Modified lateral neck dissection in the case of papillary thyroid carcinoma (PTC) is usually advocated for patients with clinically evident lymph node metastases in the lateral neck. Functional lateral neck dissection requires a large skin incision to provide adequate exposure of the surgical field and neck structures. After acquiring a quite large experience with video-assisted neck surgery (video-assisted thyroidectomy and parathyroidectomy, video-assisted central neck dissection) we decided to evaluate the feasibility of functional lateral neck dissection in patients with PTC.

In this video we report the case of a 23 years old female with bilateral lymph node metastases of PTC who underwent a video-assisted functional bilateral neck dissection.

The patient had a 35 mm right lobe thyroid nodule and bilaterally enlarged lateral neck nodes. Preoperative fine-needle aspiration biopsy showed a PTC with lymph node metastases on the right side. Total thyroidectomy and central neck dissection were accomplished through a 4.0 cm central skin incision between the cricoid cartilage and the sternal notch, as well as left lateral neck node sampling (mid jugular). Frozen section showed metastases of PTC in the removed lymph nodes of the left side. Thus a bilateral functional lateral neck dissection was carried out. Dissection was performed under endoscopic vision using a technique very similar to conventional surgery through the single 4-cm skin incision used for thyroidectomy. A 5-mm 30° endoscope and small (2- to 3-mm in diameter) instrumentation were used as already describe for video-assisted thyroidectomy. The operative time was 220 minutes. A transient postoperative hypocalcemia that required for a 10 days supplementation oral calcium and vitamin D was registered. No other complication occurred.

The final histology showed a multi-focal sclerosis variant of PTC with lymph node metastases in 5 out of 11 central neck nodes, in 3 out of 29 and in 9 out of 21 lateral neck nodes on the right and on the left side, respectively.

Post-operative sTg on LT4 was undetectable (<1ng/ml) and 0.4 ng/ml after LT4 withdrawal. Post-operative ultrasonography did not show any thyroid remnant or lymph node enlargement. Pre-ablation 131I neck uptake (RAIU) was 0.14% with minimal residual on the thyroid bed. The patient considered the cosmetic result as excellent.

This experience demonstrates that video-assisted functional lateral neck dissection is feasible. However some doubts still persist about the oncologic validity of this approach. For definitive conclusions larger series and comparative studies are necessary.