Welcome to the First Issue of

Our "Spotlight Feature" Series in which we highlight Endocrine Surgery, with the emphasis on

Robotic Thyroid Surgery and one of the pioneers of Robotic Thyroidectomy

Dr. Emad Kandil, MD, MBA, FACS, FACE

Professor and Elias Hanna Chair in Surgery.

Chief, General, Endocrine & Oncological Surgery.

Edward G. Schlieder Chair in Surgical Oncology.

 

Spotlight Feature

What is Endocrine Surgery?

Endocrine surgery involves procedures upon the glandular system of the human body (thyroid, parathyroid, adrenal, and endocrine pancreas). Diseases in this category range from common conditions like goiter, thyroid and pancreatic cancer to unusual problems such as Cushing's disease, Conn's Syndrome and the Multiple Endocrine Neoplasia Syndrome.

The American Association of Endocrine Surgeons recognizes surgeons “who have a major interest and devote significant portions of their practice or research to endocrine surgery, and who are certified by the American Board of Surgery”

The Section of Endocrine Surgery at Tulane University Medical Center provides cutting-edge surgical care to patients with complex endocrine problems. Minimally invasive surgery can dramatically diminish – or in some cases, eliminate altogether – scars that typically result from surgical incisions.

In This Issue We Will Focus On Robotic Thyroid Surgery

  • Incision is made under the arm.
  • No visible scarring.
  • Three-Dimensional enhanced high-definition with up to 10x magnification resulting in an enhanced view of patient anatomy.
  • A field of vision that is superior to open or endoscopic surgery.
  • Instrument dexterity and range of motion that is greater than the human hand.
  • Dr. Kandil's hand movements are scaled, filtered and seamlessly translated into precise movements using electromechanically enhanced instruments that relay feedback sensations from the operative field throughout the procedure.
  • Some patients may not be a candidate for robotic-assisted surgery due to disease complications or health status.

Thyroid Disorders

Thyroid issues can affect both men and women. The effects of the disorders differ in men and women. There are tests your doctor can do to see if your thyroid is functioning normally. Once tests are done you can work with your doctor to find the proper way to treat your condition.

Thyroid Issues in Men

Having hypothyroidism can cause lethargy and depression in men as well as a decreased libido. It may also cause your muscles to be weaker than they appear. Hyperthyroidism can lead to muscle wasting and weakness, especially in thighs and upper arms. It can also upset the balance between testosterone and the female sex hormone, estradiol, in the body. Some men experience breast tenderness or enlargement and difficulty with erections. Thyroid cancer is rare but if there are nodules in the thyroid gland, in men they are more likely to be cancerous. If you are experiencing any of these problems have your doctor examine your thyroid and check your TSH levels with a blood test.

Thyroid Problems in Women

More women than men suffer from hypothyroidism, and many more women than men with thyroid issues have problems with weight gain. Women experience low thyroid and weight gain primarily because:

Women spend much of their lives dieting, usually in a yo-yo cycle of feasting and then fasting. This undermines your metabolism and decreases your metabolic rate, a compounding factor for the thyroid, especially during perimenopause.
Women tend to internalize stress, which affects their adrenal, brain, and thyroid function, resulting in increased cravings for sweets and simple carbs to provide instant energy and feel-good hormones.
Women experience monthly hormonal fluctuations that affect their biochemistry.

Hyperthyroidism can occur at any age but it is more likely to occur after the age of 15, and more so to those in their 30's and 40's. Although the exact cause is not known it is believed that your immune system does not work properly and the body produces a substance that makes more hormone than it needs. Instead of protecting the body's tissue, antibodies produced in the body's immune system attack tissue and as a result cause the thyroid gland to overproduce

From Endoscopic to Robotic-Assisted Thyroidectomy

The application of endoscopic visualization to thyroid surgery has allowed surgeons to perform thyroidectomy through incisions far smaller and less visible than the conventional Kocher’s incision—the so-called “less is more.” In general, these endoscopic techniques attempt to minimizing the extent of dissection, improving cosmesis, reducing postoperative pain, shortening hospital stay, and enhancing postoperative recovery. Michel Gagner was the first to apply endoscopic technique to neck surgery when he reported a totally endoscopic subtotal parathyroidectomy for a 37-year-old man suffering from familial hyperparathyroidism.

The application and feasibility of the endoscopic approach was given a further boost with the availability of various robotic systems such as the da Vinci system (Intuitive Surgical, Sunnyvale, California). Unlike other cancers such as prostate cancer, the initial enthusiasm of using the robot in thyroid cancers was not great because of its relatively high cost, bulkiness of the robotic arm, and long operating time. However, since the publication of two large surgical series demonstrating the feasibility and safety of robotic-assisted thyroidectomy in differentiated thyroid carcinoma, an increasing number of specialized surgical centers worldwide are beginning to accept and perform this procedure.

The theoretical advantages of using the robot over the endoscopic approach include the three-dimensional view offer to the operating surgeon, the flexible robotic instruments with seven degree of freedom and 90° articulation, the increased tactile sensation, and the ability to filter any hand tremors....for complete story  Click here

• Conventional open surgery involves a scar on the neck.
• Endoscopic or videoscopic techniques are done using a small camera, however, this still involves a neck scar. The neck scar is shorter in these approaches, but still there is an incison in the neck.
• With the new method, Robotic gasless transaxillary thyroidectomy, there is no scar on the neck whatsoever.

Dr. Chung set out to find a way to perform thyroidectomy without causing the four-inch horizontal neck scar typical of traditional thyroid surgery. “Many Asian people, especially young women, don’t want to have a neck scar after surgery, because a hypertrophic scar is more frequent in Asian people,” Dr. Chung said in an e-mail.

Development of Robotic Gasless Transaxillary Thyroid Surgery

Robotic gasless transaxillary thyroidectomy is a newly developed minimally invasive surgical technique to remove all or part of the thyroid. This was developed by Dr. Chung in South Korea. With this new technique, a small incision is made under the arm.

Before its development there were different options for thyroid surgery: conventional open surgery, endoscopic surgery or transaxillary approach with gas insufflation.

How does Robotic Gasless Transaxillary Thyroidectomy work?

Robotic gasless transaxillary thyroidectomy eliminates the neck scar by accessing the thyroid gland through a hidden incision under the arm. The special designed robotic arms allow the surgeon to operate with very precise movements. Robotic instruments do work just like hands. However, they are amazingly small. The robot is completely under the control of the surgeon. The robotic system also proides 3D visualization, with a special designed high-definition camera with an excellent magnification of 10x.

This technique is not only about avoiding an incision and a scar on the neck. From a surgical standpoint, safely performing these procedures depends on clear visualization of important nearby structures, including nerves and parathyroid glands.

Initially, robotic approach was done with gas insufflation to the neck area, however this gas can be retained, which can cause retained pneumomediastinum or subcutaneous air with uncomfortable crepitations. The patient may experience significant metablic problems with CO2 retention. The gas eventually will be absorbed, but it can cause siginificant discomfort until this completely absorbes. These patients needed to stay hospitalized longer than they used to with conventional surgery for observation. With this new approach, gas insufflations is avoided, so Co2 retention complications are also avoided.

This procedure was recently approved by FDA and is is proven to be a safe approach. However, special training and experience with robotic surgery is a must to proceed. With more experience, more patients can be offered this approach. Large thyroid nodules over 4cm were initially not candidates for this procedure, however, now the surgery is able to be offered to these patients with an excellent outcome.

Dr. Emad Kandil of Tulane University School of Medicine is one of the first in the country to perform this new form of endoscopic surgery that uses a small incision under the arm to remove all or a portion of the thyroid or parathyroid glands without leaving a scar on the neck. Not only is Dr. Kandil one of the few surgeons in the US trained to perform the surgery, but he chairs an annual symposium at Tulane to teach surgeons how to perform minimally invasive thyroid surgery and will be teaching the technique to doctors from across the country.

Leader in robotic thyroid surgery develops neck dissection
Published on Jan 25, 2016

Emad Kandil, Chief of Endocrine and Oncological Surgery division at Tulane University School of Medicine, pioneered robotic-assisted thyroid and parathyroid surgery. He’s now one of the first surgeons in the country using the technology to perform extensive neck dissections. He explains in this video.

Dr. Emad Kandil of the Tulane Thyroid Center is the only endocrine surgeon in the country that is qualified to perform robotic-assisted thyroid and parathyroid surgery; he has successfully treated patients who were previously considered not to be candidates for this surgical approach.

Thyroid and Parathyroid Surgery Without a Neck Scar

Transaxillary robotic-assisted thyroid and parathyroid surgery utilizes the latest da Vinci® Si High Definition minimally invasive robotic surgical system to make a two inch incision below the armpit.  This allows Dr. Kandil to maneuver a small camera and specially designed surgical and nerve monitoring instruments between the muscles of the neck to access the thyroid or parathyroid gland; diseased tissue can be removed through this incision, eliminating the prominent neck scar that is a byproduct of the traditional surgical approach, and reducing the risk of injury to the nearby glands and nerves.

Why Robotic Assisted Surgery?

Dr. Emad Kandil of the Tulane Thyroid Center is the only endocrine surgeon in the country that is qualified to perform robotic-assisted thyroid and parathyroid surgery; he has successfully treated patients who were previously considered not to be candidates for this surgical approach.

  • Incision is made under the arm.
  • No visible scarring.
  • Three-Dimensional enhanced high-definition with up to 10x magnification resulting in an enhanced view of patient anatomy.
  • A field of vision that is superior to open or endoscopic surgery.
  • Instrument dexterity and range of motion that is greater than the human hand.
  • Dr. Kandil’s hand movements are scaled, filtered and seamlessly translated into precise movements using electromechanically enhanced instruments that relay feedback sensations from the operative field throughout the procedure.
  • Some patients may not be a candidate for robotic-assisted surgery due to disease complications or health status.

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Dr. Emad Kandil Receives 2017 Shipley Award
December 07, 2018 10:15 AM

Congratulations to Dr.Emad Kandil - the recipient of the 2017 Shipley Award from the Southern Surgical Association!! This is a huge honor from this prestigious society and is a “distinction of astute surgical scholarship”.

Dr. Kandil’s reputation in clinical research has led to him receiving the prestigious Shipley Award from the Southern Surgical Association, one of the oldest surgical societies in the country. This award is known as a distinction of astute surgical scholarship. Dr. Kandil is only the third Tulane faculty member to have received the award in the 60 years since the award was founded.