Comparison of surgical outcomes between endoscopic and robotic thyroidectomy

Postoperative Pain Following Transoral Thyroidectomy via Vestibular Approach and Cervical Thyroidectomy: A Systematic Review and Meta-Analysis

Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) represents a minimally invasive alternative to traditional open thyroidectomy (OT). The objective of this systematic review and meta-analysis was to comprehensively analyze and compare postoperative pain outcomes between conventional open thyroidectomy (COT) and TOETVA. We conducted a systematic search across multiple databases, including PubMed, Medline, Elton B. Stephens Company (EBSCO), and Google Scholar, to identify cohorts and randomized trials comparing postoperative pain outcomes between patients undergoing transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) and those undergoing conventional thyroidectomy. The search period spanned from the earliest available article up to January 15, 2022. Keywords such as "scarless thyroidectomy," "endoscopic transoral via vestibular thyroidectomy," "conventional thyroidectomy," "transcervical thyroidectomy," "postoperative pain," and "visual analog pain score" were utilized to retrieve relevant studies. A total of 1,291 patients from 11 studies were included in our analysis, with 10 studies originating from Asia and one from Europe. Among these studies, seven were prospective, while four were retrospective. The primary outcome measure was postoperative pain. Various statistical tests were also performed for data analysis, including the Chi-square and random effects model. The Newcastle Ottawa Scale was used to assess the quality of studies. There was no significant statistical difference observed between the endoscopic transoral vestibular route and the conventional cervical approach in terms of visual analog scale (VAS) score, with an odds ratio of -0.37 and a 95% confidence interval ranging from -0.9 to 0.17. The overall effect had a P-value of 0.18. However, substantial heterogeneity was noted, with an I2 value for heterogeneity of 98% and a P-value for heterogeneity of less than 0.001. The Chi-square value was calculated as 364.02, and the main difference was 9. In comparison, TOETVA exhibited lower pain levels on the first day post-operation compared to conventional thyroidectomy, with an odds ratio of -1.36 and a 95% confidence interval ranging from -2.65 to -0.06. Transoral endoscopic thyroidectomy via the vestibular approach demonstrated superior outcomes compared to conventional thyroidectomy in terms of postoperative pain management on the first day following surgery. However, when considering overall pain management throughout the recovery period, no significant difference was observed between the two approaches. More extensive studies evaluating pain levels on the day of surgery and controlling for analgesic interventions are warranted.

Clinical analysis of a new multifunctional instrument set for gasless endoscopic thyroidectomy with two different approaches

BACKGROUND

Following the rapid development of endoscopic thyroidectomy techniques, various surgical procedures have been developed (e.g., transoral, submandibular, areolar, axillary, retroauricular, and combined procedures), and each of these procedures has its own advantages. In recent years, gasless endoscopic thyroidectomy has emerged as a feasible procedure, and it has replaced traditional CO2 insufflation approaches because of advantages such as stable cavity construction, pollution reduction, resource saving, and risk reduction. However, each gasless procedure requires special instruments for cavity construction, and this results in enormous wastage of medical resources. In the present study, we introduced a set of instruments developed by our team. This set of instruments is designed to be compatible with the current gasless endoscopic thyroidectomy approaches, including transoral, submandibular, transareolar, transaxillary, retroauricular, combined, and lateral cervical lymph node dissection. Here, we introduced this set of instruments for two gasless endoscopic thyroidectomy procedures (transaxillary and transareolar). Following the incorporation of this set of instruments in regular clinical practice, it could be used for more gasless endoscopic thyroidectomy procedures in the future.

OBJECTIVE

To investigate the feasibility, safety, and efficacy of the self-developed instruments for gasless endoscopic thyroidectomy in two different approaches.

METHODS

A total of 180 patients diagnosed to have papillary thyroid carcinoma (PTC) between January 2020 and April 2022 were retrospectively investigated. The patients were assigned to a gasless transaxillary group (group A) and a gasless transareolar group (group B). The same gasless endoscopic-assisted instruments were used for both groups. The clinical characteristics, treatment results, and complications were compared between the two groups.

RESULTS

All 180 patients were successfully operated. The extent of surgical resection in all patients was the same: "unilateral glandular lobectomy + isthmus combined with ipsilateral central zone lymph node dissection." There were 130 and 50 patients in group A and group B, respectively; one patient in the former group was converted to open surgery due to intraoperative bleeding. No significant difference was observed between the two groups in terms of gender, age, body mass index (BMI), education level, and proportion of concomitant Hashimoto's thyroiditis (P > 0.05). The establishment of cavity time was significantly longer in group A than in group B (35.62 ± 5.07 min vs. 17.46 ± 2.55 min, P < 0.01). The number of lymph nodes cleared was slightly less in group A than in group B (4.06 ± 2.93 vs. 4.52 ± 2.38, P = 0.07). Moreover, the two groups showed no significant differences (P > 0.05) in the total operative time (145.54 ± 45.11 min vs. 143.06 ± 46.70 min), tumor size (0.68 ± 0.46 cm vs. 0.71 ± 0.49 cm), postoperative hospital stay (4.08 ± 1.48 days vs. 3.72 ± 1.07 days), vocal cord paralysis [4 (3.1%) vs. 2 (4%)], postoperative swallowing discomfort [24 (18.5%) vs. 5 (10%)], and postoperative recurrence and satisfaction scores (3.27 ± 1.52 vs. 3.28 ± 1.53).

CONCLUSION

Although the two approaches of gasless endoscopic surgery have different operative paths and different time periods for cavity construction, both approaches are similar in terms of the principle of cavity construction, safe and reliable postoperative efficacy, and good cosmetic effect. Therefore, the same set of instruments can be used to complete the surgery in both approaches, thus saving medical resources and facilitating the popularization of this technology.

Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study

BACKGROUND

Robot-assisted and endoscopic thyroidectomy are superior to conventional open thyroidectomy in improving cosmetic outcomes and postoperative quality of life. The procedure of these thyroidectomies was similar in terms of surgical view, feasibility, and invasiveness. However, it remains uncertain whether the robotic-assisted bilateral axilla-breast approach (BABA) was superior to the endoscopic bilateral areolar approach (BAA) thyroidectomy. This study aimed to investigate the clinical benefit of these two surgical procedures to evaluate the difference between these two surgical procedures by comparing the pathological and surgical outcomes of endoscopic BAA and robotic-assisted BABA thyroidectomy in differentiated thyroid carcinoma.

METHODS

From November 2018 to September 2021, 278 patients with differentiated thyroid carcinoma underwent BABA robot-assisted, and 49 underwent BAA approach endoscopic thyroidectomy. Of these patients, we analyzed 42 and 135 patients of endoscopic and robotic matched pairs using 1:4 propensity score matching and retrospective cohort study methods. These two groups were retrospectively compared by surgical outcomes, clinicopathological characteristics, and postoperative complications.

RESULTS

The mean operation time was significantly longer in the EG than in the RG (p < 0.001), The number of retrieved lymph nodes was significantly lower in the ET group than in the RT group (p < 0.001). The mean maximum diameter of the thyroid was more expansive in the EG than in the RG (p = 0.04). There were no significant differences in the total drainage amount and drain insertion days between the two groups (p = 0.241, p = 0.316, respectively). Both groups showed that cosmetic satisfaction (p = 0.837) and pain score (p = 0.077) were similar. There were no significant differences in complication frequencies.

CONCLUSION

Robotic and endoscopic thyroidectomy are similar minimally invasive thyroid surgeries, each with its advantages, both of which can achieve the expected surgical outcomes.

TRIAL REGISTRATION

Retrospectively registered.

Efficacy and Safety of Minimally Invasive Thyroid Surgery: A Network Meta-Analysis

OBJECTIVES

Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods.

DATA SOURCES

The PubMed, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar.

REVIEW METHODS

The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed.

RESULTS

EO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding.

CONCLUSION

It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470-2479, 2023.

Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless alternative to open thyroidectomy (OT). This systematic review and meta-analysis aimed to synthesize evidence comparing the intraoperative and postoperative outcomes of TOETVA and OT.

METHODS

A systematic literature search of PubMed, Web of Science, the Cochrane Library, and Google Scholar was performed to identify studies comparing the outcomes of TOETVA and OT published before February 2023. The outcomes of interest were operative time, intraoperative blood loss, hospital stay, postoperative pain, number of central lymph nodes retrieved, number of metastatic central lymph nodes, and incidences of transient and permanent recurrent laryngeal nerve injury, transient and permanent hypocalcemia, hematoma, and infection.

RESULTS

Thirteen studies published between 2016 and 2022, involving a total of 2889 patients (TOETVA, n =1085; OT, n =1804) were included in this systematic review and meta-analysis. Meta-analysis showed that the TOETVA group had a significantly longer overall operative time (weighted mean difference [WMD] 55.19; 95% CI, 39.15, 71.23; P <0.001), longer hospital stay (WMD, 0.27; 95% CI, 0.14, 0.39; P <0.001), and lower pain scores on postoperative day 1 (WMD, -1.41; 95% CI, -2.79, -0.03; P =0.04) than the OT group. Other intraoperative and postoperative outcomes were not significantly different between the groups.

CONCLUSION

TOETVA has a similar safety profile to OT with less postoperative pain, making it an appropriate and more cosmetically appealing alternative to OT for select patients.

Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: A network meta-analysis

BACKGROUND

To assess the surgical outcomes of various minimally invasive and remote-access surgical approaches for thyroid cancer patients.

METHODS

We collected studies from January 2020 to July 2022 in 6 databases. Pairwise and network meta-analyses were performed for outcomes and complications of 9 minimally invasive interventions (minimally invasive video-assisted, endoscopic or robotic bilateral axillo-breast approach, endoscopic or robotic postauricular, endoscopic or robot transaxillary approach, transoral endoscopic thyroidectomy vestibular approach or robotic thyroidectomy) and conventional thyroidectomy (control).

RESULTS

Multiplicity and bilaterality of cancer, lymph node metastasis, and coincidence of thyroiditis showed no significant difference between minimally invasive interventions and control. However, larger tumor size (robotic bilateral axillo-breast approach standardized mean difference -1.3989, 95% confidence interval [-2.1717 to -0.6262]), higher body mass index (robot transaxillary approach standardized mean difference -0.5350, 95% confidence interval [-0.9557 to -0.1144], robotic bilateral axillo-breast approach standardized mean difference -0.2301, 95% confidence interval [-0.4389 to -0.0214]), and frequent extrathyroidal extension (robotic bilateral axillo-breast approach standardized mean difference 0.7435, 95% confidence interval [0.5602-0.9869]) were observed in control. In surgical outcomes and adverse effects, there was no significant difference in hospitalization or retrieved lymph node number between minimally invasive interventions and control. However, longer operative time was observed in the robotic bilateral axillo-breast approach(standardized mean difference 6.5393, 95% confidence interval [5.0476-8.0309]) and transoral robotic thyroidectomy (standardized mean difference 5.4946, 95% confidence interval [2.9984-7.9907]) groups than in control. In surgical completion, the rate of low postoperative serum thyroglobulin, postoperative thyroglobulin level, and postoperative radioactive iodine ablation dose showed no significant difference between minimally invasive interventions and control.

CONCLUSION

Minimally invasive thyroidectomy did not show inferior results compared to conventional thyroidectomy despite the longer operative time. Surgeons need to prudently consider all aspects of patients to determine the proper surgical approach for thyroid cancer.

Single-Port Transaxillary Robotic Modified Radical Neck Dissection (STAR-RND): Initial Experiences

OBJECTIVES

This study aimed to demonstrate the usefulness of single-port transaxillary robotic modified radical neck dissection (STAR-RND) for metastatic thyroid cancer, and its potential to make small and invisible surgical wounds possible compared to open modified radical neck dissection.

METHODS

Between January 2020 and July 2021, 30 thyroid cancer patients who underwent lateral neck dissection surgery with the da Vinci SP at Yonsei University Health System (Seoul, Korea) were studied.

RESULTS

All 30 patients, diagnosed with papillary thyroid cancer were women. The average operating time was 293.80 ± 36.58 (min), and the average postoperative hospital stay was 4.77 ± 0.57 (days). All patients were discharged after the expected number of hospitalization days without major complications.

CONCLUSION

STAR-RND is technically feasible and safe with a short length of the incision. To our knowledge, this is the first report on the use of a single-port robotic system for modified radical neck dissection. LEVEL OF EVIDENCE BY USING 2011 OCEBM: 4 Laryngoscope, 133:709-714, 2023.

Remote-access robotic thyroidectomy: A systematic review

BACKGROUND

Recently, robotic surgery has been introduced as a new surgical approach to the thyroid.

OBJECTIVES

The primary objective of this systematic review is to critically examine safety and feasibility of the different robotic approaches.

METHODS

The literature on robotic thyroidectomy was systematically reviewed. Primary endpoints were surgery duration, length of hospital stay, complications, postoperative pain and cosmetic satisfaction.

RESULTS

Sixty-eight studies with a total of 14433 patients were included. Depending on the robotic approach used, operative duration ranged between 89 and 230 min and hospitalisation stay between 0.1 and 5.6 days. Complication rates varied between 7.3% and 29%. Postoperative pain visual analogue scores (VAS) ranged from 0.6 to 4.71.

CONCLUSION

Robotic thyroidectomy results in high cosmetic satisfaction and quality of life. No differences in complication rates between robotic and traditional approaches are observed, supporting safety and feasibility of these robotic techniques.

VITOM-3D-assisted retroauricular neck surgery (RANS-3D): preliminary experience at Candiolo Cancer Institute

Objective

The recent introduction of 3D exoscopic surgery has engendered interesting technical improvements in head and neck surgery. The main goal of this study was to describe the application of 3D exoscopic technology on a wide range of pathologies of the neck, benign and malignant, through a minimally invasive retroauricular approach.

Methods

In the period January-December, 2019, 40 consecutive patients underwent neck surgery with a retroauricular approach, enhanced by using a 3D exoscope at the Head and Neck Oncological Unit of Candiolo Cancer Institute.

Results

Data regarding time to drain removal, length of hospitalisation, degree of pain experienced, need for opioid drugs during hospitalisation and after discharge, and intra-operative and post-operative complications were collected. All patients were followed for a minimum of 90 days with possible complications evaluated at each post-operative visit. Post-operative outcomes were evaluated at 3 months after surgery.

Conclusions

The current study indicates that VITOM-3D-assisted retroauricular neck surgery (RANS-3D) may be an interesting approach for neck surgery. The hybrid execution of neck dissection under direct and exoscopic vision represents a valid alternative to video-assisted endoscopic- and robot-assisted techniques.

Transaxillary gasless endoscopic thyroidectomy versus conventional open thyroidectomy: systematic review and meta-analysis

Aim

This systematic review and meta-analysis evaluates surgical outcome and safety results of conventional (OT) versus endoscopic transaxillary gasless thyroidectomies (ET).

Material and methods

A systematic literature search was performed. The weighted mean differences or the odd ratios with corresponding 95% CIs were examined for surgical outcomes and complications. The results were analysed using fixed- or random-effects models. The heterogeneity was checked by the Cochran Q test and the extent of inconsistency was evaluated by the I² statistic.

Results

Ten studies and 1597 patients were included. All studies found that ET required longer operative time. Postoperative pain was significantly lower after ET on day 1 and day 7. No statistical difference was found in complication rates.

Conclusions

ET has disadvantages such as longer surgery time, but it is a feasible and safe procedure with lower postoperative pain and comparable complication rates to OT. However, good quality prospective randomised studies are necessary to draw firmer conclusions.

Current therapeutic options for low-risk papillary thyroid carcinoma: A scoping evidence review

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis

PURPOSE

Conventional thyroidectomy has been standard of care for surgical thyroid nodules. For cosmetic purposes different minimally invasive and remote-access surgical approaches have been developed. At present, the most used robotic and endoscopic thyroidectomy approaches are minimally invasive video assisted thyroidectomy (MIVAT), bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET), bilateral axillo-breast approach robotic thyroidectomy (BABA-RT), transoral endoscopic thyroidectomy via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy.

METHODS

A systematic search was conducted in Medline, Embase and Web of Science to identify original articles investigating operating time, length of hospital stay and complication rates regarding recurrent laryngeal nerve injury and hypocalcemia, of the different minimally invasive techniques.

RESULTS

Out of 569 identified manuscripts, 98 studies met the inclusion criteria. Most studies were retrospective in nature. The results of the systematic review varied. Thirty-one articles were included in the meta-analysis. Compared to the standard of care, the meta-analysis showed no significant difference in length of hospital stay, except a longer stay after BABA-ET. No significant difference in incidence of recurrent laryngeal nerve injury and hypocalcemia was seen. As expected, operating time was significantly longer for most minimally invasive techniques.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis comparing the eight most commonly used minimally invasive thyroid surgeries individually with standard of care. It can be concluded that minimally invasive techniques do not lead to more complications or longer hospital stay and are, therefore, not inferior to conventional thyroidectomy.

Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

OBJECTIVE

We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches.

STUDY DESIGN

Retrospective analysis.

SETTING

The National Cancer Database (NCDB) was queried between 2010 and 2016.

SUBJECTS AND METHODS

National cohort of patients. Descriptive statistics were performed using χ² test, Mann-Whitney U test, t test and analysis of variance. To investigate complication rates, patient matching was performed with subsequent analysis using simple and multivariable logistic regressions.

RESULTS

We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures (P = .025). Robotic thyroid surgery was associated with increased risk of positive margins (P = .046), while endoscopic thyroid surgery was associated with a higher rate of unplanned hospital readmission (OR, 1.55; 95% CI, 1.09-2.22), longer inpatient stays (OR, 1.55; 95% CI, 1.19-2.02), and higher 90-day postoperative mortality (OR, 4.45; 95% CI, 1.58-12.6).

CONCLUSION

Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open surgery.

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.

Endoscopic Thyroidectomy in Anterior Chest Approach Versus Open Thyroidectomy for Patients with Papillary Thyroid Carcinomas, a Retrospective Study

Background: To compare the endoscopic thyroidectomy (ET) with the open thyroidectomy (OT) for patients with papillary thyroid carcinomas and share our experience of central lymph nodes dissection and recurrent laryngeal nerve exposure. Materials and Methods: From January 2015 to July 2017, 197 patients were enrolled in our hospital. Among them, 85 underwent ET and 112 underwent OT. The mean age of the patients was 38.15 ± 11.72 years in ET group and 47.79 ± 10.51 years in OT group. Unilateral thyroidectomy was performed in 47 patients of ET group and 63 patients of OT group. Bilateral thyroidectomy was performed in 38 patients of ET group and 49 patients of OT group. Intraoperative information, including operation time, hemorrhage, tumor size, capsular invasion, central LN metastasis, number of retrieved lymph nodes, hospital stay, cost, postoperative complication, and cosmetic satisfaction, was compared between the two groups. Results: The operation time of ET group was significantly longer (P < .05). There were no significant differences between the two groups in postoperative complications (P > .05). The patients in ET group were more satisfied with the cosmetic effects (P < .05). Conclusion: ET was a safe and effective alternative operation method for selected patients with papillary thyroid carcinomas.

A Tactile Device Generating Repulsive Forces of Various Human Tissues Fabricated from Magnetic-Responsive Fluid in Porous Polyurethane

In this study, a controllable tactile device capable of realizing repulsive forces from soft human tissues was proposed, and its effectiveness was verified through experimental tests. The device was fabricated using both porous polyurethane foam (PPF) and smart magnetorheological fluid (MRF). As a first step, the microstructural behavior of MRF particle chains that depended on the magnetic field was examined via scanning electron microscopy (SEM). The test samples were then fabricated after analyzing the magnetic field distribution, which was crucial for the formation of the particle chains under the squeeze mode operation. In the fabrication of the samples, MRF was immersed into the porous polyurethane foam and encapsulated by adhesive tape to avoid leakage. To verify the effectiveness of the proposed tactile device for appropriate stiffness of soft human tissues such as liver, the repulsive force and relaxation stress were measured and discussed as a function of the magnetic field intensity. In addition, the effectiveness and practical applicability of the proposed tactile device have been validated through the psychophysical test.

Robotic Thyroidectomy Decreases Postoperative Pain Compared With Conventional Thyroidectomy

BACKGROUND

This retrospective study compared postoperative pain between patients undergoing open thyroidectomy (OT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT).

MATERIALS AND METHODS

We analyzed the electronic medical records of 1269 patients who underwent OT or RT at Chung-Ang University Hospital between January 1, 2010 and April 30, 2016. On the basis of the surgical procedure performed, patients were categorized into an OT (n=1128) and a BABA RT (BRT) group (n=141). On the basis of covariates, patients in these groups were matched using propensity score matching (n=86 in each group).

RESULTS

After propensity score matching, no intergroup differences were observed in the covariates. The visual analogue scale scores for pain on postoperative day 0 were lower in the BRT than in the OT group (2.57±0.95 vs. 2.28±0.95, P=0.040). However, no statistically significant differences were observed in the use of rescue analgesics, the numerical rating scale score for nausea, and the use of rescue antiemetics.

CONCLUSIONS

Pain on postoperative day 0 was lesser in the BRT than in the OT group. Similarly, the severity of nausea was lesser in the BRT group, despite longer operation time and broad dissection performed for docking the robotic arms.

Drainage During Endoscopic Thyroidectomy

Background

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

Methods and Materials

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

Results

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

Conclusions

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

Transoral vestibule approach for thyroid disease: a systematic review

OBJECTIVES

Transoral endoscopic/robotic thyroidectomy vestibule approach (TOETVA/TORTVA) is a novel technology that has been proposed for the treatment of thyroid disease. Its adoption has increased because of its satisfying cosmetic effects. The primary aim of this systematic review was to assess the feasibility and safety of this approach, and the secondary aim was to discuss the indications for this technology.

MATERIALS AND METHODS

According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we searched Pubmed, Embase and the Cochrane databases for published studies on the feasibility and safety of TOETVA or TORTVA.

RESULTS

11 articles containing 864 patients met the inclusion criteria after full-text screening, of which two were reports of randomized controlled trial (RCT), two were retrospective cohort studies and the remaining seven studies were case series. Only studies that evaluated the feasibility and safety of this approach were included. TOETVA/TORTVA was successfully performed in 857 out of the 864 cases (99.2%). The mean operative time ranged from 60.4 to 265.4 min. In most articles, blood loss was less than 50 mL and the mean hospital stay ranged from 1.1 to 8.2 days. The safety outcomes were presented in all articles. The total incidence of adverse events was 14.5%, of which the main complications were transient hypoparathyroidism (5.6%) and transient recurrent laryngeal nerve (RLN) injury (3.1%).

CONCLUSIONS

This review preliminarily suggests that TOETVA or TORTVA could be an effective and safe treatment for thyroidectomy. Due to the small sample size and low level of evidence, further large-scale, well-designed RCTs are required to validate our findings.

Initiating a Robotic Thyroidectomy Program in India

Robotic surgery has been successfully used for many surgical indications in head and neck surgery. Robotic thyroidectomy is getting accepted worldwide, but the majority of the literature is from South Korea. The purpose of the paper is to review and give a personal perspective on how a robotic thyroidectomy program was initiated in a tertiary care academic medical institution in India. Advantages of robotic approaches are the three-dimensional visualization, precision, dexterity, and surgeon ergonomics. Cost is an important concern. Training includes basic robotics skill training, cadaveric training, observership, and hands-on training. Sufficient preclinical and clinical training is essential before embarking onto the newer surgical modality. Surgeon credentialing, though institution dependent, has specific guidelines. Case selection is the key, especially in the initial learning curve. The authors prefer the retroauricular approach for robotic thyroidectomy, and our initial experience in the first ten cases of total thyroidectomy was encouraging.

Facelift Approach for Resecting Benign Upper Neck Masses

BACKGROUND

This study evaluated the feasibility of non-magnified resection of various benign lesions of the upper neck using the facelift incision without endoscopic equipment to establish indications for the procedure.

METHODS

This retrospective analysis examined 86 patients who underwent surgery for upper neck masses using the facelift incision or conventional transcervical incision at our institute between January 2012 and December 2015.

RESULTS

We performed 41 operations using facelift incisions (facelift group) and 45 using conventional horizontal incisions (conventional group). All 86 operations were successful. In the facelift group, no patient needed conversion to conventional open resection and no patient required the use of an endoscopic device due to a limited surgical view for safe resection. There were no major surgical complications in either group. Transient sensory changes in the auricle occurred in 26% of the patients in the facelift group, but all patients recovered within 2 months. In all patients in the facelift group, the scars were invisible as they were covered by the auricle and hair, while the surgical scars were noticeable in 91% (41/45) of the patients in the conventional group when they were wearing standard shirts (p < 0.001) at 3-4 weeks after surgery.

CONCLUSIONS

The facelift approach provides a short direct route to upper neck masses, and it enables an adequate workspace not only for endoscopic or robotic surgery, but also for open surgery with the naked eye. The surgical indications for the facelift incision include the removal of most benign tumors occurring in the upper neck at levels II and III.

Propensity score-matched analysis of robotic versus endoscopic bilateral axillo-breast approach (BABA) thyroidectomy in papillary thyroid carcinoma

PURPOSE

The da Vinci surgical robot system was developed to overcome the weaknesses of endoscopic surgery. However, whether robotic surgery is superior to endoscopic surgery remains uncertain. Therefore, the purpose of this study was to compare the surgical and oncologic outcomes between endoscopic and robotic thyroidectomy using bilateral axillo-breast approach (BABA).

METHODS

Between January 2008 and June 2015, papillary thyroid carcinoma patients who underwent thyroidectomy with central neck dissection using endoscopic (n = 480) or robotic (n = 705) BABA were primarily reviewed. We performed 1:1 propensity score matching and 289 matched pairs were yielded.

RESULTS

Operation time was significantly longer in the robotic thyroidectomy than in the endoscopic thyroidectomy (184.9 vs. 128.9 min, P < 0.001). A significantly higher number of central lymph nodes (CLNs) were resected in the robotic thyroidectomy than in the endoscopic thyroidectomy (5.3 vs. 4.4, P = 0.003). However, the incidence of other outcomes including hospital stay, postoperative duration, thyroglobulin level, radioactive iodine ablation, hemorrhage, chyle leakage, wound infection, recurrent laryngeal nerve injury, and loco-regional recurrence did not significantly differ between the endoscopic thyroidectomy and the robotic thyroidectomy.

CONCLUSIONS

Endoscopic thyroidectomy is comparable with robotic thyroidectomy in view of surgical complications and LRR. Because robotic thyroidectomy resected a larger number of CLNs than did endoscopic thyroidectomy, further long-term follow-up studies will be required to clarify the possible prognostic benefits of robotic thyroidectomy.

Endoscopic thyroidectomy along with bilateral central neck dissection (ETBC) increases the risk of transient hypoparathyroidism for patients with thyroid carcinoma

Increasing number of patients with thyroid carcinoma, especially young female patients, prefer to choose endoscopic thyroidectomy with bilateral central neck dissection (ETBC) for perfect cosmetic effects. However, the incidence of hypoparathyroidism after ETBC has not been well studied. Ninety six patients with papillary thyroid carcinoma were enrolled. All patients, including 49 ETBC and 47 open surgery patients, underwent total thyroidectomy with bilateral central neck dissection (CND). Some patients also underwent lateral neck dissection simultaneously. The incidence of hypoparathyroidism and parathyroid hormone (PTH) level were examined. Patients in the open surgery group had more advanced lesions, with larger tumor (p = 0.000), older age (p = 0.000), and more serious local involvement. The dissection extent of the open group was significantly larger than that of the ETBC group (p = 0.006). In contrast, the ETBC group with less dissection extent showed a significantly higher incidence of transient hypoparathyroidism than the open group (59.2 vs. 29.6 %, p = 0.004). The average PTH decline of the ETBC group was significantly higher than that of the open group on postoperative day 1 (POD1) (32.1 vs. 21.6 pg/ml, p = 0.010). Furthermore, the ETBC group had a significantly higher portion of patients with a PTH <10 pg/ml on POD1 (p = 0.001). One patient in the ETBC group developed permanent hypoparathyroidism. Autotransplantation and inadvertent removal rates of parathyroid did not differ between the two groups. Although generally considered a safe method for patients with thyroid carcinoma, ETBC may increase the risk of transient hypoparathyroidism compared with conventional open surgery.

Oncologic Safety of Robot Thyroid Surgery for Papillary Thyroid Carcinoma: A Comparative Study of Robot versus Open Thyroid Surgery Using Inverse Probability of Treatment Weighting

The aim of this study was to evaluate the oncologic safety of robot thyroid surgery compared to open thyroid surgery for papillary thyroid carcinoma (PTC). We enrolled 722 patients with PTC who underwent a total thyroidectomy with central compartment node dissection (CCND) from January 2009 to December 2010. These patients were classified into open thyroid surgery (n = 610) or robot thyroid surgery (n = 112) groups. We verified the impact of robot thyroid surgery on clinical recurrence and ablation/control-stimulated thyroglobulin (sTg) levels predictive of non-recurrence using weighted logistic regression models with inverse probability of treatment weighting (IPTW). Age, sex, thyroid weight, extent of CCND, and TNM were significantly different between the two groups (p < 0.05); however, there was no significant difference in recurrence between the open and robot groups (1.5% vs. 2.7%; p = 0.608). The proportion of patients with ablation sTg < 10.0 ng/mL and control sTg < 1.0 ng/mL was comparable between the two groups (p > 0.05). Logistic regression with IPTW using the propensity scores estimated by adjusting all of the parameters demonstrated that robot thyroid surgery did not influence the clinical recurrence (OR; 0.784, 95% CI; 0.150-3.403, p = 0.750), ablation sTg (OR; 0.950, 95% CI; 0.361-2.399, p = 0.914), and control sTg levels (OR; 0.498, 95% CI; 0.190-1.189, p = 0.130). Robot thyroid surgery is comparable to open thyroid surgery with regard to oncologic safety in PTC patients.

Solo-Surgeon Retroauricular Approach Endoscopic Thyroidectomy

BACKGROUND

This study aimed to evaluate the feasibility and efficacy of solo-surgeon retroauricular thyroidectomy.

MATERIALS AND METHODS

For solo-surgery, we used an Endoeye Flex Laparo-Thoraco Videoscope (Olympus America, Inc.). A Vitom Karl Storz holding system (Karl Storz GmbH & Co.) composed of several bars connected by a ball-joint system was used for fixation of endoscope. A snake retractor and a brain-spoon retractor were used on the sternocleidomastoid.

RESULTS

Endoscopic thyroidectomy using the solo-surgeon technique was performed in 10 patients having papillary thyroid carcinoma. The mean patient age was 36.0 ± 11.1 years, and all patients were female. There were no postoperative complications such as vocal cord paralysis and hematoma. When compared with the operating times and volume of drainage of a control group of 100 patients who underwent surgery through the conventional retroauricular approach between May 2013 and December 2015, the operating times and volume of drainage were not significantly different (P = .781 and .541, respectively).

CONCLUSION

Solo-surgeon retroauricular thyroidectomy is safe and feasible when performed by a surgeon competent in endoscopic thyroidectomy.

Retroauricular Endoscope-Assisted Approach to the Neck: Early Experience in Latin America

Introduction There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. In this subset, endoscope-assisted and robotic procedures allowed the development of new approaches to the neck, including the retroauricular access, which is now routinely used, especially in Korea.

Objectives This study aims to provide a descriptive analysis of our initial experience with retroauricular endoscope-assisted approach assessing feasibility, safety, and aesthetic results.

Methods Prospective analysis of the first 11 eligible patients submitted to retroauricular endoscope-assisted approach for neck procedures in the Head and Neck Surgery Department at AC Camargo Cancer Center.

Results A total of 18 patients were included in this study, comprising 7 supraomohyoid neck dissections, 8 submandibular gland excisions, 3 thyroid lobectomies, and one paraganglioma excision. There was no significant local complications, surgical accident, or need for conversion into conventional open procedure in this series.

Conclusion Our initial experience has shown us that this approach is feasible, safe, oncologically efficient, and applicable to selected cases, with a clear cosmetic benefit.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic Thyroidectomy Versus Nonrobotic Approaches: A Meta-Analysis Examining Surgical Outcomes

Background Robotic surgery has been recently used as a novel tool for remote access thyroid surgery. We performed a meta-analysis of the current literature to examine the safety and oncological efficacy of robotic surgery compared to endoscopic and conventional approaches for different thyroid procedures. Methods A systematic search of the online data bases was done using the following (MeSH) terms "robotic surgery," "robotic thyroidectomy," "robot-assisted thyroidectomy," and "robot-assisted thyroid surgery." Outcomes measured included total operative time, length of hospital stay, postoperative thyroglobulin levels, and postoperative complications. Statistical differences were analyzed between groups through the standard means and/or relative risk by using STATA analytical software. Results In this study, 144 articles were identified; of which 18 of them met our inclusion criteria, totaling 4878 patients. Robotic approach was associated with longer total operative time (mean difference of 43.5 minutes) when compared to the conventional cervical approach (95% CI = 20.9-66.2; P < .001). Robotic approach was also found to have a similar risk of total postoperative complications when compared to the conventional and endoscopic approaches. Conclusion Robotic thyroid surgery is as safe, feasible and provides similar periperative complications and oncological outcomes when compared to both, conventional cervical and endoscopic approaches. However, robotic thyroid surgery is associated with longer operative time when compared to the conventional open approach.

Transaxillary thyroidectomies: a comparative learning experience of robotic vs endoscopic thyroidectomies

OBJECTIVE

Robotic and endoscopic approaches have become more accepted in thyroid surgery, with current literature documenting the experience of high-volume centers. We adopted both approaches concurrently, and this series presents our initial experience to assess the more practical option for low- to moderate-volume centers starting out with transaxillary thyroidectomies.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic center.

SUBJECTS AND METHODS

Over a period of 4 years, 101 patients underwent transaxillary thyroidectomies, of whom 48 underwent robotic thyroidectomy and 53 underwent endoscopic thyroidectomy. Data analysis includes patient characteristics, procedure time, thyroid pathology, and postoperative complications. A survey was conducted among surgeons to assess the subjective experience.

RESULTS

Endoscopic hemithyroidectomies had a significantly shorter duration of operation (145.8 minutes) vs that of robotic hemithyroidectomies (193.6 minutes), P < .001. The mean time taken for the first 5 hemithyroidectomies vs the last 5 hemithyroidectomies showed a greater drop in the endoscopic group (49.1%) vs the robotic group (18.6%). There were 2 cases of transient recurrent laryngeal nerve injury. In the surgeon survey, the endoscopic technique was perceived to have less need for peripheral support, while the robotic technique was preferred for its shorter learning curve.

CONCLUSION

In terms of outcome, both techniques are comparable at least in the initial phase. Based on our early experience, the endoscopic technique may be less intuitive with a longer learning curve, although at steady state, it may be the quicker procedure. This is relevant for low- to moderate-volume centers starting their transaxillary thyroidectomy program.

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

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

A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach

OBJECTIVES

We introduce surgical outcomes regarding 300 cases of robotic thyroidectomy using a bilateral axillo-breast approach (BABA).

METHODS

From April 2010 to October 2013, 300 patients who underwent robotic thyroidectomy were analyzed and compared with 300 cases of open total thyroidectomy. Robotic surgery was performed with a snake retractor to allow for complete central lymph node dissection. We performed robotic surgery using BABA without drains in 170 cases; subfascial dissection was performed to reduce post-operative wound adhesion.

RESULTS

The learning curve for robotic thyroidectomy was 40 cases; after that, the operation time significantly decreased (233 min vs. 185 min, P=0.001). A snake retractor was selectively useful for the dissection of paratracheal lymph nodes located in the deep areas. In patients who underwent drainless BABA, additional aspirations were required in only 19 (6.3%). The number of retrieved lymph nodes of robot and open surgery were 6.7 ± 0.2 and 8.9 ± 0.3, respectively (P<0.001). The mean serum thyroglobulin of thyroid hormone was 0.80 ± 0.19 and 1.77 ± 0.29 ng/ml, respectively (P=0.001). Post-operative complications of robot surgery, including transient hypocalcemia (n=33, 23.0%) in total thyroidectomy, transient recurrent laryngeal nerve palsy (n=8, 2.6%) without permanent palsy rarely observed.

CONCLUSION

Robotic thyroidectomy using BABA is an effective and comparable treatment option. J. Surg. Oncol. 2015 111:135-140.

Can robotic thyroidectomy be performed safely in thyroid carcinoma patients?

Since the adoption of the Da Vinci robotic system for remote access thyroid surgery, robotic thyroidectomy (RT) has become a popular surgical option for patients who want to avoid neck scars. Surgeons in South Korea pioneered this surgical technique and have reported successful outcomes. Although many studies have reported that RT is a feasible and safe therapeutic alternative, concerns over the surgical and oncological safety of RT remain. This article reviews the advantages and disadvantages of RT and compares the surgical safety and oncological completeness of RT with conventional open thyroidectomy.

Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique

BACKGROUND

A new approach to modifying facelift incision was recently developed for robotic thyroid surgery that seemed to be advantageous over other existing approaches. In this study, we aimed to investigate the feasibility and safety of the facelift approach not only for robotic thyroid surgery, but also for endoscope-assisted thyroid surgery.

METHODS

Endoscope-assisted facelift thyroid lobectomy was performed for 11 patients with papillary microcarcinoma.

RESULTS

All 11 operations were successfully performed endoscopically. This approach through a modified facelift incision provided safe dissection of the laryngeal nerves and exposed an adequate working space. We identified and preserved all neighboring critical structures (parathyroid gland and superior and recurrent laryngeal nerves) during surgery. The operative duration for simple thyroid lobectomy with central lymph node dissection in 11 patients was 120-180 min (average duration: 140 min). Sensory change around the earlobe occurred in three patients and was recovered within 2 months after surgery in all patients. No patient displayed laryngeal nerve palsy or a low-pitched voice.

CONCLUSIONS

The facelift approach seems to provide a shorter and more direct route to the thyroid, requiring minimal dissection, and an adequate workspace not only for robotic surgery but also for endoscopic surgery. It is worthwhile to develop and refine the surgical techniques of endoscopic facelift thyroid surgery.

Robotics in general surgery: an evidence-based review

Since its introduction, robotic surgery has been rapidly adopted to the extent that it has already assumed an important position in the field of general surgery. This rapid progress is quantitative as well as qualitative. In this review, we focus on the relatively common procedures to which robotic surgery has been applied in several fields of general surgery, including gastric, colorectal, hepato-biliary-pancreatic, and endocrine surgery, and we discuss the results to date and future possibilities. In addition, the advantages and limitations of the current robotic system are reviewed, and the advanced technologies and instruments to be applied in the near future are introduced. Such progress is expected to facilitate the widespread introduction of robotic surgery in additional fields and to solve existing problems.

A systematic review and meta-analysis comparing outcomes between robotic-assisted thyroidectomy and non-robotic endoscopic thyroidectomy

BACKGROUND

Despite its feasibility, using the da Vinci robot in remote-access thyroidectomy remains controversial. This meta-analysis compared surgical and oncological outcomes between robotic-assisted thyroidectomy (RT) and non-robotic endoscopic thyroidectomy (ET).

METHODS

A systematic review was performed to identify studies comparing outcomes between RT and ET. Outcomes included operating time, drain output, complications, number of central lymph nodes retrieved, and preablation stimulated thyroglobulin level. A random-effects model was used.

RESULTS

Six studies were eligible. Of the 3510 patients, 2167 (61.7%) underwent RT whereas 1343 (38.3%) underwent ET. Despite a higher drain output (185.8 mLs versus 173.3 mLs, P = 0.019), RT had fewer temporary recurrent laryngeal nerve injury (2.6% versus 3.3%, P = 0.035) and shorter length of hospital stay (3.4 d versus 3.5 d, P = 0.030). In terms of oncological outcomes, despite higher incidence of multicentricity and larger tumors, the number of central lymph nodes retrieved during unilateral central neck dissection in RT was significantly greater than ET (4.5 ± 2.6 and 3.4 ± 2.5, P < 0.001) whereas the preablation stimulated thyroglobulin was comparable (0.8 ng/mL versus 1.1 ng/mL, P = 0.456). However, follow-up data were relatively scarce.

CONCLUSIONS

Adding the robot in remote-access thyroidectomy was associated with a significantly lower risk of temporary recurrent laryngeal nerve injury and shorter length of hospital stay. However, despite achieving a comparable level of surgical completeness for low-risk differentiated thyroid carcinoma between RT and ET, this study highlighted the limitations with the current literature and the need for more prospective studies with adequate follow-up.

Robotic modified radical neck dissection by bilateral axillary breast approach for papillary thyroid carcinoma with lateral neck metastasis

BACKGROUND

The purpose of this study was to evaluate the safety of robotic modified radical neck dissection compared to open modified radical neck dissection.

METHODS

We enrolled 78 patients who were diagnosed with papillary thyroid cancer and underwent total thyroidectomy, bilateral central neck dissection, and modified radical neck dissection between March 2011 and February 2013. Of these patients, 65 underwent an open procedure and 13 underwent a robotic procedure using the bilateral axillary breast approach (BABA). These 2 groups were retrospectively compared.

RESULTS

The mean age, sex, body mass index (BMI), and tumor size were not significantly different between groups. There were no differences in the number of retrieved lymph nodes, metastatic lymph nodes, or stimulated thyroglobulin level between the 2 groups. The operation time was longer in the robotic group than in the open group.

CONCLUSION

Robotic modified radical neck dissection using BABA is safe and shows oncologic and postoperative outcomes comparable to those of the open procedure.

Hybrid-type endoscopic thyroidectomy (HET: Tori's method) for differentiated thyroid carcinoma including invasion to the trachea

Background

Endoscopic thyroidectomy (ET) or robotic thyroidectomy is yet to be applied to thyroid carcinoma invasive to the trachea and to wide lymph node node metastasis. On the other hand, small-incision thyroidectomy lacks sufficient working space and clear vision. The author has newly developed hybrid-type endoscopic thyroidectomy (HET) to overcome these problems.

Methods

From March 2011 to February 2012, HET was performed for 85 patients. Clinicopathologic characteristics were analyzed. To evaluate the superiority of HET for malignancy representatively, conventional lobectomy with central compartment node dissection (CCND) performed 1 year previously was compared with HET. In lobectomy and node dissection, a single skin incision (1.5 cm) is made above the clavicle, with a port incision (5 mm) made 3 cm below the clavicle. Then CCND is performed directly through the incision by lifting up the isthmus. To obtain sufficient working space for the lobectomy, the strap muscles are taped and pulled toward the head, then hung by the cradle. The thyroid lobe is retracted to the midline with a retractor, followed by isolation of the inferior laryngeal nerve and transection of the inferior thyroid vessels with the monitor of the scope. Lateral lymph nodes dissection can be performed at the same time, if necessary. In total thyroidectomy, the same procedure is performed at the opposite side. The scalpel can be used to shave through each incision in case of tracheal invasion.

Results

Of the 85 cases, 62 were malignant, involving papillary thyroid carcinoma (PTC), and 23 were benign. Total thyroidectomy was performed for 22 of the PTC cases and CCND for 49 of the cases. Shaving for tracheal invasion was performed for eight patients. No mortality, complications, recurrence, or metastasis was found 1–2 years after the operation. Compared with conventional thyroidectomy, HET was superior in blood loss, visual analog scale, and postoperative hospital stay.

Conclusion

The author’s method (Tori’s method) might be less invasive, cosmetically excellent, and moreover, safe and feasible for differentiated thyroid carcinoma including invasion to the trachea.

Surgical outcomes of robotic thyroid surgery using a double incision gasless transaxillary approach: analysis of 400 cases treated by the same surgeon

BACKGROUND

The purpose of this study was to evaluate the surgical outcomes of 400 cases of robotic thyroid surgery using a double incision gasless transaxillary approach.

METHODS

We analyzed 400 patients who underwent a robot-assisted thyroidectomy performed by a single surgeon.

RESULTS

All patients underwent successful operations without conversion to open surgery. Transient hypoparathyroidism was the most common complication (51.7%) and permanent hypoparathyroidism occurred in only 2 patients (1.4%). The mean number of retrieved central lymph nodes was 6.5 ± 4.4 for ipsilateral central compartment node dissection and 8.4 ± 5.1 for bilateral central compartment node dissection. The proportion of patients with stimulated thyroglobulin (sTg) levels at the time of remnant ablation <10 ng/mL and sTg levels 6 to 12 months after the first ablation <1 ng/mL was 84.9% and 88.3%, respectively.

CONCLUSION

Robotic thyroid surgery is technically safe and may be a surgical option for patients with well-differentiated thyroid cancer.

Indications for the gasless transaxillary robotic approach to thyroid surgery: experience of forty-seven procedures at the american hospital of paris

BACKGROUND

Thyroid surgery is in a state of evolution from traditional open approaches to novel robotic techniques. The gasless transaxillary approach to thyroid surgery is effective in the management of thyroid cancer, and complications after robotic thyroidectomy are no higher than experienced after open or endoscopic techniques. The transaxillary robotic approach also avoids an anterior neck scar. This paper presents what the authors believe to be the largest cohort of patients reported in Europe undergoing gasless transaxillary robotic thyroid surgery, with the aim of defining the indications for this procedure.

METHODS

Forty-six patients underwent robotic thyroid surgery via the transaxillary approach and were enrolled in this study between March 2010 and September 2012. All patients were operated on by one surgeon at one clinical center. Reviewed data included patient characteristics, pathological characteristics, extent of surgery and postoperative complications. The mean follow-up time was 7.29 months.

RESULTS

Forty-six patients underwent 47 procedures, the average age of the patients was 43 years and the male to female ratio was 1:22. Undertaken were 30 lobectomies, 3 subtotal thyroidectomies, 13 total thyroidectomies and 1 totalization. One case was converted to an open procedure. The ratio of malignant to benign disease was 1:6.67 (6:40 cases) and analysis of the surgical specimens showed 6 follicular lesions, 24 follicular adenomas, 3 colloid lesions, 1 case of thyroiditis/lymphatic lesion, 3 adenomatoid lesions, 3 oncocytic adenomas, 3 papillary cancers and 3 microcapillary cancers. The overall average size of an individual specimen removed was 45.40 ± 28.95 cm(3) (range 5-160, n = 47) and the average largest diameter of the lesion removed was 3.72 ± 0.95 cm (range 1.4-6.0, n = 47). Postoperatively, there were 5 recurrent laryngeal nerve injuries (4 transient), 2 transient brachial plexopathies, 1 case of postoperative dysphagia and 1 of collection of blood at the site of surgery. There were no cases of disease recurrence at follow-up.

CONCLUSIONS

The gasless robotic transaxillary approach to thyroid surgery has been predicted to become a standard technique. It has been shown to be efficacious in the management of thyroid cancer with lateral neck metastases; however, more data relating to oncological safety in long-term follow-up is required. This intervention is also appropriate for benign thyroid disease including Graves' disease. To achieve consistently successful results, careful patient selection is fundamental in terms of patient characteristics and the anatomical aspects of the lesion. This is especially important with a geographical expansion to include North America and Europe. The excellent cosmetic results of this procedure make it ideal for patients who have esthetic concerns regarding particular difficulties with healing; however, in common with all new surgical procedures, further evidence must be sought to confirm its indications over time.

Safety of robotic thyroidectomy approaches: meta-analysis and systematic review

BACKGROUND

This study compared the efficacy of robotic thyroidectomy via a gasless, axillary approach with conventional cervical and endoscopic techniques by meta-analysis.

METHODS

Articles were identified from the following keyword searches: robotic/robot-assisted thyroidectomy/thyroid surgery. Outcomes included operative time, hospital stay, complications, and cosmetic satisfaction after surgery. Between-group outcome differences were calculated using random-effects models.

RESULTS

In all, 87 publications were identified and 9 studies met inclusion criteria, totaling 2881 patients, 1122 of whom underwent robotic thyroidectomy. Those who underwent robotic surgery reported greater cosmetic satisfaction, with a pooled net mean difference of -1.35 (95% confidence interval [CI]: -1.69, -1.09). Robotic approach operative time was longer than that of the conventional approach (95% CI: 29.23, 54.87), with a trend to be shorter than the endoscopic approaches. Robotic surgery had similar risks to open and endoscopic approaches.

CONCLUSIONS

Our meta-analysis suggests that robotic thyroidectomy is as safe, feasible, and efficacious as conventional cervical and endoscopic thyroidectomy, showing superior cosmetic satisfaction than that of conventional thyroidectomy.

Comparative study comparing endoscopic thyroidectomy using the axillary approach and open thyroidectomy for papillary thyroid microcarcinoma

BACKGROUND

Endoscopic thyroidectomy has been applied prudently to malignant thyroid tumors. The purpose of our study was to compare the surgical outcomes of endoscopic thyroidectomy (ET) and conventional open thyroidectomy (COT) for micropapillary thyroid carcinoma.

METHODS

From October 2002 to December 2008, 78 patients underwent unilateral lobectomy and isthmectomy with central lymph node dissection for papillary thyroid microcarcinoma. Of these, 37 patients underwent ET and 41 patients COT. Surgical outcomes, including operation time, number of retrieved lymph nodes, postoperative complication rate and patients' satisfaction with the cosmetic results, were analyzed.

RESULTS

The mean age of the patients was 42.3 ± 7.6 years in the ET group and 49.0 ± 10.8 years in the OT group (P = 0.003). The operation time was shorter in the COT group (112.3 ± 14 min) than in the ET group (138.4 ± 36.9 min, P< 0.01). However, there were no significant differences in tumor size (0.5 ± 0.231 vs. 0.41 ± 0.264 cm, P = 0.116), number of retrieved lymph nodes (3.63 ± 2.1 vs. 3.82 ± 3.28, P = 0.78) or postoperative hospital stay (3.35 ± 0.94 vs. 3.17 ± 1.16 days, P = 0.457). Patients in the ET group experienced more pain than those in the COT group at 1 and 7 days after the operation as evaluated by a visual analog scale (P = 0.037, 0.026). Cosmetically, patients in the ET group were very satisfied with the operative procedure according to the questionnaire we used (1.43 ± 0.55 vs. 3.21 ± 0.72, P< 0.001). The mean follow-up period was 54.3 months in the ET group and 47.4 months in the COT group, and each group exhibited one case of tumor recurrence detected at the other thyroid lobe within 2 years.

CONCLUSIONS

Large series of prospective studies and long-term follow-up are needed, but the results of ET using the axillary approach for micropapillary thyroid carcinoma were not inferiortothose using COT, and it might be a safe and feasible procedure with good cosmetic results.