Raymon Grogan, MD, associate professor of surgery at Baylor College of Medicine and section chief of endocrine surgery at Baylor St. Luke’s Medical Center, talks about the new procedure they are using to remove thyroids.
“You mentioned that at the end of the procedure you move the camera from the midline to the lateral ports, why do you switch those back and forth?
RAYMON GROGAN: That’s simply because the middle incision is the larger incision and is where the camera is during the main part of the procedure. That’s the incision where the gland has to come out of. So, in order to remove the gland from that midline port, we have to move the camera from the midline to the lateral part in order to take the gland out through the midline.
Can you give us a nice little summary statement of how this procedure works?
RAYMON GROGAN: The point of this operation is to remove any visible scar on the front of the neck. We’re able to do that by hiding the incisions on the inside of the lower lip. We put three small incisions there, one in the midline and two on each corner of the mouth, basically inside the lip so that they are not visible. And we tunnel down between the skin and the jawbone and use laparoscopic instruments similar to instruments we use for a laparoscopic cholecystectomy or laparoscopic appendectomy to go down and remove either the thyroid or the parathyroid that way. Then we’re able to remove the gland, as we just said, through the midline incision.
Will you show us with your fingers physically the distance from the chin to the thyroid so that we can have an understanding of where the gland is coming from?
RAYMON GROGAN: The thyroid gland sits in the middle of the neck. This distance is going to be different depending on the length of the individual’s neck, but it’s essentially from the chin to the neck there (just below the adam’s apple). So you’re only talking about a distance of about this far (a few centimeters). It’s very close in terms of distance, which is one of the advantages that this operation has over previous versions of minimally invasive or scarless thyroid and parathyroid surgery.
And what is the – what’s the texture that you’re pulling it out through? Is it squishy? I mean, describe how much resistance there is as the gland comes out.
RAYMON GROGAN: When you talk about parathyroid glands, they are small and fairly soft. They come out quite easily. There’s really no resistance or anything like that. With the thyroids, thyroid glands are a bit larger. Sometimes, they can have nodules in them. Sometimes they can be more firm. The tracks that we use to remove thyroid glands sometimes have to be dilated a little bit in order to allow the gland to move through. But thyroid glands also are compressible. And so they can come through much smaller incisions than you might imagine.
Is there a track already there? Are you creating that?
RAYMON GROGAN: We create that. That’s right.
How? Do you drill it through? Or how does it?
RAYMON GROGAN: No, we used dilators. There are dilators that we’ve used for decades for other types of surgical procedures, and we can apply those dilators to this area of the body as well.
In the gee whiz factor here, because as I told you, walking down here, anybody I’ve told is just amazed that this can happen, how do you even think to do something like this, I guess is the question?
RAYMON GROGAN: Right, this has been an ongoing process. This is a culmination of research in the medical field that’s been going on since probably the late 80s, early 90s. There’s been a motivation to remove visible scars on the front of the neck for these operations since thyroid surgery began at the turn of the century, in the early 1900s. And over time, as people have experimented with different ways of removing thyroids, we’ve slowly come to the realization that we could take it out with this approach.
They don’t lose any kind of sensitivity? It seems like there would be a lot of nerve endings.
RAYMON GROGAN: No, that was a concern in the beginning of this operation and that caused, some questions as to whether or not that was going to be a problem. In particular, there’s a nerve called the mental nerve, which supplies sensation to the skin of the chin and the lower lip as well as to the gumline. That’s a nerve that dentists might anesthetize, for example, to numb up the lower front teeth. That nerve is very close in proximity to where these ports are being placed and incisions are being made, but we’ve modified how the incisions are made in order to prevent damage to that nerve. We do know it’s possible, particularly if someone were to have an aberrant anatomy of that nerve, but from what we can see in the literature so far, injury to that nerve is extremely rare.
So, the basic mechanics have been around for a long time. But let’s fast forward to 2020. How much better is it now in some of the elements that have been subject to change over the years?
RAYMON GROGAN: The operation in its current form first was introduced in about 2016. Since that time, we have made several minor modifications to that procedure to make it even faster, to make it have reduced risk of complications and things like that. It has evolved over the last couple of years to be an even safer and more quick operation.
How long is that operation total?
RAYMON GROGAN: It depends on what you’re doing. We do several types of things with this. We do parathyroid surgery. We do thyroid lobectomies. We do total thyroidectomies. Some people can even do central neck dissections. It all depends. I guess the easier way to answer that question is it’s similar in time to the traditional approach. We can see it adds maybe somewhere between 20 and 30 minutes additional time to the traditional approach.
You got this whole human body and you’ve got one little tiny thing that can create a whole lot of trouble.
RAYMON GROGAN: Yes.
For a human being. Let’s switch over now to our patient and describe, if you would, her situation when she came to you.
RAYMON GROGAN: That problem was associated with the parathyroid glands. Parathyroids are little glands that are typically about the size of a couple of grains of rice, about the size of the tip of my finger, and there are four of them. There are two on each side of the neck. They sit next to the thyroid. Those glands produce a hormone called parathyroid hormone. The main function of that hormone is to regulate calcium levels in the blood, and when one or more of those glands become overactive, they produce too much hormone. That hormone excess causes the calcium levels in the blood to rise, and the place where that calcium is coming from usually is from the bones, and it’s causing the calcium to leach out of the bones and come into the bloodstream. That causes bone mineral density loss, also known as osteoporosis. It can also change the way the kidneys are excreting calcium in the urine and can lead to kidney stones. In addition it can lead to constipation and abdominal cramping pain as well as tiredness, lethargy, mild memory problems, insomnia, and just mild changes in memory and mood as well. When we see these issues, most people that we find with the problem that’s a biochemical diagnosis do have reasons to have it removed, and that was the case here.
You’ve got these tiny little grains of rice and all this is going on. And she had looked and looked and looked for months and then finally settled on this surgery. Do you know what triggered hers or what might be the cause of some of this?
RAYMON GROGAN: We don’t know exactly why these parathyroid glands grow to be abnormally large in these cases. It’s likely there’s some kind of DNA change within an individual cell, and that cell then starts to replicate and expand itself and cause the gland to grow. That’s one possible explanation, but we don’t know why that occurs to begin with. So, that’s the most likely cause. A lot of people wonder if they’ve done something, if they’ve been exposed to something, if there’s some environmental factor that they could have changed or should change in the future. And the truth is, is we just don’t know the answer to that question.
They have to come in with a particular set of symptoms in order to figure out that this has gone haywire, basically?
RAYMON GROGAN: The diagnosis is typically found through biochemistry. That’s through a blood test. The way the typical person gets diagnosed with this is by having a routine blood test, a calcium level drawn by their primary care physician or other physician, which is shown to be a little bit elevated. That, then, triggers the whole workup process where you look for parathyroid hormone. If that’s elevated, then we have the diagnosis. Patients go on to have imaging studies to decide if there’s one or more than one glands that are abnormal, so on and so forth. That’s typically how it’s diagnosed. Other times, though, it’s diagnosed through the symptoms either the bone mineral density loss/osteoporosis, kidney stones, abdominal cramping, pain and constipation. Sometimes patients will have those symptoms, go to their physician and ask about those symptoms, which then triggers the blood tests, which then goes on to make the diagnosis.
Sounds like it could be an easy thing to miss. In fact, I think hers might have been not correctly diagnosed earlier in the process. So when you take it out, I mean, what replaces that? Is in a lifetime of drugs to keep her stable?
RAYMON GROGAN: No, the parathyroid, like we said before, there are four of them. You only need half of one for normal function. When we remove just one gland, you still obviously have three remaining glands that are normal. You maintain normal calcium regulation that way.
In the operating room, just walk us through briefly, because this is amazing. Do you take the lip and you tape it down or how does this work?
RAYMON GROGAN: To make the incision, we simply just hold the lip up and then we make a small incision on the midline and in the two corners of the mouth there, and then we use little tunnelers or dilators to dilate the tract. Through those tracts, we put ports. They’re called laproscopic ports. Those ports are what keep the tracks open. Through those ports, we’re able to slide our instruments through those ports, to take them in and out as needed during the surgery. It’s a very common procedure that’s been done for decades now, started out with laproscopic gallbladder removal, laparoscopic cholecystectomy. That concept has now been applied all over the body. It’s a minimally invasive concept. Using these ports to place laproscopic instruments through these ports is an extremely common procedure. In fact, 99 percent of all gallbladder surgery is now done through these type of ports rather than through the older open procedure, essentially.
As a surgeon and physician, what about this gives you immense satisfaction? With your patient here that we interviewed, she’s a young woman. She didn’t want to scar. She’s in sales. I mean, think about what’s satisfying to you at the end of the day?
RAYMON GROGAN: Yeah, I think that’s kind of the key factor that keeps surgeon’s motivated with this procedure, is that the patient’s return and are very happy about this operation. We do a six month follow up on everyone to ask, how are things going? How do you feel? How was the procedure? And almost unanimously, everyone who’s had this operation says they’re so thankful that they had it this way because they wanted to avoid that scar. To me, it’s the most satisfying part of being a part of this new procedure and being able to explore it and expand it and work with it. A lot of people talk about these scars. They say, “Well, it’s just a small scar” or, “Why do you really care about having a scar on the neck since it’s a procedure you needed?” But these scars are different than other types of surgical scars, mainly because they’re constantly visible. They’re constantly visible not only to other people, but they’re constantly visible to the patient themselves. It’s a constant reminder that you had the surgery in some cases, for example, in cancer patients. You don’t want to have to think about having cancer every single day of your life. Part of the way we recover from a cancer diagnosis is to kind of incorporate it into our daily lives and not have it at the forefront of our minds. The problem with thyroid cancer is that that scar is constantly there and constantly reminding people that they had this operation. Now, when you remove that scar, we think it helps the quality of life improve because now the patient doesn’t have to think about this scar constantly every single day. In addition to that, there’s privacy concerns. So, when someone’s on a blood pressure medication, you don’t have to go around advertising to everyone that you’re on a blood pressure medication, right? But if you’ve had a thyroid or a parathyroid surgery with a scar here, you’re basically…that’s what you’re doing every single day. You’re kind of advertising that. That’s just a basic kind of fundamental right in health care is for the patient to be able to decide who they disclose their information to. By allowing us to do this without leaving the scar, we’re better able to return some patient autonomy to them in that way. This concept of the scar and the concept of these neck scars is much more complex and much more nuanced than what people think it is.
What specifically are you teaching them about this, the nuances?
RAYMON GROGAN: We teach basically from A to Z with this operation. There are several courses that have been set up around the world. There’s some here in the U.S. and in other parts of the world, and they’re typically two to three day courses where we have a lot of lecturing, which talks about everything from the history of where this operation came from to what the advantages and disadvantages are complications and how to avoid them, who’s eligible for the procedure. You name it, we lecture about it. The following days are cadaver labs where we have human cadavers, where surgeons are able to actually go in with the cadaver and practice doing the procedure on the cadavers before they start doing it with real patients. In addition to that, we also have the surgeons come and observe the operations real time in the operating room. We also go to their hospital when they are starting this operation to help them and guide them in their first several cases prior to them going on doing this on their own.
END OF INTERVIEW
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