He has a photographer’s eye, and therefore different angles matter to Dr Thomas Varughese. The photographs in his cellphone speak of his interests: hibiscus and travel. But his patients take priority, with a bunch of photographs chronicling their progress. And it was one of his patients who made Varughese, head, surgical oncology and reconstructive surgery, Renai Medicity hospital, Kochi, look at thyroid surgery from a different angle.
Ten years ago, an IT professional, in her early 20s, came to Varughese, who was working with another hospital then, with a swelling in the thyroid gland. It was a malignant tumour (above 60 per cent of thyroid swellings are benign). A surgery was a must but she had one question: can he do it without leaving a scar? And thus, Varughese came up with the horizontal lateral thyroidectomy or ‘Thomas technique’.
Varughese improvised on the conventional technique developed by Swiss physician Emil Theodor Kocher in the 1870s (he received the Nobel Prize in 1909 for his work on the thyroid gland). In Kocher’s technique, the incision is made on the front of the neck, which leaves behind a lifelong scar. Varughese, however, decided to approach it laterally, using a 3D interactive digital anatomy of the neck for the surgery.
The neck, says Varughese, consists of compartments—central and lateral. Kocher, however, was not aware of this concept. The thyroid gland, shaped like a butterfly, is located below the Adam’s apple, and traditionally it has been described as a midline organ. “In the central compartment, there are only two organs in the midline—the trachea in the front and the oesophagus behind,” he says. “The only part of the thyroid in the midline is the isthmus, the connecting part. The thyroid [lobes] are on either side of the midline, hugging the trachea and the oesophagus. So, it is a lateral organ in the central compartment. My surgery is based on this principle.”
In the conventional technique, there are four major risk factors—nerve injury, bleeding, damage to the parathyroid glands and scarring. The thyroid region has two prominent nerves—recurrent laryngeal nerve and superior laryngeal nerve—and any damage to these can change the voice quality or even lead to a loss of voice.
Also, the thyroid gland is richly supplied by blood vessels, says Varughese. The first patient Kocher operated on bled to death. “At that time, they did not know how to handle the bleeding,” he says. “In lateral thyroidectomy, I first control the blood supply to the thyroid without touching the gland. The gland shrinks; it loses its blood supply. So my blood loss for the entire surgery is hardly 5ml.”
Also, when there is bleeding, it makes it difficult for the surgeon to identify the small parathyroid glands, which regulate the body’s calcium levels, and the laryngeal nerves. Since the blood vessels are tackled upfront in the Thomas technique, it makes for easier identification of the parathyroid glands, located in the posterolateral part of the neck.
“All the important structures that need to be saved during the surgery are located on the side of the neck,” says Varughese. “So I asked myself, ‘if everything you want to save is on the lateral side, why do you want to go from the front?’ This is the logical, pure anatomical basis of this surgery.”
Earlier, scars used to be the least of a patient’s worries. Today it has become a priority, especially among unmarried women. To ensure that his procedure left no lasting scars, Varughese turned to the neck's “natural creases or fold” called Langer’s lines. “If one respects the natural creases, then there will be no scar as (the incision is) on the line,” he says.
What further helped Varughese in his scarless surgery was platysma, the subcutaneous (under the skin) muscles in the neck, which heals quickly. “It comes from both sides of the neck and merges on to the chin, but is deficient in the most exposed part—the root [base] of the neck,” he says. In Kocher’s technique, the incision is made in the area with no platysma. With no muscles here, only the fat is sutured together. But in Thomas technique, the incision falls on the platysma. “So when I suture it together, the fibrosis is fine,” says Varughese. “It heals the scar. In the lateral aspect of the neck, the entire width has platysma. That is an important point in why it avoids scarring.”
Anu (name changed) was a third year medical student when she first noticed a lump on the neck in July 2017. The tests revealed that she had thyroid adenoma, a benign tumour. She was kept under observation for a year. While her thyroid levels were normal, the tumour had grown. She decided to go for surgery. “I wasn’t supposed to go for open surgery at all. I was supposed to go for an endoscopic one because I am 23 and I didn’t want a scar,” she says. “But then Malayala Manorama carried an article on Dr Thomas Varughese. That was the time when we were looking for surgeons. We read about him, and got an appointment and met him.” She was operated on December 1 and discharged on December 3.
“All my patients go home in 24 hours,” says Varughese. More than 1,500 patients, from seven-year-olds to 80-year-olds, have benefited from the Thomas technique, he says. He recounts the case of an 80-year-old patient who had an enlargement that had reached her chest. She visited many hospitals in Kochi and was told that they would have to open her chest to remove the gland. “I said I will do it without opening the chest,” he says. He removed it through a small incision in the neck. Also, he lets his patients decide where they want the incision.
There are other options like robotic and endoscopic surgeries, but these could be expensive. Also, in endoscopic surgery, multiple incisions might have to be made in the armpit and on the nipple areola complex for the scope to pass through. But in Thomas technique, both sides can be operated on through one incision, says Varughese, who won the ‘Best Innovation in Surgery’ award at MGR Medical University, Chennai, in 2012. He has presented his paper at several international conferences, too. But how can the technique be made more popular among doctors in India? By understanding its principles, says Varughese, and with extensive training.