A century is a very long time for a medical procedure to remain unchanged. Techniques and procedures often evolve overnight, with the old and outdated discarded. Yet, for more than 122 years, thyroid surgery, one of the commonest procedures performed in hospitals across the globe, has remained largely the same. The classical procedure, known as Kocher's technique, was developed by Theodore Kocher in the 1890s and it still remains the first line of operation, notwithstanding the tremendous advances made in the field of diagnostic and imaging techniques.
Shiby Abdul Kalam was just 31 when she first noticed a persistent hoarseness in her voice. Friends told her that her neck looked swollen. This young housewife from Kochi, settled in Saudi Arabia, was worried. It was in November 2010 and Shiby had come home on vacation. Her family doctor suspected a thyroid neoplasm. Shiby was then referred to Dr Thomas Varughese, who heads the surgical oncology division at the Lakeshore hospital in Kochi. Dr Varughese confirmed the diagnosis and told Shiby that she would require a surgery.
Shiby's biggest worry was about the lifelong scar; she knew a few who had undergone the procedure. The doctor assured her that she need not worry about that and told Shiby about a new technique in thyroid surgery he had developed—a scarless, bloodless technique. It sounded too good to be true. Yet, she was a bit worried. Encouraged by her family, Shiby decided to go for the procedure. Two days later, she returned home, minus the scar and thyroid worries.
The horizontal lateral thyroidectomy or the ‘Thomas technique' developed by Varughese has, over the last three years, come to the aid of more than 500 patients like Shiby. In a remarkable improvisation of the Kocher's technique, Varughese makes use of the 3D interactive digital volumetric anatomy of the neck to operate on affected thyroids. Other procedures available for thyroid surgery—endoscopic and robotic methods—have their own limitations as they are effective only in handling neoplasms up to 3cm, and they are also hampered by the location.
In the Kocher's procedure, the incision is made on the most exposed part of the neck, right in the front. It cuts across the neck like a necklace, resulting in scarring, which, in most cases, is permanent. For most patients, the lifelong scar causes mental trauma. But in the new technique, the incision is made on either side of the neck—on the skin crease—as per patients' choice and not surgeons' as is routinely practised. The procedure is based on the anatomical fact that the thyroid lobes are largely lateral structures, with either lobes of this butterfly shaped gland receiving blood supply from the major vessels running on the sides of the neck. The nerves that are concerned with voice, too, has the potential risk of injury while undergoing surgery as they are located lateral and posterior to the gland. The parathyroid glands, too, have a posterolateral disposition. Therefore, approaching the thyroid glands from the sides is the optimal option.
“As the anterior compartment of the neck with its rich network of veins communicating with either jugular veins, the strap muscles and the investing layer of the deep fascia in the anterior aspect are left untouched, the patient does not suffer from neck oedema,” said Varughese. We met Jayasree Sanalkumar, 36, of Alappuzha a day after her surgery. A small strip of bandage on the neck was all that was left to indicate that she had a major surgery less than 24 hours earlier. “If not for this new technique, we would have postponed the surgery further as I was worried about the ugly scar on my neck,” said Jayasree, waiting for getting her discharge papers signed. “From one side, you can operate even on the opposite gland; that, too, regardless of the size and pathology of the tumour. Therefore, in most cases, there is only a unilateral incision, with no scar at the front,” said Varughese.
Apart from the aesthetic merits, the ‘Thomas technique' has several other advantages. One of the serious risk factors of conventional thyroid surgery is the possibility of nerve damage. Two major nerves—recurrent laryngeal nerve and superior laryngeal nerve—pass through the region. Any damage to these nerves can result in change in voice quality and sometimes even loss of voice. With the new technique, the nerves are left untouched, thereby eliminating any possibility of an injury.
Bleeding during an operation is always a surgeon's nightmare. In traditional thyroid surgery, bleeding is a possibility as the blood supply is not tackled upfront. “In Kocher's approach, training is prioritised for controlling of haemorrhage due to handling. Surgery on a stained, bleeding gland leads to complications because tissue planes are obscured. The extravasated blood and the haem in blood are the most potent tattooing agents of tissue plains, which forms an inseparable bondage,” said Varughese. In his method, the blood vessels are ligated upfront, which makes the gland avascular (absence of blood vessels), causing it to shrink by more than 50 per cent before it is removed. This makes the procedure quicker and simpler, limiting the loss of blood to less than 5-10ml in total.
The ‘Thomas' technique' also leaves the parathyroid glands, which, too, have a posterolateral disposition, untouched. Hormones produced by the parathyroid glands regulate calcium levels in the body and any injury to the glands can lead to deficiency of calcium in the blood stream, which is another major risk factor during regular thyroid surgeries. In ‘Thomas' technique', the parathyroid glands stay protected because its identification in an unstained tissue plane is easier.
Ayyappadas, a 36-year-old businessman of Alappuzha, had been suffering from a very large (over 20cm in size) thyroid for quite some time. He came to Varughese after he heard that the new procedure was really quick and he need not waste a few weeks for the surgery. While signing his discharge sheet, Varughese assured him that he could go back to work in 48 hours. The doctor says his technique considerably reduces the time a patient has to spend in hospital and ultimately it benefits all stake-holders. The time for the surgery is reduced by nearly 60 per cent, freeing up hospital resources, including theatre time. While the traditional model requires five to ten days, depending upon the procedure, in the hospital and a fortnight of recuperation, people opting for the new technique can leave the hospital a day after the surgery. This saves money for the patient, the hospital and the insurance companies, making it a win-win proposition for all. It also saves manpower as patients can go back to work four days after the surgery.
Three years after the surgery, Shiby is perfectly healthy, and happy. Her neck shows no signs of a major surgery and there is not even a hint of a scar. Back home in Kochi on another vacation, she cannot thank Varughese enough. “When I was told that I needed to undergo thyroid surgery, I was devastated. As the doctor listed the likely complications of the classical procedure, I even thought of living with the condition as long as I can. Moreover, I knew someone who lost her voice after the surgery. I also did not want to have a permanent scar on my neck. So when Varughese suggested an alternative, I decided to go for it, though it was a relatively untried method. My family supported me fully. Looking back, I can see that I made the right choice,” said Shiby.
Varughese says the best reward for him is to see the smiling faces of people who benefited from the procedure. The medical fraternity has recognised this path-breaking innovation. His findings have been accepted by several national and international forums like the Union for International Cancer Control, International College of Surgeons, Eurasian Federation of Oncology, World Thyroid Congress and the Association of Surgeons of India. The doctor, however, feels that awareness about the procedure and its medical as well as economic advantages should be spread among the public. “This is a gift to the world from God's own country,” said Varughese. “Now I want everyone who requires a thyroid surgery to take advantage of this procedure.”