Endoscopic sistrunk using bilateral axillo-breast approach – A minimal access technique for thyroglossal duct cysts

Abstract

Sistrunk procedure for thyroglossal duct cyst (TGDC) includes removal of the thyroglossal cyst, middle portion of the hyoid bone and the tract towards the foramen caecum. Endoscopic approaches have surpassed the traditional open approaches for the treatment of benign thyroid swellings and TGDCs. Endoscopic Sistrunk procedure using bilateral axillo-breast approach is a safe and better alternative for the successful treatment of TGDC and provides excellent cosmetic results.

INTRODUCTION

Thyroglossal duct cyst (TGDC) arises from the persistent epithelial remnants of the thyroglossal duct. It represents 75% of congenital midline neck swellings. Despite being one of the most common congenital anomalies of the neck in childhood, they may not be symptomatic or clinically evident until far into adulthood.[1] Dr. Schlange first described an open technique excision of TGDC along with the middle portion of the hyoid bone in 1893. However, a 30% recurrence rate was observed. In 1923, Dr. Walter Ellis Sistrunk emphasized that along with the removal of TGDC and the middle portion of the hyoid bone, the tract towards the foramen caecum also should be excised. This reduced the recurrence rate to less than 10% and offered a cure rate of 96%.[2] The standard trans-cervical approach inevitably results in an external scar which is cosmetically undesirable as most of the patients undergoing the procedure are young adults. Apart from that, complications such as wound infection, stitch abscess, laryngotracheal injury, abscess, and haematoma formation made surgeons to seek alternative methods for the excision of TGDC.[3] Various minimal access techniques have been reported to address these problems. One such method for TGDC removal is the endoscopic Sistrunk procedure using the bilateral axillo-breast approach (BABA).

OUR MODIFICATION

Here, we report a case of a 40-year-old man, presented with a painless, midline neck swelling for 3 months. On clinical examination, there was a 2 cm × 2 cm sized, soft, fluctuant swelling which moves up with deglutition and protrusion of the tongue as well [Figure 1]. Blood investigations and thyroid function tests were within the normal limits. Ultrasound and contrast-enhanced computed imaging revealed a heterogeneously hyperdense lesion measuring 1.1 cm × 1.7 cm × 1.2 cm just above the isthmus abutting bilateral infrahyoid muscles suggestive of thyroglossal cyst. Technetium pertechnetate thyroid scan showed euthyroid gland and no functioning thyroid tissue was seen in thyroglossal cyst [Figure 2]. After pre-anaesthetic evaluation, the patient was taken for Endoscopic Sistrunk using BABA approach.

Figure 1.

Pre-operative clinical picture of thyroglossal cyst (black arrows) (a: Lateral view, b: Anterior view)

Figure 2.

Radio-imaging of thyroglossal cyst (a: Sagittal view of CT scan, b: Axial view of CT scan; c and d: Euthyroid picture of technetium pertechnetate thyroid scan). CT: Computed tomography

TECHNIQUE

• The patient was placed in a supine position with neck slightly extended and both arms abducted. A 5-mm incision was taken on the right anterior axillary fold for the left working port. A 10-mm incision was taken superior to the right areola for the camera port. A 12-mm incision was taken superior to the left areola for the right working port. Another 5-mm incision was taken on the left anterior axillary fold for another right working port [Figure 3]

• After blunt dissection, standard 30° telescope was inserted. 6 mm Hg pressure attained with continuous carbon-di-oxide (CO2) insufflation. Right and left working ports were inserted under vision

• Subcutaneous dissection was carried out till we reached the midline using ultrasonic energy device. Dissection proceeded further above between two sternocleidomastoids. Strap muscles were opened up in the midline using laparoscopic hook with monopolar diathermy

• A 1.5 cm × 1.5 cm sized thyroglossal cyst was identified above the isthmus. The cyst was separated from its lateral as well as posterior attachments. The thyroglossal duct tract was identified above the thyroglossal cyst encroaching towards the hyoid bone [Figure 4]

• The middle portion of the hyoid bone was cut using hook scissors. Tract extending beyond the hyoid bone towards the foramen caecum was dissected, transfixed using polyglactin 2’0 and cut using ultrasonic energy device. Strap muscles were approximated using self-locking delayed absorbable barbed sutures

• The thyroglossal cyst was removed under vision through the 12 mm right working port.

Figure 3.

Illustration of ports placement

Figure 4.

Intraoperative pictures of thyroglossal cyst (a - thyroglossal cyst beneath the strap muscles, b - anterior dissection of thyroglossal cyst, c - posterior dissection of thyroglossal cyst, d - superior dissection of thyroglossal cyst) (white asterisk - thyroglossal cyst, white arrows – thyroglossal tract, black arrows – hyoid bone)

The surgery lasted for 108 min with a blood loss of approximately 5 ml. There were no intraoperative complications. The patient was discharged on the 3^rd post-operative day with a cosmetic satisfaction score of 2.3. Histopathological examination of the resected specimen was consistent with the thyroglossal cyst. Follow-up visit after 6 months was uneventful [Figure 5].

Figure 5.

Post-operative scar picture on follow-up (white arrows) (a: Anterior view, b: Anterolateral view)

BENEFITS

The BABA approach is cosmetically acceptable as it pushes the scar from the neck to the axillae and areolae. Owing to the magnified better visualisation, intraoperative complications are virtually nil. The usage of ultrasonic devices in dissection helps in reduced bleeding and minimises adjacent thermal damage as well as post-operative oedema, seroma formation despite the extensive subcutaneous dissection.[4] As there are no major vessels or vital structures in the operative space, this approach is safe and feasible. The narrow working space makes the learning curve steeper.[5] TGDC can be safely removed by endoscopic Sistrunk using the BABA approach as it offers superior aesthetics and reduces complications. Nonetheless, further trials with a large sample size and longer follow-up duration are warranted to establish long-term outcome results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.