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LETTER TO EDITOR
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 233-234

DUBAI triangle and Amin's Triangle, a new invention during TransOral Endoscopy Thyroidectomy Vestibular Approach (TOETVA) for critical view of safety for preservation of vital structures


1 Dubai Medical College, Dubai; Sharjah Medical University, Sharjah; Dubai Hospital, Dubai, UAE
2 Dubai Medical College; Dubai Hospital, Dubai, UAE
3 Lecturer, Omdurman Islamic University, Omdurman, Sudan
4 Associate Professor, Dubai Medical College and Hospital, Dubai, UAE
5 Professor, Muhammad bin Rashid Medical College, Al Zahra Hospital, Dubai, UAE

Date of Submission01-Nov-2022
Date of Acceptance03-Nov-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Yasir Amin A.Latif
Department General Surgery, Dubai Hospital, Al Baraha Street, Postal Code 7272, Dubai
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_101_22

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How to cite this article:
A.Latif YA, Ishaq A, Khalid MK, Ghazi EH, Hartung R. DUBAI triangle and Amin's Triangle, a new invention during TransOral Endoscopy Thyroidectomy Vestibular Approach (TOETVA) for critical view of safety for preservation of vital structures. Hamdan Med J 2022;15:233-4

How to cite this URL:
A.Latif YA, Ishaq A, Khalid MK, Ghazi EH, Hartung R. DUBAI triangle and Amin's Triangle, a new invention during TransOral Endoscopy Thyroidectomy Vestibular Approach (TOETVA) for critical view of safety for preservation of vital structures. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:233-4. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/233/364683



Dear Editor,

Transoral Endoscopy Thyroidectomy Vestibular Approach (TOETVA) procedure through vestibular approach for scarless thyroidectomies and parathyroidectomies has gained increasing interest in the recent past. Although promising cosmetic results with excellent patient satisfaction have been reported safety issues have to been discussed. Special emphasis has to be put on a standardised anatomical and surgical approach in order to prevent injury of the recurrent laryngeal nerve (RLN) as well as vascular structures.

Therefore, we have been running a cadaveric study in Sharjah Surgical Institute to establish a anatomic approach which would be easily reproducible for the procedure and could be also applied in the training for head and neck surgeons, general surgeons, ENT, and endocrine surgeons who want to be introduced into this method.

In the following, we will shortly describe our experience gained by cadaver studies which could be implemented into clinical applications:

We used standard laparoscopic instruments (e.g., like for laparoscopic appendectomy) perform TOETVA surgery and the surgeons stood behind the head of the 'patient' which was slightly extended.

As a first step, a space in the submental and submandibular region was created by performing a 10 mm incision through the middle of the vestibulum. Following this, the space was extended by the use of cautery as well as hydrodissection (diluted adrenaline solution 1:500,000) which was injected through a Veress needle from the vestibular area toward the anterior side of the neck. Once a sufficiently big space was created, a 10-mm trocar could be inserted and insufflation with CO2 at a pressure of 6 mm Hg was started.

Under vision of a 30° laparoscopic camera, two 5-mm trocars were inserted at the junction between the incisor and canine on both sides, avoiding the entering of mental nerves and pointing down to the anterior neck.

The whole procedure and operator's view were cranio-caudal. The superior border was the hyoid bone, the inferior border the suprasternal notch, and lateral borders the anterior and medial borders of both sternocleidomastoid muscles. Laterally, the dissection was continued until the medial border of the sternocleidomastoid muscle was reached, which could be extended more laterally if needed.

The median raphe was divided to open the mid line. Then, the strap and sternocleidomastoid muscles were retracted toward the lateral sides transcutaneously using 2/0 silk. The isthmus of the thyroid gland was identified and completely dissected from the trachea.

Following this, Dissection Under-vision By Assistant Indicators (which we named as DUBAI triangle) was carried out to avoid injury to the RLN, the superior laryngeal nerve (SLN) as well as the parathyroid glands or their blood supply.

The assistant anatomic indicators were retracted strap muscles (sternothyroid, sternohyoid muscles, and superior belly of omohyoid) and sternocleidomastoid muscles forming the lateral border of the DUBAI TRIANGLE. The medial border was the thyroid-hyoid membrane covered by thyrohyoid muscle, thyroid cartilage, cricothyroid membrane covered by cricothyroid muscle, trachea, and tracheoesophageal groove. The base of DUBAI triangle formed by the lateral part of the body of the hyoid bone (greater Cornu of the hyoid bone and retracted part of retracted strap muscle (sternothyroid and superior belly of omohyoid muscle). Once the triangle was identified, the contents of the triangle were the lobes of the thyroid glands, parathyroid glands, carotid sheath contents, blood vessels to thyroid and parathyroid glands and RLN and SLN on both sides [Figure 1].
Figure 1: Crainiocaudal view of the Right side of DUBAI Triangle

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Then dissection can be started from the upper pole of the thyroid gland or lateral to the thyroid gland by use of an ultrasonic or bipolar energy device and retraction of the thyroid gland medially, thus identifying the bounders of Amin's triangle form the safety triangle, which highlight the course of RLN and the parathyroid blood supply and both parathyroid glands. Therefore, the Base of Amin's triangle is formed by the inferior thyroid artery, which is the main lead mark of the road course of RLN.

The medial boundary was formed by the lateral border of the thyroid gland (Zukerkandl's tubercle),[1] coricothyroid articulation, coricoid cartilage, the beginning of trachea, and tracheoesophageal groove. The lateral boundary is carotid sheeth and its contains. The floor is formed by prevertebral fascia. This was significantly helpful to localise the RLN [Figure 2]. By this technique, the RLN could be found easily between Zukerkandl's tubercle and the cricopharyngeal muscle and dissection of the thyroid lobe under careful medial retraction could be performed.
Figure 2: Left side of Amin's Triangle and DUBAI Triangle at the same side. Amines triangle is highlighted by yellow colors and the details of Amines triangle by white colored. Dubai Triangle is highlighted by black dots

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The resected thyroid lobe was inserted into an Endo bag and extracted through the median port.

Based on these cadaver studies, the identification of DUBAI and Amin' triangle seems to provide reliable assistance to recognise the vital structures during TOETVA surgery. Furthermore, we feel that the introduction of Dubai and Amin' triangle could help to shorten the learning curve of this procedure and would warrant a study to confirm its clinical use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Winer L, Jha P, Cowan SW, Yeo CJ, Goldstein SD, Emil Zuckerkandl MD. (1849-1910). Bridging anatomic study and the operating room table. Am Surg 2016;82:189-91.  Back to cited text no. 1
    


    Figures

  [Figure 1], [Figure 2]



 

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