Robotic thyroidectomy by bilateral axillo-breast approach: review of 1026 cases and surgical completeness

Bilateral Axillo-Breast Approach Robotic Thyroidectomy (BABA RT) Does Not Interfere with Breast Image Follow-Up

BACKGROUND

Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) is frequently performed and has excellent cosmetic results. However, there has been concern that subcutaneous tunneling in construction of the operation field might interfere with subsequent breast imaging. In this study, we evaluated whether BABA RT interferes with breast imaging by evaluating serial perioperative results of mammography and ultrasonography.

METHODS

We selected female patients who underwent BABA RT between 2008 and 2012, and who also had mammography or ultrasonography pre- and postoperatively, and compared the results of pre- and postoperative imaging. The results of mammography and ultrasonography were reported according to the Breast Imaging Reporting and Data System (BIRADS).

RESULTS

A total of 175 nodules from 108 female patients were analyzed. The mean age of the patients was 42.9 ± 9.7 years, and the median follow-up period was 34.1 months. Ninety-four patients (87.0%) underwent total thyroidectomy, and 101 patients (93.5%) had malignant thyroid disease. After BABA RT, mammography and ultrasonography were performed an average of 2.9 ± 2.0 times and 3.3 ± 2.0 times per person, respectively. Six patients required breast intervention according to mammography or ultrasonography after BABA RT, and all procedures were successfully conducted.

CONCLUSIONS

BABA RT did not cause diagnostic difficulties such as poor sonic window in subsequent breast imaging studies. Routine breast imaging studies for breast nodule follow-up could be performed without difficulties resulting from BABA RT.

Transoral endoscopic surgery for papillary thyroid carcinoma: initial experiences of a single surgeon in South Korea

Purpose

The transoral endoscopic thyroid surgery vestibular approach (TOETVA) is one of the newest techniques which do not result in an anterior neck scar. We report herein our initial experience with TOETVA and its short-term outcomes in patients with papillary thyroid carcinoma (PTC).

Methods

This case series consisted of all consecutive patients who underwent TOETVA in our institution between August 2016 and June 2017. Indications for TOETVA were an fine needle aspiration-confirmed PTC or follicular neoplasm, an intrathyroidal tumor with a diameter of less than 2 cm, and no clinical evidence of central or lateral lymph node metastasis. A total of 20 patients underwent TOETVA and we retrospectively reviewed clinicopathologic data and short-term postoperative outcomes.

Results

Among the 20 TOETVA cases, 7 were total thyroidectomy, 12 were lobectomy and 1 was wide isthmusectomy. Mean age was 50.8 years and mean operation time was 152 ± 51.4 minutes. Tumor size ranged from 0.2–1.4 cm and the mean size of harvested central lymph nodes was 2.8 (range, 0–10). Neither mental nerve injury nor surgical site infection occurred. One patient had transient vocal cord palsy and 1 patient developed a neck seroma. Among 7 total thyroidectomy patients, 3 patients developed transient hypocalcemia.

Conclusion

Transoral thyroid surgery could be an alternative surgical option for some PTC patients.

Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients

BACKGROUND

Transoral thyroid surgery is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. Nonetheless, technical obstacles have precluded the wide dissemination of this procedure. We present the surgical procedures and outcomes of transoral robotic thyroidectomy (TORT).

METHODS

From September 2012 to June 2016, we performed TORT at Korea University Hospital. We used three intraoral ports and a single axillary port for the system's four robotic arms. The surgical outcomes were retrospectively reviewed.

RESULTS

Twenty-four female patients (mean age 39.6 ± 11.6 years; mean tumor size 1.0 ± 1.3 cm) underwent unilateral thyroid lobectomies with or without ipsilateral central neck dissection. Twenty patients had papillary thyroid carcinomas (PTC), three had benign nodules, and one had a follicular thyroid carcinoma. The mean surgical time was 232 ± 41 min; the mean hospital stay was 3.3 ± 0.8 days. The number of retrieved central lymph nodes in the PTC patients was 4.7 ± 3.2. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the median follow-up period of 16.8 months. Paresthesia of the lower lip and the chin due to mental nerve injury was observed in nine of the first 12 patients (six transient, three permanent), but no further reports of paresthesia were recorded after patient 12, when the locations of the intraoral incisions were modified.

CONCLUSIONS

TORT is feasible and safe for selected patients after technical refinements, and can be a potential alternative approach for scarless thyroid surgery.

Robotic modified radical neck dissection with bilateral axillo-breast approach

Bilateral axillo-breast approach (BABA) robotic thyroidectomy has been performed since 2008, and the indications of the BABA robotic operation has been widened to the robotic modified radical neck dissection (MRND). The indication for BABA robotic MRND is suspicious lateral neck metastasis of well-differentiated thyroid carcinoma, and the contraindication is far advanced carcinoma such as encasement of common carotid artery. Surgical procedures start from flap formation as a routine BABA robotic thyroidectomy and the lateral neck dissection is performed from level IV and Vb to level III and IIA. The procedures are very similar to those of open MRND. Comparison between robotic MRND and open MRND in mean age, sex, body mass index, and tumor size were not different significantly. There was no statistically significant difference in the number of retrieved lymph nodes, metastatic lymph nodes or stimulated thyroglobulin level between the groups. The operation time was longer in the robotic group. BABA robotic MRND can be safe and feasible method to treat lateral neck metastasis of well differentiated thyroid carcinoma. More prospective, controlled, multicenter studies are required to establish robotic MRND as an alternative standard and to justify additional costs beyond the cosmetic advantages.

Bilateral axillo-breast approach robotic thyroidectomy: review of evidences

The bilateral axillo-breast approach (BABA) is one of the most popular contemporary remote-access thyroidectomy techniques. While the initial experiences with BABA endoscopic thyroidectomy (ET) were associated with some technical challenges and safety concerns, many limitations of the technique could now be substantially overcome by BABA robotic thyroidectomy (RT). In this review, the current literature evidences of BABA RT were analyzed. Data regarding the patient selection, the learning curve, and the comparison with open thyroidectomy (OT) and BABA ET were examined. Careful case selection for BABA RT should be undertaken according to factors related to the patient and the thyroid pathology. The learning curve of BABA RT was about 40 cases. Comparing to OT, BABA RT was comparable to OT for the complication profiles and most perioperative outcomes. But it was associated with longer operative time, higher cost and possibly inferior oncological control with lower number of central lymph node (LN) retrieved. When compared to BABA ET, BABA RT was comparable for most perioperative outcomes except longer operative time and higher cost. Yet, BABA RT was superior to BABA ET for better oncological control. BABA RT is a safe and effective procedure for most benign thyroid conditions and low-risk differentiated thyroid cancers (DTC).

Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences

Recently, natural orifice transluminal endoscopic surgery (NOTES) has been applied in thyroid surgery with transoral access. The benefit of transoral endoscopic thyroidectomy is the potential for scar-free surgery. However, there are many concerns over some aspects, such as infection, recurrent laryngeal nerve injury, and oncological outcome. In this paper, we have reviewed the development history and the current clinical evidence of this innovative surgery. We conclude that the transoral endoscopic thyroidectomy vestibular approach (TOETVA) is feasible and can be considered no longer an experimental operation.

Technical, Oncological, and Functional Safety of Bilateral Axillo-Breast Approach (BABA) Robotic Total Thyroidectomy

BACKGROUND

The aim of this study was to identify whether bilateral axillo-breast approach (BABA) robotic total thyroidectomy (RoTT) is technically, oncologically, and functionally safe.

MATERIALS AND METHODS

One hundred eighteen patients underwent BABA robotic thyroidectomy between July 2010 and February 2013. Ninety-one (77.1%) patients underwent RoTT, and 27 (22.9%) underwent robotic unilateral lobectomy.

RESULTS

RoTT (n=91) resulted in lower rate of surgical complication and in higher rate of transient hypocalcemia comparing with robotic unilateral lobectomy (n=27) (35.16% vs. 3.7%; P<0.013), but not in a permanent hypocalcemia, transient, or permanent recurrent laryngeal nerve palsy (2.2% vs. 0%; P=1.000, 3.3% vs. 0%; P=1.000, and 0% vs. 0%; P=NS), respectively. Successful remnant ablation rate for the patients with RoTT was 100% on a subsequent 6 months follow-up. No significant differences between 2 groups existed in mean Voice Handicap Index-10 scores during postoperative 6 months (P=0.308).

CONCLUSIONS

BABA RoTT might be oncologically safe as well as technically and functionally safe procedure.

Bidirectional Approach of Video-Assisted Neck Surgery (BAVANS): Endoscopic complete central node dissection with craniocaudal view for treatment of thyroid cancer

INTRODUCTION

Endoscopic thyroidectomy is a well-established surgical technique that is mainly performed for benign thyroid disease. We considered that endoscopic surgery could also be widely indicated for the treatment of thyroid cancer. We herein describe our new bidirectional approach of video-assisted neck surgery (BAVANS) for complete central node dissection in endoscopic thyroid cancer surgery.

METHODS

BAVANS involves two different directional pathways to the cervical lesion. Before lymph node dissection, we perform endoscopic thyroidectomy via a conventional gasless precordial or axillary approach. After thyroidectomy, the surgeon repositions by the head of the patient and inserts three ports in front of the upper neck lesion in the submandibular area to approach the paratracheal lesion from an overhead-to-caudal direction.

RESULTS

BAVANS allows for an excellent craniocaudal view and easy access to the peritracheal lymph nodes. Sixteen patients with papillary thyroid cancer underwent BAVANS and progressed satisfactorily after surgery. Of those patients, eight underwent total or near total thyroidectomy, and five patients underwent bilateral central node dissection. The average number of retrieved lymph nodes with unilateral central node dissection was nine, which was higher than that achieved with conventional open surgery. All patients began oral intake within 5 h after surgery. Postoperative Horner syndrome occurred in one patient. No other complications were noted.

CONCLUSIONS

BAVANS is a very effective surgical procedure that many endoscopic surgeons can perform safely and easily. It has both a cosmetic advantage and excellent curability in endoscopic thyroid cancer surgery.

Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy

BACKGROUND

It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy.

METHODS

All consecutive patients (N = 22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805 nm; filter: 825 nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes.

RESULTS

ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203 ± 89 (125-331) and 207 ± 112 (130-356) s, respectively. The mean (range) fluorescence duration in these glands was 20.8 ± 6.0 (16.6-35.8) and 20.1 ± 7.3 (15.5-33.8) min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P = 0.048).

CONCLUSIONS

ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.

Propensity score-matched analysis of robotic versus endoscopic bilateral axillo-breast approach (BABA) thyroidectomy in papillary thyroid carcinoma

PURPOSE

The da Vinci surgical robot system was developed to overcome the weaknesses of endoscopic surgery. However, whether robotic surgery is superior to endoscopic surgery remains uncertain. Therefore, the purpose of this study was to compare the surgical and oncologic outcomes between endoscopic and robotic thyroidectomy using bilateral axillo-breast approach (BABA).

METHODS

Between January 2008 and June 2015, papillary thyroid carcinoma patients who underwent thyroidectomy with central neck dissection using endoscopic (n = 480) or robotic (n = 705) BABA were primarily reviewed. We performed 1:1 propensity score matching and 289 matched pairs were yielded.

RESULTS

Operation time was significantly longer in the robotic thyroidectomy than in the endoscopic thyroidectomy (184.9 vs. 128.9 min, P < 0.001). A significantly higher number of central lymph nodes (CLNs) were resected in the robotic thyroidectomy than in the endoscopic thyroidectomy (5.3 vs. 4.4, P = 0.003). However, the incidence of other outcomes including hospital stay, postoperative duration, thyroglobulin level, radioactive iodine ablation, hemorrhage, chyle leakage, wound infection, recurrent laryngeal nerve injury, and loco-regional recurrence did not significantly differ between the endoscopic thyroidectomy and the robotic thyroidectomy.

CONCLUSIONS

Endoscopic thyroidectomy is comparable with robotic thyroidectomy in view of surgical complications and LRR. Because robotic thyroidectomy resected a larger number of CLNs than did endoscopic thyroidectomy, further long-term follow-up studies will be required to clarify the possible prognostic benefits of robotic thyroidectomy.

Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy with Open Thyroidectomy for Graves' Disease

BACKGROUND

There is an ongoing debate about whether robotic thyroidectomy (RT) is appropriate for Graves' disease. The aim of this study was to compare the safety of bilateral axillo-breast approach (BABA) RT with that of open thyroidectomy (OT) in patients with Graves' disease.

METHODS

From January 2008 to June 2014, 189 (44 BABA RT and 145 OT) patients underwent total thyroidectomy for Graves' disease. Recurrence of Graves' disease, intraoperative blood loss, hospital stay, and complication rates including recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism were analyzed between BABA RT and OT groups, after propensity score matching according to age, gender, body mass index, surgical indication, the extent of operation, excised thyroid weight, and follow-up period.

RESULTS

No patient experienced recurrence of Graves' disease after median follow-up of 35.0 months. Intraoperative blood loss (151.8 ± 165.4 mL vs. 134.5 ± 75.4 mL; p = 0.534) and hospital stay (3.4 ± 0.7 day vs. 3.3 ± 0.7 day; p = 0.564) were not different between BABA RT and OT groups. Complication rates including transient RLN palsy (11.4 vs. 11.4%; p = 1.000), transient hypoparathyroidism (18.2 vs. 20.5%; p = 0.787), permanent RLN palsy (0 vs. 2.3%; p = 0.315), and permanent hypoparathyroidism (2.3 vs. 2.3%; p = 1.000) were also comparable between groups.

CONCLUSIONS

BABA RT for Graves' disease showed comparable surgical completeness and complications to conventional OT. BABA RT can be recommended as an alternative surgical option for patients with Graves' disease who are concerned about cosmesis.

Revisiting robotic approaches to endocrine neoplasia: do the data support their continued use?

PURPOSE OF REVIEW

Although the advent of the robot has revolutionized the modern treatment of endocrine neoplasia, substantial controversies exist on its applicability, safety and benefits over the conventional laparoscopic operations. The present review aims to review the recent literature on various robotic approaches in treating thyroid, parathyroid, adrenal and pancreatic endocrine neoplasia and see whether its continued use should be supported.

RECENT FINDINGS

In summary, the role of robotic thyroidectomy has been clearly established and should be continued by experienced surgeons on selected patients. Because of the limited availability of evidence, the feasibility of robotic parathyroidectomy has yet to be elucidated. With proven favorable perioperative outcomes, robotic adrenalectomy and pancreatectomy should be continued as potential alternatives to conventional surgery.

SUMMARY

Robotic endocrine procedures still play a pivotal role in minimally invasive endocrine surgery with demonstrable safety and effectiveness. Future research should embark on prospective randomized-controlled trials on robotic endocrine procedures to collect higher level of evidence and long-term survival data.

Incidence of permanent hypocalcaemia after total thyroidectomy with or without central neck dissection for thyroid carcinoma: a nationwide claim study

OBJECTIVE

Permanent hypocalcaemia is the most common and serious complication after total thyroidectomy (TT). This study examined the impact of central neck dissection (CND) and institutional volume on rates of permanent hypocalcaemia by analysing data held in the nationwide claim database of South Korea.

DESIGN

Data from patients who underwent TT due to thyroid carcinoma from 2007-2013 were obtained from the Health Insurance Review and Assessment Service database. Of these, patients prescribed more than 1000 mg of elemental calcium for more than 288 days during the first 360 days postsurgery were defined as having permanent hypocalcaemia.

RESULTS

In total, 192 333 patients (32 988 male and 159 345 female) were eligible for analysis. Of these, 52 707 (27·4%) underwent TT alone and 139 626 (72·6%) underwent TT plus CND. The incidence of permanent hypocalcaemia was greater in the TT plus CND group than in the TT alone group (5·4% vs 4·6%, P < 0·001). The age- and sex-adjusted risk for permanent hypocalcaemia in the TT plus CND group was 1·20 (P < 0·001). CND did not raise the rates of permanent hypocalcaemia in institutes with a low volume of annual cases (<200), whereas permanent hypocalcaemia was more common in the TT plus CND group than in the TT alone group (3·5% vs 2·9%, P = 0·002) in institutes with a large volume of annual cases (≥800).

CONCLUSIONS

TT plus CND was associated with a greater risk of permanent hypocalcaemia than TT alone. Surgeons should consider the risk of permanent hypocalcaemia when deciding whether to perform CND.

Long-Term Voice Outcomes After Robotic Thyroidectomy

BACKGROUND

The purpose of this study was to evaluate the long-term voice function after robotic thyroidectomy in comparison with conventional transcervical thyroidectomy.

METHODS

We prospectively evaluated the voice functions of 54 patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillary or axillo-breast approach and of 70 patients who underwent conventional thyroidectomy. Subjective voice symptom score (VSS) was evaluated in questionnaires before thyroidectomy and then at 3, 6, 12, and 24 months after surgery. Objective acoustic parameters analyzed during the same period included fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, highest frequency, frequency and intensity range, and maximal phonation time.

RESULTS

At 3 months after surgery, VSS was better in the robotic group than in the conventional group. At 2 years after surgery, VSS had recovered to the pre-operative level in the robotic group, whereas it remained significantly worse at 2 years in the conventional group. The phonatory frequency range and highest frequency were significantly wider and higher, respectively, in the robotic group than the conventional group at 6, 12, and 24 months postoperatively.Within the robotic group, the frequency range and highest frequency recovered to pre-operative levels by 6 months, whereas in the conventional group they remained below the pre-operative levels at 2 years post-operatively. There were no differences in other acoustic parameters between the two groups of patients at any period.

CONCLUSION

Up to 2 years post-operatively, robotic thyroidectomy has advantages in terms of recovery of voice symptoms and acoustic parameters over conventional thyroidectomy.

The Learning Curve for Robotic Thyroidectomy Using a Bilateral Axillo-Breast Approach From the 100 Cases

PURPOSE

The purpose of this study was to examine the learning curve for robotic thyroidectomy using a bilateral axillo-breast approach.

METHODS

We examined the first 100 robotic thyroidectomies with central lymph node dissection due to papillary thyroid cancer between April 2010 and August 2011. We evaluated the clinical characteristics, operative time, pathologic data, and complications.

RESULTS

Operative time was reduced significantly after 40 cases; therefore, the patients were divided into 2 groups: group A (1 to 40 cases) and group B (41 to 100 cases). The mean operative time in group A (232.6±10.0 min) was longer than that in group B (188.9±6.0 min) with statistical significance (P=0.001). Other data, including characteristics, drainage amount, hospital stay, retrieved lymph nodes, thyroglobulin, and complications, were not different between the 2 groups. The learning curves with lobectomy and total thyroidectomy were reached at the same time.

CONCLUSIONS

The learning curve for robotic thyroidectomy with central lymph node dissection using bilateral axillo-breast approach was 40 cases for beginner surgeons. Robotic total thyroidectomy was performed effectively and safely after experience with 40 cases, as with lobectomy.

Surgical safety and oncological completeness of robotic thyroidectomy for thyroid carcinoma larger than 2 cm

BACKGROUND

The safety of robotic thyroidectomy (RT) for small-sized thyroid carcinomas has been well established. The surgical outcomes of bilateral axillo-breast approach RT for thyroid carcinomas larger than 2 cm were evaluated and compared with those of open thyroidectomy (OT).

METHODS

The medical records of patients who underwent total thyroidectomy or hemithyroidectomy followed by completion thyroidectomy for differentiated thyroid carcinomas measuring 2-4 cm were retrospectively reviewed.

RESULTS

The study included 86 patients who underwent RT (n = 21) or OT (n = 65) with mean ages of 30.8 and 51.6 years, respectively. The mean tumor size was 2.8 cm in both groups. There were no significant differences between the RT and OT groups in vocal cord palsy rate (transient, 19.0 vs. 9.2 %; permanent, 0 vs. 1.5 %), postoperative hypoparathyroidism rate (transient, 19.0 vs. 33.8 %; permanent, 4.8 vs. 1.5 %), and the number of retrieved central lymph nodes in papillary thyroid carcinoma patients (6.4 ± 3.5 vs. 6.1 ± 3.9, respectively). The proportion of the patients with serum stimulated thyroglobulin level of <1.0 ng/ml at the initial radioactive iodine treatment was 64.7 % (11/17) for RT group and 66.0 % (35/53) for OT group (p = 0.920). There were three patients (1 RT and 2 OT) who had a biochemical incomplete response, and there was no case of anatomical recurrence or mortality during the median follow-up period of 40.2 months.

CONCLUSION

RT is a safe and oncologically sound treatment option for differentiated thyroid carcinomas measuring 2-4 cm in a selected group of patients. The role of RT should be evaluated in correlation with technological advances and increased experience.

Influence of body habitus on the surgical outcomes of bilateral axillo-breast approach robotic thyroidectomy in papillary thyroid carcinoma patients

Purpose

Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. The purpose of this study was to analyze the influence of body habitus including obesity on the surgical outcomes of the Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) in papillary thyroid carcinoma (PTC) patients.

Methods

The medical records of 456 PTC patients who underwent BABA RoT between January 2011 and December 2012 were reviewed, and 310 women PTC patients who had undergone BABA robotic total thyroidectomy with central lymph node dissection were examined. Body habitus were evaluated by measuring body mass index (BMI), body surface area, and neck circumference. We divided the patients into BMI < 25 kg/m² and BMI ≥ 25 kg/m² groups. Clinicopathological data, surgical outcomes, and postoperative complications were evaluated.

Results

Clinicopathological characteristics did not differ between the 2 BMI groups. The creation of working space time (P = 0.210) and other surgical outcomes showed no significant differences between the groups. There were no statistically significant differences between body habitus indexes and postoperative length of hospital stay, number of retrieved central lymph nodes, postoperative thyroglobulin levels, occurrence of hypoparathyoidism, recurrent laryngeal nerve injury and wound complication.

Conclusion

Patient with large body habitus undergoing BABA RoT were not at an increased risk of surgical complications and showed good surgical outcomes. BABA RoT may be a good alternative operative method for PTC patients for whom cosmetic outcome is an important consideration.

A novel robotic surgical technique for thyroid surgery: bilateral axillary approach (BAA)

INTRODUCTION

Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT) is proven to be a feasible method for the treatment of well-differentiated thyroid cancers in terms of oncology as well as cosmesis. However, BABA RT causes postoperative sternal discomfort and needs an incision over the nipple areolar area. Here, we suggest a novel robotic surgical technique for thyroid surgery that does not need a breast incision-bilateral axillary approach (BAA).

PATIENTS AND METHODS

We recruited 51 patients who were willing to undergo the novel BAA robotic thyroid surgery. We performed a propensity score-matched analysis to compare the BAA robotic thyroid surgery group (BAA group) with the conventional open thyroid surgery group (open group).

RESULTS

Mean operation time in the BAA group (129.7 min) was significantly longer than that in the open group (103.1 min) (p < 0.001). However, no significant differences in the mean number of metastatic lymph nodes (LNs), mean number of retrieved LNs, vocal cord palsy, hypoparathyroidism, and mean stimulated thyroglobulin level were observed between the two groups. There was no case of postoperative bleeding or chyle leak. Of the 51 patients who had undergone the BAA procedure, 27 patients answered the questionnaire. The mean scale, ranging from 0 to 10, at postoperative 1 day/2 weeks was as follows: voice change score, 3.0/1.6; swallowing difficulty score, 4.0/2.0; anterior neck pain score, 4.6/3.6; anterior neck numbness score, 5.4/4.3; right chest pain score, 3.8/2.1; left chest pain score, 3.6/2.3; right chest numbness score, 3.2/2.8; left chest numbness score, 2.4/2.7; right breast pain score, 0.9/0; left breast pain score, 1.2/0; right breast numbness score, 1.7/0; and left breast numbness score, 2.6/0, respectively.

CONCLUSION

BAA robotic thyroid surgery is a novel, safe, and feasible oncoplastic method, especially for patients who have fear of procedures around the nipple areolar complex.

Comparison of the Quality of Life for Thyroid Cancer Survivors Who Had Open Versus Robotic Thyroidectomy

OBJECTIVES

The purpose of this study was to compare the quality of life (QoL) between conventional open and robotic total thyroidectomy in papillary thyroid carcinoma.

MATERIALS AND METHODS

From January 2011 to July 2013, 229 patients (112 robot and 117 open) were randomly selected. QoL, including overall satisfaction, cosmetic results, voice/sensory change, postoperative pain and impairment of swallowing, neck/shoulder movement, and physical/psychological activity, was recorded.

RESULTS

The follow-up period was 32.3 ± 6.3 months. The satisfaction levels of the overall and cosmetic results were 8.95 ± 1.23, 8.40 ± 1.20 and 3.86 ± 0.04, 3.21 ± 0.10 for robotic and open surgery, respectively; these differences were statistically significant (P = .006, <.001). The sensory change might be more noticeable with robotic thyroidectomy (P = .064). There were no differences in the results concerning other variables among the two groups.

CONCLUSION

Robotic thyroidectomy shows comparable results to conventional open thyroidectomy in terms of the postoperative long-term QoL.

A comparative study of postoperative pain for open thyroidectomy versus bilateral axillo-breast approach robotic thyroidectomy using a self-reporting application for iPad

Purpose

Postoperative pain for robotic thyroid surgeries including bilateral axillo-breast approach (BABA) has not been well studied. In this study, we have developed a self-reporting application (SRA) for iPad and prospectively collected pain scores from open thyroidectomy (OT) and BABA robotic thyroidectomy (RT) patients.

Methods

Female patients who underwent total thyroidectomy for papillary thyroid carcinoma were included. Patients recorded pain scores for throat, anterior neck, posterior neck, chest, and back on postoperative days 1, 2, and 3. Once discharged, on postoperative day 14, a survey was also conducted on satisfaction of SRA and cosmesis.

Results

A total of 54 patients were enrolled (27 BABA RT and 27 OT). There were no significant differences between the 2 groups in clinicopathological characteristics and postoperative complication rates. Postoperative pain scores at days 1, 2, 3, and 14 were not significantly different between the groups for throat, anterior neck, posterior neck, or back. Postoperative analgesic requirements were similar between the 2 groups. Wound satisfaction scores were significantly higher in the BABA RT group (BABA RT 7.4 vs. OT 5.7; P = 0.016). Satisfaction scores for the usefulness of SRA were above 7.2 for all four questionnaire items on the 10-point scale.

Conclusion

Postoperative pain for BABA RT is equivalent to OT but offers greater cosmetic satisfaction for patients. A mobile device application such as SRA may facilitate proper assessment and management of pain in postoperative patients.

Comparison of Robotic versus Conventional Selective Neck Dissection and Total Thyroidectomy for Papillary Thyroid Carcinoma

OBJECTIVE

To compare the surgical outcomes of robotic selective neck dissection (SND) with total thyroidectomy and conventional transcervical SND with total thyroidectomy.

STUDY DESIGN

Case series with chart review.

SETTING

University tertiary care facility.

SUBJECT AND METHODS

We retrospectively analyzed 66 patients who underwent total thyroidectomy with SND (≥3 levels of II-V) and bilateral central neck dissection for cN1b papillary thyroid carcinoma, of whom 41 underwent conventional SND and 25 of whom underwent robotic SND. Subjective pain, sensory change, and cosmetic satisfaction were evaluated regularly for 3 months with a questionnaire.

RESULTS

Compared with the conventional group, patients in the robotic group were younger (mean, 36.7 vs 47.5 years; P = .003) and more female dominant (96.0% vs 73.2%; P = .023). Mean total operative time was longer in the robotic group than the conventional group (298 vs 236 minutes; P < .001). Anterior chest pain was higher in the robotic group at postoperative 1 day (pain score, 1.88 vs 0.62; P = .011), 1 week (1.30 vs 0.43; P = .036), and 1 month (0.90 vs 0.18; P = .029). Postoperative cosmetic satisfaction was significantly superior in the robotic group.

CONCLUSION

Compared with conventional transcervical SND with total thyroidectomy, robotic SND with total thyroidectomy yields superior outcomes for cosmetic satisfaction, longer operative time, and higher chest pain in the short term. Further study with a larger number of patients is mandatory.

American Thyroid Association Statement on Remote-Access Thyroid Surgery

BACKGROUND

Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption.

METHODS

A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery.

RESULTS

Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision.

CONCLUSIONS

Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.

Robotic versus Open Thyroidectomy for Differentiated Thyroid Cancer: An Evidence-Based Review

While open thyroidectomy (OT) is advocated as the gold standard treatment for differentiated thyroid cancer, the contemporary use of robotic thyroidectomy (RT) is often controversial. Although RT combines the unique benefits of the surgical robot and remote access thyroidectomy, its applicability on cancer patients is challenged by the questionable oncological benefits and safety. This review aims to analyze the current literature evidence in comparing RT to OT on thyroid cancers for their perioperative and oncological outcomes. To date, no randomized controlled trial is available in comparing RT to OT. All published studies are nonrandomized or retrospective comparisons. Current data suggests that RT compares less favorably than OT for longer operative time, higher cost, and possibly inferior oncological control with lower number of central lymph nodes retrieved. In terms of morbidity, quality of life outcomes, and short-term recurrence rates, RT and OT are comparable. While conventional OT continues to be appropriate for most thyroid cancers, RT should better be continued by expert surgeons on selected patients who have low-risk thyroid cancers and have high expectations on cosmetic outcomes. Future research should embark on prospective randomized studies for unbiased comparisons. Long-term follow-up studies are also needed to evaluate outcomes on recurrence and survival.

Robotic thyroidectomy versus conventional open thyroidectomy for differentiated thyroid cancer: meta-analysis

Objective:

To conduct a meta-analysis to compare the short-term outcomes of robotic thyroidectomy and conventional open thyroidectomy for differentiated thyroid cancer.

Methods:

Medline, Embase, Science Citation Index Expanded and the Cochrane Library databases were searched for relevant literature. The evaluated endpoints were intra-operative and post-operative outcomes.

Results:

Twelve eligible, non-randomised comparative studies involving 2513 patients were included, with 923 patients in the robotic thyroidectomy group and 1590 patients in the conventional open thyroidectomy group. Meta-analysis results revealed that robotic thyroidectomy was associated with significantly longer operative time and a lower number of retrieved central lymph nodes, as compared with conventional open thyroidectomy. No significant differences were found between robotic thyroidectomy and conventional open thyroidectomy in terms of post-operative outcomes.

Conclusion:

Robotic thyroidectomy appears to be a feasible and safe surgical procedure for patients with differentiated thyroid cancer. However, more high-quality randomised clinical trials should be undertaken to confirm these findings.

Indocyanine green as a near-infrared fluorescent agent for identifying parathyroid glands during thyroid surgery in dogs

BACKGROUND

Surgical procedures involving the thyroid gland require identification of the parathyroid glands. Indocyanine green (ICG) is a near-infrared (NIR) fluorescent contrast agent used for a variety of procedures such as intraoperative angiography, extrahepatic cholangiography, and lymph node mapping. In this study, we used a canine model to evaluate ICG for NIR fluorescent imaging of the parathyroid gland.

METHODS

Three dogs were used for the study. The dogs were administered general anesthesia, and after surgical dissection, each dog received a series of intravenous ICG doses ranging from 12.5 to 100 µg/kg ICG. The excitation light source used to illuminate the operating field was a NIR laser (λ = 785 nm). Intravascular ICG fluorescence (λ = 835/45 nm) was recorded using a charge-coupled device that employed optical filtering to block ambient and laser light. Fluorescent imaging was assessed after injection of each dose of ICG.

RESULTS

NIR fluorescent imaging visualized the parathyroid glands. The intensity curves showing the peak and plateau of fluorescence are similar regardless of the concentration of ICG. The time to peak fluorescent intensity was 50.2 ± 2.0 s after injection of ICG. Taking into consideration background fluorescent intensity, the estimated optimal dose of ICG was 18.75 µg/kg. At 106.7 ± 5.8 s, the parathyroid glands lost much of their fluorescence, although they remained sufficiently fluorescent to be distinguishable. There was a positive correlation of fluorescent intensity with ICG dose escalation up to 25 µg/kg.

CONCLUSIONS

ICG NIR fluorescent imaging was useful in detecting the parathyroid glands of dogs. By allowing detection of parathyroid glands, the current technique shows promise for use by endocrine surgeons performing thyroidectomies.

A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach

OBJECTIVES

We introduce surgical outcomes regarding 300 cases of robotic thyroidectomy using a bilateral axillo-breast approach (BABA).

METHODS

From April 2010 to October 2013, 300 patients who underwent robotic thyroidectomy were analyzed and compared with 300 cases of open total thyroidectomy. Robotic surgery was performed with a snake retractor to allow for complete central lymph node dissection. We performed robotic surgery using BABA without drains in 170 cases; subfascial dissection was performed to reduce post-operative wound adhesion.

RESULTS

The learning curve for robotic thyroidectomy was 40 cases; after that, the operation time significantly decreased (233 min vs. 185 min, P=0.001). A snake retractor was selectively useful for the dissection of paratracheal lymph nodes located in the deep areas. In patients who underwent drainless BABA, additional aspirations were required in only 19 (6.3%). The number of retrieved lymph nodes of robot and open surgery were 6.7 ± 0.2 and 8.9 ± 0.3, respectively (P<0.001). The mean serum thyroglobulin of thyroid hormone was 0.80 ± 0.19 and 1.77 ± 0.29 ng/ml, respectively (P=0.001). Post-operative complications of robot surgery, including transient hypocalcemia (n=33, 23.0%) in total thyroidectomy, transient recurrent laryngeal nerve palsy (n=8, 2.6%) without permanent palsy rarely observed.

CONCLUSION

Robotic thyroidectomy using BABA is an effective and comparable treatment option. J. Surg. Oncol. 2015 111:135-140.

Can robotic thyroidectomy be performed safely in thyroid carcinoma patients?

Since the adoption of the Da Vinci robotic system for remote access thyroid surgery, robotic thyroidectomy (RT) has become a popular surgical option for patients who want to avoid neck scars. Surgeons in South Korea pioneered this surgical technique and have reported successful outcomes. Although many studies have reported that RT is a feasible and safe therapeutic alternative, concerns over the surgical and oncological safety of RT remain. This article reviews the advantages and disadvantages of RT and compares the surgical safety and oncological completeness of RT with conventional open thyroidectomy.