Video-assisted subtotal or near-total thyroidectomy for Graves' disease

Bibliometric analysis of research trends and hotspots on robot-assisted thyroid surgery

BACKGROUND

Thyroid surgery involves the partial or complete removal of the thyroid gland and is a frequently performed surgical procedure. The adoption of robots, equipped with flexible and stable operating systems, has garnered acceptance among numerous surgeons for their capability to enable precise anatomical dissection in thyroid surgery. To gain a comprehensive insight into the present research landscape of robot-assisted thyroid surgery, this paper endeavored to conduct a thorough analysis of the field through bibliometric analysis.

METHODS

Relevant literature pertaining to robot-assisted thyroid surgery was retrieved from the Web of Science Core Collection (WOSCC) database, spanning from the inception of WOSCC to October 17, 2022. Visual analyses of publication quantity, distribution across countries/regions, institutions/organizations, authorship, journals, references, and keywords were conducted using Microsoft Excel, the bibliometrix package in R, Citescape, and VOSviewer software.

RESULTS

A total of 505 articles from 406 institutions in 36 countries/regions were included. South Korea emerged with highest number of publications. Notably, Professor CHUNG WY from Yonsei University in South Korea and the journal "Surg Endosc" stood out with the most publications. The current research landscape indicated significant interest in endoscopic thyroidectomy, surgical procedures, and the axillary approach. In addition, transoral robotic thyroidectomy (TROT), and learning curve (LC) were recognized as research frontiers, representing potential future hotspots in this field.

CONCLUSION

This study marks the first bibliometric analysis of the literature on robot-assisted thyroid surgery. The results highlight endoscopic thyroidectomy, surgical procedures, and the axillary approach as current research hotspots, with TROT and LC identified as potential future research hotspots.

Mechanisms of recurrent laryngeal nerve injury in endoscopic thyroidectomy for papillary thyroid carcinoma: A large data from C hina

Purpose

To investigate the mechanisms of recurrent laryngeal nerve (RLN) injury during endoscopic thyroidectomy via breast approach (ET-BA) in patients with papillary thyroid carcinoma (PTC).

Methods

The records of 416 PTC patients who underwent ET-BA with intraoperative neural monitoring (IONM) from May 2015 to May 2021 in Beijing Friendship Hospital affiliated to Capital Medical University were retrospectively analyzed.

Results

All patients were women. Mean age was 37.80 (7.87) years. The ET-BA was performed in 416 patients. Overall incidence of RLN injury was 4.3% (18 patients). Injury was transient in 13 patients (3.1%) and permanent in five (1.2%). Macroscopic physical changes were apparent in the injured nerve in five patients (27.8%) and postoperative hoarseness or cough after drinking water were present in 11 (61.1%). Two RLN injuries occurred during nerve identification at the RLN laryngeal entry point into the surgical field, 15 during early nerve dissection somewhere between the first 0.5 and 2 cm of the nerve's course through the surgical field, and one occurred distal to 2 cm. The percentage of patients with separation, transection, traction and thermal mechanisms of injury was 27.8%, 22.2%, 22.2%, and 16.7%, respectively. The mechanism of injury was unknown in 11.1%.

Conclusions

RLN injury may still occur during ET-BA despite endoscopic magnification and early nerve identification even when IONM is used. Separation, transection, and traction injuries were the most frequent causes of injury.

Oncologic safety and surgical outcomes of the different surgical approaches of endoscopic thyroidectomy for papillary thyroid carcinoma

PURPOSE

To evaluate the oncologic safety and surgical outcomes of endoscopic thyroidectomy (ET) performed via different surgical approaches for papillary thyroid carcinoma (PTC).

METHODS

We reviewed the medical records of PTC patients who underwent ET between May 2015 and May 2021, at the Department of General Surgery, Beijing Friendship Hospital (affiliated with Capital Medical University). The patients were divided into three groups: the ET via breast approach (ETBA) group, the transoral ET vestibular approach (TOETVA) group, and the ET via transaxillary approach (ETTA) group. We evaluated the safety and surgical outcomes of each of these ET approaches.

RESULTS

A total of 490 patients were included in the analysis: 416 in the ETBA group, 57 in the TOETVA group, and 17 in the ETTA group. There were no significant differences among the groups in clinicopathologic characteristics or surgical procedures, or in the incidences of complications such as hematoma, subcutaneous emphysema, infection, and chyle. The incidences of transient and permanent recurrent laryngeal nerve (RLN) injury were 1.4% and 4.3%, respectively, with no significant difference among the three groups. The incidences of transient and permanent postoperative hypoparathyroidism were 13.7% and 1.4%, respectively. The incidence of transient hypoparathyroidism in the TOETVA group was 1.7%, which was significantly lower than that in the ETBA group. The postoperative 1-, 3- and 5-year rates of disease-free survival were 99.5%, 96.8%, and 95.9%, respectively. Univariate and multivariate analyses showed that ET was not a significant risk factor for recurrence or metastasis (p = 0.83 and p = 0.49, respectively), regardless of the surgical approach.

CONCLUSIONS

TOETVA may be associated with a lower incidence of temporary hypoparathyroidism than ETBA. Apart from this difference, ETBA, ETTA and TOETVA showed comparable oncologic safety and surgical outcomes.

Case Report: Implantation of Dedifferentiated to Poorly Differentiated Thyroid Carcinoma After Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy is widely accepted for its advantages. However, implant metastasis remains a significant complication of endoscopic thyroidectomy.

Methods

This is the first report of breast implantation diagnosed with poorly differentiated thyroid carcinoma following endoscopic thyroidectomy.

Results

We present a case of a 35-year-old woman who was initially diagnosed with a 3.0 cm conventional papillary thyroid carcinoma after endoscopic thyroidectomy via total areola. Two years later, she was reported to have recurring poorly differentiated thyroid carcinoma in the right areola. Implantation after endoscopic thyroidectomy is rare, and even rarer is dedifferentiated papillary thyroid carcinoma around the implant site.

Conclusions

Stringently evaluated endoscopic surgery indications, appropriate preoperative evaluation, meticulous surgical technique, and adequate protective measures can significantly reduce the incidence of local implantation or recurrence.

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.

Transoral Vestibular Thyroidectomy: Current State of Affairs and Considerations for the Future

CONTEXT

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a recently described procedure for surgical management of select thyroid pathology that avoids a cutaneous scar. TOETVA is far from the first described remote-access approach to the thyroid. In fact, numerous such techniques have been described over the past 20 years, although none has gained widespread implementation in North America or Europe. However, with its rapid growth worldwide and excellent outcomes to date, TOETVA may succeed where these prior techniques have failed.

EVIDENCE ACQUISITION

The English literature was reviewed using the following keywords: transoral thyroidectomy, remote-access thyroidectomy, minimally invasive thyroidectomy, and TOETVA. Because three systematic reviews of this technique were recently conducted, this manuscript does not seek to provide a fourth. Rather, we summarize salient findings from these reviews and focus on candidates for the procedure, technique-specific characteristics that have led to early success with TOETVA, and prospects for the future.

EVIDENCE SYNTHESIS

TOETVA is the only thyroidectomy approach obviating the need for a cutaneous incision, and it offers several advantages over previously described remote-access thyroidectomy techniques. These include a favorable anatomic surgical perspective, a comparatively short learning curve, no requirement for expensive instrumentation, and a broad inclusion criterion. These characteristics have facilitated the excellent surgical outcomes to date.

CONCLUSIONS

TOETVA is a suitable surgical option with proven safety and feasibility for a carefully selected patient population. The potential value of the procedure outside enhanced cosmesis continues to be defined.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides excellent cosmetic results from its potential for scar-free operation. The procedure has been applied successfully for Graves' disease by the authors of this work and compared with the standard open cervical approach to evaluate its safety and outcomes.

METHODS

From January 2014 to November 2016, a total of 97 patients with Graves' disease were reviewed retrospectively. Open thyroidectomy (OT) and TOETVA were performed in 49 patients and 46 patients, respectively. For TOETVA, a three-port technique through the oral vestibule was utilized. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device. Patient demographics and surgical variables, including operative time, blood loss, and complications, were investigated and compared.

RESULTS

TOETVA was performed successfully in all 45 patients, although conversion to open surgery was deemed necessary in one patient. All patient characteristics for both groups were similar. Operative time was shorter for the OT group compared to the TOETVA group, which totaled 101.97±24.618 and 134.11±31.48 minutes, respectively (P<<0.5). Blood loss was comparable for both groups. The visual analog scale (VAS) pain score for the TOETVA group was significantly lower than for the OT group on day 1 (2.08±1.53 vs. 4.57±1.35), day 2 (0.84±1.12 vs. 2.57±1.08) and day 3 (0.33±0.71 vs. 1.08±1.01) (P<<0.05). Transient recurrent laryngeal nerve (RLN) palsy was found in four and two cases of TOETVA and OT group, respectively. Transient hypocalcemia was found in ten and seven cases of TOETVA and OT group, respectively. No other complications were observed.

CONCLUSIONS

TOETVA is a feasible and safe treatment for Graves' disease in comparison to the standard open cervical approach. It is considered a viable alternative for patients who have been indicated for surgery with excellent cosmetic results.

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.

Extrathyroidal implantation of thyroid hyperplastic/neoplastic cells after endoscopic thyroid surgery

OBJECTIVE

To report a case of the implantation of thyroid hyperplastic or neoplastic tissue after endoscopic thyroidectomy and discuss this complication in aspects of prevalence, pathogenesis, protection, and therapies.

METHODS

A systematic search of literature from the PubMed database was conducted for identifying eligible studies on implantation of thyroid hyperplastic or neoplastic cells after endoscopic thyroid surgery.

RESULTS

Overall, 5 reported cases on patients suffering from endoscopic thyroid surgery with implantation of thyroid hyperplastic or neoplastic cells were included in the systematic review.

CONCLUSIONS

Unskilled surgeons, rough intraoperative surgical treatment, scarification or rupture of tumor, contamination of instruments, chimney effect, aerosolization of tumor cells may be associated with the implantation after endoscopic thyroidectomy. To minimize the risk of such complication, we should be more meticulous and strict the endoscopic surgery indications.

Bilateral axillo-breast approach robotic thyroidectomy for Graves' disease: an initial experience in a single institute

BACKGROUND

Bilateral axillo-breast approach (BABA) robotic thyroidectomy has shown excellent cosmetic and surgical outcomes. The aim of the present study was to evaluate the safety, feasibility, and initial outcome of this procedure in patients with Graves' disease.

METHODS

From June 2008 to July 2001, a total of 30 patients with Graves' disease were reviewed retrospectively. Patient demographics, operative indications, and surgical variables, including operative time, blood loss, excised thyroid weight, and complications, were collected and investigated.

RESULTS

The thyroidectomies were classified as total (n = 21), near-total (n = 6), or subtotal (n = 3). There were five indications for surgery: concomitant thyroid carcinoma or suspicious nodule (n = 22), recurrence after antithyroid medication (n = 2), local compressive symptoms (n = 1), patient's preference (n = 4), and side effects of antithyroid medication (n = 1). The mean operative time, console time, blood loss, and excised thyroid weight were 190 min (range: 105-298 min), 113 min (range: 60-227 min), 229 mL (range: 50-550 mL), and 36.6 g (range: 7.8-123.0 g), respectively. There were no cases of postoperative bleeding or conversions to open surgery. Postoperative transient hypoparathyroidism and vocal cord palsy occurred in 13 (43.3 %) and 4 (13.3 %) cases. Permanent hypoparathyroidism occurred in 1 (3.3 %) case. All patients were satisfied with the cosmetic outcomes.

CONCLUSIONS

BABA robotic thyroidectomy is a feasible and safe treatment for Graves' disease. It is recommended as an alternative for patients who are concerned by the cosmetic effects of traditional thyroidectomy.

Thyroidectomy for Graves' disease: a feasibility study of the robotic transaxillary approach

INTRODUCTION

Graves' disease (GD) is considered a relative contraindication for endoscopic approaches to the thyroid gland, due to a larger gland size and increased vascularity.

METHODS

A retrospective analysis of a single surgeon's experience was performed. We included all patients who underwent thyroidectomy for the treatment of GD over a 3-year period.

RESULTS

Twenty-five patients with GD were identified. Twelve of them underwent robotic thyroidectomy and 13 patients underwent conventional thyroidectomy. Age, gender, and BMI were similar in both groups (p > 0.05). The conventional approach allowed for resection of larger thyroid volumes (147.3 ± 153.6 ml), as compared to the robotic approach (62.3 ± 47.8 ml, p = 0.08). The average total operative times were similar in both groups (p = 0.98). There was no difference with respect to intraoperative blood loss (p = 0.49), duration of hospital stay (p = 0.38), and complication rates (p = 0.99).

CONCLUSION

Robotic thyroidectomy is feasible and can be safely performed in appropriately selected patients with GD.

Feasibility and safety of minimal-incision thyroidectomy for Graves' disease: a prospective, single-center study

BACKGROUND

The role of minimally invasive surgery in Graves' disease is still controversial. The aim of this study was to compare the clinical outcomes of patients undergoing minimal-incision thyroidectomy with those undergoing conventional thyroidectomy for Graves' disease.

METHODS

A prospective study was performed on 148 patients undergoing total thyroidectomy. Seventy-one patients underwent minimal-incision thyroidectomy and 77 underwent conventional thyroidectomy. Minimal-incision thyroidectomy was proposed if the thyroid volume was ≤ 50 mL.

RESULTS

There were no significant differences in the operative time between minimal-incision thyroidectomy and conventional thyroidectomy. The length of skin incision was significantly shorter in the minimal-incision thyroidectomy than that in the conventional thyroidectomy group. The incidence of postoperative complications was similar in the 2 groups. Patients undergoing minimal-incision thyroidectomy experienced significantly less postoperative pain and were more satisfied with the cosmetic result than patients who underwent conventional thyroidectomy.

CONCLUSIONS

Minimal-incision thyroidectomy is a feasible and safe option for the surgical treatment of selected patients with Graves' disease.

Operative technique of endoscopic thyroidectomy: a narration of general principles

Endoscopic thyroidectomy is fast becoming a reality with increasing experience in endocrine surgery. Many techniques of minimally invasive video-assisted thyroidectomy through cervical and extra-cervical routes such as chest wall, transaxillary, trans-oral, post-auricular, trans-luminal approach have been attempted. At present anterior chest wall or trans-axillary routes are favourite extra-cervical routes. In this context, we describe our operative technique of endoscopic thyroidectomy through chest wall to highlight the surgical steps of practical importance.

Endoscopic subtotal thyroidectomy: the procedure of choice for Graves' disease?

BACKGROUND

The aim of this study was to evaluate the feasibility and outcomes of endoscopic subtotal thyroidectomy for Graves' disease.

METHODS

From August 1998 to April 2008, a total of 100 patients with benign thyroid diseases underwent endoscopic thyroidectomy via the breast approach. Among these patients, 42 underwent subtotal thyroidectomy for Graves' disease.

RESULTS

The resection was successfully completed endoscopically in 41 patients (98%). Overall, the mean operating time, mean blood loss, and mean resected thyroid weight were 277 minutes, 76 ml, and 49.9 g, respectively. As the resected thyroid weight increased, the operating time was significantly prolonged and the blood loss significantly increased. Morbidities included one permanent and one temporary case of recurrent laryngeal nerve palsy with hypocalcemia. A hypertrophic scar was seen in the right breast medial margin in three men. Thyroid function was classified as euthyroidism, hypothyroidism, and recurrent hyperthyroidism in 5, 34, and 3 patients, respectively. At 92 months of median follow-up, two patients had modest operation-associated symptoms: one with swallowing discomfort and another with paresthesia in the anterior chest wall at the time of discharge. However, both patients' symptoms disappeared within 36 months after surgery. Young women were highly satisfied, with an overall mean satisfaction rating of 9.3 points.

CONCLUSIONS

Although the endoscopic approach may be relatively contraindicated for large thyroid glands, endoscopic subtotal thyroidectomy via the breast approach is a safe, feasible procedure with excellent cosmetic benefits, and it may be the procedure of choice in carefully selected patients with Graves' disease.

Minimally invasive video-assisted thyroidectomy for benign thyroid disease: an evidence-based review

BACKGROUND

A decade after nearly all surgical disciplines developed minimally invasive techniques, the first report of a single case of minimally invasive thyroidectomy was published. Minimally invasive video-assisted thyroidectomy (MIVAT) is now considered the most widely practiced and most easily reproducible minimally invasive procedure for thyroidectomy. The aim of this review was to analyze the treatment of benign thyroid diseases by MIVAT.

METHODS

A systematic evidence-based literature review focusing on three questions was carried out. Additional data were obtained on the basis of our personal experience. (1) Are minimally invasive procedures indicated in the treatment of thyroid diseases? (2) Is MIVAT a safe technique and what are the demonstrated advantages? (3) Since different thyroid diseases may be treated by MIVAT, is it of any value in the treatment of benign thyroid diseases?

RESULTS

MIVAT can be considered an appropriate treatment of some thyroid diseases; it represents a safe procedure with the same incidence of complications as traditional surgery, and also has advantages in terms of both cosmetic result and postoperative distress.

CONCLUSIONS

In spite of an increasing trend toward performing more extensive procedures other than thyroidectomy alone during videoscopic procedures, the current literature seems to reaffirm that the main and safest indication for MIVAT is benign disease.

A camera handler for Miccoli's minimally invasive video-assisted thyroidectomy and paratiroidectomy procedures

BACKGROUND

Minimally invasive video-assisted thyroidectomy and paratiroidectomy (MIVAT/P) are surgical procedures performed with 5-mm cameras handled by a camera assistant.

METHODS

The authors created a new camera handler for video-assisted neck surgery. It consists of a telescopic tripod device designed for mechanical handling of the camera, which is directly oriented by the operator even in solo surgery procedures. The camera is placed inside an O-shaped support, and moved by the operator himself for exploration and work on the surgical field.

RESULTS

Thanks to this simple device, the camera holder provides a firm field and prevents blood stains in limited working spaces.

CONCLUSIONS

The novel camera handler may be useful in either MIVAT/P or other simple laparoscopic procedures (i.e., cholecystectomy) for a steady handling of the camera, even in solo surgery procedures.