Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

Transoral thyroidectomy (TOETVA): Complications, surgical time and learning curve

BACKGROUND

Since 2018, transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a true scarless thyroid surgery. In this study, we explore early outcomes and learning curve of this new approach.

METHODS

A retrospective cohort including conventional thyroidectomies and TOETVAs performed in a cancer center was designed. Learning curve and early surgical outcomes of TOETVA were assessed and compared to conventional thyroidectomy.

RESULTS

A total of 56 TOETVAs and 745 conventional thyroid procedures were included. In the TOETVA group, we had a 14.4% total complication rate with no permanent vocal cord paresis or hypocalcemia. The mean surgical time dropped from 167 to 117 min (p = 0.0001) after the 15 first cases. Comparing to conventional procedures, we didn't find any significant difference in complications rate. Operative time was longer in the TOETVA group.

CONCLUSIONS

In this study, TOETVA was safe and feasible, with a learning curve of 15 cases.

Predictors of recurrence after total thyroidectomy plus neck dissection and radioactive iodine ablation for high-risk papillary thyroid carcinoma

BACKGROUND

American Thyroid Association (ATA) proposed management guidelines for differentiated thyroid cancer, including a three-tiered risk stratification system for structural recurrence. This study aimed to compare the various 2015 ATA criteria for the strength of association with the recurrence of high-risk papillary thyroid carcinoma (PTC).

STUDY DESIGN

This study included 545 consecutive patients who underwent total thyroidectomy plus neck dissection and radioactive iodine ablation (RAI) for previously untreated high-risk PTC. The association of recurrence-free survival (RFS) with clinicopathological factors was evaluated by univariate and multivariate Cox proportional hazard regression analyses.

RESULTS

During a follow-up median period of 89 months, 90 (16.5%) patients had any-site recurrence. Of the high-risk factors, high stimulated thyroglobulin (sTg) level and >3-cm sized lymph nodes (LNs) were significantly associated with recurrence (all P < .005). Sex, tumor size, lymphovascular invasion, multifocality, number of positive LNs, extranodal extension, T and N classifications, and overall tumor-node-metastasis stage were also significantly associated with recurrence (all P < .05). In multivariate analyses, high sTg level [adjusted hazard ratio (HR) = 7.18] and N1b (adjusted HR = 3.27) were independent factors predictive of recurrence (all P ≤ .001).

CONCLUSIONS

Postoperative high serum sTg level might be the most important predictor of PTC recurrence after total thyroidectomy plus neck dissection and RAI.

Protective Effect of Alpha-Lipoic Acid on Salivary Dysfunction in a Mouse Model of Radioiodine Therapy-Induced Sialoadenitis

Radioiodine (RI) therapy is known to cause salivary gland (SG) dysfunction. The effects of antioxidants on RI-induced SG damage have not been well described. This study was performed to investigate the radioprotective effects of alpha lipoic acid (ALA) administered prior to RI therapy in a mouse model of RI-induced sialadenitis. Four-week-old female C57BL/6 mice were divided into four groups (n = 10 per group): group I, normal control; group II, ALA alone (100 mg/kg); group III, RI alone (0.01 mCi/g body weight, orally); and group IV, ALA + RI (ALA at 100 mg/kg, 24 h and 30 min before RI exposure at 0.01 mCi/g body weight). The animals in these groups were divided into two subgroups and euthanized at 30 or 90 days post-RI treatment. Changes in salivary ^99mTc pertechnetate uptake and excretion were tracked by single-photon emission computed tomography. Salivary histological examinations and TUNEL assays were performed. The ^99mTc pertechnetate excretion level recovered in the ALA treatment group. Salivary epithelial (aquaporin 5) cells of the ALA + RI group were protected from RI damage. The ALA + RI group exhibited more mucin-containing parenchyma and less fibrotic tissues than the RI only group. Fewer apoptotic cells were observed in the ALA + RI group compared to the RI only group. Pretreatment with ALA before RI therapy is potentially beneficial in protecting against RI-induced salivary dysfunction.

Unusual iodine-131 postablation whole-body scintigraphy patterns in patients after robot-assisted/endoscopic thyroidectomy: Case series

Robot-assisted/endoscopic thyroidectomy causes irritation due to instruments or implantation of thyroid tissue on the anterior chest wall and lower neck. We present three patients who exhibited unexpected focal lesions on postablation Iodine-131 single-photon emission computed tomography/computed tomography without biochemical and structural diseases. Meticulous surgical techniques are important to prevent complications.

Endoscopic thyroid lobectomy vs Conventional open thyroid lobectomy

BACKGROUND AND OBJECTIVE

Surgical managements for these suspicious nontoxic swellings requires open conventional method of thyroidectomy by neck incisions that can result in prominent scars and immediate risk usually hemorrhage. However new technological innovations came into practiced that include video assisted minimal invasive endoscopy by axillo-breast approach that gives very promising results with excellent cosmesis. In this study, we compared conventional open surgery with minimal invasive endoscopic techniques and associate various complaints and complications that were encountered in surgery.

METHODS

Sixty patients were enrolled in this comparative study. It was conducted from period February 2018 to February 2019. The patients were randomized alternatively in two groups. Group-I patients underwent conventional lobectomy while Group-II patients were operated endoscopically, Patients having nodules less than 3cm and Thy 1 and 2 were included in this study. Patient having nodules greater than 3cm, Multinodular goiter, recurrent nodule and Thy 3-6 were excluded from the study.

RESULTS

Patients who underwent endoscopic lobectomy were much more satisfied about scar marks whereas some developed post-operative complications. It included hoarseness of voice in Three (13.62%) patients, two patients developed seroma (9.08%), three patients (13.62%) erythema, whereas no postoperative complications were seen in patients who underwent open thyroid lobectomy. No signs of hypocalcemia noted in both approaches.

CONCLUSIONS

The complications with endoscopic approaches are higher but they are minor and resolved spontaneously within maximum period of six weeks. However scar mark satisfaction was much higher in endoscopic lobectomy group.

Voice outcomes of transoral robotic thyroidectomy: Comparison with conventional trans-cervical thyroidectomy

OBJECTIVES

The purpose of this study was to compare the short-term voice outcomes of transoral robotic thyroidectomy (TORT) and trans-cervical thyroidectomy.

MATERIALS AND METHODS

The acoustic parameters and the voice handicap index (VHI)-10 scores were compared between the two groups preoperatively, and 1 week, 1 month, and 3 months postoperatively.

RESULTS

Forty-two patients in the TORT group and 47 patients in the trans-cervical group completed the VHI-10 questionnaire and acoustic analysis. The highest frequency and pitch range was higher and broader, respectively, in the TORT group than in the trans-cervical group until 3 months after surgery. They were not significantly impaired by surgery in the TORT group. The postoperative VHI-10 score was not significantly different between the two groups at any time point. Surgical approach (TORT vs. trans-cervical) and age were independent factors related to highest frequency and pitch range in multiple regression analysis.

CONCLUSION

TORT has advantages of excellent postoperative voice outcomes compared to trans-cervical thyroidectomy in the short-term period.

Clinical Applied Anatomy in Trans-Areolar Endoscopic Thyroidectomy: Crucial Anatomical Landmarks

Introduction: Endoscopic thyroidectomy (ET) has been successfully established as an excellent surgical approach. This study summarizes and describes the crucial anatomical landmarks for clinical applied anatomy in trans-areolar ET, which may help further improve the quality and safety of trans-areolar ET. Materials and Methods: Five hundred forty patients who underwent trans-areolar ET from January 2015 to June 2018 at our institution were evaluated. Several crucial anatomical landmarks were described during the surgical procedures. The surgical outcomes, including the operative time, conversion, intraoperative blood loss, postoperative complications, and postoperative stay, were collected. Results: All patients successfully underwent trans-areolar ET without conversion. The mean operative time was 142.18 ± 49.91 minutes (150.84 ± 50.32 minutes for total thyroidectomy and 110.20 ± 32.4 for lobectomy with isthmusectomy). The mean intraoperative blood loss was 20.45 ± 10.89 mL. The postoperative stay was 5.42 ± 1.49 days. The postoperative complication rate was 7.78%, including transient hypocalcemia in 30 patients, transient recurrent laryngeal nerve palsy in 3 patients, and skin ecchymosis in 9 patients. Conclusions: An understanding of crucial anatomical landmarks for clinical applied anatomy may improve the quality and safety of trans-areolar ET and subsequently help promote the development of ET.

Comparison of the vessel sealer Extend® with harmonic ACE® in robotic bilateral axillary-breast approach thyroid surgery

Background

Harmonic ACE^® (Harmonic) Curved Shears are frequently used for vessel sealing in patients undergoing robotic thyroidectomy. Unlike other robotic devices with articulation, the Harmonic device can only move in a straight-forward direction without articulation. The recently introduced Vessel Sealer Extend^® (VSE) provides bipolar sealing and cutting with articulation movement. This study compared the VSE and Harmonic devices in robotic bilateral axillary-breast approach (BABA) thyroid surgery.

Methods

From December 2018 to March 2019, 35 consecutive patients underwent robotic BABA thyroidectomy, 20 using the VSE and 15 using the Harmonic device. Patient characteristics, pathologic results, and clinical outcomes, including complications, were evaluated.

Results

The characteristics of patients in the two groups were similar. Surgical time from robot docking to completion of lobectomy was longer in the VSE than in the Harmonic group (45.00±9.52 vs. 39.72±12.76 min; P=0.170). The number of camera cleanings during lobectomy was significantly lower in the VSE group (0.55±0.51 vs. 1.93±1.71; P=0.002). Intraoperative blood loss (53.00±43.29 vs. 28.67±41.03 mL; P=0.102), hospital stay after surgery (3.55±0.95 vs. 3.67±0.90 days; P=0.715), and pain scores on the first (2.85±0.37 vs. 2.93±0.26; P=0.458) and second (2.55±0.51 vs. 2.60±0.51; P=0.775) postoperative days were similar in the VSE and Harmonic groups. No patient experienced vocal cord palsy or postoperative bleeding.

Conclusions

VSE can be safely applied to robotic BABA thyroid surgery.

Effect of Botulinum Toxin A on Scar Healing after Thyroidectomy: A Prospective Double-blind Randomized Controlled Trial

The persistence of neck scarring is a common concern among patients undergoing thyroidectomy. Botulinum toxin A (BTA (Botox)) has been shown to suppress scar enlargement at the incision site. The objective of this study was to evaluate the effect of intraoperative Botox administration on neck scarring after thyroidectomy. A prospective double-blind randomized clinical trial was performed in patients undergoing conventional thyroidectomy. Forty patients were randomly allocated to a Botox or a control group (both, n = 20). The wound was closed after injection into the platysma muscle of 50 U of Botox diluted in 1 mL of normal saline or 1 mL of saline alone. Skin scars were assessed using the modified Stony Brook Scar Evaluation Scale (SBSES) and Manchester Scar Scale (MSS) at 1, 12, and 24 weeks postoperatively. The SBSES and MSS scores of the Botox group were significantly better than those of the control group (p = 0.034 and p = 0.039). At 24 weeks postoperatively, the SBSES and MSS scores were significantly better in the Botox group (p = 0.006 and p = 0.030). BTA injected into the incision site can suppress postoperative scar formation and thereby improve the cosmetic outcome.

Prognostic value of tumor size and minimal extrathyroidal extension in papillary thyroid carcinoma

BACKGROUND

Tumour size and extrathyroidal extension (ETE) may impact papillary thyroid carcinoma (PTC) outcomes. We therefore examined the prognostic value of tumour size and ETE for predicting posttreatment recurrence in PTC patients.

METHODS

A total of 2,902 patients who underwent thyroidectomy for previously untreated T1-T3 PTC (7th edition American Joint Committee on Cancer) at our tertiary referral center were included. Univariate and multivariate Cox proportional hazard regression analyses were used to determine significant factors predictive of posttreatment recurrence-free survival (RFS).

RESULTS

In univariate analysis, tumour factors (including tumour size, multifocality, ETE, and lymphovascular invasion), nodal factors (including positive lymph node number, lymph node ratio, and extranodal extension), and MACIS (metastases, age, completeness of resection, invasion, and size) scores were significantly associated with RFS outcomes (P < 0.001). In multivariate analysis, tumour size >4 cm (P < 0.001) and multifocality (P = 0.038) were the independent factors of RFS. Nodal factors and MACIS scores were also independent factors of RFS.

CONCLUSION

Tumour size impacts RFS after thyroidectomy in T1-T3 PTC patients.

Risk factors for posttreatment recurrence in patients with intermediate-risk papillary thyroid carcinoma

BACKGROUND

Papillary thyroid carcinoma (PTC) is generally associated with favorable outcomes; however, intermediate-risk requires further evaluation. We therefore examined risk factors for posttreatment recurrence in patients with intermediate-risk PTC.

METHODS

This study involved 1782 patients who underwent thyroidectomy for intermediate-risk PTC. Univariate and multivariate Cox proportional hazard regression analyses were used to identify the significant factors predictive of posttreatment recurrence-free survival (RFS).

RESULTS

Of intermediate-risk factors, univariate analyses showed that clinical and pathological cervical lymph node (LN) positivity (cN1 and pN1), aggressive histology, and multifocality with microscopic extrathyroidal extension were significantly associated with RFS outcomes (all P < 0.05). In multivariate analyses, cN1, >5 pN1, and posttreatment radioactive iodine (RAI)-avid metastatic foci of intermediate risk remained the independent factors predictive of RFS (all P < 0.05). The combination of any three or more of these intermediate-risk factors appeared to increase the posttreatment recurrence rate.

CONCLUSION

Clinical nodal positivity, the number of positive LNs, and the presence of RAI-avid metastatic foci in the ATA intermediate-risk category might independently decrease RFS in patients with intermediate-risk PTC.

Evaluation of the efficacy of postoperative antibiotic treatment in transoral endoscopic thyroidectomy: a prospective randomised controlled trial

Transoral endoscopic thyroid surgery (TOET) is a new, minimally-invasive approach that does not result in a scar in the anterior neck. To prevent infection of the surgical site from oral cavity flora into the thyroidectomy area, postoperative antibiotics are generally given orally for 3-7 days. However, there is no clinical evidence to support this approach. This study was an open-label, randomised, controlled trial to evaluate the clinical usefulness of postoperative antibiotics given orally to patients having TOET. Patients were randomly assigned to receive amoxicillin-clavulanate 625mg orally three times a day for a week after operation (treated group) or no antibiotics (untreated group). Fifty patients - 25 treated and 25 untreated - were enrolled. Maximum body temperature, pulse rate, white blood cell count, and C-reactive protein concentrations did not differ between the two groups. Evaluation of the surgical site showed no significant differences between them. Seven patients in the treated group developed nausea, vomiting, and diarrhoea compared with none in the untreated group. The results suggest that postoperative oral antibiotics are not essential after TOET. Large-scale prospective series are required to confirm this finding.

Novel Approaches for Treating Autonomously Functioning Thyroid Nodules

Benign thyroid nodules are exceedingly common in the adult population. Only a small percentage of nodules are toxic or autonomously functioning thyroid nodules (AFTNs). The options clinicians have for treating the symptoms of hyperthyroidism include anti-thyroidal medications, radioactive iodine, or surgery. Depending on the patient population treated, these options may not be suitable or have inherent risks that are undesirable to the patient. On the other hand, untreated hyperthyroidism can lead to osteoporosis, atrial fibrillation, emotional lability, and neurological consequences. Thus, we present a review of two novel safe and effective approaches for treating AFTN; one surgical (transoral endoscopic thyroid surgery) and one non-surgical (radiofrequency ablation), as a means for expanding our treatment armamentarium.

Robotics in Cleft Surgery: Origins, Current Status and Future Directions

The field of robotic surgery is an exciting and growing field that has bolstered its way to become a mainstream application in a number of surgical disciplines. The application of robotic surgery in cleft surgery is novel and has captivated many with the benefit it provides: the slender and small arms with wrist articulation at the instrument tip; motion scaling; tremor elimination; and high fidelity, three-dimensional visualization make the robot a very attractive platform for use in confined spaces with small surgical targets. The story of the origin of robotic surgery in cleft surgery is an interesting one, and one that has arisen from other allied surgical specialities to render robotic cleft surgery as its own specialised field. A field that has coined its own terms and has demonstrated a number of applications for its use. This review details the origins of robotic cleft surgery, its evolution and its current status and elaborates on future directions to enhance its application.

Port-Site Implantation Diagnosed by Iodine-131 Post-Ablation Single-Photon Emission Tomography-Computed Tomography After Robotic Thyroidectomy: A Case Report

Patient: Female, 37

Final Diagnosis: Port-site implantation after robotic thyroidectomy

Symptoms: None

Medication: —

Clinical Procedure: Iodine-131 post-ablation whole body scan and single photon emission tomography-computed tomography

Specialty: Nuclear Medicine

Safety and efficacy of transoral robotic and endoscopic thyroidectomy: The first 100 cases

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of transoral robotic and endoscopic thyroidectomy.

METHODS

We analyzed and compared the first 100 cases of transoral robotic (71 cases) and endoscopic (29 cases) thyroidectomy with 207 cases of conventional transcervical thyroidectomy.

RESULTS

Transoral thyroidectomy was completed successfully in all patients, except for three who were converted to the robotic facelift or transcervical approach. The mean operative time of the transoral procedure was significantly longer than that of the conventional procedure. Perioperative complications such as hypoparathyroidism, vocal cord palsy, hematoma, and seroma did not differ between the two groups. However, there were some unusual complications such as CO₂ embolism, surgical site infection, skin trauma, burn, and ecchymosis in transoral thyroidectomy. Postoperative cosmesis was significantly better in the transoral group.

CONCLUSION

Transoral robotic and endoscopic thyroidectomy is feasible and comparable to conventional transcervical thyroidectomy in highly selected patients.

Robot-assisted excision of thyroglossal duct cyst by a postauricular facelift approach

Introduction

A trend towards robotic scarless surgery using remote site incisions has developed in head and neck surgery for better cosmetic outcomes. We have carried out robot-assisted excision of thyroglossal duct cysts (TGDC) by a postauricular facelift approach to avoid visible scars in the central neck related to the trans-cervical Sistrunk operation.

Aim

To evaluate the technical feasibility and safety of robot-assisted excision of TGDC by a postauricular facelift approach.

Material and methods

Six patients who underwent robot-assisted excision of TGDC by a postauricular facelift approach were analyzed.

Results

The robotic procedures were done successfully in all patients, without any conversion to a trans-cervical approach or incomplete removal of the lesions. In terms of cosmetic satisfaction, three patients were "very satisfied" and three were "satisfied".

Conclusions

Robot-assisted Sistrunk operations for TGDC by a postauricular facelift approach are feasible and safe and yield excellent postoperative cosmesis.

Comparison of postoperative cosmesis in transaxillary, postauricular facelift, and conventional transcervical thyroidectomy

BACKGROUND

The most important advantage of remote-access robotic and endoscopic thyroidectomies is believed to be the excellent postoperative cosmesis. The purpose of this study was to compare directly the postoperative cosmetic outcomes of robotic/endoscopic thyroidectomy via gasless transaxillary and postauricular facelift approaches with those of conventional thyroidectomy.

METHODS

We prospectively studied 100 patients who underwent robotic/endoscopic thyroidectomy using a gasless unilateral axillary (GUA) approach (50 patients) or a postauricular facelift approach (50 patients), and 50 who underwent conventional transcervical thyroidectomy. Postoperative cosmetic satisfaction scores and scar consciousness scores were evaluated at 3 months and 1 year after surgery using questionnaires developed by us. Vancouver scar scales were evaluated at the same time. The cosmetic satisfaction score was defined as the sum of the two cosmetic satisfaction questions with a rating scale of 1-5 each. The scar consciousness score was defined as the sum of the four scar consciousness questions with a rating scale of 0-3 each.

RESULTS

The cosmetic satisfaction and scar consciousness scores were significantly lower (corresponding to greater satisfaction) in the transaxillary and postauricular facelift groups than the conventional group at 3 months and 1 year postoperatively. They did not differ between the transaxillary and postauricular facelift groups. However, the Vancouver scar scale score of the conventional group was significantly lower than those of the transaxillary and postauricular facelift groups (P < 0.001 in both).

CONCLUSION

Robotic/endoscopic thyroidectomy via transaxillary or postauricular facelift approaches results in better cosmesis than the conventional approach. However, scar healing itself is worse in the transaxillary and facelift approaches than the conventional approach.