[Total videoendoscopic thyroid resection by the axillobilateral breast approach. Operative method and first results]

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience

Background

Thyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical “remote” approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction.

Methods

In a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls.

Result

The overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ²; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison.

Conclusion

Endoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

Recurrent Laryngeal Nerve Morbidity: Lessons from Endoscopic via Bilateral Areola and Open Thyroidectomy Technique

BACKGROUND AND AIM

Elucidating the mechanism of recurrent laryngeal nerve (RLN) injuries through intraoperative electromyographic (EMG) and laryngeal examination approaches may deepen our knowledge regarding its prevention strategies. To date, no studies have been reported on the mechanism of RLN injury caused by endoscopic thyroidectomy via bilateral areola approach (ETBAA).

METHODS

Both intraoperative EMG profiles and postoperative laryngeal examination were used to investigate the mechanisms of RLN injury and compare the safety aspects between ETBAA and open thyroidectomy approach (OTA).

RESULTS

This study examined 1420 nerves at risk. The mean follow-up period was 17 ± 4 (range 6-48) months. The incidence of vocal cord paralysis was 4.1% (59/1420). The number of cases with decreased EMG signals and vocal cord palsy was higher in ETBAA group than in OTA group (P < 0.05). The left RLNs in ETBAA group were at higher risk compared to the right nerves.

CONCLUSIONS

The results of the current study indicate that ETBAA exhibits higher risk of RLN injury. The topic includes a video.

[Tips and technical issues for performing transoral endoscopic thyroidectomy with vestibular approach (TOETVA): a novel scarless technique for neck surgery]

BACKGROUND

Nowadays, minimally invasive thyroid and parathyroid gland resections for both benign and malignant tumors are rarely performed. Recently, promising new endoscopic transoral approaches to the anterior neck have been described with good results and few complications. This study describes the first clinical series in Germany using transoral endoscopic thyroidectomy-vestibular approach (TOETVA) and identifies technical issues and solutions.

METHODS

The technique is indicated for hemithyroidectomy in patients without pre-existing neck operations. The technical steps consist of a 10 mm incision at the center of the oral vestibule, followed by subplatysmal hydrodissection. A blunt dissector stick is inserted creating a space below the platysma to the anterior neck and the infrahyoid muscles then three trocars are inserted in the vestibular area. After separation of the infrahyoid muscles, the thyroid isthmus is transected. Anatomical structures, such as the superior thyroid artery, parathyroid glands and the recurrent laryngeal nerve can be easily identified with magnification. Intraoperative neuromonitoring is used routinely, adding safety in avoiding nerve damage.

RESULTS

An optimal operative field due to subplatysmal dissection enables exposure of the thyroid and parathyroid glands. Several critical steps and suitable solutions were identified in the study. 1 Positioning of the team and technical improvements using the a 4K laparoscopic tower allowing enhanced view of the anatomy especially for dissection of the recurrent laryngeal nerve. 2. Lateral and upper positioning of lateral trocars avoiding mental nerve injury. 3. Initial hydrodissection of the subplatysmal space. 4. Use of one dissector progressively creating the operative space in the anterior cervical region. 5. Using internal-external sutures to retract the infrahyoid muscles. 6. Intraoperative neuromonitoring used routinely through the trocars or percutaneously through a 1 mm incision. 7. Extraction of the specimen through a recovery bag. 8. Drainages are possible, but can be avoided in small operative fields.

CONCLUSION

The new TOETVA technique for thyroid surgery is a promising option for selected patients to enable transoral thyroid and parathyroid surgery through the vestibular approach. Further studies in clinical series, especially regarding safety are needed to evaluate the indications of the technique.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

Comparison of conventional thyroidectomy and endoscopic thyroidectomy via axillo-bilateral breast approach in papillary thyroid carcinoma patients

BACKGROUND

Endoscopic thyroidectomy has been applied to solve the cosmetic problems that resulted from conventional thyroidectomy. The aim of this study was to evaluate and compare the surgical outcomes of conventional and endoscopic thyroidectomies via axillo-bilateral-breast approach (ABBA) in patients with papillary thyroid carcinoma (PTC).

METHODS

Between May 2007 and February 2011, 1003 patients with PTC underwent thyroidectomies. The eight hundred and thirty patients underwent conventional thyroidectomy and 173 patients underwent endoscopic thyroidectomy via ABBA. Clinicopathologic characteristics, complications, and surgical completeness were analyzed.

RESULTS

The mean age was 49.53 years who received a conventional thyroidectomy and 38.90 years in endoscopic thyroidectomy (P < 0.0001). The conventional thyroidectomy group underwent more extensive surgery than the endoscopic thyroidectomy group but the operation time was longer in the endoscopic thyroidectomy group (P < 0.0001). The mean hospitalization length was 6.98 days following open thyroidectomy and 6.40 days after endoscopic thyroidectomy (P = 0.003). The tumor size was larger in the conventional thyroidectomy group than the endoscopic thyroidectomy group and a lesser number of lymph nodes were retrieved in the endoscopic thyroidectomy group compared to the conventional thyroidectomy group (P < 0.0001). The postoperative complications and thyroglobulin levels in both groups were not significantly different.

CONCLUSION

These results suggest that conventional and endoscopic thyroidectomy via ABBA has similar surgical outcomes in PTC patients. Therefore, endoscopic thyroidectomy via ABBA may be an appropriate surgical alternative to conventional thyroidectomy for treating PTC in selected patients.

Surgery for thyroid cancer

The incidence of thyroid cancer, particularly papillary thyroid cancer, is rising at an epidemic rate. The mainstay of treatment of most patients with thyroid cancer is surgery. Considerable controversy exists about the extent of thyroid surgery and lymph node resection in patients with thyroid cancer. Surgical experience in judgment and technique is required to achieve optimal patient outcomes.

Single-port access transaxillary totally endoscopic thyroidectomy: a new approach for minimally invasive thyroid operation

PURPOSE

Various techniques for minimally invasive thyroid surgery have been described over the last decade. As interest in single-port access laparoscopic surgery (SPA™) continues to grow, the authors present their technique and short-term outcomes for single-port access transaxillary totally endoscopic thyroidectomy in the management of benign thyroid tumors in a series of 4 patients.

PATIENTS AND METHODS

Four consecutive patients from a prospectively maintained endoscopic thyroidectomy database were analyzed under an institutional review board-approved protocol. Clinical characteristics and short-term outcomes were reviewed.

RESULTS

All the patients were young women with no prior neck surgery. A single-port totally endoscopic thyroidectomy was performed for thyroid adenoma in 2 cases and for nodular goiter in 2 cases. Retraction, exposure, and extraction were possible in all cases. The average operating room time was 92.5 minutes. Postoperative pain scores on postoperative day 1 were all 1/10. No patient experienced complications. The median hospital stay was 1.75 days. The mean specimen size was 2.7 cm × 2.375 cm × 2.625 cm. The patients were uniformly pleased with the cosmetic results of the operation.

CONCLUSIONS

Single-port access transaxillary totally endoscopic partial thyroidectomy appears to be safe and feasible. This technique may provide both an attractive way to reduce injury to the anterior neck tissue and a method for ideal cosmetic effect.