Thyroidectomy - Minimally Invasive Video-Assisted Thyroidectomy (MIVAT)

The more frequent early diagnosis of thyroid nodules and small thyroid cancers has made minimally invasive surgical techniques possible and such techniques are requested by many patients. Since the early 2000’s, several minimally invasive surgical techniques have been used to limit the length of the cervical incision, with questionable improvement in the cosmetic results. Several of the formerly recommended endoscopic approaches, have been abandoned, and remote access, surgery is currently only recommended by a few surgeons. It is generally agreed upon that many of these operative techniques use small incisions but require more extensive surgery and therefore cannot be considered “minimally invasive” for several reasons: (a) the considerably longer operative time required since all the endoscopic techniques, and the robotic transaxillary technique, require more time to reach the thyroid gland from a remote access. (b) the extensive dissection required to reach the neck (contradictory to the definition itself of what should be a “minimally invasive” surgical technique), and (c) the questionable cosmetic improvement when compared to the traditional thyroidectomy since the endoscopic techniques require three to five small incisions in the neck. Many of these minimally invasive techniques are only done by a few surgeons who initially proposed these techniques so that other surgeons may not achieve the same excellent results. Jean-Francois Henry, in 2006, proposed the main requirements that a surgical technique should follow to be considered “Minimally Invasive”: (a) the incision should be less than 3 cm, in the neck (direct approach), (b) the surgery should be assisted by an endoscope, to have the benefit of a magnified field, and thus, better vision. With these principles in mind, it is clear that not all of the new techniques described for thyroidectomy adhere to this definition: an operation can be “scarless” in the neck, robotic, or endoscopic, but these operations are not “minimally invasive” from our point of view. The two techniques that comply with this more strict definition are therefore the endoscopic lateral approach described by J.F. Henry, and the Minimally Invasive Video-Assisted Thyroidectomy (MIVAT), created by two separate Italian teams in the late ‘90s. This chapter explores the indications for MIVAT techniques and illustrates its surgical details. We believe that MIVAT is at present the most widely used minimally invasive technique for thyroid resections.