This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).
For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid’s superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.
The recent increase in the incidence of papillary thyroid microcarcinoma (PTMC)1,2, predominantly affecting young women, necessitates advancements in surgical techniques that offer both medical effectiveness and aesthetic sensitivity3,4. The primary goal of the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA), introduced by Chung in 20045, is to provide an optimal surgical method that marries these two needs.
GETTA was developed as an answer to the drawbacks of traditional open surgery, such as noticeable scars leading to patients' self-consciousness and potential negative impact on their work and social activities. Endoscopic thyroid surgery has been gradually applied in the treatment of benign and malignant thyroid diseases3,4, offering a less invasive alternative to open surgery. Yet, the innovation of GETTA lies in its unique gasless approach. The GETTA procedure holds several advantages over alternative techniques. It establishes the cavity through the natural folds of the axilla, rendering the incision hidden and yielding superior postoperative cosmetic results6. Moreover, GETTA omits the need for CO2 gas inflation during the operation, thereby averting complications related to CO2 gas. Furthermore, this approach leaves the anterior neck flap intact, which protects the function of the anterior cervical region post-surgery and prevents postoperative swallowing skin-tracheal linkage6,7.
The technique is situated within the wider body of literature concerning endoscopic thyroid surgery. While there are ample research reports on the transoral and breast approach of endoscopic thyroid surgery8,9, non-inflatable thyroid surgery remains underreported10,11. Consequently, this method constitutes a significant contribution to this field, providing a comprehensive protocol for the GETTA procedure.
For readers contemplating the application of this method, it is most suitable for early-stage, low-risk papillary thyroid carcinoma patients who desire minimal scarring post-surgery. However, the success of this technique depends on the practitioner's proficiency in endoscopic procedures due to its spatial constraints. As such, the method may not be appropriate for practitioners without advanced endoscopic skills or those in medical centers with limited access to the necessary equipment.
This article aims to bolster the understanding of the GETTA procedure, offering insights into its application, and hopefully promoting its adoption in more medical centers. The benefits of GETTA extend beyond medical effectiveness, meeting patients' desire for less invasive surgery with favorable cosmetic results.
This study was conducted in strict accordance with the ethical principles outlined in the Declaration of Helsinki and adhered to the guidelines established by our institution's Human Research Ethics Committee. The research protocol underwent a thorough review and received approval from the Ethics Committee of West China Hospital of Sichuan University. All participating patients provided written informed consent before their involvement in the study, and stringent measures were taken to ensure the privacy and confidentiality of their data throughout the research process. Patients with benign thyroid nodules, follicular neoplasms, or papillary microcarcinomas, with a tumor size of less than 2 cm, and the absence of lymph node metastasis, were included in the present study. On the other hand, patients with advanced thyroid cancer, tumors larger than 2 cm, evidence of lymph node metastasis, a history of neck surgery that might have resulted in anatomical distortions, or severe comorbidities were excluded from this study.
1. Initiation of the procedure
2. Incision making
3. Creating surgical cavities
4. Recognition and safeguarding of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection
5. Identification and protection of superior laryngeal nerve and superior parathyroid gland and dissection of the superior pole of the thyroid
6. En Bloc resection of the thyroid and central neck lymph nodes
7. Post-surgery procedures
In this study, a cohort of 200 female patients, all with a mean age of 36 years (SD = 4.52; ranging from 20 to 59 years), underwent the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) (Table 1). The patients had an average Body Mass Index (BMI) of 22.79 kg/m2 (SD = 4.52; range = 18.27-27.31). The sonogram indicated an average tumor size of 7.09 mm (SD = 3.84). All patients were fully informed of the surgical options available and subsequently chose GETTA. Of the total, 54 (27%) patients had a history of operations and opted for GETTA to avoid keloid scarring. The remaining 146 (73%) patients primarily chose this approach due to aesthetic reasons.
Pathologically, 194 (97%) of the tumors were confirmed as papillary carcinoma, with the remaining 6 (3%) identified as follicular carcinoma. The location of the tumors was almost equally distributed between the left (92 patients, 46%) and the right (108 patients, 54%) sides of the thyroid gland. Most of the patients, 196 (98%), were in stage I of the TNM classification, with the remaining 4 (2%) in stage II. Parathyroid was auto-transplanted in 52 (76.5%) of the patients.
The surgery had an average duration of 96.12 min (SD = 26.13) with an average intraoperative blood loss of 6.32 mL (SD = 4.22). The average hospital stay was 6.04 days (SD = 0.87). Five patients experienced temporary recurrent laryngeal nerve signal weakening post-surgery, which resolved after a month. No cases of permanent recurrent laryngeal nerve injuries were observed. However, 3 patients required conversion to open surgery due to intraoperative bleeding, all of whom had benign thyroid nodules with large diameters.
Figure 1: Incision and surgical cavity creation. (A) Body position and incision design. (B) The first anatomical landmark: Sternocleidomastoid sternal head. (C) The second anatomical landmark: Scapula Hyoid muscle. (D) Completion of cavity construction. Please click here to view a larger version of this figure.
Figure 2: Sequential Steps in the surgical procedure. (A) Exposure of the tracheoesophageal groove. (B) Dissection of the recurrent laryngeal nerve. (C) Coagulation and cutting of the inferior thyroid blood vessels to expose the trachea. (D) Central lymph node dissection. (E) Probing of the superior laryngeal nerve. (F) Preservation of the upper parathyroid gland in situ. Please click here to view a larger version of this figure.
Figure 3: Resection and post-surgery procedures. (A) Amputation of the thyroid isthmus and en bloc resection of the thyroid. (B) Removal of the surgical specimen. (C) Rinsing with distilled water and placement of a drainage tube. (D) Transplantation of the parathyroid gland. (E) Suturing of the axillary incision. Please click here to view a larger version of this figure.
Variable | GETTA Patients | ||
Age (year) | mean ± SD, range | 36.07 ± 4.52 (20-59) | |
Gender | Female | 200 (100%) | |
Male | 0 | ||
BMI (kg/m2) | mean ± SD | 22.79 ± 4.52 | |
range | (18.27-27.31) | ||
History of operation | Yes | 54 (27%) | |
No | 146 (73%) | ||
Sonogram tumor size (mm) | 7.09 ± 3.84 | ||
Pathology | Papillary carcinoma | 194 (97%) | |
Follicular carcinoma | 6 (3%) | ||
Tumor Location | Left (n) | 92 (46%) | |
Right(n) | 108 (54%) | ||
TNM stage | I | 196 (98%) | |
II | 4 (2%) | ||
Parathyroid autotransplantation | Yes | 52 (76.5%) | |
No | 16 (23.5%) | ||
Duration of the surgery (min) | 96.12 ± 26.13 | ||
Intraoperative Blood loss (mL) | 6.32 ± 4.22 | ||
Hospital stay (day) | 6.04 ± 0.87 | ||
Temporary recurrent laryngeal nerve signal weakening | 5 | ||
Permanent recurrent laryngeal nerve injuries | 0 | ||
Conversion to open surgery | 3 | ||
Data are presented as mean ± SD or number (%); SD: standard deviation, BMI: body mass index. |
Table 1: Clinical characteristics and outcome of patients. Data are presented as mean ± SD or number (%); SD: standard deviation, BMI: body mass index.
The Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) is a novel surgical method that addresses the rising incidence of Papillary Thyroid Microcarcinoma (PTMC) while yielding aesthetically pleasing outcomes14,15,16. Nevertheless, this technique requires a deep understanding of key operational steps17. Before commencing the actual surgery, surgeons are expected to familiarize themselves with the procedure by studying existing demonstrations provided by experts in the field16. The principal steps include creating an incision within the natural folds of the axilla to minimize visible scarring, establishing the operating space without CO2 gas inflation, and carefully preserving the anterior neck flap to safeguard the function of the anterior cervical region post-surgery18,19.
While the GETTA procedure offers several advantages, it also allows for customization based on individual patient circumstances or surgeon preferences16. Surgeons may need to adapt the approach when dealing with larger benign masses that could complicate the procedure due to limited operational space. Case selection plays a crucial role in mitigating these issues, with the recommendation being that beginners should choose early-stage PTMC patients with normal thyroid volume and without Hashimoto's thyroiditis15.
Despite its innovative benefits, GETTA has several limitations that must be considered. The technique demands advanced endoscopic skills and spatial proficiency, potentially limiting its accessibility in some medical settings. Effective implementation may be challenging in medical centers lacking the necessary equipment or training.
In comparison to traditional endoscopic thyroidectomy, GETTA represents significant advancements18. GETTA's incisions, concealed within the axilla's natural folds, offer markedly improved cosmetic results20. Furthermore, by eliminating CO2 gas inflation, GETTA reduces associated complications such as gas embolism, Subcutaneous Emphysema, and Cardiovascular Complications, demonstrating enhanced medical effectiveness21.
Looking ahead, the GETTA technique holds promising potential for broader applications33,34. As surgical expertise grows and technology advances, it is plausible that adaptations of GETTA could further minimize invasiveness and recovery times. Wider implementation of GETTA would necessitate dedicated training programs to equip more surgeons with this technique, thereby increasing its global accessibility and utilization. This integration of aesthetic and functional considerations represents a promising path in the development of thyroid surgical techniques. Through ongoing research and application, GETTA could play an increasingly significant role in improving both surgical outcomes and patient satisfaction in the field of endoscopic thyroid surgery.
This study demonstrates that the gasless endoscopic thyroidectomy trans-axillary approach (GETTA) is a viable and safe technique for patients with early low-risk papillary thyroid carcinoma who wish to avoid a cervical scar. Compared with other endoscopic surgery methods, GETTA has distinctive characteristics for papillary thyroid carcinoma patients due to its unique approach and suspension method.
The authors have nothing to disclose.
None.
EMG Endotracheal Tube | Medtronic Xomed, Inc. | 20173666541 | EMG Endotracheal Tube |
Forceps | Kangji Medical | 106.890.A | Gasless endoscopic thyroidectomy trans-axillary approach Equipment (Within) |
Gasless endoscopic thyroidectomy trans-axillary approach Equipment | Kangji Medical | 106.890.A | Gasless endoscopic thyroidectomy trans-axillary approach Equipment |
Intraoperative neuromonitoring (IONM) Device | Medtronic Xomed, Inc. | 20083210370 | NIM-Response 2.0 |
Laparoscopic aspirator | Kangji Medical | 106.891.A | Gasless endoscopic thyroidectomy trans-axillary approach Equipment (Within) |
Nerve monitoring probe | Medtronic Xomed, Inc. | 20173666541 | EMG Endotracheal Tube (Within) |
Retractors (Two types) | Kangji Medical | 106.890.A | Gasless endoscopic thyroidectomy trans-axillary approach Equipment (Within) |
Trocar | Johnson & Johnson | B5LT | Trocar (5 mm) |
Ultrasonic scalpel | Johnson & Johnson | HAR36 | Ultrasonic scalpel |