Using Air-Saline Hybrid Method to Create the Working Space in Endoscopic Thyroidectomy

Abstract

Introduction:

Creating a broad, bloodless, and clearly defined dissection plane is pivotal for endoscopic thyroidectomy. ¹ We present an air–saline hybrid method that combines limited air insufflation with epinephrine–saline infiltration to rapidly establish the working space while reducing bleeding, electrosurgical resistance, and scope fogging. ²

Methods:

An epinephrine–saline solution containing saline, ropivacaine (20 mg/20 mL), epinephrine (0.1 mg), and dexamethasone (10 mg) was infiltrated, with 10 mL administered to each areolar site and 6 mL to the anterior chest (total 36 mL).

In patients with poor skin compliance, periareolar skin incisions were created before air insufflation to serve as pressure-relief outlets, thereby reducing subcutaneous pressure and the theoretical risk of gas embolism during initial injection. Air insufflation was then performed in two stages, with 100 mL below the manubrium and 300 mL above the manubrium into the cervical region, facilitating rapid creation of the working space. Skin vascular markings or rib contours were used to confirm correct plane expansion. Three small incisions were subsequently made, followed by blunt dissection along the air-created plane. Finally, CO₂ insufflation was applied to maintain the working space.^3,4

Results:

The hybrid method facilitates immediate fascial-plane recognition, reduces bleeding, and minimizes ultrasonic-scalpel fogging. In routine conditions, the working space can be expanded to the level just above the cricoid cartilage in approximately 4 mins, enabling smooth trocar placement and subsequent dissection.

Conclusion:

The air–saline hybrid method is a simple and reproducible way to create and maintain the working space for endoscopic thyroidectomy. It appears to shorten setup time and improve visualization while supporting atraumatic, layer-based dissection and more precise separation along natural tissue planes. Future case series will be required to quantitatively evaluate its safety and clinical outcomes.

Patient Consent:

The authors have received and archived patient consent for video recording and publication in advance of the video recording of the procedure. This study was performed in accordance with institutional ethical standards.

Funding Information:

This research was supported by Clinical Research Center for Precision Management of Thyroid Cancer of Fujian Province (grant no.: 2022Y2006; 2024YGPT003) and Joint Funds for the Innovation of Science and Technology, Fujian Province (grant no.: 2023Y9190; 2023Y9135; 2023Y9119). Fujian Provincial Health Technology Project (grant no.: 2025CXA006), and Education and Teaching Research Project of Fujian Province (grant no.: YT25002).

The authors declare that they have no commercial associations within the past 2 years that could represent a conflict of interest related to this video.

Running time of the video: 5 mins 13 secs.