Yonsei Experience of 5000 Gasless Transaxillary Robotic Thyroidectomies

Transoral robotic thyroidectomy: Lessons learned from consecutive series of 1,000 patients

BACKGROUND

Transoral robotic thyroidectomy has gained popularity as a promising approach for thyroid surgery owing to its improved cosmetic outcomes. The objective of this retrospective study was to describe the surgical and safety outcomes of 1,000 consecutive transoral robotic thyroidectomy cases.

METHODS

1,000 consecutive patients who underwent transoral robotic thyroidectomy for thyroid disease were reviewed at a large metropolitan tertiary hospital (Seoul, Korea) between September 2012 and March 2022.

RESULTS

The study comprised 1,000 patients (815 women), with 891 cancer cases. Lobectomy was the most common procedure (89.4%), followed by total thyroidectomy (9.8%) and isthmusectomy (0.8%), and their respective mean total operative times were 173.8 ± 36.2, 236.8 ± 50.5, and 107.5 ± 19.8 minutes. An obvious learning curve was noted. The respective postoperative pain scores on postoperative days 0, 1, and 2 were 4.6 ± 1.3, 3.1 ± 0.8, and 2.5 ± 0.8. The mean postoperative hospital stay duration was 2.6 ± 0.9 days. Complications occurred in 3.6% of cases, including oral wound infection, skin flap burn, bleeding, chyle leakage, transient and permanent mental nerve injury, and transient and permanent recurrent laryngeal nerve injury. Transient hypoparathyroidism occurred in 4.1% of total thyroidectomy cases. Thirty-seven patients (4.2%) underwent additional radioactive iodine therapy. The median follow-up period was 39 months, and there were no cases of recurrence.

CONCLUSIONS

Under the expertise of an experienced surgeon, transoral robotic thyroidectomy results in favorable cosmetic outcomes, tolerable postoperative pain, and acceptable complication rates in carefully selected patients.

A New Transoral Vestibulum Single Incision Endoscopic-Assisted Thyroidectomy with Gasless

OBJECTIVE

We developed a novel method for thyroidectomy using a single-incision oral vestibular approach. To assess its advantages and disadvantages, we compared the perioperative parameters of this approach with those of transoral three-incision thyroidectomy and trans-areolar thyroidectomy.

METHODS

In a study of 136 papillary thyroid carcinoma patients (2016-2018), precise thyroidectomy and neck dissection were conducted. Among them, 52 chose single-incision oral vestibular approach, 33 chose three-incision variant, and 51 underwent trans-areolar thyroidectomy. Perioperative aspects of the transoral single-incision group were compared with those of transoral three-incision group, and transthoracic group.

RESULTS

In the cohort, meticulous tumor level VI lymph node dissection was performed, achieving intended resection extent with one case requiring a switch from transoral to transthoracic approach. No nerve palsy occurred in the transoral group. Thyroidectomy duration varied significantly across groups. Transoral single-incision had a shorter duration than transoral three-incision and longer than transthoracic. Minor differences were observed in blood loss and drainage. Perioperative factors like hematoma, infection, hypocalcemia, et al., remained consistent. Notably, no tumor recurrence was observed in this study.

CONCLUSIONS

This new transoral video-assisted neck surgery (TOVANS) method for thyroidectomy without gas insufflation approach did not increase the surgical complexity compared with the transoral vestibular three-incision thyroidectomy and the trans-areolar thyroidectomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2976-2984, 2024.

The updated surgical steps of gasless transaxillary endoscopic thyroidectomy with neck level and region orientation for thyroid cancer

Introduction

We previously made a detailed expansion to the gasless transaxillary endoscopic thyroidectomy(GTET) procedure described in the previous literatures. In this study, we optimized the procedure focused on the limitation of the approach in terms of trauma and lymph node dissection and made a comparison with the early procedure.

Materials and methods

This paper gave a detailed description of the updated procedure and prospectively collected data about patients with papillary thyroid carcinoma(PTC) performed by the two procedures from December 2020 to April 2023. The differences in surgical outcome, surgical trauma and parathyroid gland(PG) function protection were analyzed.

Results

Of the 302 patients, 184 underwent with early procedure(EP), and 118 underwent with updated procedure(UP). The surgical outcomes of operative time, time of thyroidectomy and central neck dissection, blood loss, drainage and postoperative hospital stay were shorter in UP than that of the EP. The mean number of lymph nodes retrieved and weight of dissection lymphatic tissue in the UP were significantly more than that in EP without increasing the mean number of metastatic lymph nodes. Postoperative complications did not differ between the two procedures. The UP had more advantages in the identification and preservation of the superior parathyroid gland, however, it did not improve the preservation in situ of the inferior parathyroid gland. The visual analog scale score for pain and the changes among inflammation factors was lower in the UP.

Conclusion

The UP of GTET could perform safely and efficiently while reducing surgical trauma in selected patients.

An institutional experience of intraoperative neurophysiological monitoring application in robotic thyroidectomy: a retrospective case-control study

Purpose

Intraoperative neurophysiological monitoring (IONM) has been introduced in thyroid surgery to prevent injury of the recurrent laryngeal nerve (RLN). However, its effectiveness remains controversial in robotic thyroidectomy (RT). This study aimed to compare the surgical outcome of RT in patients with and without the application of IONM.

Methods

This retrospective case-control study included 100 patients who underwent total thyroidectomy via robotic bilateral axillo-breast approach in a tertiary center. A study group of 50 patients who had IONM during RT was compared to a control group of 50 patients who underwent RT with nerve visualization alone.

Results

The sex ratio (4:45 vs. 7:43, P = 0.538), mean age (39.3 ± 7.1 years vs. 37.5 ± 10.4 years, P = 0.304), and body mass index (23.1 ± 2.6 kg/m2 vs. 22.2 ± 3.9 kg/m2, P = 0.215) were comparable between the IONM and control groups. Pathologic features including tumor size (0.8 cm vs. 0.9 cm, P = 0.283), extrathyroidal extension (58.0% vs. 24.0%, P = 0.316), lymph node metastasis (30% vs. 34%, P = 0.668), and number of lymph nodes (5.3 vs. 5.3, P = 0.668) showed no differences. There was no permanent RLN palsy, postoperative bleeding, and wound complications. Transient hypoparathyroidism was observed in 12 (24.0%) and 14 (28.0%), permanent hypoparathyroidism in 0 (0%) and 1 (2.0%), and transient RLN palsy was observed in 3 (6.0%) and 3 (6.0%), respectively.

Conclusion

We did not demonstrate a clear advantage of IONM in RT. Controversies regarding the effectiveness of IONM is not closed.

A meta-analysis of unilateral axillary approach for robotic surgery compared with open surgery for differentiated thyroid carcinoma

OBJECTIVE

The Da Vinci Robot is the most advanced micro-control system in endoscopic surgical instruments and has gained a lot of valuable experience today. However, the technical feasibility and oncological safety of the robot over open surgery are still uncertain. This work is to systematically evaluate the efficacy of the unilateral axillary approach for robotic surgery compared to open surgery for differentiated thyroid carcinoma.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were utilized to search for relevant literatures of robotic thyroid surgery using unilateral axillary approach compared to open thyroid surgery, and a meta-analysis was performed using RevMan software version 5.3. Statistical analysis was performed through Mantle-Haenszel and inverse variance methods.

RESULTS

Twelve studies with a total of 2660 patients were included in the meta-analysis. The results showed that compared with the open group, the robotic group had a longer total thyroidectomy time, shorter hospital stay, less intraoperative bleeding, more postoperative drainage, fewer retrieved central lymph nodes, and higher cosmetic satisfaction (all P < 0.05). In contrast, temporary and permanent laryngeal recurrent nerve injury, temporary and permanent hypoparathyroidism or hypocalcemia, brachial plexus nerve injury, number of retrieved central lymph nodes, number of retrieved lymph nodes in the lateral cervical region, number of lymph node metastases in the lateral cervical region, hematoma, seroma, lymphatic leak, stimulated thyroglobulin (sTg) and unstimulated thyroglobulin (uTg), and the number and recurrence rate of patients with sTg <1ng/ml were not statistically different between the two groups (P > 0.05).

CONCLUSIONS

The unilateral axillary approach for robotic thyroid surgery may achieve outcomes similar to those of open surgery. Further validation is required in a prospective randomized controlled trial.

Expansion of thyroid surgical territory through 10,000 cases under the da Vinci robotic knife

With the progress of robotic transaxillary thyroid surgery (RTTS), the indications for this procedure have gradually expanded. This study presents the insights gained from performing 10,000 RTTS cases at a single institution, along with the expansion of indications over time. RTTS was performed on 10,000 patients using the da Vinci robot system between October 2007 and April 2023 at the Yonsei University Health System, Seoul, Korea. Among 10,000 patients, 9461 (94.0%) were diagnosed with thyroid cancer, whereas 539 (5.4%) had either a benign thyroid nodule or Graves' disease. Surgical procedures were performed using four-arm-based robots (da Vinci S, Si, or Xi) for 8408 cases (84.1%), with the remaining 1592 cases (15.9%) being performed using the da Vinci SP surgical robotic system. Notably, for 53 patients with nodules ≥ 5 cm, which were not included in the eligibility criteria of the previous study, RTTS was performed safely without significant complications. The most common postoperative complication was transient hypoparathyroidism (37.91%), and recurrence occurred in 100 patients with thyroid cancer (1.1%). In conclusion, RTTS appears safe and feasible from both surgical and oncological perspectives, and the spectrum of indications suitable for RTTS surgery is progressively expanding.

A scoping review of endoscopic and robotic techniques for lateral neck dissection in thyroid cancer

Introduction

Lateral neck dissection (LND) in thyroid cancer has traditionally been performed by a transcervical technique with a large collar incision. With the rise of endoscopic, video-assisted, and robotic techniques for thyroidectomy, minimally invasive LND is now being performed more frequently, with better cosmetic outcomes.

Methods

The purpose of this paper is to review the different minimally invasive and remote access techniques for LND in thyroid cancer. A comprehensive literature review was performed using PubMed and Google Scholar search terms "thyroid cancer" and "lateral neck dissection" and "endoscopy OR robot OR endoscopic OR video-assisted".

Results

There are multiple surgical options now available within each subset of endoscopic, video-assisted, and robotic LND. The approach dictates the extent of the LND but almost all techniques access levels II-IV, with variability on levels I and V. This review provides an overview of the indications, contraindications, surgical and oncologic outcomes for each technique.

Discussion

Though data remains limited, endoscopic and robotic techniques for LND are safe, with improved cosmetic results and comparable oncologic and surgical outcomes. Similar to patient selection in minimally invasive thyroidectomy, it is important to consider the extent of the LND and select appropriate surgical candidates.

Future Directions in the Treatment of Thyroid and Parathyroid Disease

The surgical management of thyroid and parathyroid disease has evolved considerably since the era of Theodor Kocher. We review the current trends in thyroid and parathyroid surgery concerning robotic surgery for remote access, the use of parathyroid autofluorescence detection technology to aid in the prevention of hypocalcemia as well as the use of thermal ablation to target thyroid nodules in a minimally invasive way. We also discuss how artificial intelligence is being used to improve the workflow and diagnostics preoperatively as well as for intraoperative decision-making. We also discuss potential areas where future research may enhance outcomes.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

A propensity score matching analysis of gasless endoscopic transaxillary thyroidectomy with five-settlement technique versus conventional open thyroidectomy in patients with papillary thyroid microcarcinoma

BACKGROUND

In a previous study, we proposed a novel anatomy-based five-settlement method for transaxillary endoscopic thyroidectomy (fs-TAT) for patients with papillary thyroid carcinoma. The safety of this new method has been reported in a retrospective study of a single cohort. The safety and short-term oncological outcome of this method was confirmed by comparing it with conventional open surgery (COT) in patients with papillary thyroid microcarcinoma.

METHODS

The medical records of patients who underwent fs-TAT or COT by a single surgeon from February 2019 to December 2021 were reviewed retrospectively. All patients were diagnosed with papillary thyroid microcarcinoma and underwent lobectomy and ipsilateral central compartment neck dissection. Propensity score matching was used to compare the technical safety and short-term oncologic outcomes of fs-TAT and COT for the purpose of reducing potential selection bias. Reporting was consistent with the STROCSS 2021 guidelines.

RESULT

After propensity score matching, 460 (fs-TAT: 230; COT: 230) patients remained in the study population. There were no significant differences in sex, age, tumor size, Hashimoto's thyroiditis, or tumor multifocality between the groups. The operative time was longer [104.5 (90.3, 120.0) vs. 62.0 (52.0, 76.0), P < 0.001] and the total postoperative drainage volume [135(90, 210) vs. 75 (55, 115), P < 0.001] was greater in the fs-TAT group than in the COT group. However, intraoperative bleeding [3.0 (2.0, 5.0) vs. 5.0 (5.0, 7.5), P < 0.001] was greater, and the median number of lymph nodes yielded [5.0 (2.3, 8.0) vs. 7.0 (5.0, 11.0), P < 0.001] was greater in the COT group than in the fs-TAT group. The groups exhibited no significant difference in the rate of complications (fs-TAT: 2.2% vs. COT: 2.6%, P = 0.856), rate of positive lymph nodes (fs-TAT: 32.2% vs. COT: 36.5%, P = 0.377), length of postoperative hospital stay (3 days vs. 3 days, P = 0.305) or total medical costs (26,936 vs. 26,549, P = 0.144).

CONCLUSION

Compared to conventional open surgery, fs-TAT offered excellent safety and acceptable short-term oncological outcomes in a selected cohort of patients with papillary thyroid microcarcinoma.

First Experience of Single-Port Robotic Areolar Approach Thyroidectomy

OBJECTIVES

Numerous minimally invasive thyroidectomy techniques have been developed and are actively utilized in hospitals around the globe. Herein, we describe a recently developed minimally invasive thyroidectomy technique that employs the da Vinci SP, and we present the preliminary clinical outcomes of single-port robotic areolar thyroidectomy (SPRA).

METHODS

A 3-cm semi-circular incision on the right areola and a small 8-mm incision on the left areola were created. Using hydro-dissection and an advanced bipolar device, a subcutaneous skin flap was created, extending from the areola to the thyroid cartilage. The da Vinci SP was then inserted through the incision in the right areola. Between December 2022 and March 2023, 21 SPRA procedures were conducted. Patients' medical records and surgical videos were subsequently reviewed.

RESULTS

Lobectomy was performed in 17 patients, isthmectomy in 2 patients, and total thyroidectomy in 2 patients. The mean flap time was 14.9±4.2 minutes and the console time was 62.4±17.1 minutes. The mean tumor size was 0.89± 0.65 cm and the number of retrieved lymph nodes was 3.94±3.98 (range, 0-12). There were no observed instances of vocal cord palsy or hypoparathyroidism.

CONCLUSION

We successfully developed and performed the novel SPRA for the first time worldwide. Unlike other robotic surgery.

METHODS

SPRA is less invasive and leaves no visible scars. This technique employs a sophisticated single-port robotic device. However, to assess the efficacy of this method, we need to analyze more cases and conduct comparative studies in the near future.

Comparison of surgical completeness in patients operated on conventional open total thyroidectomy (OT) or trans-axillary robot-assisted total thyroidectomy (RATT) by a single axillary approach

Trans-axillary robot-assisted total thyroidectomy (RATT) is nowadays worldwide accepted but the completeness obtained by RATT is still debated. The Aim of this study was to compare the completeness and safety of RATT with conventional open thyroidectomy (OT). We enrolled patients with nontoxic multinodular goiter, cytologically indeterminate nodules and well differentiated thyroid cancer without local and/or distant metastasis. In all cases the biggest nodule should be < 6 cm. The surgical completeness was evaluated by means of serum thyroglobulin (hs-Tg) and neck ultrasound (nUS) performed three months postoperatively. 100 patients underwent either RATT or OT. The type of surgical procedure was chosen by patients. They were then divided in two subgroups based on benign or malignant histology. There were no significant differences in the postoperatively values of hs-Tg in patients operated with RATT or OT, both in benign and malignant subgroups. The post-operative thyroid remnant volume estimated by nUS was not significantly different between the two groups, both in benign and malignant subgroups. We also analyzed the difference of the volume of the thyroid remnant ipsilateral to the axillary access vs that of the remnant on the contralateral side and there was not significantly difference in both subgroups. RATT was demonstrated to determine a comparable surgical completeness as OT, both in benign and malignant thyroid diseases, with no differences in the prevalence of surgical complications. In our hands the surgical completeness of RATT by a single trans-axillary was satisfying.

Robotic transaxillary thyroidectomy: time to expand indications?

In 2016, the American Thyroid Association published a statement on remote-access thyroid surgery claiming that it should be reserved to patients with thyroid nodule ≤ 3 cm, thyroid lobe < 6 cm and without thyroiditis. We retrospectively enrolled all patients who underwent robotic transaxillary thyroidectomy between February 2012 and March 2022. We compared surgical outcomes between patients who presented a thyroid gland with a nodule ≤ 3 cm, thyroid lobe < 6 cm and without thyroiditis (Group A) and patients without these features (Group B). The rate of overall complications resulted comparable (p = 0.399), as well as the operative time (p = 0.477) and the hospital stay (p = 0.305). Moreover, bleeding resulted associated to thyroid nodule > 3 cm (p = 0.015), although all bleedings but one occurred in the remote-access site from the axilla to the neck. In experienced hands, robotic transaxillary thyroidectomy is feasible and safe even in patients with large thyroid nodules or thyroiditis.

Quality of Life Following Robotic Transaxillary Versus Conventional Hemithyroidectomy: A Comparative Analysis

Background: Robotic technology has proven safe and effective for thyroidectomy procedures. Few studies have addressed the quality-of-life outcomes of robotic thyroidectomy compared with conventional thyroidectomy. Materials and Methods: The database of a tertiary medical center was retrospectively reviewed for all patients with thyroid disease who had undergone robotic hemithyroidectomy in 2012-2020. All patients treated by transaxillary robotic surgery and a similar number of randomly selected patients treated by conventional cervical surgery completed a standardized self-administered thyroid disease-specific quality-of-life (QOL) questionnaire (ThyPRO). Clinical data were derived from the medical files. The results were compared using mean comparison tests and multivariate logistic regression models. Results: The cohort consisted of 131 patients: 63 after robotic thyroidectomy and 68 after conventional thyroidectomy. The mean age was 38.87 ± 14.11 and 58.85 ± 14.1 years, respectively (P < .0001). The robotic hemithyroidectomy group reported better QOL outcomes in physical and mental health parameters, including decreased anxiety, depression, lower sex life impairment, and cognitive impairment scores (P < .0001). Furthermore, after adjusting for age, gender, malignancy status, and surgical approach, we found that patients undergoing robotic hemithyroidectomy had a lower probability of experiencing depressive symptoms than the conventional hemithyroidectomy group (odds ratio = 0.31; 95% confidence interval, 0.11-0.88). Of interest, no significant difference in cosmetic outcomes was found. Conclusions: Patients who underwent robotic thyroidectomy report better postoperative QOL after surgery than patients operated by the conventional approach in terms of anxiety, depression, cognitive and sex-life scores.

Clinical Application of Pectoralis Nerve Block II for Flap Dissection-Related Pain Control after Robot-Assisted Transaxillary Thyroidectomy: A Preliminary Retrospective Cohort Study

Simple Summary

The main findings of the study are that pectoralis nerve block II (PECS II) may be a valuable analgesic option that alleviates flap dissection pain and stress during a robot-assisted transaxillary thyroidectomy (RATT) and reduces opioid consumption in the early recovery phase. Patients who received PECS II experienced a more comfortable recovery and required fewer painkillers. PECS II may serve as a valuable new pain relief modality in addition to the multimodal analgesic strategy for patients undergoing RATT. Although we have yet to investigate the optimal block duration, regions of sensory loss, optimal technique, and possible complications, our preliminary study suggests that PECS II reduces flap dissection pain and thus promotes recovery. Appropriate analgesia during RATT remains challenging, but is a key issue for postoperative recovery. A further prospective investigation is required to validate our results and establish the optimal pain control regimen for patients undergoing RATT.

Abstract

Few studies have examined the clinical utility of ultrasonography-guided pectoralis nerve block II (PECS II) during wide flap dissection of a robot-assisted transaxillary thyroidectomy (RATT). We assessed the ability of PECS II to reduce postoperative pain. We retrospectively reviewed 62 patients who underwent elective RATT from December 2021 to April 2022 at Seoul St. Mary’s Hospital (Seoul, Korea). The patients were divided into a block group (n = 28, 50.9%) and no-block group (n = 27, 49.1%). Pain was measured using a visual analog scale (VAS) at 4, 10, 20, 25, 35, and 45 h after surgery, and the requirements for rescue painkillers in the post-anesthesia care unit and ward were recorded. The VAS scores did not differ significantly between the two groups at 4 h postoperatively. The block group had significantly lower VAS scores at 10 and 25 h (p = 0.017 and p = 0.034, respectively). The block group required fewer painkillers in the post-anesthesia care unit than the no-block group, although the difference was not statistically significant in the ward. PECS II may serve as a new pain relief modality and valuable addition to the current multimodal analgesic strategy for patients undergoing RATT.

Re-do Operation Using a Robotic System due to Locoregional Recurrence after Initial Thyroidectomy for Thyroid Cancer

Locoregional recurrent thyroid cancer is commonly treated with re-do operation. This study aimed to investigate the feasibility of using robotic system for re-do operation in locoregional recurrent thyroid cancer. Sixty-five patients who underwent re-do robotic operation using trans-axillary approach for locoregional recurrent thyroid cancer from October 2007 to April 2021 at Yonsei University Hospital were analyzed. Completion total thyroidectomy (CTT) was performed in 26 cases, CTT and modified radical neck node dissection (mRND) in 16, and mRND in 23. Most of the re-do robotic operations were performed at site of previous incision. All patients were diagnosed with papillary thyroid carcinoma (PTC). CTT with central compartment neck dissection (CCND) took 117.6 ± 26.3 min, CTT with mRND 255.6 ± 38.6 min, and mRND, 211.7 ± 52.9 min. Transient hypocalcemia occurred in 17 (26.2%) patients and permanent hypocalcemia occurred in 3 (4.6%). There was one case of recurrent laryngeal nerve(RLN) injury. One patient was diagnosed with structural recurrence after re-do robotic operation. Median follow-up duration was 50.7 ± 37.1 months. Re-do robotic operation can be an alternative for patients who are diagnosed with locoregional recurrent thyroid cancer after thyroidectomy, with no increase in morbidity, similar oncologic outcomes, and superior cosmetic satisfaction.

Single Surgeon Experience with 500 Cases of the Robotic Bilateral Axillary Breast Approach (BABA) for Thyroid Surgery Using the Da-Vinci Xi System

Objectives: Robotic bilateral axillary breast approach (BABA) thyroid surgery began in 2008 and is now one of the most widely used remote-access thyroid surgeries worldwide. This study aimed to analyze the results of 500 robotic BABA thyroid surgeries performed in a single institution in Korea compared with open thyroid surgery. Methods: From December 2018 to March 2020, 502 robotic BABA thyroidectomies (RTs) and 531 conventional open thyroidectomies (OTs) were performed in our institution by a single endocrine surgeon. We retrospectively reviewed patient medical records and performed a comparative analysis of OT and RT. Results: The RT group was younger (43.41 ± 11.41 versus 54.28 ± 13.41 years, p < 0.001) and had a higher proportion of females (84.3% versus 69.3%, p < 0.001), a lower BMI (24.66 ± 3.97 versus 25.83 ± 4.07 kg/m²), a higher proportion of lobectomies (52.6% versus 45.2%) and a lower proportion of lateral neck dissections (3.4% versus 10.0%, p < 0.001). The RT group had a longer operation time (145.33 ± 40.80 versus 93.39 ± 43.55 min, p < 0.001) and higher surgical costs. Although the OT group had a larger tumor size and a higher proportion of extrathyroidal extension, the numbers of retrieved lymph nodes were not significantly different between the two groups. Additionally, there was no difference in the stimulated thyroglobulin level before radioactive iodine therapy (7.01 ± 35.73 versus 8.39 ± 58.77, p = 0.782). The rates of transient vocal cord palsy and transient hypoparathyroidism were significantly lower in the RT group, and those of scar-related complications were higher in the OT group. Conclusions: Robotic BABA thyroid surgery has advantages not only in better cosmetic outcomes but also in lower rates of vocal cord palsy and hypoparathyroidism, with comparable lymph node retrieval and serum thyroglobulin levels.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma

BACKGROUND

The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease.

DATABASE

This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series.

CONCLUSION

In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Gasless transaxillary endoscopic thyroidectomy for unilateral low-risk thyroid cancer: Li's six-step method

The past decade has witnessed rapid advances in gasless transaxillary endoscopic thyroidectomy (GTET) for thyroid cancer, which has become a reliable procedure with good therapeutic effectiveness, aesthetic benefits, and safety. This procedure has been widely promoted in some Asian countries; however, few studies have described the specific surgical steps for unilateral low-risk thyroid cancer. Based on a review of the literature and our own clinical experience, we introduce in detail the surgical procedure of GTET for the unilateral low-risk thyroid cancer, briefly summarized into Li's 6 steps: surgical position and incision design; creation of surgical cavities; dissection of the superior pole of the thyroid and its vessels, and identification and protection of superior laryngeal nerve; identification and protection of the superior parathyroid gland, and identification of the inferior parathyroid gland; identification and protection of the recurrent laryngeal nerve and the inferior parathyroid gland, and central neck dissection; and processing of the suspensory ligaments of thyroid gland and en bloc resection of the tumor. The six-step approach is simple to learn. The lymph nodes are dissected first, followed by resection of the primary lesion and protect important structures, which meets the principles of radical tumor treatment. It is hoped that the proposed Li's six-step method can promote the standardized, safe, and wide application in treating early thyroid cancer.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic Completion Thyroidectomy via the Bilateral Axillo-Breast Approach

BACKGROUND

Bilateral axillo-breast approach (BABA) robotic thyroidectomy has been successfully performed for thyroid cancer patients with excellent cosmetic results. Completion thyroidectomy is sometimes necessary after thyroid lobectomy, and whether it has a higher complication rate than the primary operation due to the presence of adhesions remains controversial. The aim of this study was to evaluate surgical outcomes, including operation time and postoperative complications, in patients who underwent BABA robotic completion thyroidectomy.

METHODS

From Jan 2012 to Aug 2020, 33 consecutive patients underwent BABA robotic completion thyroidectomy for a thyroid malignancy after BABA robotic thyroid lobectomy. The procedures were divided into five steps: (1) robot setting and surgical draping, (2) flap dissection, (3) robot docking, (4) thyroidectomy, and (5) closure. Clinicopathological characteristics, operation time, and postoperative complications were reviewed.

RESULTS

The total operation time was shorter for completion thyroidectomy than for the initial operation (164.8 ± 31.7 min vs. 179.8 ± 27.1 min, p = 0.043). Among the robotic thyroidectomy steps, the duration of the thyroidectomy step was shorter than that of the initial operation (69.6 ± 20.9 min vs. 83.0 ± 19.5 min, p = 0.009. One patient (1/33, 3.0%) needed hematoma evacuation under the flap area immediately after surgery. Three patients (3/33, 9.1%) showed transient hypoparathyroidism, and one patient (1/33, 3.0%) had permanent hypoparathyroidism. Two patients (2/33, 6.1%) showed transient vocal cord palsy and recovered within 3 months following the completion thyroidectomy. There were no cases of open conversion, tracheal injury, flap injury or wound infection.

CONCLUSIONS

BABA robotic completion thyroidectomy could be performed safely without completion-related complication.

Hypoglossal nerve palsy after gasless trans-axillary endoscopic thyroidectomy: a case report

Background

Gasless trans-axillary endoscopic thyroidectomy (GTAET) has satisfactory cosmetic effects for the patients who have benign goiter and small thyroid carcinoma, however the complications of this surgical procedure have not been fully documented. Ipsilateral hypoglossal nerve palsy (IHNP) associated with GTAET has never been reported before.

Case presentation

A 33-year old male patient presented with a 4 × 5 mm solid thyroid nodule in the right lobe. Papillary thyroid carcinoma was confirmed by the fine needle aspiration. He had strong cosmetic demand, therefore GTAET for right lobectomy and central cervical lymphadenectomy was performed in a supine position with cervical extension. Six hours after the operation, he developed tongue deviation to the right side, speech and swallowing difficulties, indicating IHNP. Head and cervical MRI showed no abnormality. The intravenous steroid was used for three days, and oral vitamin B1 and mecobalamin was prescribed for 1 month. Nine days after surgery, he was discharged. Three months after the operation, all the symptoms were completely resolved.

Conclusions

To the best of the authors’ knowledge, this is the first case of IHNP after GTAET, which will be valuable to add our knowledge to diagnose and treat rare complications of GTAET.

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.

Microscopic Thyroidectomy: The Way We Do It

The present study was conducted with an intent to document the reduced morbidity in terms of postoperative hypocalcemia, injury to recurrent laryngeal and external branch of superior laryngeal nerve, in patients undergoing microscope assisted thyroidectomy. The present study enrolled a total of 878 patrients who underwent hemi, total and completion thyroidectomies, over a period of 3 years at Jain ENT Hospital, Jaipur. In the present study, out of 1118 RL nerves dissected temporary paresis was found in 1.52% and permanent palsy in only 0.36%. Temporary hypocalcemia was seen in 8.12% while permanent hypocalcemia in 0.6% patients. EBSLN could be identified in 1082 of the 1118 nerves dissected. We recommend the use microscope routinely for all thyroid surgeries, starting from the very first step in view of the reduced morbidity that it offers.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Robotic Transaxillary Hemithyroidectomy Using the da Vinci SP Robotic System: Initial Experience With 10 Consecutive Cases

Background: Many studies have shown the operative feasibility and safety of robotic thyroidectomy. However, there is still a concern on the operative invasiveness of robotic thyroidectomy owing to the wide flap dissection. The aim of this study was to introduce our novel robotic technique, which can minimize the dissection extent using the da Vinci SP robotic system. Methods: Ten patients underwent robotic transaxillary thyroidectomy using the da Vinci SP robotic system between December 2018 and April 2019 at Yonsei University Hospital (Seoul, Korea). All procedures were performed successfully using the single-port robotic system. Results: All 10 patients were women and diagnosed with papillary thyroid carcinoma. The mean operative time was 148.7 ± 26.8 minutes. The mean operative time using the gasless method was shorter than that using the gas insufflation method (130.5 ± 14.1 vs 176.0 ± 12.8 minutes). All patients were discharged on the third day after operation without any complications. Conclusions: Robotic transaxillary thyroidectomy using the da Vinci SP robotic system is technically feasible and safe with a short length of incision, shorter than what earlier reported. To our knowledge, this is the first study to use a single-port robotic system for thyroidectomy. To verify the superior operative outcomes, further clinical trials are necessary.

Robot-assisted Nipple-sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience

Seeking smaller and indistinct incisions, physicians have attempted endoscopic breast surgery in breast cancer patients. Unfortunately, there are some limitations in the range of movement and visualization of the operation field. Potentially addressing these limitations, we investigated the outcomes of gas and gasless robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR). Ten patients underwent 12 RANSM with IBR between November 2016 and April 2018. Patients with tumors measuring >5 cm in diameter, tumor invasion of the skin or nipple-areolar complex, proven metastatic lymph nodes, or planned radiotherapy were excluded. Age, breast weight, diagnosis, tumor size, hormone receptor status, and operation time were retrospectively collected. Postoperative outcomes including postoperative complications and final margin status of resected were analyzed. The median total operation time and console time were 351 min (267–480 min) and 51 min (18–143 min), respectively. The learning curve presented as a cumulative sum graph showed that the console time decreased and then stabilized at the eighth case. There was no open conversion or major postoperative complication. One patient had self-resolved partial nipple ischemia, and two patients experienced partial skin ischemia. We deemed that RANSM with IBR is safe and feasible for early breast cancer, benign disease of the breast, and BRCA 1/2 mutation carriers. RANSM is an advanced surgical method with a short learning curve.

Robotic thyroidectomy via bilateral axillo-breast approach: Experience and learning curve through initial 220 cases

OBJECTIVE

This study is aim to summarize the experience of robotic thyroidectomy via bilateral axillo-breast approach of our center and also to find out the learning curve of this technique.

METHODS

In total 220 initial patients who have undergone robotic thyroidectomy via bilateral axillo-breast approach from May 2015 to September 2017 were involved in this study. The data of operation time, clinical characteristics, surgical outcomes and oncological outcomes were collected. The moving average method is use to explore the learning curve.

RESULTS

All patients had undergone robotic thyroidectomy successfully without conversion to other surgical approaches. The mean age of the enrolled subjects was 34.4 ± 7.8 years old, while the sex ratio (male/female) was 38/182. There were 50 benign tumor cases and 170 malignant tumor cases. The mean total operation time was 105.3 ± 37.6 min. Lymph node metastasis was observed in 61 (35.9%) patients. The mean retrieved lymph node count was 5.1 ± 3.8 while the mean metastatic lymph node count was 0.7 ± 1.5. The operation time decreased significantly after about 30-35 cases and formed the plateau. After 80 cases, the operation time significantly decreased again.

CONCLUSION

For skilled endocrine surgeons, robotic thyroidectomy has proved to be safe and feasible, which could be applied extensively in patients strictly selected in high-volume centers, with a relatively short learning curve of about 30-35 cases. While the surgeons getting more experienced, this technique would be more efficient.

Microscopic Thyroidectomy: A Prudent Option

Microscopic Thyroidectomy is not a new surgical technique but it is not explored much. The routine use of microscope in thyroid surgery can reduce the rate of nerve palsy and hypocalcemia. Nine cases were done exclusively with the microscope only and postoperative nerve palsy and hypocalcemia were noted. We have also discussed about optimum working distances and magnification for critical structures during thyroid surgery. No patient has any nerve palsy while one patient reported transient hypocalcemia. Recurrent laryngeal nerve could be identified at 2 × but optimal magnification for dissection of nerve should be 4 ×. We find this technique easy to adopt and critical structures can be identified and preserved easily with microscopic thyroidectomy then conventional and loupe technique. It is better to have standardized and optimum working distance and magnification during different steps of surgery. It is great teaching tool in view of its better illumination and magnification.

Impact of body mass index on robotic transaxillary thyroidectomy

Obesity is associated with increased operating times and higher complication rates in many types of surgery. Its impact on robotic thyroidectomy however, is not well documented. The aim of this study was to investigate the relationship between body mass index (BMI) and robotic transaxillary thyroidectomy (RTAT). A retrospective review of prospectively collected data of all patients who underwent RTAT at Yonsei University Health System from October 2007 to December 2014 was performed. Patients were divided into three groups based on BMI (Group 1: BMI < 25, Group 2: BMI 25-29.99, Group 3: BMI ≥ 30), and compared. A total of 3697 patients were analyzed. No differences between the three groups were observed in clinicopathological factors, extent of surgery or length of stay. After multivariate analysis, only seroma and transient voice hoarseness were related to increasing BMI. Total operative time was significantly longer for Group 3 patients with less-than-bilateral total thyroidectomy (BTT), but was not significantly different for patients with BTT. Although obese patients undergoing RTAT have a slightly higher risk of seroma, transient voice hoarseness, and longer operative times, BMI did not influence the other important surgical outcomes of thyroidectomy. Therefore, obesity should not be a contraindication for performing RTAT.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Quantitative Assessment of the Learning Curve for Robotic Thyroid Surgery

With the increased utilization of robot thyroidectomy in recent years, surgical proficiency is the paramount consideration. However, there is no single perfect or ideal method for measuring surgical proficiency. In this study, we evaluated the learning curve of robotic thyroidectomy using various parameters. A total of 172 robotic total thyroidectomies were performed by a single surgeon between March 2014 and February 2018. Cumulative summation analysis revealed that it took 50 cases for the surgeon to significantly improve the operation time. Mean operation time was significantly shorter in the group that included the 51st to the 172nd case, than in the group that included only the first 50 cases (132.8 ± 27.7 min vs. 166.9 ± 29.5 min; p < 0.001). On the other hand, the surgeon was competent after the 75th case when postoperative transient hypoparathyroidism was used as the outcome measure. The incidence of hypoparathyroidism gradually decreased from 52.0%, for the first 75 cases, to 40.2% after the 76th case. These results indicated that the criteria used to assess proficiency greatly influenced the interpretation of the learning curve. Incorporation of the operation time, complications, and oncologic outcomes should be considered in learning curve assessment.

Conventional Robotic Endoscopic Thyroidectomy for Thyroid Cancer

The conventional robotic endoscopic remote access techniques detailed in this article have been discussed in a series of increasing volumes in the literature, including for the treatment of thyroid cancer. Lower-volume centers now perform most robotic thyroidectomies in the United States and are responsible for recent increases in utilization patterns despite higher complication rates. These trends highlight the importance of increasing surgeon exposure to and experience with these techniques in order to improve procedure safety. Additional large-volume, multicenter studies to define patients who will most benefit from these conventional robotic endoscopic procedures for thyroid cancer are needed.

Thyroid surgery for differentiated thyroid cancer - recent advances and future directions

Population-based studies have demonstrated that an increasing number of incidental thyroid nodules are being identified. The corresponding increase in thyroid-based diagnostic procedures, such as fine-needle aspiration biopsy, has in part led to an increase in the diagnoses of thyroid cancers and to more thyroid surgeries being performed. Small papillary thyroid cancers account for most of this increase in diagnoses. These cancers are considered to be low risk because of the excellent patient outcomes, with a 5-year disease-specific survival of >98%. As a result, controversy remains regarding the optimal management of newly diagnosed differentiated thyroid cancer, as the complications related to thyroidectomy (primarily recurrent laryngeal nerve injury and hypoparathyroidism) have considerable effects on patient quality of life. This Review highlights current debates, including undertaking active surveillance versus thyroid surgery for papillary thyroid microcarcinoma, the extent of thyroid surgery and lymphadenectomy for low-risk differentiated thyroid cancer, and the use of molecular testing to guide decision-making about whether surgery is required and the extent of the initial operation. This Review includes a discussion of current consensus guideline recommendations regarding these topics in patients with differentiated thyroid cancer. Additionally, innovative thyroidectomy techniques (including robotic and transoral approaches) are discussed, with an emphasis on patient preferences around decision-making and outcomes following thyroidectomy.

First report of in-situ preservation of a subcapsular parathyroid gland through super-meticulous capsular dissection during robotic radical thyroidectomy

PURPOSE

Meticulous capsular dissection can preserve the function of the parathyroid gland in most patients, but it is difficult to identify and preserve the subcapsular parathyroid gland. We performed in-situ preservation of the subcapsular parathyroid gland during robotic radical thyroidectomy using super-meticulous capsular dissection, and evaluated its effect on postoperative parathyroid function.

METHODS

A 45-year-old woman was admitted with bilateral thyroid nodules. Color Doppler ultrasound demonstrated a 7 × 7 × 6 mm hypoechoic area in the middle and inferior part of the right lobe and 3 × 3 × 3 mm hypoechoic nodule in the middle part of the left lobe. She was diagnosed with right thyroid papillary cancer by fine-needle aspiration. Robotic bilateral thyroidectomy plus right central lymph node dissection was performed. During the left thyroidectomy, we found that the left inferior parathyroid gland was just under the true capsule. Subsequently, the super-meticulous capsular dissection was performed for in-situ preservation of the parathyroid gland.

RESULTS

The patient's serum parathyroid hormone concentration was 43.77 pg/ml before and 37.98 pg/ml after surgery (normal: 15-65 pg/ml). Her blood calcium level was 2.21 mmol/l before and 2.18 mol/l after surgery (normal: 2.10-2.65 mmol/l).

CONCLUSIONS

The super-meticulous capsular dissection, which could cut through the true capsule to identify subcapsular parathyroid and protect its anatomic structure as well as blood supply, is recommend for in-situ preservation of subcapsular parathyroid gland during robotic radical thyroidectomy.

Efficacy and Safety of Robotic Procedures Performed Using the da Vinci Robotic Surgical System at a Single Institute in Korea: Experience with 10000 Cases

PURPOSE

To evaluate the efficacy and safety of robotic procedures performed using the da Vinci Robotic Surgical System at a single institute.

MATERIALS AND METHODS

We analyzed all robotic procedures performed at Severance Hospital, Yonsei University Health System (Seoul, Korea). Reliability and mortality rates of the robotic surgeries were also investigated.

RESULTS

From July 2005 to December 2013, 10267 da Vinci robotic procedures were performed in seven different departments by 47 surgeons at our institute. There were 5641 cases (54.9%) of general surgery, including endocrine (38.0%), upper (7.7%) and lower gastrointestinal tract (7.5%), hepato-biliary and pancreatic (1.2%), and pediatric (0.6%) surgeries. Urologic surgery (33.0%) was the second most common, followed by otorhinolaryngologic (7.0%), obstetric and gynecologic (3.2%), thoracic (1.5%), cardiac (0.3%), and neurosurgery (0.1%). Thyroid (40.8%) and prostate (27.4%) procedures accounted for more than half of all surgeries, followed by stomach (7.6%), colorectal (7.5%), kidney and ureter (5.1%), head and neck (4.0%), uterus (3.2%), thoracic (1.5%), and other (2.9%) surgeries. Most surgeries (94.5%) were performed for malignancies. General and urologic surgeries rapidly increased after 2005, whereas others increased slowly. Thyroid and prostate surgeries increased rapidly after 2007. Surgeries for benign conditions accounted for a small portion of all procedures, although the numbers thereof have been steadily increasing. System malfunctions and failures were reported in 185 (1.8%) cases. Mortality related to robotic surgery was observed for 12 (0.12%) cases.

CONCLUSION

Robotic surgeries have increased steadily at our institution. The da Vinci Robotic Surgical System is effective and safe for use during surgery.

Robotics in otorhinolaryngology - head and neck surgery

A look at the past, present and future.

Transoral endoscopic surgery for papillary thyroid carcinoma: initial experiences of a single surgeon in South Korea

Purpose

The transoral endoscopic thyroid surgery vestibular approach (TOETVA) is one of the newest techniques which do not result in an anterior neck scar. We report herein our initial experience with TOETVA and its short-term outcomes in patients with papillary thyroid carcinoma (PTC).

Methods

This case series consisted of all consecutive patients who underwent TOETVA in our institution between August 2016 and June 2017. Indications for TOETVA were an fine needle aspiration-confirmed PTC or follicular neoplasm, an intrathyroidal tumor with a diameter of less than 2 cm, and no clinical evidence of central or lateral lymph node metastasis. A total of 20 patients underwent TOETVA and we retrospectively reviewed clinicopathologic data and short-term postoperative outcomes.

Results

Among the 20 TOETVA cases, 7 were total thyroidectomy, 12 were lobectomy and 1 was wide isthmusectomy. Mean age was 50.8 years and mean operation time was 152 ± 51.4 minutes. Tumor size ranged from 0.2–1.4 cm and the mean size of harvested central lymph nodes was 2.8 (range, 0–10). Neither mental nerve injury nor surgical site infection occurred. One patient had transient vocal cord palsy and 1 patient developed a neck seroma. Among 7 total thyroidectomy patients, 3 patients developed transient hypocalcemia.

Conclusion

Transoral thyroid surgery could be an alternative surgical option for some PTC patients.