Endoscopic neck surgery by the axillary approach

Robotic-assisted breast-axillo insufflation thyroidectomy (RABIT): a retrospective case series of thyroid carcinoma

OBJECTIVE

To evaluate the feasibility and safety of robotic-assisted breast-axillo insufflation thyroidectomy (RABIT) for differentiated thyroid cancer.

METHODS

In this retrospective case series, patients with differentiated thyroid carcinoma were enrolled in our hospital from January 2018 to December 2018. All patients underwent indirect laryngoscopy to assess the status of vocal cord preoperatively. RABIT was performed with five separate breast-axillo incisions. All the procedures were performed using da Vinci Xi Robotic Surgical System, a single docking method using CO₂ insufflation.

RESULTS

Twelve patients completed RABIT, in which one case needed conversion to open thyroidectomy. The mean age was 30.25 ± 7 with male to female ratio being 1:1. Preoperative diagnosis showed papillary carcinoma (n = 9) and follicular neoplasm (n = 3). The mean operative time for RABIT was 140 ± 50.45 min and average blood loss during surgery was 22.92 ± 9 mL. Mean hospital stay was 4.42 ± 1.08 days. Final pathology confirmed classical papillary thyroid carcinoma (n = 10; 83.3%) and follicular variant of papillary carcinoma (n = 2; 16.7%). None of the cases reported injury or paralysis to the recurrent laryngeal nerves.

CONCLUSION

RABIT is a safe and feasible approach for thyroidectomy. It has several advantages in that it provides similar symmetrical view to conventional open surgery and enables to maintain specimen integrity and use of assistant port permits better handling of the gland. Additionally, the largest operating angles with this technique prevent collision between the robotic arms and provide excellent cosmetic satisfaction due to very small, five separate breast-axillo incisions.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience

Introduction

Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery.

Materials and Methods

This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version.

Operative Technique

Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy.

Results

Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95-160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas).

Conclusions

Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.

Detailed comparison of robotic and endoscopic transaxillary thyroidectomy

BACKGROUND

Robotic thyroidectomy is increasingly used for patients with papillary thyroid carcinoma (PTC). We compared the differences between robotic and endoscopic transaxillary thyroidectomy with regard to surgical procedures.

METHODS

This retrospective study enrolled 40 patients with PTC who underwent robotic hemithyroidectomy (robot group) using the Da Vinci S system and 37 patients (endoscopic group) who underwent endoscopic hemithyroidectomy. Video files of surgery for all patients were analyzed to compare the operation procedures: (flap creation, docking [only for robot group], dissection of the superior pole, dissection of the inferior pole, identification of parathyroid glands [PTGs] and the recurrent laryngeal nerve [RLN], dissection of the thyroid along the trachea, bleeding control, application of a drain, and wound closure). The duration of each procedure and the clinicopathological characteristics were analyzed.

RESULTS

Procedure time for patients in the robot group was shorter for inferior pole dissection and for identification of the PTGs and RLN (37.5 min vs. 50.5 min, p = 0.008). Mean total operative times for the two groups were comparable (153.0 min vs. 150.2 min, p = 0.732); however, excluding the docking procedure, operation time was shorter for the robot group (133.3 min vs. 150.2 min, p = 0.038). The number of sacrificed PTGs was also significantly smaller in the robot group (0.35 ± 0.53 vs. 0.65 ± 0.68, p = 0.036).

CONCLUSION

Compared to endoscopic thyroidectomy, robotic transaxillary thyroidectomy involved a shorter time for inferior pole dissection and PTGs and RLN identification; moreover, more PTGs were spared using this procedure.

Drainage During Endoscopic Thyroidectomy

Background

Conventional cervical drainage tubes are placed crossing the suprasternal fossa during endoscopic thyroidectomy. In our clinical experience, some patients show shallow or absent suprasternal fossa, which affects the cosmetic outcome in the patient. Therefore, this study aimed to assess the feasibility and significance of restoring the suprasternal fossa by changing the position of neck drainage tubes.

Methods and Materials

A total of 117 female patients were enrolled and divided into 2 groups, including 59 and 58 individuals in the Conventional (conventional anterior neck region negative pressure drainage) and Improvement (improved method with a negative pressure drainage) groups. Then, restoration of the suprasternal fossa in all subjects was observed at 1 day postsurgery, the day of extubation, and 3 months postoperatively. In addition, drainage volume, the time to extubation, and abnormal neck sensations were compared between the groups.

Results

Compared with the Conventional group, the Improvement group showed improved restoration of the suprasternal fossa, with the patients more satisfied with the cosmetic outcome. However, operation time, postoperative drainage volume, and extubation time were not significantly different between the 2 groups.

Conclusions

In endoscopic thyroidectomy via the chest and breast approach, using the new drainage technique described here could yield improved restoration of the suprasternal fossa, ameliorating the cosmetic outcome and patient satisfaction.

Robotic Neck Surgery in the Pediatric Population

Introduction:

Thyroid, parathyroid, and thymus surgeries are traditionally performed via a cervical approach. However, robot-assisted procedures can provide a safe alternative for neck surgeries. We report our experiences with robotic transaxillary and retroauricular approaches in pediatric patients.

Case Presentation:

We conducted a retrospective review of pediatric patients who underwent robot-assisted neck surgery by a single surgeon between April 2010 and May 2017. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated.

Management and Outcomes:

Nine surgeries in 7 female patients were reviewed (mean age, 16.0 ± 1.58 years; mean body mass index, 22.5 ± 0.75). Two thyroid lobectomies, 2 complete thyroidectomies, 1 subtotal thyroidectomy, 1 thyroid lobectomy with thymectomy, 2 subtotal parathyroidectomies with thymectomy, and 1 dermoid cyst excision were performed. Two surgeries with the retroauricular approach had a mean surgical time of 142.0 ± 6.13 minutes. Seven surgeries with the transaxillary approach had a mean surgical time of 146.1 ± 21.01 minutes. There were no reported conversions, permanent vocal cord paralysis, permanent hypoparathyroidism, hematoma, or seroma. There was 1 case (11%) of temporary shoulder hypoesthesia and 2 cases of temporary vocal cord paresis (22%).

Discussion:

This series on robot-assisted neck surgeries in children describes procedures performed with robotic transaxillary and retroauricular approaches. In the hands of a high-volume surgeon the techniques are feasible and safe options for operations in the neck in a select group of pediatric patients.

The Learning Curve for Surgeons Regarding Endoscopic Thyroidectomy via the Oral-vestibular Approach

BACKGROUND

For selected patients, endoscopic thyroidectomy via the oral-vestibular approach (ETOVA) can be used to achieve a very good esthetic effect. This study aimed to assess the learning curve for ETOVA and identify improvements.

PATIENTS AND METHODS

This retrospective study evaluated the outcomes of 101 patients who underwent ETOVA by surgeons A and B. The patients were classified according to whether they had undergone surgery during the primary or advanced stage of the learning curve, respectively. Proficiency with the procedure in various types of cases and the operation time, operative blood loss, hospital stay length, and postoperative complications were analyzed.

RESULTS

In total, 56 and 45 patients were treated by surgeons A and B, respectively. For both surgeons, the operation times decreased considerably after 20 cases. Statistically significant differences with respect to stage were observed in terms of operation time (P<0.05) and drainage tube reservation (P<0.05). By contrast, significant differences were not observed between stages in terms of operative blood loss (P>0.05) or postoperative hospital stay length (P>0.05). The total postoperative complication rate was low and comparable with that of open surgery.

CONCLUSIONS

The specific learning curve identified for ETOVA suggests that surgeons with sufficient endoscopic surgery experience could achieve a stable proficiency after ∼20 cases. A standardized training program and exposure to more cases would reduce the learning curve.

Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA): experiência inicial no Brasil

RESUMO Objetivo: apresentar a experiência inicial no Brasil com a tireoidectomia transoral endoscópica por abordagem vestibular (TOETVA). Métodos: estudo prospectivo de pacientes submetidos à TOETVA no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Regional do Oeste, Chapecó, Santa Catarina. Foram candidatos para o estudo os pacientes entre 18 e 65 anos de idade, ASA I e II, com volume glandular de até 35cm3e nódulos de até de 4cm. Dados dos pacientes, dos nódulos, tempo cirúrgico, complicações, e tempo de internação foram registrados. Resultados: nove pacientes foram operados entre maio de 2017 e abril de 2018. Todos eram mulheres, com idades entre 33 e 64 anos. O tamanho do nódulo variou de 1cm a 4cm. Dois pacientes eram portadores de neoplasia maligna e a tireoidectomia total foi feita em oito casos. Sete pacientes tiveram uma internação de apenas um dia. Um paciente sofreu uma complicação menor na pele, mas não ocorreram lesões dos nervos laríngeos recorrentes ou hipoparatireoidismo definitivo. Conclusão: a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos.

Differentiated thyroid cancer theranostics: radioiodine and beyond

The term theranostics is the combination of a diagnostic tool that helps to define the right therapeutic tool for specific disease. It signifies the "we know which sites require treatment (diagnostic scan) and confirm that those sites have been treated (post-therapy scan)" demonstrating the achievable tumor dose concept. This term was first used by John Funkhouser at the beginning of the 90s, at the same time the concept of personalized medicine appeared. In nuclear medicine, theranostics is easy to apply and understand because of an easy switch from diagnosis to therapy with the same vector. It helps in maximizing tumor dose and sparing normal tissue with high specific and rapid uptake in metastasis. The oldest application of this concept is radioactive iodine I-131 (RAI). The first treatment based on the theranostic concept was performed on thyroid cancer patients with RAI in 1946. From then on management of differentiated thyroid cancer (DTC) has evolved on the multimodality concept. We now use the term "our" patient instead of "my" patient to signify this. However, the initial surgical management followed by RAI as per the theranostics has remained the mainstay in achieving a cure in most of DTC patients. The normal thyroid cells metabolise iodine, the principle of which is utilized in imaging of the thyroid gland with isotopes of iodine. RAI treatment of DTC is based on the principle of sodium iodide symporter (NIS) expressing thyroid cells with DTC cells having the ability of trapping circulating RAI successfully helping in treatment of residual and metastatic disease. NIS is usually negative in poorly differentiated cells and is inversely proportional to Glucose transporter receptor Type 1 expression. Both positive and negative NIS are the key components of the theranostic approach in treatment of DTC. Presence or absence of NIS is documented by either whole body iodine scintigraphy (WBS) or 2-deoxy-2(18F) fludeoxyglucose (FDG) positron emission tomography computed tomography (PET-CT). Currently, single photon emission CT and CT (SPECT-CT) has significantly improved the precision and sensitivity of whole body iodine scintigraphy with its capability of accurate localization of disease foci whether iodine avid or non-avid. This has helped in a more personalized approach in treatment. This review will give an overview of the role of NIS in the theranostic approach to management with RAI, its current status and also the molecular approach to treatment in RAI refractory disease.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Yonsei Experience of 5000 Gasless Transaxillary Robotic Thyroidectomies

BACKGROUND

Since the use of robot systems in thyroid surgery was introduced in 2007, we have advanced a novel method of robotic thyroidectomy (RT) using a gasless transaxillary approach (TAA). We report our experience with this technique and detail the surgical outcome of 5000 robotic thyroidectomies.

METHODS

From October 2007 to May 2016, we successfully performed 5000 robotic thyroidectomies using a gasless TAA at the Department of Surgery, Yonsei University Health System. The medical records of the patients are reviewed retrospectively, and the details of clinicopathologic characteristics, operation times, perioperative complications, and oncologic outcomes are analyzed.

RESULTS

The 5000 patients with thyroid tumor (4804 with cancer and 196 with benign tumor) underwent RT using a gasless TAA. Mean operation time was 134.5 ± 122.0 min. The most common histologic subtype of thyroid cancer was papillary (98%), and the mean tumor size was 8.0 ± 6.0 mm. Stage I was found in 85.4% patients regarding tumor nodes metastasis staging. The 196 benign tumors consisted of 104 adenomatous hyperplasias (53.0%), 43 follicular adenomas (21.9%), 30 Graves' diseases (15.3%), and 19 others (9.7%). Postoperative complication occurred in 24.1% without any serious one, and overall morbidity tended to decrease over time. No disease-specific mortality was observed during the follow-up period. Locoregional recurrence was developed in 26 patients (0.5%).

CONCLUSION

The authors have tried to improve RT technique using gasless TAA and achieved acceptable surgical outcomes. The rapid evolution of surgical robot technology and our constant effort to advance RT technique using gasless TAA would make it possible to reduce the perioperative morbidity and gain the best possible operative and oncologic outcomes.

A Systemic Review of Transoral Thyroidectomy

BACKGROUND

Transoral thyroidectomy is a kind of "natural orifice transluminal endoscopic surgery (NOTES)" which is now being performed in increasing frequency. However, the safety and feasibility have not been concluded yet.

MATERIALS AND METHODS

A systemic literature search was performed in Pubmed, Cochrane, and Embase databases to identify all studies written in English and published up to April 2017. The keywords used were "transoral endoscopic," "transoral robotic," "oral vestibular endoscopic," and "oral vestibular robotic" combined with "thyroidectomy" or "thyroid surgery."

RESULTS

Ten articles containing 211 cases matched the review criteria. The weighted average operative time was 119.9 minutes with an average intraoperative blood loss of 35.5 mL while the weighted average length of hospital stay was 4.0 days. The overall conversion rate to open surgery was 1.9%. An overall incidence rate of temporary hypoparathyroidism was 7.1%, temporary recurrent laryngeal nerve injury was 4.3%, whereas of mental nerve palsy was 4.3%.

CONCLUSIONS

According to those reviewed literatures, we can conclude that transoral thyroidectomy is safe and feasible in well-selected patients and offers good perioperative and postoperative outcomes.

Endoscopic Thyroid Surgery Through Trans-oral Vestibular Approach (TOVA): A Case Series and Review of Literature

Endoscopic surgery is now standard of care for different Endocrine Disorders; the endoscopic thyroid surgery is becoming more popular and different approaches has been practice by many thyroid surgeon worldwide. Trans-orovestibular approach, based on the principle of natural orifice transluminal surgery is truly scar free thyroid surgery and has minimal dissection. We are presenting here three cases of benign solitary thyroid nodule operated endoscopically through trans-oro-vestibular approach in one male and two female patients. Described about the approach, challenges during surgery and outcome. These surgeries documented very few in literatures in live human patients. Transoral endoscopic thyroid surgery through vestibular approach is shortest and direct remote access approach. The need of limited dissection in this approach provides less complication and excellent cosmetic outcome in strictly selected patients.

A single-incision thoracoscopic and robotic hybrid procedure via the axillary approach in a patient with thyroid, lung, and mediastinal tumors

A 66-year-old woman was referred to our institute for an enlarging tumor of the thyroid, and neck and chest computed tomography scan showed not only a thyroid tumor, but also an anterior mediastinal tumor and ground-glass nodules in the lung. Because of persisting symptoms, an enlarging thyroid mass, and the possibility of cancer, excision of the tumors was proposed. A 6-cm-long vertical skin incision was made in the right axilla, a mini-thoracotomy was made in the third intercostal space, and an additional port was placed in the fifth intercostal space. Thoracoscopic partial resection of the right upper lobe of the lung was performed first. Then, the da Vinci surgical system (da Vinci, Intuitive Surgical Inc., Sunnyvale, CA, USA) was introduced through the mini-thoracotomy. The mediastinal tumor was then excised circumferentially robotically. After resection of the lung and mediastinal tumors, the da Vinci was undocked, and a subcutaneous tunnel from the axillary incision to the thyroid was created using the flap dissection technique. The da Vinci was re-introduced through the axillary incision. A long camera port was used, and the skin and muscle flap was elevated to maintain adequate working space during the robot-assisted thyroidectomy. Total operating time was 277 min, and the patient's postoperative course was uneventful. The histopathological examinations of the lung, mediastinal, and thyroid tumors were adenocarcinoma, thymolipoma, and adenomatous goiter, respectively. In conclusion, single-incision robotic surgery for three lesions was achieved safely with good clinical results and excellent cosmetic results.

Transoral Endoscopic Thyroidectomy: Review of 81 Cases in a Single Institute

OBJECTIVE

To evaluate the clinical efficacy and safety of transoral endoscopic thyroidectomy (TOET).

MATERIALS AND METHODS

A total of 81 patients with thyroid nodules underwent TOET in our department from November 2011 to September 2015. The surgical outcomes, cosmetic results, and complications were evaluated.

RESULTS

Seventy-nine patients were performed TOET successfully, and 2 cases were transferred to open thyroidectomy due to intraoperative CO₂ embolism. The average operation time was 89.0 ± 38.6 minutes, and intraoperative blood loss was 29.3 ± 27.6 mL. Two cases experienced transient perioral numbness, and 2 cases experienced transient opening mouth pain. Two cases had transient increased saliva when swallowing. Transient anterior cervical region discomfort was found in 3 cases, and postoperative anterior cervical region infection was found in 4 cases. Other complications were not observed in any case. The average postoperative length of stay was 4.77 ± 2.61 days, and the mean follow-up period was 39.1 ± 22.6 months. During the follow-up period, there were no long-term complications or recurrent patient, and all the patients were satisfied with the cosmetic effect.

CONCLUSIONS

TOET is a safe and effective procedure with a low incidence of complications and perfect cosmetic effect for patients with thyroid diseases.

Gasless trans-axillary robotic thyroidectomy: the introduction and principle

A historic review of the main stages of evolution of the minimally-invasive techniques in thyroid surgery. The endoscopic era is divided into direct and indirect approaches. Examples are the minimally invasive video-assisted thyroidectomy (MIVAT) and the minimally invasive lateral approach. The indirect approach is divided into transaxillary and chest/breast incisions. A brief historic review of the advent of robots to the medical and mainly surgical field. And finally, an introduction to transaxillary robotic thyroidectomy.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

Single-Incision, Gasless, Endoscopic Trans-Axillary Total Thyroidectomy: A Feasible and Oncologic Safe Surgery in Patients with Papillary Thyroid Carcinoma

BACKGROUND

The aim of this study is to compare the feasibility and oncologic safety of Single-incision, gasless, Endoscopic trans-axillary bilateral Total thyroidectomy (SET) with open cervical total thyroidectomy in patients with papillary thyroid carcinoma (PTC).

MATERIALS AND METHODS

From March 2008 to December 2012, PTC patients underwent bilateral total thyroidectomy. Conventional, open surgery was performed on 538 patients (Group O) and endoscopic surgery was performed on 200 patients (Group E). We analyzed the patient's clinicopathologic, postoperative complications, and surgical completeness.

RESULTS

The mean ages of the patients were 48.9 ± 0.5 (range = 24-77) in Group O and 39.5 ± 0.8 (range = 17-73) in Group E with statistical significance (P < .001). Percentage of female patients were 74.3% in Group O and 96.0% in Group E with statistical significance (P < .001). The postoperative hospital stay in Group O was significantly longer than Group E (4.60 ± 0.05 versus 3.30 ± 0.05; P < .001). The operation time in Group E was significantly longer than Group O (93.9 ± 1.3 versus 142.6 ± 3.3; P < .001). More transient hypocalcemia was found in Group O compared to Group E with statistical significance (28.1% versus 22.4%; P < .001). There were no significant differences with respect to permanent hypocalcemia, permanent recurrent laryngeal nerve palsy, seroma, and hematoma. The mean 1 year-stimulated sTg was 0.23 ± 0.03 and 0.18 ± 0.02 in Group O and E, respectively. Tumor recurrence during short-term follow-up at neck ultrasonography (1 year) was detected in 4 patients in Group O.

CONCLUSION

SET is safe and effective, not only for low-risk patients with early-detected cancer, but also for selected cases of advanced cancer.

[Pectoral-retroauricular approach for endoscopic parathyroidectomy (experimental study)]

AIM

To develop and investigate in the experiment the method of endoscopic parathyroidectomy in order to prevent intraoperative 'conflict of the instruments' and to reduce surgical trauma via extracervical approach.

MATERIAL AND METHODS

The results of 10 experimental endoscopic parathyroidectomies with original pectoral-retroauricular approach were analyzed.

RESULTS

Mean time of surgery was 77.8±10.2 minutes (65-97), mean time of surgical exposure - 50.3±6.7 minutes (41-59). Visualization and identification of parathyroid glands were achieved in 100% of cases. Recurrent laryngeal nerve was preserved in 100% of cases.

CONCLUSION

Original endoscopic pectoral-retroauricular approach for parathyroidectomy is methodologically and technically justified and can be recommended for clinical application.

Robotic retroauricular thyroid surgery

Surgery is the gold standard treatment for patients with thyroid cancer or nodules suspicious for cancer. Open conventional approach is the standard surgical approach. However, a visible neck incision could be a concern for most young female patients, especially for patients with a history of healing with keloid or hypertrophic scars. Robotic remote access approaches have evolved into a safe and feasible approach in selected patients, providing a hidden scar with good patient satisfaction. This review will focus on the performance and safety of robotic retroauricular thyroid surgery.

Comparison of the breast and areola approaches for endoscopic thyroidectomy in patients with microcarcinoma

The safety, advantages and disadvantages of thyroidectomy for microcarcinoma through the areola approach and breast approach were compared. Fifty patients diagnosed with thyroid microcarcinoma in our department from January 2014 to June 2015 were selected. The areola approach was carried out for 21 patients whereas the breast approach for 29 patients. Endoscopic thyroid lobectomy, isthmus resection and dissection of central group lymph nodes was performed. The clinical outcomes of the two surgical approaches were compared. Comparing operating time, blood loss during surgery, number of lymph node dissections, postoperative hospitalization time and surgical complications between the surgical approaches, there were no significant differences (P>0.05). Comparing patient satisfaction of cosmetic results from the incisions, the difference was statistically significant (P<0.05). Endoscopic thyroidectomy via areola approach and breast approach have equal curative effects for the treatment of thyroid microcarcinoma. However, the areola approach can achieve better cosmetic results and is a safe and ideal surgical method, that we recommend be widely used.

Implementation of Intraoperative Neuromonitoring for Transoral Endoscopic Thyroid Surgery: A Preliminary Report

BACKGROUND

Transoral endoscopic approach is the natural orifice surgery applied in thyroidectomy to achieve an excellent cosmetic result. Recurrent laryngeal nerve (RLN) injury is the most common complication and little advancement was achieved in the previous clinical studies of transoral thyroid surgery. Herein, we introduced the method of intraoperative neuromonitoring (IONM) for transoral endoscopic thyroid surgery.

MATERIALS AND METHODS

Patients with thyroid carcinoma received transoral endoscopic thyroid surgery through vestibular approach (TOETVA) for thyroidectomy and central node dissection (CND). IONM was implemented to identify whether the RLN benefited from oral tracheal intubation. The laryngeal electromyography (EMG) response, operation time, number of CND, drainage volume, hospital duration, surgical complications, and cosmetic results were evaluated.

RESULTS

From August to October 2015, 10 cases were performed with TOETVA and IONM. All EMG responses were recorded intraoperatively, and no case experienced transient or permanent RLN palsy. The operation time ranged from 130 to 215 minutes in ipsilateral lobectomy with CND, whereas bilateral lobectomy with ipsilateral CND lasted 345 minutes. The number of CNDs ranged from three to eight. The average time of drainage extubation and discharge was 4 days (3-5 days) postoperatively. All patients were satisfied with the cosmetic results, and no infection was observed at lip wound or in the anterior neck region.

CONCLUSION

IONM system implemented in transoral thyroid surgery was feasible and serviceable in preventing RLN injury. The method of TOETVA shows promise for thyroidectomy with CND due its ideal cosmetic results.

Single-incision endoscopic thyroidectomy by the axillary approach with gas inflation for the benign thyroid tumor: retrospective analysis for a single surgeon's experience

BACKGROUND

Trans-axillary endoscopic thyroid surgery offers the advantage of a good cosmetic outcome; however, it requires a wider dissection field compared to the other endoscopic approaches or open surgery. Therefore, it might cause severe postoperative pain occasionally. To reduce the dissection field required, we perform trans-axillary single-incision endoscopic thyroidectomy (SIET) with gas inflation. The aim of this study was to present a single surgeon's experience with SIET and to investigate the learning curve of SIET.

METHODS

Between June 2009 and September 2014, a total of 105 patients who underwent hemithyroidectomy for benign thyroid tumor via an SIET procedure were included in the present study. All of the procedures were performed by the same surgeon. Each patient's operative outcomes were collected and retrospectively analyzed. The cumulative summation (CUSUM) analysis was used to assess the learning curve of SIET.

RESULTS

No mortality or serious morbidity was observed during the study period. The adverse postoperative outcomes included wound hematoma (2 cases; 1.9 %), transient skin paresthesia (5 cases; 4.76 %), transient voice change (5 cases; 4.76 %), skin pigmentation (1 case; 0.9 %), and fibrous band of wound (1 case; 0.9 %). The overall mean operative time was 105 min, and the mean operative time in the experienced phase was 95 min. CUSUM analysis showed a decreasing trend at the 35th patient, suggesting that more than 35 cases were needed for the surgeon to gain proficiency. In 76.19 % of the cases, patients showed extreme satisfaction with the cosmetic results.

CONCLUSION

Our results showed reasonable surgical outcomes compared to previous studies on endoscopic thyroidectomy. The SIET procedure is safe and feasible for benign thyroid tumors and has an acceptable learning curve for surgeons who are proficient in conventional endoscopic thyroidectomy.

Minimally invasive thyroidectomy: a ten years experience

BACKGROUND

The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient's quality of life, postoperative morbidity. The mini invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases.

METHODS

We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay.

RESULTS

The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3-4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%).

CONCLUSIONS

The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.

A Review on the History of 'Thyroid Surgery'

The history of thyroid surgery is both interesting and illustrative. The ambitions of a thyroid surgeon have evolved along the length of time. The objective of this article is to give an idea about the evolution of thyroid surgery thus giving inspiration to future surgeons in their quest for a perfect technique, which would take into consideration disease elimination and maintenance of physiology and cosmesis. The history of thyroid surgery back to as early as 952 AD, when Albucasis first performed the surgery. Thereafter, the course of this surgery had its crests and troughs. At one point of time, surgeons refused to perform this surgery because of the complications. But later on, surgeons like Billroth and Kocher gave this procedure a new leash of life, after which this surgery became popular and underwent numerous modifications to where now it stands. History reveals that thyroid surgery has travelled a long path in time. From an operation which once was considered dreadful to the present times when techniques are being tried to make the incision as small as possible. The quest is still on to develop the perfect technique.

Minimally Invasive Video-Assisted Total Thyroidectomy (mi V.A.T.T.) - Case Series of 48 Patients

PURPOSE

The first report of miVATT was published in 1998 by Miccoli, leading to a revolution in the field of thyroid surgery. This prospective study aims to evaluate the technique with regard to our department's experience over a four-year period.

MATERIAL-METHODS

Between September 2009 and October 2013, 48 adult patients (37 females, 11 males) with a mean age of 41.3 (± 11.6) years underwent scheduled miVATT for benign thyroid lesions. Selection criteria included thyroid volume <15 ml and nodules not exceeding 3.5 cm of diameter. Thyroiditis, previous neck surgery and previous irradiation, mediastinal goiter and involvement in another clinical study constituted the exclusion criteria. The procedure we performed was miVATT as described by Miccoli with the only additions being the use of the Harmonic Scalpel and the fixation of the endoscope on a holding device. Also, no drains were applied.

RESULTS

No conversions to open surgery were needed. Operation time for total thyroidectomy was 71.23 min (± 23.81) with a mean hospitalization of 1.14 days (± 0.4). Five patients (10.4%) exhibited transient hypocalcemia, whereas there were no recurrent laryngeal nerve palsies. Post-operative pain was mild and the final aesthetic result was considered excellent by the patients.

CONCLUSION

miVATT is a safe and feasible alternative to the conventional thyroidectomy when performed in carefully selected patients by experienced surgeons.

Minimally invasive supraomohyoid neck dissection by total endoscopic technique for oral squamous carcinoma

BACKGROUND AND OBJECTIVE

To study the feasibility of a total endoscopic technique for selective neck dissection in oral cancers and to compare the technique with conventional open technique with a long cervical scar.

METHODS

We included patients with early intraorally resectable squamous carcinomas and excluded patients whose primary lesion required reconstruction with microvascular flaps. We compared the following intraoperative parameters: cumulative length of the incision(s), duration of surgery, estimated blood loss, and intraoperative complications. The postoperative parameters included hospital stay, shoulder function, duration of analgesic use, and early postoperative complications. We used Shoulder Pain And Disability Index scores to assess shoulder function and assessed the oncologic outcome histopathologically by the number of nodes dissected.

RESULTS

The mean operative time for minimally invasive supraomohyoid neck dissection (MISOND) was 53.7 ± 29.8 min, which was significantly longer than 39.4 ± 5.0 min for the open technique. The estimated blood loss in the MISOND group was significantly lower compared with the open technique (p < 0.001), and there were no major intraoperative complications in either group. Postoperative recovery assessed by hospital stay and time to resume routine work was slightly shorter in the MISOND group but not statistically significant. There were no reported early postoperative complications such as haemorrhage, wound dehiscence, or chyle leakage in either group. The mean Shoulder Pain And Disability Index score assessed 2 weeks postoperatively for the MISOND group was 14.35 ± 0.71 %, which was significantly better than 44.14 ± 1.18 % for the open technique (p < 0.001). The number of nodes dissected showed no significant difference between groups.

CONCLUSIONS

MISOND is a feasible and safe procedure with immediate oncologic outcomes comparable with those of conventional open SOND and provides better cosmetic and functional outcomes.

Robotic thyroid surgery for papillary thyroid carcinoma: lessons learned from 100 consecutive surgeries

PURPOSE

To evaluate the feasibility and safety of robotic thyroidectomy using the da Vinci surgical system.

PATIENTS AND METHODS

Between July 2008 and April 2011, the data revealed an initial series of 100 consecutive patients who underwent robotic thyroidectomy with the da Vinci-S surgical system using the bilateral axillo-breast approach for thyroid cancer. Prospectively collected data were analyzed retrospectively.

RESULTS

There were 88 cases of total thyroidectomy, 11 cases of lobectomy, and 1 case of total thyroidectomy with modified radical neck dissection. There was no conversion. The mean total operation time was 287.15±45.19 minutes for total thyroidectomy and 236.27±48.98 minutes for lobectomy. Nineteen patients experienced transient hypocalcemia and 3 patients experienced transient vocal fold palsy. All of the patients recovered within 3 months.

CONCLUSIONS

Robotic thyroid surgery for patients with thyroid malignancy is safe and results in fewer postoperative complications than open thyroid surgery.

Surgical options for primary hyperparathyroidism

Over the last two decades, surgery for primary hyperparathyroidism has evolved to offer a panel of procedures based on improvements in imaging, new technology and, consequently, novel surgical techniques. Multiple courses of action are possible, consistent with varying degrees of complexity. From the simplest scenario of a single adenoma localized by at least two preoperative tests in the context of sporadic primary hyperparathyroidism, to revision surgery related to recurrent, persistent or multiglandular disease, the surgeon has the opportunity to adapt his strategy. However, whatever surgical approach is used, even in the absence of formal guidelines, the clinical judgment of an experienced and skilled practitioner in endocrine surgery is the real guide and key of success in complex situations.

Endoscopic thyroidectomy using the EZ-VANS method

PURPOSE

Several video-assisted and robotic surgery techniques have been reported for resection of the thyroid and parathyroid glands. Our institute has started performing endoscopic thyroidectomy using the Lap-protector and E·Z-access system, referred to as E·Z-access using video-assisted neck surgery (EZ-VANS). In this report, we evaluate the safety and efficacy of this technique.

METHODS

From January 2007 to September 2014, 110 patients underwent resection of a primary thyroid tumor, 73 who underwent a cervical collar incision (the Open group) and 37 underwent EZ-VANS (the EZ-VANS group).

RESULTS

The average operating time was 159 and 172 min in the Open group and EZ-VANS group, respectively; the amount of blood loss was 46.5 and 54.7 ml, respectively; and the length of hospital stay after surgery was 4.3 and 5.2 days, respectively, with no significant differences observed between the two groups. The learning curve for the EZ-VANS technique was shorter than for open surgery.

CONCLUSIONS

We confirmed that the EZ-VANS technique is a safe and useful method for resection of benign and early malignant thyroid tumors.

Complete Endoscopic Thyroidectomy via Oral Vestibular Approach Versus Areola Approach for Treatment of Thyroid Diseases

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) is gaining interest because it allows operations without skin incisions. The aim of this study was to evaluate the feasibility, safety, and cosmetic results of endoscopic thyroidectomy via the oral vestibular approach (ETOVA) compared with endoscopic thyroidectomy via the areola approach (ETAA) in patients with thyroid diseases.

MATERIALS AND METHODS

Eighty-two patients with thyroid diseases were randomized to receive either ETOVA (n=41) or ETAA (n=41). Perioperative and follow-up data were assessed.

RESULTS

The surgery was completed in all cases, and all patients were followed up for at least 1 year. There were no differences between the two groups in operation time, blood loss, or postoperative hospital stay. Respective pain scores were 1.7 versus 2.1 and 0.6 versus 0.8 on Days 1 and 3, respectively, postoperatively. The white blood cell counts and C-reactive protein levels were not significantly different between the two groups. Complications were the same in both groups. Oral incision scars were invisible in the ETOVA group. Rates of skin traction sensation on the surgical field were lower in the ETOVA group than in the ETAA group at 3 and 6 months postoperatively (53.7% versus 80.5% and 24.4% versus 46.3%, respectively). The respective satisfaction score was 9.61 versus 9.22 (P=.021). No recurrent cases were observed in the study.

CONCLUSIONS

Both the ETOVA and the ETAA procedures are feasible for thyroid diseases. The ETOVA eliminated skin incision scars and gained better cosmetic results in the short-term follow-ups, and the trauma was the same between the two approaches. However, more cases and longer-term follow-ups are needed for confirmation.

Minimally invasive video-assisted thyroidectomy for papillary thyroid cancer: a prospective 5-year follow-up study

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) was initially introduced for the treatment of selected patients who met certain thyroid volume, nodule size and pathological criteria. Recent studies indicate that the completeness of resection of malignant nodules is comparable to that obtained with conventional thyroidectomy.

AIMS

To compare the 5-year outcomes in patients with papillary thyroid carcinoma (PTC) treated with MIVAT versus conventional thyroidectomy.

METHODS

In this prospective cohort study conducted over 2 years (July 2005-June 2007), 172 patients with node-negative, nonmetastatic PTC underwent either MIVAT (n = 67) or conventional thyroidectomy (n = 105). Study outcomes were 1) the cumulative dose of radioactive iodine (RAI) to achieve a disease-free state, defined as a stimulated serum thyroglobulin (Tg) level &lt;2 ng/mL with negative Tg antibody and no tumor on a whole-body scan or cross-sectional imaging, and 2) the 5-year serum Tg level.

RESULTS

The clinical parameters of the MIVAT and conventional thyroidectomy groups were comparable except for age (mean 43 ± 12 vs. 59 ± 17 years, respectively; p = 0.03) and operative time (mean 69 ± 24 vs. 53 ± 16 minutes, p = 0.02); the mean tumor size was similar between groups (1.3 ± 0.7 vs. 1.6 ± 0.9 cm, p = 0.14). Surgical morbidity was similar in both groups. Median follow-up was 5 years. RAI dose (mean 72 ± 38 vs. 96 ± 47 mCu, p = 0.34) and serum Tg at 5 years (mean 0.3 ± 0.2 vs. 0.5 ± 0.3 ng/mL, p = 0.30) were not significantly different between the MIVAT and conventional thyroidectomy groups.

CONCLUSIONS

MIVAT can be safely utilized in patients with localized PTC, providing comparable completeness of resection and oncological outcome to conventional thyroidectomy.

Benefits of a circular approach to mobilize the thyroid during an endoscopic thyroidectomy

BACKGROUND

Mobilization of the thyroid during an endoscopic thyroidectomy (ET) via a breast approach was originally carried out from the lower pole to the upper pole (upward approach). Here, we applied a modified circular approach to achieve better exposure of the surgical field, in which the path of thyroid mobilization started from the isthmus and resembled a circle. The purpose of this study is to evaluate the safety and feasibility of the circular approach compared with the upward approach.

PATIENTS AND METHODS

From December 2008 to June 2013, 144 patients who underwent attempted ET via a breast approach were enrolled in this study, and their clinical outcomes were evaluated.

RESULTS

In total, 141 of 144 procedures were successfully performed under endoscopy, including 60 (42.6%) via the upward approach and 81 (57.4%) via the circular approach. The mean operating time was significantly shorter in the circular approach group than in the upward approach group (90.6 minutes versus 112.5 minutes for hemithyroidectomy; 109.5 minutes versus 133.2 minutes for subtotal thyroidectomy; P<.05). Furthermore, the incidence of the transient recurrent laryngeal nerve palsy decreased in the circular approach group compared with the upward approach group (2.5% versus 13.3%; P<.05).

CONCLUSIONS

These results seem to indicate that the circular approach is a better method of mobilizing the thyroid, especially for large nodules located in the lower pole of the thyroid. This approach may provide a better view of the surgical field, reduced operating times, and fewer postoperative complications.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Clinical application of endoscopic thyroidectomy via an anterior chest wall approach

BACKGROUND

Endoscopic minimally invasive surgery of the cervical region is currently used to treat benign thyroid disease. The aim of this study was to evaluate the safety, feasibility, and inflammatory response to endoscopic thyroidectomy (ET) via an anterior chest wall approach.

METHODS

Between January 2007 and January 2012, 320 patients underwent sub-total/total thyroidectomy. Of these, 160 had endoscopic surgery through an anterior chest wall approach (ET, group A) and 160 had traditional open surgery (group B). Demographics, operation time, intraoperative blood loss, complications, hospital stay, cost, and postoperative outcomes were compared between the 2 groups. Serum Interleukin-6 and C-reactive protein levels were measured preoperatively and at 2, 12, 24, and 48 hours postoperatively.

RESULTS

Patient demographics, tumor size, operation time, and pathologic diagnoses were similar in both groups. There was no difference in procedure time and postoperative complication rates. Intraoperative blood loss and length of hospital stay were significantly lower in group A (P<0.05), but cost was higher (P<0.05). Serum Interleukin-6 and C-reactive protein levels increased significantly after both procedures, with levels at the 24-hour and 48-hour time points higher in group B (P<0.05). Two cases in group A and 1 in group B developed a transient hoarse voice postoperatively, which recovered 7.5 days (range, 5 to 12 d) later. There were no serious complications during the 2-year follow-up.

CONCLUSIONS

ET through an anterior chest wall approach is safe and feasible for benign thyroid disease, and offers the advantage of no visible scar.