Minimally invasive surgery for thyroid small nodules: preliminary report

Analysis of Surgical Outcomes in Endoscopic-Assisted Lateral Neck Dissection

BACKGROUND

Currently, endoscopic-assisted lateral neck dissection (EALND) is performed to reduce postoperative scarring of the anterior neck. This study aimed to compare surgical outcomes between EALND and conventional open lateral neck dissection (COLND) for papillary thyroid carcinoma (PTC) with lateral lymph node metastases (LNM).

METHODS

The study reviewed 103 PTC patients who were classified on the basis of surgical type and statistically compared using propensity score matching analysis.

RESULTS

The mean operation time is longer, and the cost of surgery is higher in the EALND group than COLND group (all p < 0.05). The numbers of retrieved and positive level II LNs, the rate of level II LNs detection between two groups do not differ significantly (all p > 0.05). The incidence of postoperative neck numbness is lower, and patients are more satisfied with postoperative neck scarring in the EALND group than COLND group (all p < 0.05). The common complications of two groups are transient recurrent laryngeal nerve injury and transient hypoparathyroidism.

CONCLUSIONS

EALND is safe and feasible compared with COLND. The incision is more aesthetically satisfactory, which makes EALND a surgical approach for PTC patients with lateral LNM.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2221-2227, 2024.

Mini-invasive video-assisted thyroidectomy vs robot-assisted transaxillary thryoidectomy: analisys and comparison of safety and outcomes

Thyroid surgery is characterized by large volumes and typically affects a young female population. Mini-invasive or remote access surgical techniques are born driven by the desire to improve aesthetic outcomes of the traditional technique, following technological advances that have upset the surgical world in the last 20 years. In our multicenter, retrospective observational study, we first compared an endoscopic technique with a robotic one: minimally invasive video-assisted thyroidectomy (MIVAT) and robot-assisted transaxillary thyroidectomy (RATT). We evaluated intraoperative features, complications, and cosmetic outcomes in a cohort of 609 patients. The efficacy and safety of these techniques are proven by a large literature and the comparison made in our study does not show inferiority of one technique compared to the other. Even the aesthetic results tend to be equal in the long term. It is desirable that further prospective and randomized studies are conducted to evaluate the outcomes of these procedures and the cost-benefit ratio.

Modern internet search analytics and thyroidectomy: What are patients asking?

Objectives

Thyroidectomy is among the most commonly performed head and neck surgeries, however, limited existing information is available on topics of interest and concern to patients.

Study Design

Observational.

Setting

Online.

Methods

A search engine optimization tool was utilized to extract metadata on Google-suggested questions that "People Also Ask" (PAA) pertaining to "thyroidectomy" and "thyroid surgery." These questions were categorized by Rothwell criteria and topics of interest. The Journal of the American Medical Association (JAMA) benchmark criteria enabled quality assessment.

Results

A total of 250 PAA questions were analyzed. Future-oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management, risks or complications of surgery, and technical details were significantly less popular among the "thyroid surgery" group (P < 0.001, P = 0.005, and P < 0.001, respectively). PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain (335 and 319 vs. 113 combined search engine response page count, respectively). The overall JAMA quality score remained low (2.50 ± 1.07), despite an increasing number of patients searching for "thyroidectomy" (r(77) = 0.30, P = 0.007).

Conclusions

Patients searching for the nonspecific term "thyroid surgery" received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery, as compared to patients with higher health literacy who search with the term "thyroidectomy." This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.

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.

Comparisons of different approaches and incisions of thyroid surgery and selection strategy

To date, the traditional open thyroid surgery via a low collar incision remains the standard approach for patients undergoing thyroidectomy. However, this conventional approach will inevitably leave patients a neck scar and even cause a variety of complications such as paresthesia, hypesthesia, and other uncomfortable sensations. With the progress in surgical techniques, especially in endoscopic surgery, and the increasing desire for cosmetic and functional outcomes, various new approaches for thyroidectomy have been developed to avoid or decrease side effects. Some of these alternative approaches have obvious advantages compared with traditional surgery and have already been widely used in the treatment of thyroid disease, but each has its limitations. This review aims to evaluate and compare the different approaches to thyroidectomy to help surgeons make the proper treatment strategy for different individuals.

Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

BACKGROUND

The aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.

METHODS

This study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.

RESULTS

Overall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (± 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave's disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.

CONCLUSION

Our results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery.

Surgical Steps of Gasless Transaxillary Endoscopic Thyroidectomy: From A to Z

In the past 30 years, the incidence of differentiated thyroid cancer (DTC) has been increasing rapidly and has become one of the most common malignant tumors in females. Currently, the main surgical treatment for DTC is standard open thyroidectomy (SOT) via a traditional Kocher mid-cervical incision, but postoperative neck scarring was associated with significantly worse health-related quality of life (HRQOL) scores. To offer better cosmesis, robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular, or transoral approaches have been developed over the past 20 years. In general, gasless transaxillary endoscopic thyroidectomy (GTET) has advantages in terms of convenience, clarity of vision, and aesthetic incision. The current work aims to provide a step-by-step description of GTET, supported by a high-quality, pictorial guide.

Safety and Efficacy of Transoral Robotic Thyroidectomy for Thyroid Tumor: A Systematic Review and Meta-Analysis

Simple Summary

This systemic review and meta-analysis compared and analyzed the safety and effectiveness of transoral robotic thyroidectomy on the thyroid tumor with other thyroid approaches. Transoral robotic thyroidectomy showed similar results to other robotic-assisted thyroid surgeries. Compared to a conventional open thyroidectomy, transoral robotic thyroidectomy had longer operational times and hospitalization days, and worse postoperative pain, but a higher cosmetic satiation score. However, more randomized controlled studies need to be included and analyzed.

Abstract

Background: To assess the safety and effectiveness of transoral robotic thyroidectomy (TORT) in thyroid tumor. Methods: PubMed, Embase, Web of Science, SCOPUS, Cochrane database, and Google Scholar up to June 2022. Studies comparing outcomes and complications between TORT and control groups (robotic bilateral axillo-breast, trans-axillary, postauricular approach, conventional open thyroidectomy (OT), and transoral endoscopic approach) were analyzed. Results: Ten studies of 1420 individuals. The operative time (SMD 1.15, 95%CI [0.48; 1.89]) was significantly longer and the number of retrieved lymph nodes (LNs) (SMD −0.27, 95%CI [−0.39; −0.16]) was fewer in TORT than in the control group. The postoperative cosmetic satisfaction score (SMD 0.60, 95%CI [0.28; 0.92]) was statistically higher in TORT than in the control group. In subgroup analysis, there was no significant difference between robotic surgeries. However, TORT had significantly longer operative times (SMD 2.08, 95%CI [0.95; 3.20]) and fewer retrieved LNs (SMD −0.32, 95%CI [−0.46; −0.17]) than OT. TORT satisfied significantly more patients in cosmetic view. However, it increased hospitalization days and postoperative pain on the operation day and first day compared to OT. Conclusions: TORT is not inferior to other robotic-assisted approaches. Its operation time and hospitalization days are longer and postoperative pain is greater than OT, although its cosmetic satisfaction is high.

Video-Assisted Thyroidectomy Using a Surgical Energy Device: Initial Experience in a Japanese Single-Center Cohort

Objective

Video-assisted thyroidectomy (VAT) was approved for coverage under the Japanese public health insurance system in 2016. In our department, we introduced VAT in 2018, and we have since been performing the procedure with the assistance of surgical energy devices. We herein summarize our cases undergoing VAT, including a review of points to consider when introducing the procedure, and characteristics of the surgical energy devices.

Methods

We enrolled 24 patients (14 women and 10 men; age: 24-83 years; mean: 59.0 years) with thyroid/parathyroid tumors who underwent VAT between January 2018 and March 2021 at our department. The medical records of the patients were reviewed, and demographic data, clinical characteristics, histological type, treatment outcomes, and complications were analyzed.

Results

The surgical energy devices used were LigaSure® in the first 4 cases, Acrosurg®. Scissors S17 in the next 13 cases, and Acrosurg®. Revo S15 in the latest 7 cases. The operation time (range: 72-250 min; mean: 147 min), intraoperative blood loss (range: 5-370 mL; mean: 33 mL), indwelling time of wound drain (range: 2-6 days; mean: 3.5 days), and hospitalization period (range: 3-8 days; mean: 5.5 days) were within acceptable ranges. In this study, it is suggested that Acrosurg®. Revo S15 can shorten the indwelling time and the hospitalization period. There were no serious complications, but 1 patient developed transient vocal cord paralysis, which improved 3 months after surgery. It was suggested that the microwave energy devices, Acrosurg®. Scissors S17 and Acrosurg®. Revo S15, may be more effective with respect to sealing/hemostasis/coagulation capacity and controllability than the high-frequency electrosurgical device, LigaSure®.

Conclusion

Based on this initial experience, VAT using surgical energy devices appeared to be a safe, effective, and minimally invasive procedure for the treatment of thyroid/parathyroid tumors. Further studies confirming these early findings are needed.

Papillary Thyroid Cancer Prognosis: An Evolving Field

Simple Summary

Over the last couple of decades, the prognostic stratification systems of differentiated thyroid cancer (DTC) patients have been revised several times in an attempt to achieve a tailored clinical management reflecting the single patients’ needs. Such revisions are likely to continue in the near future, since the prognostic value of a number of promising clinicopathological features and new molecular biomarkers are being evaluated. Here, we will review the current staging systems of thyroid cancer patients and discuss the most relevant clinicopathological parameters and new molecular markers that are potentially capable of refining the prognosis.

Abstract

Over the last few years, a great advance has been made in the comprehension of the molecular pathogenesis underlying thyroid cancer progression, particularly for the papillary thyroid cancer (PTC), which represents the most common thyroid malignancy. Putative cancer driver mutations have been identified in more than 98% of PTC, and a new PTC classification into molecular subtypes has been proposed in order to resolve clinical uncertainties still present in the clinical management of patients. Additionally, the prognostic stratification systems have been profoundly modified over the last decade, with a view to refine patients’ staging and being able to choose a clinical approach tailored on single patient’s needs. Here, we will briefly discuss the recent changes in the clinical management of thyroid nodules, and review the current staging systems of thyroid cancer patients by analyzing promising clinicopathological features (i.e., gender, thyroid auto-immunity, multifocality, PTC histological variants, and vascular invasion) as well as new molecular markers (i.e., BRAF/TERT promoter mutations, miRNAs, and components of the plasminogen activating system) potentially capable of ameliorating the prognosis of PTC patients.

Long-term cosmetic results of video-assisted thyroidectomy: a comparison with conventional surgery

PURPOSE

We present the long-term cosmetic results of the video-assisted thyroidectomy (MIVAT) in comparison to the conventional operation.

METHODS

Forty-eight patients (four males, 44 females; mean age 47.4 ± 12.5 years) constituted the video-assisted group (VA-Group). These were compared with 48 patients (10 males, 38 females; mean age 47.4 ± 12.5 years) operated by conventional surgery (C-Group). The patients were selected from all thyroid operations performed between January 2016 and June 2017. Patient Scar Assessment Scale (PSAS) and Observer Scar Assessment Scale (OSAS) were used for the evaluation performed by an independent surgeon. Both scales contained six items scored numerically on a ten-step scale ranging from 1 (normal skin) to 10 (worst result). Moreover, photos of all scars were taken and analyzed by six team surgeons using modified OSAS.

RESULTS

The mean follow-up time was 31.7 ± 6.4 months for the MIVAT group and 32.9 ± 4.6 months for the conventional group (p = 0.39). The mean scar length in the VA-Group was 2.6 cm vs. 3.8 cm in the C-Group (p < 0.0001). The total score of PSAS was 9.93 (6-35) for MIVAT and 9.72 (6-29) for conventional thyroidectomy (p = 0.22). The total OSAS score by the independent surgeon showed a better cosmetic outcome for conventional surgery (13.19 vs. 12.33; p = 0.01). The total OSAS score by the six team surgeons did not differ between both groups in five of six ratings; one surgeon favored MIVAT (12.2 vs. 13.6; p = 0.04).

CONCLUSIONS

This study does not find cosmetic advantages of minimally invasive video-assisted thyroidectomy compared to conventional thyroidectomy.

Case report and literature review: Horner syndrome subsequent to endoscopic thyroid surgery

Background

Horner syndrome (HS), mainly characterized by symptoms including ptosis, miosis, and anhidrosis on the affected face, is a condition that is well documented but rarely reported as a postoperative complication of thyroidectomy, particularly in endoscopic thyroid surgery (ETS). We hereby report a case of HS due to ETS with a brief literature review on this topic.

Case presentation

A 31-year-old female was admitted to our hospital with an unexpected physical examination finding of two thyroid nodules that were hypoechoic, had an irregular shape, and exhibited calcification. Subsequently, the results of a fine-needle aspiration (FNA) biopsy from the thyroid nodules and BRAF^V600E mutation further confirmed the malignancy of these nodules. Thus, total thyroidectomy combined with central lymph node dissection (CLND) by ETS via the bilateral axillo-breast approach was performed on this patient. Histology confirmed the diagnosis of papillary thyroid microcarcinoma (PTMC) concurrent with Hashimoto’s thyroiditis (HT). However, this patient developed HS with ptosis in her left eye on postoperative day 3. All symptoms gradually resolved before the 3-month follow-up.

Conclusion

HS subsequent to ETS is a rare complication. Thus, standardized and appropriate operative procedures, as well as subtle manipulation, are essential in preventing and reducing the occurrence of HS. In addition, the early diagnosis and management of this rare complication are also important for a favorable outcome.

Endoscopic thyroidectomy: Which one is the better technique for the beginners?

Introduction:

Endoscopic thyroidectomy is an advanced procedure and has a long learning curve. Most commonly employed approach is combined axillary-breast approach (ABA). Recently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) is being popularised as a scarless procedure. However, it is not established whether TOETVA or ABA approach is better to begin with.

Purpose:

The purpose of the study was to compare the initial experience of TOETVA and ABA with respect to difficulties and outcomes.

Methodology:

A prospective non-randomised interventional study was conducted including the initial ten patients in each group who underwent hemithyroidectomy for benign solitary thyroid nodule. Sigma plot version 12.3 was used for the statistical analysis.

Results:

All the patients were female and comparable with respect to age (33.2 vs. 28.2 years) and size of nodule (2.7 vs. 3 cm) (TOETVA vs. ABA). The operative time (121 vs. 138.5 min, P = 0.34) and blood loss (50 vs. 60 ml, P = 0.9) were similar in both the groups. Even though the flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001), it was associated with more difficulty in approaching upper pole (P = 0.02) and lower pole (P < 0.001), more intra-operative events (30% vs. 10%, P = 0.58) and conversions to open (20% vs. 10%, P = 1). Similarly, post-operative pain scoring was more with TOETVA (3 vs. 2, P = 0.04). Hospital stay was similar in both the groups (2.5 vs. 3 days, P = 1). Patients in both the groups had both overall and cosmetic satisfaction.

Conclusions:

Axillary-breast approach should be preferred to start learning the endoscopic thyroidectomy, as it is easier and safer than transoral endoscopic vestibular approach.

Recent Trends in Surgical Approach to Thyroid Cancer

Over the past decade, the incidence of thyroid cancer has rapidly increased worldwide, and thyroid surgery has become one of the most common performed surgical procedure. Even though conventional open thyroidectomy remains the gold standard, this approach leaves a neck scar which could be worrying mainly for young women. The recent progress in surgical technology, as well as patient cosmetic requests, have led to the development of alternative access to the thyroid lodge. Thus, alternative techniques have been established in order to potentially provide a more appealing cosmetic result, both with a minimally-invasive cervical or remote-access approach. However, the introduction of these new techniques was initially approached with caution due to technical challenges, the introduction of new complications and, above all, skepticism about the oncologic effectiveness. Among several alternative approaches proposed, the minimally invasive video-assisted thyroidectomy and the robot-assisted transaxillary thyroidectomy became popular and obtained the favor of the scientific community. Moreover, the recent introduction of the trans-oral endoscopic thyroidectomy with vestibular approach, although the safety and the efficacy are still under discussion, deserves particular attention since it represents the only technique truly scarless and provides the best cometic result. The purpose of this article is to provide an overview of the current main alternative approaches for the treatment of thyroid cancer with particular focus on the oncological effectiveness of the procedures.

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.

Surgical approaches to thyroid

Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIX^th century, has become the "gold standard". It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed "new approaches" to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these "new approaches" have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients.

Application of minimal invasive technique for thyroidectomy without remote access in locally advanced thyroid carcinoma with gross extra-thyroidal extension

•

Minimally invasive thyroidectomy (MIT) is useful and famous technique that is being applied to thyroid carcinoma.

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MIT without remote access is useful and applicable in thyroid disease and carcinoma in terms of cost effect and cosmetic outcome.

•

MIT without remote access can be feasible method for thyroid carcinoma with gross extra-thyroidal extension, especially, upper pole carcinoma.

Introduction

Minimally invasive thyroidectomy (MIT) is technically less damaging tissue and is better cosmetic results with small neck scar, decreasing postoperative pain and neck discomfort. We present the experience of MIT without remote access with case of grossly extra-thyroidal extension positive papillary thyroid carcinoma.

Presentation of case

A 44-year-old, female presented 1.6 cm irregular hypoechoic nodule at upper pole in Right thyroid gland and diagnosed to papillary thyroid carcinoma. The tumor was suspicious to have extra-thyroidal extension. We performed MIT without remote access for this patient with 2 cm cervical incision. Postoperative course was uneventful and patient was discharged on the 3th postoperative day. At present, she is taking 100mcg levothyroxine and is free of disease 3 years post-surgery.

Conclusion

If experienced surgeons can get sufficient resection margin and control bleeding of superior thyroid artery, MIT without remote access can be feasible method for thyroid carcinoma with gross extra-thyroidal extension, especially, upper pole carcinoma.

Pure transoral robotic thyroidectomy; institutional adaptation and early results from a tertiary endocrine surgery centre

PURPOSE

Novel thyroidectomy techniques have been described to minimize the visible scar. Hereby, we aim to present our experience with transoral robotic thyroidectomy (TORT) without axillary access.

MATERIAL AND METHODS

Between August 2018 and March 2019, six eligible patients were enrolled to undergo TORT. Procedures were performed by using the Da Vinci Xi platform under intermittent intraoperative nerve monitoring.

RESULTS

All patients were female, and the mean age was 40.0 ± 14.4 years. Three patients underwent total thyroidectomy, and lobectomy was performed for the remaining three patients. In one patient, the procedure was converted to conventional open thyroidectomy due to bleeding. The mean docking time, console time and total operative time were 22.8 ± 5.2 min, 118.5 ± 48.7 min and 218.29 ± 50.6 min for total thyroidectomy and 21.8 ± 4.1 min, 68.6 ± 6.1 min and 177.6 ± 15.1 min for lobectomy, respectively. All patients were discharged uneventfully.

CONCLUSIONS

Pure TORT is a safe procedure, when performed in carefully selected patients by experienced surgeons, but further prospective studies with larger number of patients are required.

Minimally invasive video-assisted thyroidectomy in Asian patients: experience from Singapore

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) although well established in Europe has not yet gained widespread acceptance in Asia. We describe our learning experience in the first reported series of 105 cases from Singapore.

METHODS

A retrospective analysis of outcomes in 105 patients who underwent MIVAT from April 2011 to 2018 was performed. The inclusion criteria were - symptomatic benign thyroid pathologies and follicular lesions or neoplasms needing a hemi-thyroidectomy. A thyroid lobe volume less than 35 mL was used as cut-off. Patients underwent surgeon-performed thyroid ultrasound with biopsy of solid nodules. All cases were operated by one surgeon using standard Miccoli technique with energy device used in all cases.

RESULTS

From a total of 424 patients with nodular goitres undergoing thyroidectomy, 105 (24%) symptomatic eligible patients underwent the MIVAT procedure (M:F - 23:82). The mean incision lengths at start and completion were 1.7 cm (range 1.5-2 cm) and 2.4 cm (range 2-2.7 cm), respectively. Mean operating time was 97 min (range 59-160 min). There were four conversions (3.8%) in the first 25 cases and four patients (3.8%) experienced transient hoarseness with full recovery. Visual analogue pain scores at 6 and 24 h post-operatively were 2.7 and 1.1, respectively. Scar satisfaction was reported as excellent (75%), satisfactory (23%) and poor (2%).

CONCLUSION

Although technically more demanding, MIVAT is a safe and useful operation in a thyroid surgeon's armamentarium. The limitation of goitre size, however, allows only a small percentage of symptomatic patients to undergo this procedure.

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.

Mini-invasive thyroidectomy and intraoperative neuromonitoring: a high-volume single-center experience in 215 consecutive cases

BACKGROUND

Endocrine surgery recent evolution has been characterized by introduction of mini-invasive video-assisted technique. When a new technique is introduced in surgical use the rate of adverse events must be the same of previous standardized technique. In MIVAT procedure complication rate and in particular nerve injury risk is associated surgeon's experience. The new approach is the intraoperative neuro-monitoring (IONM) use in MIVAT in order to reduce the laryngeal nerve injury rate in a more technically difficult surgical procedure.

METHODS

We analyzed clinical and surgical data regarding 215 patients treated with MIVAT technique and simultaneous IONM utilization from September 2014 to December 2019 in a single high-volume surgical center. We recorded data regarding age, gender, preoperative diagnosis, surgical time, early postoperative hypocalcemia, hematoma and vocal cord palsy. We compared these data to our first 211 cases of MIVAT (July 2005 to June 2009) at the beginning of the learning curve, performed without using IONM. We tried to highlight the impact of MIVAT and IONM simultaneous use on surgical outcome comparing results to our previous studies, also highlighting the learning curve effect.

RESULTS

We detected a postoperative transitory clinical hypocalcemia in 14 patients (6.5%). No postoperative hematoma was recorded. Using I-IONM during thyroidectomy, we recorded in five cases a loss of signal; in three cases (1.4%) we experienced a temporary postoperative vocal cord palsy, only one case of definitive palsy. We did not observe any significant differences in surgical complications rate between the first 211 cases and these last 215 cases. We have not found any statistically significative difference regarding IONM use during MIVAT procedure related to MIVAT performed without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). Surgical indication has changed.

CONCLUSIONS

In our experience we report that the use of IONM in MIVAT is as helpful to improve the safe of procedure. The risk of nerve palsy in literature associated to MIVAT is the same of the related one to classic technique (CT). We have not found statistical positivity to use IONM in MIVAT related to MIVAT without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). The most important IONM effect, in our opinion is the "safety feeling" experienced by the surgeon using IONM in a more challenging procedure. As a University Hospital, training surgery residents, we also identified the IONM as a very useful teaching support.

Transoral thyroid surgery vestibular approach: does size matter anymore?

BACKGROUND

Various approaches for endoscopic and minimally invasive thyroid operations have been reported, with some becoming popular to date. The aim of these procedures is to reduce and prevent visible scars in the neck. This led to the transoral endoscopic thyroidectomy vestibular approach (TOETVA) technique applicable in small thyroid specimen. To amend TOETVA and to broaden the indication for transoral thyroid surgery, our aim was to combine the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach.

METHODS

After successful implementation of the TOETVA technique in 2017, we evaluated the transoral technique regarding feasibility and safety in well-selected patients in Germany and Austria. With the combination of TOETVA and EndoCATS, we were able to optimize the extraction process of the specimen by avoiding damage to the thyroid capsule and to broaden the indication of transoral surgery by operating on thyroid glands with higher volume. Patients' characteristics, surgical outcome and complications were determined.

RESULTS

Seventy-one transoral procedures were performed in 70 patients. The TOETVA procedure was performed in 60 patients, and 10 female patients underwent TOVARA with transoral thyroid lobe mobilization and removal of the specimen via the retroauricular access. Overall, median operation time was 205 min (range 96-370 min) and permanent RLNP rate was 1% accordant to 99 nerves at risk (39 hemithyroidectomies, 29 total thyroidectomies, 2 parathyroid resections, and 1 thyroglossal cyst resection). No conversion to conventional open surgery was necessary. Long-term mental nerve injury occurred in two patients. No infection was identified.

CONCLUSIONS

Transoral thyroid and parathyroid surgery via the vestibular approach is both feasible and safe in Western Europe. The combination of the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach, called TOVARA, is a promising opportunity to allow for thyroid surgery without a visible scar in specimen with volume of more than 40 ml also.

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.

Minimally invasive video-assisted thyroidectomy (MIVAT)

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain.

Methods

The authors conducted a retrospective analysis about patients who underwent MIVAT between 1998 and 2019 in the Endocrine Surgery Unit of the University Hospital in Pisa. Indications and contraindications are mentioned and strictly followed.

Results

Total thyroidectomy was performed in 1,862 cases (69%) and hemithyroidectomy was performed in 763 cases (28.3%). Conversion occurred in 43 cases (1.6%). In 188 cases (7%) a postoperative transient hypoparathyroidism was reported, whereas definitive hypoparathyroidism was reported in 12 cases (0.4%). Thirty-eight patients (1.4%) suffered from a definitive postoperative recurrent laryngeal nerve palsy. No definitive bilateral recurrent laryngeal nerve palsy occurred.

Conclusions

From our multi-years' experience which spreads over 20 years, we can reaffirm the concept that MIVAT is a safe procedure which is not burdened by an increase complications rate or additional costs. Furthermore, this technique offers advantages in terms of cosmetic results and post-operative pain.

Minimally Invasive Video-Assisted Surgical Management for Parapharyngeal Metastases From Papillary Thyroid Carcinoma: A Case Series Report

Background: Papillary thyroid carcinoma (PTC) is the most prevalent cancer type in the endocrine system. Metastases to parapharyngeal lymph nodes (PPLNs) are rare. Herein, we reported a case series of PTC patients with PPLN metastases operated on by using the minimally invasive video-assisted (MIVA) technique to evaluate the safety and effectiveness of this technique. Method: In this single-institutional study, six consecutive PTC patients with PPLN metastases between January 2012 and July 2018 were enrolled. All PPLNs were managed by the MIVA technique. Result: Six patients (three women and three men) who underwent surgery were enrolled in the current study. The median age of patients was 40.5 years (39-66). Five patients (83.3%) were diagnosed with primary PTC with PPLN metastases, and one patient had PTC recurrence in the PPLNs 17 years after her first PTC surgery. Surgical treatment was successful in all patients, and the median operative time and bleeding volume were 185 (100-280) min and 85 (30-120) ml, respectively. None of the patients experienced post-operative complications except for one patient who experienced dysphagia, which resolved within 3 months. During a median follow-up of 15 months (10-31), none of the patients exhibited recurrence or persistent disease. Conclusion: The MIVA transcervical approach was technically feasible and reliable, with less invasiveness for PTC patients with PPLN metastases. Future studies are needed to accumulate more experience, investigate the indications of the technique, and determine the long-term oncological safety.

[Transoral endoscopic thyroid surgery]

OBJECTIVE

To analyze own initial experience of transoral thyroid surgery.

MATERIAL AND METHODS

There were 7 patients thyroid nodules who underwent surgery for the period from March 2018 to May 2019. All patients signed an informed consent to be included in the study. Surgical approach was performed through three incisions in the lower arch of the vestibule of the mouth with deployment of 10 mm endoscope and two 5 mm tools. Gas insufflation was used. All patients were females aged 43.3±11.8 years. Thyroidectomy was performed in 2 cases, hemithyroidectomy - in 5 patients. Dimensions of nodules varied from 10 to 42 mm.

RESULTS

Mean time of hemithyroidectomy and thyroidectomy was 206.4±63.8 and 232±37.5 min, respectively. Papillary carcinoma was histologically verified in 1 case. Injuries of recurrent laryngeal nerve, postoperative hypocalcemia and local complications were absent. Drainage was not applied. Postoperative hospital-stay was 3.7±1.1 days.

CONCLUSION

Transoral approach to the thyroid gland is technically feasible with standard endoscopic instruments, safe for important anatomical structures and more precise due to the optical capabilities of endoscopic equipment. Any types of procedures are possible. Undoubtedly, aesthetic outcome is also favorable.

Video-assisted neck surgery (VANS) using a gasless lifting procedure for thyroid and parathyroid diseases: "The VANS method from A to Z"

Purpose

To describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases.

Methods

We describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves’ disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available.

Results

The working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected.

Conclusions

The VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

Patient and Surgeon Candidacy for Transoral Endoscopic Thyroid Surgery

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments.

Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature

INTRODUCTION

The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature.

METHODS

Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4).

RESULTS

All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high.

CONCLUSION

Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Minimally Invasive Video-Assisted Thyroidectomy: Analysis of Complications From a Systematic Review

BACKGROUND

Nowadays, minimally invasive video-assisted thyroidectomy (MIVAT) is considered a safe and effective option. However, its complication rate has not been specifically discussed yet. The aim of this systematic review was enrolling a large number of studies to estimate early and late complications (transient and definitive, uni- and bilateral laryngeal nerve palsy; transient and definitive hypocalcemia; cervical hematoma; hypertrophic or keloid scar) of MIVAT compared with conventional technique.

METHODS

The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in PubMed and Embase. Search terms were "minimally invasive," "video-assisted," and "thyroidectomy." We enrolled randomized clinical trials, nonrandomized trials, and noncontrolled trials.

RESULTS

Thirty-two articles were considered suitable. Complication rate of MIVAT was quite similar to conventional technique: only one randomized trial found a significant difference concerning overall skin complication, and a single trial highlighted hypocalcemia significantly increased in MIVAT, concerning serologic value only. No difference concerning symptomatic nor definitive hypocalcemia was found.

CONCLUSIONS

We can confirm that MIVAT is a safe technique. It should be adopted in mean-high-volume surgery centers for thyroidectomy, if a strict compliance with indication was applied.

Transcutaneous Recording During Intraoperative Neuromonitoring in Thyroid Surgery

BACKGROUND

Recurrent laryngeal nerve (RLN) palsy remains a major source of morbidity after thyroid surgeries. Intraoperative neural monitoring (IONM) has gained increasing acceptance as an adjunct to standard practice of visual RLN identification. Endotracheal tube (ETT) surface recording electrodes systems are now widely used for IONM; however, a malpositioned ETT can cause false IONM results and requires time-consuming intraoperative verification of the ETT position and readjustment by the anesthesiologist. The aim of this experimental study was to evaluate the feasibility of the transcutaneous approach for recording evoked laryngeal electromyography (EMG) signals during IONM.

METHODS

A porcine model with well-established applicability in IONM research was used. Twelve piglets (24 nerve sides) were enrolled. Electrically evoked EMGs were recorded from surface electrodes on the ETT and from the adhesive pre-gelled surface electrodes on the anterior neck skin. The evoked EMG waveforms were measured and analyzed. The real-time signal stability of the electrodes during tracheal displacement and their accuracy in reflecting adverse EMG changes during RLN stress were evaluated during continuous IONM performed with automatic periodic vagus nerve (VN) stimulation.

RESULTS

In all nerves, both the ETT and neck adhesive skin electrodes successfully recorded typical evoked laryngeal EMG waveforms from the RLNs and VNs under stimulation with 1 mA. The transcutaneous electrodes recorded mean EMG amplitudes of 264 μV (±79) under RLN stimulation and 202 μV (±55) under VN stimulation. The electrodes recorded mean EMG latencies of 2.98 ms (±0.20) under RLN stimulation, 4.51 ms (±0.50) under right VN stimulation, and 8.13 ms (±0.94) under left VN stimulation, respectively. When tracheal displacement was experimentally induced, the EMG signals obtained by ETT electrodes varied significantly, but those obtained by transcutaneous electrodes did not. When RLN traction stress was experimentally induced, both ETT and transcutaneous electrodes recorded the same pattern of progressively degrading EMG amplitude with gradual recovery after release of traction.

CONCLUSIONS

This study confirms the feasibility of transcutaneous recording of evoked laryngeal EMG during IONM. Although this study confirms the stability and accuracy of the transcutaneous approach, it also revealed the need for new electrode designs to improve EMG amplitudes before practical clinical application of this approach.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Transoral Endoscopic Thyroidectomy: A Systematic Review of the Practice So Far

Background and Objectives

Thyroid disease largely affects young females, but the incidence is also increasing among males. In an effort to avoid the scarring of the neck that is synonymous with conventional thyroidectomy, endoscopic techniques have been developed over the years. The transoral endoscopic approach is the latest of these innovations that promises a scarless surgical outcome. This review evaluates whether this technique is safe and feasible in live patients and outlines the outcomes in published literature so far.

Database

PubMed, Medline, BioMed Central, Cochrane Library, OVID and Web of Science were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting strict inclusion and exclusion criteria. Sixteen studies were included in the final analysis.

Discussion

This systematic review presents cases of 785 patients. Surgeons in 15 of the studies used a completely vestibular approach, whereas those in the remaining 2 used the floor of the mouth for primary access. Conversion to open surgery took place in 1.3%. In total, 4.3% of patients experienced transient laryngeal nerve palsy, whereas 0.1% had permanent recurrent incidences of the condition. Transient hypocalcemia occurred in 7.4% of cases, with no recorded permanent cases. Carbon dioxide embolism occurred in 0.6% of cases, and another 0.6% had a deep-seated neck infection. The complication rates within the review were deemed acceptable and the overall technique feasible. A prospective randomized controlled trial was proposed to compare this technique with conventional thyroidectomy.

Hybrid techniques and patients' safety in implementing transoral sublingual thyroidectomy

PURPOSE

Cosmetic advantages and minimally invasive aspects become more and more important for patients undergoing thyroidectomy. We report on our personal experience and conceptual design in dealing with approaches to the thyroid gland, which we were the first to describe. We report on ideas and experiences concerning its implementation.

METHODS

Our own experiences and considerations in the process of finding an endoscopic minimally invasive access in thyroidectomy are compared in a systematic review with the available literature on minimally invasive or endoscopic thyroid surgery. We describe our failures and risk assessment.

RESULTS

Our analysis of the literature on minimally invasive thyroidectomy and our own experiences lead us to the conclusion that using different hybrid technologies during the implementation of endoscopic procedures in thyroid surgery can be helpful and could improve patients' safety. A combination of transoral endoscopic and non-transoral techniques might be a useful safer, but more traumatizing alternative for implementation. Several studies show the feasibility of the transoral access in thyroid surgery. We believe that the implementation of these new procedures as routine surgery in specialized centers must be carefully considered and discussed.

CONCLUSIONS

The transoral access seems to be less invasive than other extracollar endoscopic accesses in thyroid surgery. For a sublingual single-access routine surgery, better instruments are needed. The vestibular access is possible with standard instruments. Using hybrid technologies for implementation should not be considered as a failure. The transoral thyroidectomy can be a safe method in the hand of experienced surgeons. We expect this hybrid technique to play a major part in further spreading endoscopic transoral thyroid surgery.

Enhanced visualization of parathyroid glands during video-assisted neck surgery

PURPOSE

Visualization and precise dissection of the parathyroid glands are a crucial step of thyroidectomy. Moreover, identification of parathyroid adenoma in patients with primary hyperparathyroidism can be challenging due to the possible abnormal location of the enlarged parathyroid. Near-infrared fluorescence (NIR) can be adopted during video-assisted neck surgery in addition to standard endoscopic magnification to enhance the visualization of the parathyroid tissue.

METHODS

Between July and August 2017, five patients (one male, four females) underwent video-assisted neck surgery at our hospital. One patient suffered from primary hyperparathyroidism. The four remaining patients underwent thyroidectomy for multinodular goiter or Graves' disease. The parathyroid glands were firstly identified by the video-assisted approach and then confirmed by the NIR visualization of the endogenous autofluorescence of the parathyroid tissue. Low-dose (2.5 mg/ml) indocyanine green was administered to visualize the vascular supply during and/or after the dissection. The standard dose of 2.5 mg (1 ml per injection) was used to allow repeated injection during the same procedure.

RESULTS

An endogenous parathyroid autofluorescence could be visualized by the NIR camera in all patients. The right upper parathyroid adenoma could be detected prior to fully dissection of the gland from the surrounding tissue. Twelve out of 16 parathyroid glands have been visually identified during four total thyroidectomies. Eleven glands showed an autofluorescence prior to indocyanine green (ICG) injection. Further, ICG injection has been used for guiding the dissection of the gland in three cases and for confirmation of the vascular supply at the end of the procedure in the remaining cases. There were neither intraoperative nor postoperative complications.

CONCLUSION

The 5-mm 30° NIR camera allows for enhanced visualization of the parathyroid tissue during video-assisted thyroidectomy. This promising tool can become standard for video-assisted neck surgery.

Robotic and endoscopic transoral thyroidectomy: feasibility and description of the technique in the cadaveric model

Background

Numerous new approaches have been described over the years to improve the cosmetic outcomes of thyroid surgery. Transoral approach is a new technique that aims to achieve superior cosmetic outcomes by concealing the incision in the oral cavity.

Methods

Transoral thyroidectomy through vestibular approach was performed in two institutions on cadaveric models. Procedure was performed endoscopically in one institution, while the robotic technique was utilized at the other.

Results

Transoral thyroidectomy was successfully performed at both institutions with robotic and endoscopic techniques. All vital structures were identified and preserved.

Conclusions

Transoral thyroidectomy has been performed in animal and cadaveric models, as well as in some clinical studies. Our initial experience indicates the feasibility of this approach. More clinical studies are required to elucidate its full utility.

Modified Tumescent Solution for Creating Working Space During Endoscopic Thyroidectomy

OBJECTIVE

To study the feasibility of gas-liquid mixing tumescent solution for creating a working space (WS) in endoscopic thyroidectomy (ET).

MATERIALS AND METHODS

A prospective study was performed on 186 patients with thyroid tumor who had undergone ET via chest and breast approach. Patients were randomly divided into 2 groups to receive traditional tumescent solution as group A and modified tumescent solution (gas-liquid mixing tumescent solution) as group B. This study compares the following surgical outcome parameters between the 2 groups, including changes of blood pressure, heart rate, and oxygen saturation before and after creating a WS, time for creating a WS, operative time, hemorrhage volume for creating a WS, overall hemorrhage volume, overall postoperative drainage volume, postoperative pain score, postoperative hospitalization, number of retrieved lymph nodes, total serum calcium, serum parathyroid hormone, and cases of transient and permanent recurrent laryngeal nerve palsy.

RESULTS

No postoperative bleeding, permanent recurrent laryngeal nerve palsy, incision and surgical site infection, air embolism, flap injury occurred in both groups. The mean time for creating a WS and the whole operation in group B was significantly shorter than that in group A ( P < .05). There were no statistically significant differences in both groups in terms of other observation index ( P > .05).

CONCLUSION

The clinical application of gas-liquid mixing tumescent solution can effectively reduce the time for creating a WS and whole operative time, and worthy of being widely used in ET as a safe and effective technique.