Robotic thyroidectomy learning curve for beginning surgeons with little or no experience of endoscopic surgery

Comparison of learning curves and related postoperative indicators between endoscopic and robotic thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) yield similar perioperative outcomes. This study investigated how the learning curve (LC) affects perioperative outcomes between ET and RT, identifying factors that influence the LC.

MATERIALS AND METHODS

Two researchers individually searched PubMed, EMBASE, Web of Science, and Cochrane Library for relevant studies published until February 2024. The Newcastle-Ottawa Scale assessed study quality. A random-effects model was used to compute the odds ratio and weighted mean difference (WMD). Poisson regression comparison of the number of surgeries (N LC ) was required for ET and RT to reach the stable stage of the LC. Heterogeneity was measured using Cochran's Q. Publication bias was tested using funnel plots, and sensitivity analysis assessed findings robustness. Subgroup analysis was done by operation type and patient characteristics.

RESULTS

This meta-analysis involved 33 studies. The drainage volume of ET was higher than that of RT (WMD=-17.56 [30.22, -4.49]). After reaching the N LC , the operation time of ET and RT was shortened (ET: WMD=28.15 [18.04-38.26]; RT: WMD=38.53 [29.20-47.86]). Other perioperative outcomes also improved to varying degrees. Notably, RT showed more refined central lymph node resection (5.67 vs. 4.71), less intraoperative bleeding (16.56 ml vs. 42.30 ml), and incidence of transient recurrent laryngeal nerve injury (24.59 vs. 26.77). The N LC of RT was smaller than that of ET (incidence-rate ratios [IRR]=0.64 [0.57-0.72]). CUSUM analysis (ET: IRR=0.84 [0.72-0.99]; RT: IRR=0.55 [0.44-0.69]) or a smaller number of respondents (ET: IRR=0.26 [0.15-0.46]; RT: IRR=0.51 [0.41-0.63]) was associated with smaller N LC . In RT, transoral approach (IRR=2.73 [1.96-4.50]; IRR=2.48 [1.61-3.84]) and retroauricular approach (RAA) (IRR=2.13 [1.26-3.60]; IRR=1.78 [1.04-3.05]) had smaller N LC compared to bilateral axillo-breast and transaxillary approach (TAA). In ET, the N LC of RAA was smaller than that of TAA (IRR=1.61 [1.04-2.51]), breast approach (IRR=1.67 [1.06-2.64]), and subclavian approach (IRR=1.80 [1.03-3.14]).

CONCLUSIONS

Rich surgical experience can improve surgical results of ET and RT. After reaching the N LC , the perioperative outcomes of RT are better than those of ET. Study subjects, surgical approaches, and analysis methods can affect N LC .

A Comparison Between the Transoral Endoscopic Thyroidectomy Vestibular Approach and the Transareolar Approach Regarding Perioperative Complications: A Systematic Review and Meta-Analysis

The global adoption of remote thyroidectomy is increasing, with the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transareolar approach (TAA) emerging as predominant methods. However, existing meta-analyses comparing these approaches to operative surgeries and short-term postoperative complications have significant limitations. To address this gap, our meta-analysis provides a comprehensive comparison between the TOETVA and TAA, focusing on operation time, intraoperative blood loss, postoperative drainage, and hospital stay duration. It aims to offer robust insights into their relative efficacy and safety profiles. We searched SCOPUS, PubMed, Web of Science, MEDLINE, and Cochrane Library from June 2015 to January 2024 for studies comparing transoral endoscopic thyroidectomy with the vestibular approach and areolar thyroidectomy using keywords, including "transoral thyroidectomy" and "scarless thyroidectomy." Studies were included if they were randomized controlled trials, case-control studies, or prospective/retrospective cohort studies comparing the TOETVA and TAA. Exclusion criteria removed case series, cross-sectional studies, editorials, non-English language, animal studies, and irrelevant articles. Data on operative time, postoperative drainage, intraoperative blood loss, and hospital stay were extracted. The Newcastle-Ottawa Scale was used to assess study quality (all studies scored 7-8). The findings revealed that the operative time was longer among the TOETVA group, with less intraoperative blood loss (odds ratio (OR) = 13.31, 95% confidence interval (CI) = 4.44-22.19); OR = -1.61, 95% CI = -2.82 to -0.39, respectively). Regarding hospitalization duration and postoperative drainage, no discernible difference was observed between the endoscopic TAA (ETAA) and TOETVA (OR = -0.04, 95% CI = -0.24 to 0.16; OR = -6.74, 95% CI = -20.08 to 6.60, respectively). The TOETVA has advantages over the TAA in terms of intraoperative blood loss and shorter operation times. However, both approaches exhibited comparable outcomes in terms of hospital stay duration and postoperative drainage. Furthermore, extensive randomized trials are warranted.

The learning curve on robot-assisted transaxillary thyroidectomy performed by a single endocrine surgeon in a third-level institution in Europe: a cumulative sum (CUSUM) analysis

Robot-assisted transaxillary thyroidectomy is widely performed in Asian countries, although it is still under discussion in the Western World. However, there have been few studies reporting on the learning curve of robot-assisted transaxillary thyroidectomy. We used the cumulative sum (CUSUM) analysis to assess the learning curve of gasless robot-assisted transaxillary thyroidectomy at a third-level institution in Europe. We included all consecutive patients operated by a single surgeon without previous experience of robotic surgery from February 2012 to January 2023. The primary endpoint of the study was the learning curve extracted from the median operative time using the CUSUM method for the quantitative assessment. Overall, 583 patients were enrolled. The median operative time for thyroid lobectomy and total thyroidectomy was 70 and 90 min, respectively. The CUSUM analysis showed that the learning curve for thyroid lobectomy and total thyroidectomy is 66 and 56 cases, respectively. Moreover, the presence of thyroiditis resulted associated with shorter operative time for total thyroidectomy (p = 0.044), whereas no factors resulted associated with surgical complications. The learning curve for performing robotic transaxillary thyroid lobectomy for a surgeon without previous robotic experience is 66 cases. After that, 56 cases must be performed to acquire proficiency in robotic transaxillary total thyroidectomy. Training programs may reduce the slope of the learning curve.

Transoral thyroidectomy implemented by a novice surgeon: Efforts for safe implementation

Background

This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon.

Methods

We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy.

Results

Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome.

Conclusions

Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework.

Level of Evidence

Level 4.

Quality of Life and Surgical Outcome of Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) versus Open Thyroid Surgery: Experience from a Single Center in Vietnam

Background

It has been widely assumed that TOETVA has demonstrated a new technique and a promising approach as it is both minimally invasive and optimally cosmetic. The objective of this study was to assess the surgical outcome, aesthetic satisfaction, and postoperative quality of life of TOETVA in comparison with open thyroid surgery. Patients and Methods. The study was designed as a prospective study, in which 121 patients from a single center in Vietnam underwent thyroid surgery, and the study was divided into two groups: 60 patients in the TOETVA group and 61 patients in the open surgery group. The patients have been followed up including surgical outcomes, cosmetic satisfaction, and quality of life. These criteria were assessed at 4 weeks, 8 weeks, and 12 weeks after the surgery using SF-36 and thyroid surgery-specific questionnaire.

Results

Patients in the TOETVA group are significantly younger than patients in the open surgery group (35.8 + 10.3 vs 46.9 + 11.5, p < 0.001). The mean operating time was longer in the TOETVA group (102.9 ± 26.1 mins) than that in the open surgery group (66.8 ± 23.8 mins) with p = 0.0001. Cosmetic outcomes and overall satisfaction were significantly greater in the TOETVA group p = 0.0001. The SF-36 QOL scores of the patients in the TOETVA group were generally higher than the open surgery group.

Conclusions

TOETVA has been widely used with a low complication rate, cosmetic appeal, and surgical efficacy. Postoperative quality of life, cosmetic outcomes, and overall satisfaction were significantly superior to the open surgery group.

Practising transoral robotic surgery in a middle-income country: surgical outcomes and early challenges

Transoral robotic surgery is a minimally invasive surgical technique that recently debuted in Malaysia. However, there are concerns over its cost, practicality, and feasibility in local settings. Our study aims to evaluate the surgical outcomes of transoral robotic surgery and discuss its learning curves. The clinical records of all patients who underwent transoral robotic surgery in a university hospital were reviewed. 25 patients were identified with a mean age of 43.9 years. The commonest indication was obstructive sleep apnoea (OSA) (76%), followed by base of tongue carcinoma (16%), recurrent tonsilitis and Wharton's duct cyst (4% each). For excision of tongue base in obstructive sleep apnoea without epiglottectomy, the mean operating time was 2.3(±0.9) hours with an average of 2.8(±0.4) days of hospital stay. The success rate for OSA surgery was seen in 78.9% of cases. The mean operating time for transoral excision of tongue base carcinoma was 4.3(±2.5) hours, whereas the mean hospital stay was 9(±3.6) days. All surgical margins were cleared with no recurrence except for one patient. The recurrent tumour was successfully excised via transoral robotic surgery, and he remained disease free after one year. The most frequent post-operative complaints were dysphagia, post-nasal drip, and hypogeusia. Transoral robotic surgery in Malaysia is in the commencement phase, where some pitfalls are expected. Opportunities should be given for more surgeons to acquire this technique so that minimally invasive surgery for head and neck diseases is readily available for patients in middle-income countries.

Application of robots in general surgery

Background: Application of robotic surgery in the field of general surgery has been increasing. This paper is an overview of the current uses and future perspectives of robotic surgery in four major divisions—endocrine, upper gastrointestinal, hepato-biliary-pancreatic (HBP), and colorectal surgery.Current Concepts: In endocrine surgery, cosmetic advantage is the highest priority when selecting a surgical approach for thyroidectomy. Currently, the transaxillary route is the most common approach. The introduction of the single-port system could maximize the advantages of this technique. In upper gastrointestinal surgery, the use of robots has the advantage of better retrieval of lymph nodes, less bleeding, earlier discharge, and less complications than the laparoscopic approach. However, a more prospective comparative trial is required to confirm those findings. In the HBP field, the indications of robotic surgery have expanded, starting with cholecystectomy to more challenging procedures, such as donor hepatectomy and pancreaticoduodenectomy. Meticulous dissection using robots could provide benefits to patients. In colorectal surgery, robotic surgery is an excellent technical tool for minimally invasive surgeries for rectal cancers, especially in male patients with narrow, deep pelvises. However, further studies are required to confirm the impact of robotic surgery on rectal cancers.Discussion and Conclusion: Robots are used to provide optimal surgical outcomes. Investigating new technologies and innovative surgical procedures is the highly important for a surgeon in the era of minimally invasive surgery.

Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis

Objective

To compare the clinical efficacy between robot‐assisted minimally invasive transforaminal lumbar interbody fusion (robot‐assisted MIS‐TLIF) and traditional open TLIF surgery in the treatment of lumbar spondylolisthesis.

Methods

According to the inclusion and exclusion criteria, 48 cases with lumbar spondylolisthesis who received surgical treatment from June 2016 to December 2017 in the spinal surgery department of Beijing Jishuitan Hospital were analyzed in this study, including 23 patients who received robot‐assisted MIS‐TLIF and 25 patients who received traditional open TLIF surgery. The two groups were compared in terms of pedicle screw accuracy evaluated by Gertzbein‐Robbins classification on postoperative computed tomography (CT), operation time, blood loss, postoperative drainage, hospitalization, time to independent ambulation, low back pain evaluated by visual analog scale (VAS), lumbar function evaluated by Oswestry Disability Index (ODI), paraspinal muscles atrophy on magnetic resonance imaging (MRI), and complications.

Results

Postoperative CT showed that the rate of Grade A screws in the robot‐assisted MIS‐TLIF group was significantly more than that in the open surgery group (χ² = 4.698, P = 0.025). Compared with the open surgery group, the robot‐assisted MIS‐TLIF group had significantly less intraoperative blood loss, less postoperative drainage, shorter hospitalization, shorter time to independent ambulation, and lower VAS at 3 days post‐operation (P < 0.05). However, the duration of surgery was longer. The VAS of the robot‐assisted MIS‐TLIF group decreased from 6.9 ± 1.8 at pre‐operation to 2.1 ± 0.8 at post‐operation, 1.8 ± 0.7 at 6‐month follow‐up and 1.6 ± 0.5 at 2‐year follow‐up. The VAS of the open surgery group decreased from 6.5 ± 1.7 at pre‐operation to 3.7 ± 2.1 at post‐operation, 2.1 ± 0.6 at 6‐month follow‐up and 1.9 ± 0.5 at 2‐year follow‐up. The ODI of the robot‐assisted MIS‐TLIF group decreased from 57.8% ± 8.9% at pre‐operation to 18.6% ± 4.7% at post‐operation, 15.7% ± 3.9% at 6‐month follow‐up and 14.6% ± 3.7% at 2‐year follow‐up. The ODI of the open surgery group decreased from 56.9% ± 8.8% at pre‐operation to 20.8% ± 5.1% at post‐operation, 17.3% ± 4.2% at 6‐month follow‐up and 16.5% ± 3.8% at 2‐year follow‐up. Paraspinal muscle cross‐sectional area in 2‐year follow‐up in patients of the open surgery group decreased significantly compared to patients of robotic‐assisted MIS‐TLIF group (P = 0.016).

Conclusion

In the treatment of lumbar spondylolisthesis, robot‐assisted MIS‐TLIF may lead to more precise pedicle screw placement, less intraoperative blood loss, less postoperative drainage, less postoperative pain, quicker recovery, and less paraspinal muscle atrophy than traditional open surgery.

Evaluating the differences in the early laparoscopic donor nephrectomy learning curves of a Swiss high volume transplant program and a South African low volume transplant program after knowledge transfer

Background

To describe the retroperitoneoscopic donor nephrectomy learning curve differences between a high volume (training) hospital in Basel, Switzerland, and a low volume (trainee) hospital in Cape Town, South Africa, after knowledge transfer. The South African hospital is resource constraint in hospital and training equipment. Techniques for performing the surgery were near identical.

Methods

Both units maintained prospective databases. Comparisons were made of the first 74 cases in each database: Basel’s series were from 19 January 2001 until 28 June 2004, while the Cape Town Hospital were from 8 April 2008 until 15 July 2008. Four surgeons operated in the Basel group, while only one surgeon operated in the Cape Town group. Variables compared include operating time (first skin incision until kidney was extracted), warm ischaemic time (renal arterial occlusion until cold bench reperfusion), blood loss, graft function, and hospital stay. We also analysed the first and last 25 cases of each series. Subgroup analysis of a single Basel surgeon was conducted.

Results

Donor age (means: Basel vs. Cape Town 54 vs. 33 p < 0.0001) and gender (males vs. females Cape Town 57% male and Basel 31% male) differed widely. The Basel group did more left-sided operations (72% vs. 58%). Operative times, blood loss and donor creatinine did not differ. Warm ischaemic time was significantly shorter in the Basel group (Cape Town mean 204 s Basel mean 130 s P = 0.0023). There was double the number of early graft failures in the South African group (six vs. three)—not related to donor surgery. Both groups showed a decline in operating times, plateauing at 30–34 cases.

Conclusions

There are statistically significant differences in some aspects of the learning curves of the Swiss (training) and South African (trainee) hospitals. These differences are clinically not pronounced, and the knowledge transfer was worth the effort.

Comparing quality of life between patients undergoing trans-areola endoscopic thyroid surgery and trans-oral endoscopic thyroid surgery

Background

Compared with conventional open surgery, endoscopic thyroidectomy via the oral vestibular approach (ETVOA) and endoscopic thyroidectomy via the areola approach (ETAA) avoided scarring of the skin, which may help patients achieve a better quality of life (QOL). However, the benefit of the QOL from this technique has not been adequately investigated, therefore this study compared the QOL outcomes between ETVOA and ETAA.

Methods

131 patients were enrolled in this study. ETAA surgery and ETVOA surgery were performed in 74 patients and 57 patients, respectively. These patients were followed up at 2 weeks, 4 weeks, and 8 weeks, and their QOL was evaluated using a thyroid surgery-specific questionnaire and a short-form health survey (SF-36).

Results

There were no differences in clinical characteristics such as gender, age, body mass index (BMI), and tumor size between the two groups. The volume of intraoperative blood loss, cost of hospitalization, and complications between the two procedures showed no differences. Compared with ETAA, ETVOA has a longer operation time, no drainage, and shorter hospital stay. In the QOL questionnaire, several parameters in ETVOA were better. The satisfaction scores of patients undergoing ETVOA were higher. In addition, the cosmetic satisfaction in patients who received ETOVA was significantly better than that of patients who underwent ETAA. The degree of neck movement disorder in patients with ETVOA was milder. Patients who received ETVOA had higher score on the SF-36.

Conclusions

The trans-oral endoscopic approach can acquire better cosmetic results and achieved high-level QOL.

Transoral Endoscopic Thyroidectomy Vestibular Approach: An Initial Experience in Vietnam

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be applied to many health facilities worldwide, even in places whose medical facilities have not developed yet. To that end, our hospital is the first hospital to deploy this novel technique in Vietnam. In the study, the authors will evaluate the safety and efficacy of TOETVA, which was initially performed on patients in Vietnam.

MATERIALS AND METHODS

A TOETVA research was conducted on 28 patients in hospital K from January 1, 2018 to May 31, 2019. The surgical outcomes, cosmetic results, and complications were evaluated.

RESULTS

The mean operative time was 91 minutes (70 to 130 min). There were no cases with temporary and permanent hypoparathyroidism in the patients. One patient had temporary mental nerve injury recovered completely after 14-day surgery. No case used drains in patients. All patients were highly satisfied with the surgical outcome, especially, cosmetic results.

CONCLUSIONS

TOETVA is a safe and feasible technique with acceptable complication rates and good outcomes. The authors will carry on this procedure for selected patients. TOETVA should not only be performed in some countries with well-developed health care systems but also be done in other developing countries worldwide.

Predictive factors for prolonged operative time of robotic thyroidectomy via bilateral axillo-breast approach: Analysis of 359 cases of differentiated thyroid cancer

OBJECTIVE

This study assessed the results of robotic thyroidectomy for differentiated thyroid cancer in early stage, to identify the predictive factors of operative time and complication rate.

METHODS

A patient cohort of 359 cases in total was involved in this retrospective study. The data of clinical characteristics and follow-up results were collected.

RESULTS

The cohort of patients involved was composed of 285 female patients and 74 male ones. The mean age was 34.91 ± 7.93 years old. The mean Body Mass Index (BMI) was 22.43 ± 3.47. The mean tumor size was 0.75 ± 0.56 cm, and the mean gland size was 4.68 ± 0.83 cm. Among all the specimen, the ratio of tumor invasion of gland capsule was 63/296, and the ratio of chronic thyroiditis was 110/249. 75 patients underwent total thyroidectomy + central compartment node dissection (CCND). 284 patients underwent Lobectomy + CCND. The ratio of central lymph node metastasis was 144/215 (40.1%). The mean number of lymph node dissected was 5.26 ± 4.09. The mean operative time was 96.53 ± 25.69 min. 21(5.8%) patients had hoarseness after operation. 22(29.3%) patients had hypocalcemia after total thyroidectomy. The inadvertent parathyroidectomy was found in 66(18.4%) cases. The surgical extent (unilateral/bilateral resection), BMI and gland size were found to have a significantly correlation with the operative time (p < 0.05) after multivariate analysis.

CONCLUSION

The surgical extent, BMI and gland size are found to be independent risk factors of prolonged operative time of robotic thyroidectomy. However, these factors are not associated with a higher complication rate.

Unilateral axilla-bilateral areola approach for thyroidectomy by da Vinci robot vs. open surgery in thyroid cancer: a retrospective observational study

Background

To compare the efficacy and safety of unilateral axilla-bilateral areola (UABA) approach for robot-assisted thyroidectomy with conventional open surgery in thyroid cancer patients.

Methods

The clinicopathological features and surgical outcomes of 194 thyroid cancer patients treated by robotic surgery using the UABA approach and 217 patients treated by open surgery in our department from January 2017 to August 2018 were analysed and compared.

Results

The operation time was longer in the robotic group than in the open surgery group. The patients' satisfaction with neck appearance was higher in the robotic group than in the open surgery group (91.2% vs. 21.6%, P<0.01). After total thyroidectomy and central lymph node dissection, the incidence of postoperative transient hypoparathyroidism and postoperative permanent hypoparathyroidism in the open surgery group was 29.7% (44/148) and 6.8% (10/148), higher than that [17.9% (27/151) and 2.0% (3/151)] in the robotic group (P<0.05 respectively). No significant difference was observed in the number of dissected lymph nodes or postoperative serum thyroglobulin (TG) levels or incidence of transient or permanent hoarseness of voice between the two groups. No recurrence or metastasis was found.

Conclusions

Compared with open surgery, UABA robotic surgery preserved the neck appearance and effectively reduced hypoparathyroidism by super-meticulous capsular dissection (SMCD).

Preferences for thyroidectomy technique: Comparing traditional and transoral approaches

BACKGROUND

We investigated preferences between the transcervical and transoral thyroidectomy approach in the United States and Israel.

METHODS

An online survey assessing scar attitudes and surgical preferences, in English and Hebrew, was distributed on ThyCa.com and other platforms.

RESULTS

928 and 339 responses from the United States and Israel cohorts, respectively, were analyzed. In both countries, individuals without prior thyroidectomy preferred a scarless approach when hypothetical risks equaled those of traditional thyroidectomy (77% United States, 76% Israel, p = 0.61). U.S. respondents without thyroidectomy had greater preference to avoid a scar and would pay more to do so than those with thyroidectomy (both p < 0.001). Many respondents with prior thyroidectomy still expressed interest in scarless alternatives (57% United States).

CONCLUSIONS

Populations in Israel and the United States prefer scarless thyroidectomy when risks equal the traditional approach. While individuals without prior thyroidectomy are more likely to favor a scarless option, former thyroidectomy patients may have preferred avoiding a scar.

A Single Surgeon's 10-Year Experience in Remote-Access Thyroid and Parathyroid Surgery

BACKGROUND

Remote-access thyroid and parathyroid surgery has gained popularity recently due to its benefit of avoiding visible neck scars. Most of these techniques were described and performed in Asia, on patients with different body habitus compared to American patients. We aim to analyze the learning curve in performing these operations in North America. .

METHODS

This is a retrospective cohort study of a 10-year experience by a single surgeon at a North American institute. Patients who underwent thyroid or parathyroid procedures by a transaxillary, retroauricular, or transoral endoscopic thyroidectomy vestibular approach (TOETVA) were included. Cumulative sum (CUSUM) was used to analyze learning curves based on intraoperative blood loss and total operative times and learning phases were divided accordingly.

RESULTS

Three hundred seventy-two remote-access thyroid and parathyroid procedures were performed during the study period. Total operative time for transaxillary procedures was initially reduced after the 69th procedure and then again after the 134th case. For retroauricular procedures, marked reduction in the operative time was observed after 21 procedures. Most patients (57.02%) were discharged home on the same day during the mastering phase. In the transaxillary procedures, only 1 case of brachial plexus injury occurred prior to the routine use of somatosensory evoked potential (SSEP) monitoring.

DISCUSSION

Remote-access thyroid and parathyroid surgeries can be performed safely with minimal complications in a select group of patients. Analysis of the learning curve in performing these operations aids in structuring a safe and effective learning period for endocrine surgeons seeking to venture into this modality of treatment.

Minimally Invasive Approaches for Thyroid Surgery-Pitfalls and Promises

PURPOSE OF REVIEW

To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies.

RECENT FINDINGS

Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

Comparison of quality of life between patients undergoing trans-oral endoscopic thyroid surgery and conventional open surgery

Background

Trans-oral endoscopic thyroidectomy allows obviating scar of the neck that expects to gain quality of life (QOL). However, the benefit of the QOL from this technique has not been adequately investigated, therefore, this study compared the QOL outcomes, including cosmetic outcomes, between thyroidectomy by trans-oral endoscopy and conventional open surgery.

Methods

A study was conducted from January 30, 2017 to November 10, 2018. Thirty-two and 38 patients underwent trans-oral endoscopic thyroid surgery and conventional open surgery, respectively. Their quality of life was evaluated at 2, 6, and 12 weeks postoperatively using a thyroid surgery-specific questionnaire and a 36-item short-form questionnaire.

Results

Trans-oral endoscopic group, patients were younger and presented with smaller thyroid nodules (p < 0.05). Regarding surgical outcomes, there were no statistically significant differences between the two groups. Mean operative time was significantly longer in the trans-oral endoscopic group (p < 0.05). The quality of life parameters in the trans-oral endoscopic group was significantly better than in the conventional surgery group (p < 0.05). These parameters included reduction of physical activity, psychosocial impairment, the role of physic, and emotion at 2 weeks after surgery; swallowing impairment, psychosocial impairment, the role of physic, social function and mental health 6 weeks after surgery; tingling and feeling of vitality at 12 weeks after surgery. Cosmetic outcomes and overall satisfaction were significantly better in the trans-oral endoscopic group than in the conventional surgery group at all of our follow up times (p < 0.05).

Conclusions

The trans-oral endoscopic approach allows real scarless on the skin with better cosmetic and QOL outcomes.

Trial registration

This trial was retrospectively registered at the ClinicalTrial.gov (NCT03048539), registered on 4 March 2017.

Systematic review of learning curves in robot-assisted surgery

Background

Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery.

Methods

MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients.

Results

Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology.

Conclusion

Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.

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 via Vestibular Approach: A series of the first ten cases in Iraq

Transoral endoscopic thyroidectomy was first described as an experimental sublingual approach. This approach was modified to a vestibular approach to avoid complications. In this report, we describe the results of the first ten cases of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) performed in Iraq. All operations were performed at Al Shifa General Hospital, Basrah, Iraq, in 2017 using three laparoscopic ports inserted at the oral vestibule. One out of ten patients underwent a near total thyroidectomy, the remaining cases underwent thyroid lobectomies. The average operative time was 113.5 minutes and the average duration of hospital stay was 41.9 hours. One case of mild cervical emphysema and one case of temporary mental nerve palsy were reported but both were treated conservatively without permanent sequelae. In conclusion, TOETVA is a safe, feasible procedure with an excellent cosmetic outcome when the patients are selected carefully.

Starting a Transoral Thyroid and Parathyroid Surgery Program

Purpose of Review

To describe the necessary steps to facilitate safe implementation of a transoral thyroid and parathyroid surgery program.

Recent Findings

Transoral vestibular approaches to the central neck have been demonstrated to be safe and feasible, while avoiding the morbidity of a cutaneous scar. As operative volume expands from a select few high-volume centers, a framework for implementation has been recommended to allow the evidence-based outcomes to translate into clinical practice for new adopters of these techniques. These include securing institutional support, choosing the appropriate candidate (both patient and surgeon), appropriate case observation and instruction (live and cadaver), and adequate first-case preparation and knowledge of the learning curve(s) for the techniques.

Summary

The recommendations in this article provide a foundation from which a transoral thyroid and parathyroid program may be successfully built. An intricate understanding of conventional transcervical central neck surgery and institutional support are absolute prerequisites to safe and successful implementation of these transoral vestibular techniques.

Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform

BACKGROUND

Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy.

METHODS

We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter).

RESULTS

Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy.

CONCLUSIONS

Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial.

TRIAL REGISTRATION

Retrospectively registered on 20 july 2018 .

TRIAL REGISTRATION NUMBER

researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

Remote-Access Thyroidectomy: A Multi-Institutional North American Experience with Transaxillary, Robotic Facelift, and Transoral Endoscopic Vestibular Approaches

BACKGROUND

Many remote-access approaches (RAAs) to the thyroid have been described to circumvent anterior neck scarring, including the transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. These techniques have been popularized in Asia, but adoption has been slow in North America. We aimed to examine multi-institutional North American outcomes with RAA thyroidectomy in the context of these institutions' transcervical approach (TCA) outcomes.

STUDY DESIGN

Cases of lobectomy and total thyroidectomy via transaxillary, robotic facelift, and transoral endoscopic vestibular approaches were reviewed. Demographic characteristics, outcomes, and complications were compared with the same measures in patients undergoing lobectomy and total thyroidectomy via TCA by the primary RAA surgeons at each institution. Patients who underwent parathyroidectomy or other concomitant neck dissection procedures were excluded.

RESULTS

Two hundred and sixteen RAA thyroidectomies were attempted (92 transoral endoscopic vestibular approaches, 70 transaxillary, and 54 robotic facelift) and 410 TCA thyroidectomies were performed. There was no difference in mean index nodule sizes between RAA (2.8 ± 1.6 cm) and TCA (2.9 ± 1.9 cm) cohorts (p = 0.72). Median operative times for lobectomy were 146 minutes (range 60 to 343 minutes) and 90 minutes (range 25 to 247 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). Median operative time for total thyroidectomy was 170 minutes (range 100 to 398 minutes) vs 126.5 minutes (range 51 to 260 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). There was no difference in the rates of permanent recurrent laryngeal nerve injury between the RAA (0 of 216 [0%]) and TCA (0 of 410 [0%]) cohorts (p = 0.99).

CONCLUSIONS

Remote-access approach thyroidectomy can be performed in a select North American patient population with outcomes comparable with TCA.

Anterior cervical incision-sparing thyroidectomy: Comparing retroauricular and transoral approaches

Objectives

The robotic retroauricular approach and transoral endoscopic thyroidectomy vestibular approach (TOETVA) have been employed to avoid anterior neck scarring in thyroidectomy with good success. However, outcomes have yet to be compared between techniques. We compare our initial clinical experience with these approaches for thyroid lobectomy at our institution.

Methods

A review of initial consecutive patients who underwent robotic facelift thyroidectomy (RFT) (August 2011–August 2016) at our institution was conducted. This was compared with the same number of initial consecutive patients who underwent TOETVA (September 2016–September 2017) at our institution. Demographics, operative time, pathology, complications, and learning curve were compared between cohorts. Learning curve was defined based on the slope of linear regression models of operative time versus case number.

Results

There were 20 patients in each cohort. There was no statistically significant difference in demographic data between cohorts. One hundred percent of RFT cases versus 95% TOETVA cases (P = .999) were completed without conversion to standard open technique with median operative times of 201 (124–293) minutes versus 188 (89–343) minutes with RFT and TOETVA, respectively (P = .36). There was no incidence of permanent recurrent laryngeal nerve injury in either cohort. The slopes of the regression models were 0.29 versus −8.32 (P = .005) for RFT and TOETVA, respectively.

Conclusion

RFT and TOETVA are safe and feasible options for patients motivated to avoid an anterior neck scar. However, the quicker learning curve without the need for a costly robotic system may make TOETVA the preferred technique for institutions wishing to perform anterior cervical incision‐sparing thyroidectomy.

Level of Evidence

4

Efficacy of a clinical pathway for patients with thyroid cancer

BACKGROUND

Clinical pathways have been proposed as a way to improve organizational efficiency and maximize patient outcomes. However, little is known as to whether a clinical pathway is effective for thyroid cancer.

METHODS

The study subjects included 216 patients who were managed after clinical pathway implementation and 145 control patients. Length of stay, cost per patient, and nurses' satisfaction were compared in the 2 groups.

RESULTS

Mean length of stay was 0.8 days shorter in the clinical pathway group than in the control group (2.9 vs 3.7 days; P = .023). Cost per patient was also lower in the clinical pathway than in the control group (USD $3953.00 vs USD $4636.00; P < .001). Nurses' overall satisfaction scores improved from 71.6% before to 82.5% after implementation of the clinical pathway and their job characteristics scores increased from 61.1% to 75.0%.

CONCLUSION

Implementation of a clinical pathway for thyroid cancer can improve nurses' satisfaction with reduction of hospital stay and costs.

Factors affecting operative time in robotic thyroidectomy

BACKGROUND

The purpose of this study was to evaluate factors related to operative time in robotic thyroidectomy.

METHODS

We retrospectively analyzed 240 patients who underwent robotic thyroidectomy. The total thyroidectomy cases and lobectomy cases were both categorized into those with long operative times (LOTs; upper 25% of cases) and those with short operative times (SOTs; lower 25%).

RESULTS

Among the total thyroidectomy cases, body mass index (BMI) ≥23 kg/m² (hazard ratio [HR] 5.34; P = .008) and bilateral central neck dissection (CND; HR 14.92; P = .028) were more frequent in the LOT group in multivariate analysis. Among the lobectomy cases, BMI ≥23 kg/m² (HR 12.92; P = .003) and unilateral CND (HR 21.38; P = .017) were the only independent risk factors for prolonged operative time.

CONCLUSION

Body habitus and clinical nodal status in the central compartment should be considered in deciding the indications for robotic thyroidectomy.

Gasless trans-axillary robotic thyroidectomy: the technique and evidence

Robot assisted thyroid surgery has the advantage of a superior field vision and technical advancements of robotic technology that have permitted novel remote access thyroid surgical approaches. Gasless trans-axillary robot-assisted thyroidectomy has been proved to be among the most current feasible approaches. This approach offers an excellent cosmetic outcome, with comparable outcomes to conventional surgical approaches. This review aims to provide details of this specific remote access technique for thyroid resection with most recent evidences in the literature.

Transoral thyroidectomy and parathyroidectomy - A North American series of robotic and endoscopic transoral approaches to the central neck

OBJECTIVE

Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma.

MATERIALS AND METHODS

Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017.

RESULTS

Fifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life.

CONCLUSION

The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Quality of life and cosmetic result of single-port access endoscopic thyroidectomy via axillary approach in patients with papillary thyroid carcinoma

BACKGROUND

Endoscopic thyroidectomy for minimally invasive thyroid surgery has been widely applied in the past decade. The present study aimed to evaluate the effects of single-port access transaxillary totally endoscopic thyroidectomy on the postoperative outcomes and functional parameters, including quality of life and cosmetic result in patients with papillary thyroid carcinoma (PTC).

PATIENTS AND METHODS

Seventy-five patients with PTC who underwent endoscopic thyroidectomy via a single-port access transaxillary approach were included (experimental group). A total of 123 patients with PTC who were subjected to conventional open total thyroidectomy served as the control group. The health-related quality of life and cosmetic and satisfaction outcomes were assessed postoperatively.

RESULTS

The mean operation time was significantly increased in the experimental group. The physiological functions and social functions in the two groups were remarkably augmented after 6 months of surgery. However, there was no significant difference in the scores of speech and taste between the two groups at the indicated time of 1 month and 6 months. In addition, the scores for appearance, satisfaction with appearance, role-physical, bodily pain, and general health in the experimental group were better than those in the control group at 1 month and 6 months after surgery.

CONCLUSION

The single-port access transaxillary totally endoscopic thyroidectomy is safe and feasible for the treatment of patients with PTC. The subjects who underwent this technique have a good perception of their general state of health and are likely to participate in social activities. It is worthy of being clinically used for patients with PTC.

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

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

Remote access thyroid surgery

Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed their various advantages in terms of post-operative outcomes; however, the associated financial burden and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.

Robotic transaxillary thyroid surgery

Recent technological advances have led to a rapid progress in endocrine surgery. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, increased patient satisfaction, improved visualization, arms articulations, eliminating surgeon's natural tremor, thereby increasing precision. The main disadvantages are longer operative time, and increased cost compared to conventional thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea. Large-scale studies, mainly from South-Korea, have proved that in skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications.

A prospective 1-year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising?

BACKGROUND

The purpose of this study was to evaluate postoperative voice outcomes and functional parameters in total thyroidectomy via a transaxillary (TA) approach.

METHODS

Seventy-six patients who underwent total thyroidectomy via a TA approach (TA group) were included. A total of 204 patients who underwent conventional open total thyroidectomy (conventional group) in the same time period were analyzed as a control group. All patients underwent prospective functional evaluations before surgery and at 1 week and 1, 3, 6, and 12 months postoperatively using a comprehensive battery of functional assessments.

RESULTS

There was no conversion to conventional open thyroidectomy in the TA group. Operation time and the amount of drainage were significantly higher in the TA group than in the conventional group (p < 0.001 and p = 0.033, respectively), while vocal cord paralysis, hypoparathyroidism, and hematoma were not different among two groups (p = 0.215, 0.290, and 0.385, respectively). Regarding GRBAS, the TA group showed a more aggravated tendency postoperatively, although statistical significance was attained only at postoperative 6 months (p = 0.043). The voice handicap index abruptly increased postoperatively in the TA group, showing significant differences with the conventional group at postoperative 1 week and 1 month (p < 0.001 and p = 0.001, respectively). Fundamental frequency and maximal vocal pitch did not significantly change postoperatively in either group. The conventional group showed a more rapid decline in pain than the TA group, and paresthesias on the neck and chest were more aggravated in the TA group during the early postoperative period. The dysphagia handicap index was higher in the TA group, while cosmesis was better in the TA group at all postoperative periods.

CONCLUSIONS

Although cosmetic outcome was better with the TA approach, the longer operation time, aggravated subjective voice outcomes, paresthesia, and swallowing function need to be considered in selecting the operative approach.