avoided. It is also sometimes called robot-assisted thyroid surgery, or robot-assisted endoscopic thyroid surgery.
With this new technique, a small incision is made under the arm, and the specially-designed robotic arms work just like hands, allowing the surgeon to operate with very precise control and movements. The robotic system also allows the surgeon to see in stereo-optic three-dimension (3D), with a specially designed high-definition camera that offers magnification to ten times the normal vision. We also modified the procedure to include the use of routine intraoperative nerve monitoring.
Question: Please describe the benefits of transaxillary robotic thyroid surgery compared with traditional thyroidectomy. Dr. Kandil: A key benefit is that transaxillary robotic surgery does not result in a visible, permanent neck scar.
A risk of traditional open thyroid surgery is the risk of injury to the laryngeal nerve, which goes to the voice box. This can cause temporary or permanent hoarseness. Thyroid surgery can also cause trauma to nearby structures, including the parathyroid glands, which are near the thyroid. Parathyroid damage can result in temporary or permanent hypocalcemia, a condition that is treated with calcium supplementation.
From a safety standpoint, in transaxillary robotic thyroid surgery, the use of the high-definition robotic equipment with 10X magnification of the field and 3D vision allows us to perform a very precise operation. This means that there is a reduced likelihood of nerve damage and less risk of trauma to the nearby structures like the laryngeal nerve or parathyroid glands. It's very hard to injure the nearby structures if you can visualize the field at ten times their normal size. We are also able to monitor the nerve function during the entire operation to avoid the risk of postoperative hoarseness.
Additionally, my preliminary data showed that postoperative pain is significantly less. This is likely due to the fewer number of nerve endings under the arm, compared to the sensitive skin of the neck. Many of my patients didn't require any pain medicine after surgery. In general, recovery is also quicker for transaxillary robotic surgery, compared to other thyroid and neck surgeries.
Question: Does transaxillary robotic surgery offer any time and cost savings? Dr. Kandil: The time to perform the surgery is comparable to the traditional thyroid surgery in experienced hands. To date, we don’t have studies that have evaluated the cost effectiveness of this procedure compared to traditional thyroid surgery. When this research is done, however, it should include the risk of complications and the cost to manage these complications.
Question: How long does it take to train surgeons in transaxillary robotic surgery? Dr. Kandil: I honestly don’t know the answer to this question. I was performing robotic surgery for other endocrine and oncological procedures, so it was easy for me to adopt this technique. To my knowledge, this procedure was performed in eight institutions in the United States, however, there are only three institutions that are actively offering this type of surgery. I really believe part of this is the required experience to perform robotic surgery, because specialized training and experience with robotic surgery is essential. As more surgeons become experienced in this technique, more patients can be offered this alternative, however.
is a small gland, normally weighing less than one ounce, located in the front of the neck. It is made up of two halves, called lobes, that lie along the windpipe (trachea) and are joined together by a narrow band of thyroid tissue, known as the isthmus.
The thyroid is situated just below your "Adams apple" or larynx. During development (inside the womb) the thyroid gland originates in the back of the tongue, but it normally migrates to the front of the neck before birth. Sometimes it fails to migrate properly and is located high in the neck or even in the back of the tongue (lingual thyroid) This is very rare. At other times it may migrate too far and ends up in the chest (this is also rare).
The function of the thyroid gland is to take iodine, found in many foods, and convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid cells are the only cells in the body which can absorb iodine. These cells combine iodine and the amino acid tyrosine to make T3 and T4.
T3 and T4 are then released into the blood stream and are transported throughout the body where they control metabolism (conversion of oxygen and calories to energy). Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone "strength" as T4.
The thyroid gland is under the control of the pituitary gland
The thyroid gland is under the control of the pituitary gland,
a small gland the size of a peanut at the base of the brain (shown here in orange). When the level of thyroid hormones (T3 & T4) drops too low, the pituitary gland produces Thyroid Stimulating Hormone(TSH) which stimulates the thyroid gland to produce more hormones.
Under the influence of TSH, the thyroid will manufacture and secrete T3 and T4 thereby raising their blood levels. The pituitary senses this and responds by decreasing its TSH production. One can imagine the thyroid gland as a furnace and the pituitary gland as the thermostat. Thyroid hormones are like heat. When the heat gets back to the thermostat, it turns the thermostat off. As the room cools (the thyroid hormone levels drop), the thermostat turns back on (TSH increases) and the furnace produces more heat (thyroid hormones).
The 4 Parathyroid Glands
secrete parathormone or PTH, which is involved in regulating blood calcium levels and, indirectly, in controlling blood phosphate levels. Low blood calcium stimulates output of PTH, which mobilizes calcium from bones and aids in its absorption from the intestines and kidneys to increase the circulating level. When PTH secretion is inhibited, calcium is deposited in the bones and less calcium is reabsorbed from the intestine and kidneys until the blood level returns to normal.
The parathyroid glands
are about the size of a grain of rice, located on the posterior surface (back side) of the thyroid gland. The parathyroid glands are named for their proximity to the thyroid but serve a completely different role than the thyroid gland. They are quite easily recognizable from the thyroid as they have densely packed cells, in contrast with the follicle structure of the thyroid. However, at surgery, they are harder to differentiate from the thyroid or fat.
The major function of the parathyroid glands is to maintain the body's calcium level within a very narrow range, so that the nervous and muscular systems can function properly. When blood calcium levels drop below a certain point, calcium-sensing receptors in the parathyroid gland are activated to release hormone into the blood.
The parathyroid glands are small glands in the neck that produce parathyroid hormone
The adrenal glands are located in the retroperitoneum situated atop the kidneys
The Adrenal Glands
are located in the retroperitoneum situated atop the kidneys, one on each side. They are surrounded by an adipose capsule and renal fascia. In humans, the adrenal glands are found at the level of the 12th thoracic vertebra. Each adrenal gland is separated into two distinct structures, the adrenal cortex and medulla, both of which produce hormones. The cortex mainly produces cortisol, aldosterone, and androgens, while the medulla chiefly produces epinephrine and norepinephrine. The combined weight of the adrenal glands in an adult human ranges from 7 to 10 grams.
In mammals, the adrenal glands (also known as suprarenal glands) are endocrine glands that sit on top of the kidneys
In humans, the right suprarenal gland is triangular shaped while the left suprarenal gland is semilunar shaped. They are chiefly responsible for releasing hormones in conjunction with stress through the synthesis of corticosteroids such as cortisol and catecholamines, such as epinephrine. Adrenal glands effect kidney function through the secretion of aldosterone, a hormone involved in regulating plasma osmolarity.
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