Robotic transoral thyroidectomy: Total thyroidectomy and ipsilateral central neck dissection with da Vinci Xi Surgical System

Re-do transoral robotic thyroidectomy is feasible: preliminary results of the surgical feasibility and efficacy of completion transoral robotic thyroidectomy: cohort study

BACKGROUND

Transoral robotic thyroidectomy (TORT) has proven to be a safe and effective procedure with favourable surgical and cosmetic outcomes, but its application in completion thyroidectomy procedures remains to be established. In this study, the authors present our experience with completion TORT, assessing its surgical feasibility and efficacy. between February 2017 and August 2023.

METHODS

The authors conducted a retrospective analysis of consecutive patients who underwent completion TORT after an initial TORT procedure between February 2017 and August 2023.

RESULTS

A total of 10 patients (three males and seven females) were included in the study, with a mean age of 42.2±13.5 years. The indications for completion thyroidectomy included five cases of aggressive initial lesions and five cases of metachronous papillary thyroid carcinoma detected in the remnant lobe. The median interval between the initial and completion TORT procedures was 6.5 months. Flap dissection time showed no significant difference between the initial TORT and completion TORT operations (43.3±7.5 vs. 36.2±11.2, P =0.125). However, the mean console time (127.9±42.6 vs. 86.4±26.3 min, P =0.019) and mean total operation time (206.7±65.9 vs. 146.0±34.9 min, P =0.021) were significantly longer during the initial TORT procedure than during the completion TORT procedure. Two patients experienced transient hypoparathyroidism, which resolved within four weeks postoperatively. No other complications, such as vocal cord palsy, mental nerve injury, or bleeding, were observed. The median follow-up period was 21.5 months, and no recurrences were detected in any of the patients.

CONCLUSIONS

Our study demonstrates that re-do TORT is feasible, showing excellent cosmetic results and minimal adverse effects. Completion TORT may be considered a viable option for selected patients who require completion thyroidectomy after an initial TORT procedure.

Initial Clinical Application of Enhanced Recovery After Transoral Robotic Thyroidectomy

Background: The enhanced recovery after surgery (ERAS) protocol has been widely adopted across various surgical subspecialties. Transoral robotic thyroidectomy (TORT) has grown in popularity in the past decade. Therefore, this study aimed to discuss the initial application of ERAS in TORT. Methods: We retrospectively analyzed the clinical data of 95 patients who had undergone TORT in our department from April 2020 to March 2022. All patients were treated using the ERAS protocol. Results: TORT was successfully performed in all 95 patients. Postoperative histopathological examination revealed papillary carcinoma. The average operative time, hemorrhage volume, length of postoperative stay, and pain score (24 hours after surgery) were 227.32 ± 44.37 minutes, 35.81 ± 23.45 mL, 1.37 ± 0.62 days, and 2.11 ± 0.54, respectively. Sixty patients received an analgesia pump, with no significant difference in pain scores between the patients with and without the pump (P > .05). Eight patients experienced transient mandibular numbness, and two experienced transient hoarseness postoperatively. Of the 24 cases of total thyroidectomy/bilateral subtotal thyroidectomy (ST) or lobectomy with isthmusectomy plus contralateral ST patients, 8 developed transient hypoparathyroidism. No common complications, such as incision infection, hematoma/effusion formation, coughing while drinking, or permanent hoarseness/hypocalcemia, were reported. Conclusion: Our initial outcomes demonstrate that implementing an ERAS protocol in TORT is safe and feasible.

Feasibility of robotic thyroidectomy via hairline incision using da Vinci single port system: Initial experience with 40 consecutive cases

BACKGROUND

This study aimed to introduce our robotic technique, which can minimize dissection extent using the da Vinci SP robotic system via hairline incision.

METHODS

Forty patients underwent robotic thyroidectomy using the da Vinci SP robotic system via a hairline incision between February 2020 and April 2021 at Ulsan University Hospital. All procedures were performed successfully by one surgeon using the SP robotic system.

RESULTS

Hemithyroidectomies were performed in 32 patients and total thyroidectomies in eight patients. Central neck dissection was performed in 32 patients. The overall mean operative time was 140.2 ± 50.7 min, and the mean console time was 74.0 ± 42.7 min. All patients were discharged on the second or third day after operation without any complications.

CONCLUSIONS

Robotic thyroidectomy using the SP robotic system via hairline incision is technically feasible and safe, with a shorter incision length when compared with that of the Xi system.

Pictorial essay of vestibular incision outcomes from transoral endoscopic thyroidectomy

PURPOSE

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a new treatment option for patients with selected thyroid disease requiring surgery. The aim of this pictorial essay is to illustrate the healing outcomes of the vestibular incisions.

METHODS

TOETVA patients were recruited at two Centers in China and Italy. TOETVA is initiated with one 10-20-mm median incision in the center of the oral vestibule 10 mm above the inferior labial frenulum, and two 5-mm lateral incisions, just below the lower lip near the labial commissure. Healing of the vestibular incision was monitored through serial photographs 1, 3, 7, 30, and 90 days after surgery. Outcomes were evaluated by Landry's score, time to healing, issues affecting wound outcomes, scar, fibrin, granulation, necrotic tissue formation, and infections.

RESULTS

Results of TOETVA were monitored in 52 patients. There were no postoperative infections. All lateral incisions demonstrated favorable surgical outcomes. Landry's criteria scores indicated worse outcomes for the median incisions vs. the lateral ones (p<0.05). Median incisions healed well in 65.4% of patients, but 34.6% of patients had visible scars from the median incision 90 days after surgery. Eight (15.4%) had cicatricial diathesis, seven (13.5%) experienced displacement of the stitches, and three (5.8%) developed synechia with gingiva. When the central vestibular incision was <10mm from the gingiva, patients tended to form synechia (60%). There were no significant differences in wound healing between the Chinese and Italian patients.

CONCLUSIONS

Knowledge of vestibular incision healing is essential to provide practical TOETVA clinical guide and to define optimal outcomes evaluation for transoral surgeons. Vestibular wound problems were confined only to the central incision.

Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update

Transoral endoscopic thyroidectomy and parathyroidectomy via the vestibular approach (TOET/PVA or TOETVA-TOEPVA) is the latest remote-access technique employed in the central neck. As the only approach that does not leave any cutaneous incision, (TOET/PVA) has become popular in both the Far East and Western series since its original description in 2015. More than just a "scarless" surgery, (TOET/PVA) has been associated with a short learning curve, access to the bilateral central neck compartments, few surgical contraindications, minimal complications, and minimal additional instrumentation. To date, more than 2,000 cases have been completed, including more than 400 in North America, demonstrating brisk utilization of a novel technique relative to earlier remote access central neck approaches. Herein, we describe updates that continue to improve the safety and efficacy of the procedure.

Postoperative drain after transoral endoscopic thyroidectomy vestibular approach (TOETVA) with single incision

OBJECTIVE

To find the optimal size of a drain for the reliable drainage and the best cosmetic result in TOETVA. To explore the normal drainage flow rate after TOETVA.

METHODS

A prospective randomized controlled trial was performed in a single center from December 2016 to December 2018. One hundred and fifty-three (153) patients had TOETVA with a single incision and were randomly divided into two groups. Self-made drainage tubes with a small diameter (outer diameter 2.0 mm, inner diameter 1.0 mm) were used in 80 patients (experimental group). No. 8 tubes were used in 73 patients (control group). The clinical characteristics and results between both groups were compared by t test or chi-square test, and the results of normal drainage flow rate were calculated.

RESULTS

The experimental group had a longer intraoperative tube-inserting time, compared with the control group (9.5 ± 2.5 min vs. 5.6 ± 1.4 min, p = 0.001), a smaller scar six months after the operation (1.8 ± 2.3 mm vs. 3.1 ± 2.6 mm, p = 0.002), and a lower Vancouver Scar Scale score at both one month (3.20 ± 1.44 vs. 4.19 ± 1.92, p = 0.001) and six months after the operation(1.43 ± 1.84 vs. 2.40 ± 2.37, p = 0.006). The drainage volume, pain score on the first day, postoperative complications (tube blockage, air leakage, subcutaneous hydrops, hematoma, regional infection), and the extubation time were not significantly different. The average drainage of 148 patients without postoperative complications was 78.3 ± 10.9 ml. The cumulative drainage within 8 h, and 32 h after the operation accounted for 53.2% and 91.9% of the total drainage, respectively. The residual drainage at 32 h was estimated to be 6.5 ± 2.9 ml (P95 = 11.0 ml). A linear regression equation between total volume (V_t) and the size of resected tissue (S) was established: V_t = 1.625 S + 56.604 (p = 0.0001).

CONCLUSION

In TOETVA, a small drain can provide a good cosmetic appearance and reliable drainage. The main exudation period of the wound is within 8 h after the operation. If a residual volume of less than 11 ml is considered to be self-absorbable, the shortest safe extubation point for 95% of patients should be 32 h after the operation.

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO2 insufflation: Preclinical feasibility study

BACKGROUND

Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision.

METHODS

In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers.

RESULTS

A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands.

CONCLUSION

In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.