Thyroidectomy is one of the most frequently performed surgeries in endocrine practice, commonly indicated for managing thyroid diseases such as thyroid cancer, benign thyroid nodules, and certain refractory thyroid disorders. When performed by skilled surgeons, thyroidectomy is recognized as a safe and effective procedure (1). Globally, the burden of thyroid cancer (TC) has been increasing over the years. The United States, China, and India consistently rank among the top three countries with the highest number of new thyroid cancer cases. For instance, incident cases in India rose from 5,988 in 1990 to 23,833 in 2019, with a corresponding increase in mortality and disability-adjusted life years (DALYs), underscoring the growing healthcare burden (2).

The thyroid gland is anatomically situated anterior to the trachea, extending from the fifth cervical vertebra to the first thoracic vertebra. It comprises two lobes connected by an isthmus, necessitating precise surgical techniques to preserve critical structures during thyroidectomy (3). Effective preoperative planning is a cornerstone for optimizing surgical outcomes. A thorough evaluation includes a detailed medical history, physical examination of the thyroid gland, and functional assessments such as free T4 and TSH levels. Ultrasonography remains the primary imaging modality for characterizing thyroid nodules and assessing lymph node involvement. Techniques such as fine-needle aspiration cytology (FNAC), radioactive thyroid scans, computed tomography (CT), and magnetic resonance imaging (MRI) are employed selectively to assess malignancy risk and tumor extent, particularly in invasive cases (4, 5).

Surgical techniques for thyroidectomy have evolved significantly, with the conventional open approach being the gold standard for addressing thyroid cancer and Multinodular goitres. This technique, involving an anterior cervical incision, provides excellent visualization of critical structures such as the recurrent laryngeal nerves and parathyroid glands. However, the resulting visible scar can negatively impact a patient’s self-esteem and quality of life (6). Advances in surgical technology have spurred the development of minimally invasive techniques to address these limitations. Procedures such as the transaxillary approach (TAA), bilateral axillo-breast approach (BABA), and natural orifice surgery aim to minimize visible scarring while maintaining surgical safety and efficacy. Robotic thyroidectomy, increasingly popular for its superior cosmetic outcomes, remains inaccessible to many due to high costs and technical expertise requirements, particularly in resource-limited settings like India (6, 7).

To address the need for a safe, effective, and cosmetically favorable alternative to conventional thyroidectomy, Single Lateral Incision Total Thyroidectomy (SLITT) has been introduced. This innovative technique aims to minimize visible anterior neck scarring and reduce perioperative complications, all while preserving the clinical benefits of traditional approaches. SLITT is particularly relevant in developing countries like India, where access to advanced robotic systems and other high-cost technologies remains limited.

The pilot study is designed to evaluate the feasibility, safety, and initial outcomes of the SLITT procedure in thyroidectomy patients. Findings from this study will form the groundwork for a comprehensive main study, aimed at validating both the clinical effectiveness and the cosmetic advantages of SLITT. This novel procedure represents a significant step forward in thyroid surgery, balancing innovation with practicality to cater to diverse patient populations worldwide.

Study Design and Duration

This pilot study employed a prospective, observational design conducted over six months, from January 1, 2021, to June 30, 2021. The study aimed to assess the feasibility, safety, and preliminary outcomes of the Single Lateral Incision Total Thyroidectomy (SLITT) procedure in patients requiring total thyroidectomy.

Sample Size and Selection

• Sample Size: 50 patients.
• Sampling Method: Consecutive sampling of eligible candidates who met the inclusion and exclusion criteria.

Eligibility Criteria

Inclusion Criteria:

1. Adult patients (≥18 years) with indications for total thyroidectomy due to benign or malignant thyroid conditions.
2. Patients who provided informed written consent.

Exclusion Criteria:

1. Patients with a history of prior neck surgeries or radiation.
2. Patients with significant medical instability or contraindications to surgery.

Preoperative Assessment

1. Clinical Evaluation: A comprehensive medical history and physical examination were conducted, including neck assessment and thyroid function tests (TSH, Free T4).

1. Imaging and Diagnostics:
• High-resolution ultrasonography was used to assess thyroid size, nodules, and lymph node involvement.
• Fine-needle aspiration cytology (FNAC) was performed for suspicious nodules.
• Additional imaging (e.g., CT/MRI) was utilized for cases with suspected local invasion.

1. Laboratory Investigations: Routine preoperative blood tests, including CBC, coagulation profile, and calcium levels, were obtained.

1. Patient Counseling: Patients were provided with a detailed explanation of the procedure, benefits, risks, and alternative treatments. Informed consent was obtained after addressing patient queries.

Surgical Technique: Single Lateral Incision Total Thyroidectomy (SLITT)

Single Lateral Incision Total Thyroidectomy (SLITT) is a novel technique for performing thyroidectomy through a smaller, cosmetically favorable lateral incision on one side of the neck. The procedure involves a juxta-lateral sequential release of the ligament of Berry, either in an anticlockwise direction from the right side or a clockwise direction from the left side, depending on the surgeon's dexterity.

Patient Positioning

The patient is placed under general anesthesia in a supine position with the neck extended in the classical position and rotated to the opposite side of the planned incision. (Fig 1)

Incision and Initial Exposure

A 3 cm transverse incision is made along the most cosmetically favorable crease over the sternocleidomastoid (SCM) muscle. The platysma is incised, and a plane is created between the SCM and the strap muscles. The strap muscles are retracted medially to expose the superior pedicle of the thyroid gland.(Fig 2)

Superior Pedicle Dissection

The superior pedicle is approached and transected close to the gland using an energy device, ensuring the preservation of the external branch of the superior laryngeal nerve. The dissection progresses inferiorly, addressing the organ of Zuckerkandl, and preserving critical structures such as the superior parathyroid gland, middle thyroid vein, and the recurrent laryngeal nerve, which lies between the two layers of Berry's ligament.(Fig 3)

Inferior Pedicle Dissection

The dissection continues caudally to preserve the inferior parathyroid gland along with its venous drainage. The inferior pedicle is transected, and both parathyroids dropped down from the capsule with intact vascular attachments. (Fig 3)

Lobe Delivery

The right lobe of the thyroid is delivered into the incision after releasing the ligamentous attachments of the isthmic capsule to the trachea. The isthmus is freed into the incision. Gentle retraction with Langenbach retractors ensures minimal tissue trauma and prevents undue traction.

Contralateral Lobe Dissection

Access to the contralateral lobe begins by addressing its lower pole. The inferior pedicle is transected while preserving the venovascular attachments of the inferior parathyroid gland. Dissection progresses cranially to tackle the middle thyroid vein and the superior parathyroid gland. The contralateral organ of Zuckerkandl is mobilized and removed.

Completion of Gland Removal

The final step involves transecting the contralateral superior pedicle close to the gland while preserving the external branch of the superior laryngeal nerve. The thyroid gland is completely removed, and meticulous hemostasis is achieved to ensure a clean surgical field.(Fig 4)

Management of Lymph Nodes

In cases involving malignancies, associated lymph nodes are addressed through the same incision, allowing for modified radical neck dissections (MRNDs) and central compartment dissections as needed.

This refined technique emphasizes safety, efficacy, and cosmetic outcomes while preserving critical structures and minimizing perioperative complications.

Postoperative Care and Follow-Up

Immediate Postoperative Monitoring: Patients were monitored for signs of complications, including bleeding, hypocalcemia, or nerve injury.

Pain Management: Analgesics were administered as per protocol, and pain scores were recorded.

Length of Hospital Stay: Duration of hospital stay was documented.

Patient Satisfaction: Cosmetic outcomes were assessed using patient satisfaction surveys at discharge and follow-up visits.

Adverse Event Reporting: Any adverse events were promptly reported to the Institutional Ethics Committee (IEC).

Ethical Considerations

• Ethical approval was obtained from the Institutional Ethics Committee (IEC) prior to study initiation.
• Informed consent was documented for all participants.
• Adverse events and deviations from the protocol were reported to the IEC promptly.

In this pilot study, 50 subjects were assessed for their basic demographic characteristics. The average age of the participants is 45 years, with a standard deviation of 14 years, indicating a wide age range between 19 and 82 years. The gender distribution revealed that 80% were female and 20% were male. In terms of religion, the majority were Muslim (52%), followed by Hindu (40%) and Christian (8%). Most participants were married (88%), while 12% were unmarried. Regarding educational status, the largest group held postgraduate degrees (30%), followed by those with professional degrees (18%) and diplomas (16%). Other educational levels included intermediate (14%), high school (12%), middle school (8%), and primary education (2%). This diverse demographic profile provides an understanding of the participants' backgrounds, which may influence study outcomes. (Table 1)

The distribution of BMI categories among the study participants revealed that 54% (n=27) had normal weight, followed by 20% (n=10) who were overweight, 18% (n=9) classified as obese, and 8% (n=4) as underweight. This reflects a diverse BMI profile within the study population, with more than half maintaining a normal BMI. Co-morbidities were present in 42% (n=21) of participants, while the remaining 58% (n=29) reported no associated co-morbid conditions. The presence of co-morbidities underscores the need for careful preoperative assessment and management in this cohort. (Table 1)

Table 1: Baseline characteristics of the study subjects

Clinical and pathological conditions

The majority of participants (98%, n=49) presented with a neck mass without pressure symptoms, with only 2% (n=1) reporting associated pressure symptoms. Histopathological analysis showed that 76% (n=38) were diagnosed with multinodular colloid goiter, 14% (n=7) with Hashimoto’s thyroiditis, and 10% (n=5) with papillary thyroid cancer. Surgical indications were predominantly for goiter (70%, n=35), followed by toxic multinodular goiter (18%, n=9), non-toxic multinodular goiter (6%, n=3), solitary nodule (4%, n=2), and malignant thyroid neoplasm (2%, n=1). All patients had a palpable neck mass on local examination, validating the need for surgical intervention. These findings affirm the versatility of the SLITT technique in addressing a range of thyroid pathologies effectively. In terms of mass size, the average length of the mass is 6.97 cm (SD = 1.37), with a range from 4.0 cm to 10.0 cm. The width of the mass has a mean of 3.43 cm (SD = 0.42) , while the thickness of the mass has a mean of 4.92 cm (SD = 0.27). (Table 2)

Table 2: Clinical and pathological conditions

Intra-operative characteristics of the study subjects

Incision Side: The vast majority of patients (96%) underwent the surgery with a right lateral incision, while only 4% had the left lateral incision.

Capsular Invasion: Most patients (94%) did not exhibit capsular invasion, with only 6% having capsular invasion noted.

 Extra-thyroidal Involvement: Nearly all patients (98%) did not have extra-thyroidal involvement, with only a small percentage (2%) presenting with this condition.(Table 3)

Table 3: Frequency Distribution of Clinical Characteristics for SLITT Procedure

Incision Size (cm): The mean incision size is 3.52 cm, with a minimal variation (SD = 0.099), indicating a consistent incision length among the patients.

Intraoperative Bleeding (mL): The average blood loss during surgery is 13.60 mL, with some variation (SD = 2.96), suggesting a relatively controlled bleeding level during the procedure. Operation Time (min): The mean operation time is 15.74 minutes, with a standard deviation of 4.14 minutes, reflecting a relatively brief duration for the SLITT procedure with moderate variability.(Table 4)

Table 4: Descriptive Statistics for Intraoperative Variables in SLITT Procedure

Post operative Charecterestics

Postoperative Hospital Stay: The majority of patients (88%) had a hospital stay of 2 days after the procedure. A smaller proportion (10%) stayed for 3 days, while only 2% required a 5-day stay. This suggests that most patients recover relatively quickly after the SLITT procedure. No post operative complications presented .(Fig 5)

Analgesic Type: NSAIDs were the most commonly used analgesics, accounting for 72% of cases, while paracetamol was used in 28% of cases, suggesting a preference for NSAIDs for pain management following the SLITT procedure.

Dose Frequency: A majority of patients (62%) were administered analgesics three times daily (TID), while 38% were given the medication twice daily (BD). This suggests that a higher dose frequency was preferred for optimal pain control.(Table 5)

Table 5: Analgesic Usage and Dose Frequency

Postoperative Pain Relief: At the immediate postoperative stage, 98% of patients reported no pain at the wound site, with only 2% experiencing slight pain (VAS 1-2). At subsequent follow-ups (discharge, 30, 60, and 90 days), all patients reported no pain at the wound site. This suggests a rapid and sustained recovery in terms of pain management following the SLITT procedure. (Fig 2)

Figure 6:  Postoperative VAS Scores for Site of Wound at Various Time Points

During follow-up, all patients reported high satisfaction with the cosmetic outcomes of the procedure. Remarkably, there were no visible scars, highlighting the effectiveness of SLITT in achieving superior aesthetic results. (Fig 7)

This pilot study assessed the demographic, clinical, and intraoperative characteristics of 50 subjects undergoing the Single Lateral Incision Total Thyroidectomy (SLITT). The participants had a wide age range, with an average age of 45 years. The gender distribution was predominantly female (80%), and the majority of participants were married (88%). Educationally, the most common highest level of education was postgraduate degrees (30%).

The BMI distribution revealed that 54% of participants had normal weight, while 20% were overweight, and 18% were classified as obese. Co-morbidities were reported in 42% of participants. Most participants (98%) presented with a neck mass without pressure symptoms, and histopathological diagnoses were predominantly multinodular colloid goiter (76%). Surgical indications were mainly for goiter, with 70% of cases requiring intervention for this condition.

In terms of intraoperative details, the majority of surgeries (96%) involved a right lateral incision. Capsular invasion and extra-thyroidal involvement were rare, affecting only 6% and 2% of patients, respectively. The mean incision size was 3.52 cm, and the mean operation time was 15.74 minutes, reflecting the minimally invasive nature of the procedure. Blood loss during surgery was minimal, with an average of 13.60 mL.

Postoperatively, most patients (88%) had a short hospital stay of 2 days, with no reported complications. Pain management primarily involved NSAIDs (72%), with the majority of patients (62%) receiving analgesics three times daily. Pain relief was effective, as 98% of patients reported no pain immediately after surgery, and all patients remained pain-free during follow-up.

Serpell et al. analyzed 336 total thyroidectomies over 13 years, predominantly for multinodular goiter (69%) and thyroid malignancy (17.9%). Permanent complications such as hypoparathyroidism (1.8%) and recurrent laryngeal nerve palsy (0.3%) were rare. Temporary hypocalcemia (38.9%) was a significant finding. In contrast, our study recorded no incidences of hypocalcemia or nerve injury, underscoring the safety profile of the SLITT approach. Furthermore, our minimally invasive technique required a mean incision size of 3.52 cm, much smaller than traditional techniques, while achieving comparable outcomes. (8)

Bhattacharyya et al. reported that thyroid malignancy and goiter accounted for 73.9% of total thyroidectomies. The mean hospital stay was 2.5 days, with postoperative hypocalcemia at 6.2% and a low incidence of wound complications (<1%). Similarly, in our cohort, the mean hospital stay was 2 days, and no hypocalcemia or wound infections occurred. However, SLITT's shorter operative time (15.74 minutes vs. conventional approaches) and minimal blood loss (13.60 mL) further highlight the efficiency and reduced trauma of this approach. (9)

Zhou et al. compared traditional thyroidectomy with a modified small-incision technique in patients with thyroid cancer. Their modified approach showed significantly reduced operative time, incision length, and complication rates (11.82% vs. 34.55%). In our study, the SLITT approach demonstrated even greater reductions in incision size (3.52 cm vs. 4–5 cm) and operation time (15.74 minutes vs. traditional averages). Our complication-free outcomes align with Zhou et al.'s findings, supporting the advantages of smaller incisions and careful surgical planning. (10)

Rafferty et al. evaluated minimal incision thyroidectomies, finding that a 4 cm incision was adequate for most cases, with no major postoperative complications. Our SLITT approach further reduced the incision size while maintaining excellent access and outcomes, showing its potential as a more refined alternative.(11)

Strengths of the present Study

Innovative Approach: The SLITT technique demonstrated superior outcomes in terms of reduced incision size, minimal blood loss, shorter operative time, and early postoperative recovery compared to conventional methods.

Zero Complications: Unlike other studies reporting complications such as hypocalcemia, wound infections, and recurrent laryngeal nerve palsy, our study observed no adverse events, emphasizing the safety of this approach.

Efficient Pain Management: Effective pain control with NSAIDs resulted in 98% of patients reporting no pain immediately after surgery, a finding unmatched in many previous studies.

Short Hospital Stay: The majority of patients were discharged within 2 days, aligning with current trends in minimally invasive surgery for faster recovery and reduced healthcare costs.

Limitations and Future Directions

While our findings underscore the benefits of SLITT, the study's limited sample size (50 participants) warrants further investigation with larger cohorts to generalize results. Future studies should also explore the applicability of SLITT in cases involving more extensive thyroid pathology or malignancy, as well as its cost-effectiveness compared to traditional and other minimally invasive techniques.

The findings from this pilot study highlight the SLITT technique is a safe, effective, and minimally invasive approach to thyroidectomy, offering significant advantages such as quick recovery time, minimal blood loss, low incidence of complications and cost effective. The procedure proved versatile in managing various thyroid conditions, such as multinodular goiter, and malignancies, with excellent postoperative outcomes, including rapid pain relief and short hospital stays. Importantly, all patients reported high satisfaction with the cosmetic results, with no visible scars observed during follow-up, emphasizing the superior aesthetic outcomes of SLITT. These findings underscore SLITT’s potential as a preferred surgical option for thyroid pathologies, combining functional efficacy with outstanding cosmetic benefits.

Conflict of interest: Nil

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