Hybrid Total Thyroidectomy and Robotic-Assisted Excision of a Substernal Multinodular Goiter

Substernal goiter is a challenging disease. Surgical treatment is the standard based on symptoms, or for the risk of occult malignancy and the natural history of progressive enlargement (1). Resection can be managed through a cervical incision in the majority of cases; however, middle or posterior substernal extension may require a hybrid approach with a cervical incision combined with median sternotomy, posterolateral thoracotomy, video-assisted thoracoscopy, or a robotic approach. Anterior extension can be approached in the supine position with a right or left bump depending on the extension to the right or left of the midline. Middle or posterior extension is best approached in the posterolateral position.

A robotic-assisted technique has been described for excision of mediastinal thyroid goiter (2-6). The conduct of the operation has varied from the substernal robotic assisted mobilization and resection followed by cervical excision, to cervical mobilization and subsequent robotic-assisted resection, to cervical mobilization followed by robotic-assisted mobilization and subsequent cervical removal (2-5). Most recently, a staged procedure was described with cervical thyroidectomy followed six weeks later by robotic-assisted substernal resection (6).

The Surgery

The patient in this case is an eighty-seven-year-old man with chest pain and a cough. He had a history of coronary artery disease with LAD stents and chronic total occlusion (CTO) of the right coronary artery. A stress test showed no ischemia and left heart cardiac catheterization showed patent LAD stents in a CTO of the right coronary artery. An MRI for cardiac function incidentally discovered a 5.4 x 3.2 x 7.3 cm superior mediastinal mass. A CT scan demonstrated marked thyromegaly with a complex 4.6 x 3.3 x 4.4 cm nodule of the left inferior thyroid extending substernally. Additionally, there was a 3.5 x 3.8 x 5.6 cm superior mediastinal mass. Tumor markers were negative.

The patient underwent a hybrid approach with total thyroidectomy immediately followed by robotic-assisted excision of the substernal multinodular goiter approached from the right in the left lateral decubitus position. Final pathology demonstrated bilateral nodular and cystic thyroid hyperplasia with the right lobe of the thyroid measuring 6.0 x 3.5 x 2.5 cm, the left lobe measuring 7.5 x 7.0 x 3.0 cm, and the superior mediastinal mass measuring 8.0 x 6.5 x 4.1 cm. Postoperatively, the patient did well and was discharged home on his second postoperative day.

Conclusion

This video demonstrates hybrid total thyroidectomy and robotic-assisted excision of a substernal multinodular goiter. The authors believe that the cervical thyroidectomy and dissection should be performed first, followed by the substernal resection. Performing the substernal portion first followed by cervical dissection and extraction risks disconnecting the substernal portion of the goiter with retention in the chest, requiring retrieval.

In conclusion, hybrid total thyroidectomy and robotic-assisted excision of a substernal multinodular goiter can be performed safely with excellent exposure and minimal morbidity.

References

1. Hansen MA, Shaha AR, Wu JX. Surgical approach to the substernal goiter. Best Pract Res Clin Endocrinol Metab. 2019; 33: 101312.doi:10.1016/j.been.2019.101312.
2. Podgaetz E, Gharagozloo F, Najam F, et. al. A novel robot-assisted technique for excision of a posterior mediastinal thyroid goiter: a combined cervico-mediastinal approach. Innovations. 2009;4:225-28. doi: 10.1097/IMI.0b013e3181a69bf0.
3. Wang S, Xu S, Liu B. Resection of huge retrosternal goiter through a novel combined cervical and robotic-assisted approach.2013; 38: 431-33.
4. Amore D, Cicalese M, Scaramuzzi R, et. al. Antero mediastinal retrosternal goiter: surgical excision by combined cervical and hybrid robot-assisted approach. J Thorac Dis. 2018; 10(3): E199–E202. doi: 10.21037/jtd.2018.01.169
5. Chihara RK, Liu J, Patel SG, Sancheti M. Robotic-Assisted Retrosternal Thyroidectomy. March 2019. doi:10.25373/ctsnet.7877909.
6. Wadhavkar N, Kontopidis I, Bollig C. Transcervical and robotic-assisted thoracoscopic resection of a substernal goiter. BMJ Case Rep. 2022;15:e250953. doi: 10.1136/bcr-2022-250953.

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