Single-incision endoscopic thyroidectomy by the axillary approach with gas inflation for the benign thyroid tumor: retrospective analysis for a single surgeon's experience

Comparison of health-related quality of life and cosmetic outcome between traditional gasless trans-axillary endoscopic thyroidectomy and modified gasless trans-axillary endoscopic thyroidectomy for patients with papillary thyroid microcarcinoma

BACKGROUND

Gasless trans-axillary endoscopic thyroidectomy (GTET) has been proved to provide better cosmetic results; however, it has limitations as dissection of central neck lymph nodes is difficult. We developed a modified approach (MGTET-modified GTET) and compared it with the traditional one in terms of patients' health-related quality of life (HRQoL) and cosmetic results in order to provide more convincing therapeutic results.

METHODS

Between January 2021 and June 2021, 100 cN0 patients who had a confirmed diagnosis of papillary thyroid microcarcinoma were randomized to undergo either MGTET (n = 50) or GTET (n = 50). These two groups' baseline characteristics, intraoperative and postoperative findings, were compared. The Patient and Observer Scar Assessment Scale (POSAS) was determined 6 months after surgery. Thyroid Cancer-Specific Quality of Life Questionnaire was used to assess HRQoL at 1, 3, 6, and 12 months after surgery.

RESULTS

M-GTET was associated with a larger number of lymph nodes dissected (p < 0.001), lower drainage volume (p < 0.001), shorter hospital stay (p < 0.001), and shorter axillary incision (p < 0.001). POSAS was more favorable in M-GTET. HRQoL was significantly better for MGTET in terms of less problems with scar (p < 0.001).

CONCLUSION

Our study suggests that MGTET provides better therapeutic, cosmetic, and HRQoL outcomes.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique

Background

The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO₂)-related complications. Herein, we proposed a new technique without CO₂ called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA.

Methods

We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded.

Results

Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery.

Conclusions

Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.

Transaxillary gasless endoscopic hemithyroidectomy versus conventional open hemithyroidectomy: early single-centre experience

Conventional open thyroidectomy is defined as a gold standard in thyroid gland disease treatment. However, progressive surgery methods such as endoscopic technique provide better structure visualisation and improved cosmetic effect. Our study aim is to compare conventional open (COH) and endoscopic transaxillary hemithyroidectomy (TAH) and define the learning curve for TAH procedure. We retrospectively analysed 107 COH and 65 TAH cases. Patients' demographic data and surgery results were compared. Also, surgeon learning curve analysis using cumulative sum (CUSUM) was performed for the duration of the surgery. TAH was applied to younger female patients with lower thyroid gland volume. COH group patients were hospitalised for longer in comparison with TAH (p < 0.05). Mean TAH surgery time was longer (78.1 min, SD = 22.6) compared with COH (66.7 min, 15.3) (p < 0.05). Overall complication rate was comparable between groups. There was a tendency towards a lower unintentional parathyroidectomy rate in TAH group. TAH group results showed significantly longer surgery time for patients whose body mass index (BMI) was over 30 (kg/m²), compared to whose BMI was below 30 (kg/m²) (p = 0.004). Shortest endoscopic surgery time (64.9 ± 12.45 min) was achieved between 41 and 50 cases. CUSUM analysis showed that surgery time decreased after the 30th TAH case. TAH approach compared to COH results in longer surgery time, shorter hospital stay and comparable rate of postoperative complications. However matched pair studies are necessary to clarify the results. After thirty cases, the surgeon became proficient in transaxillary endoscopic thyroid surgery.

Comparison of quality of life and cosmetic result between open and transaxillary endoscopic thyroid lobectomy for papillary thyroid microcarcinoma survivors: A single-center prospective cohort study

BACKGROUND

Transaxillary endoscopic thyroidectomy has been introduced to achieve better cosmetic outcomes. However, the benefits of this technology on the patients' health-related quality of life (HRQoL) remain unclear. We aimed to investigate whether transaxillary endoscopic lobectomy is comparable to conventional open lobectomy in terms of QOL and cosmetic results in order to provide more evidence for establishing appropriate clinical decisions.

METHODS

Between August 2019 and May 2020, transaxillary endoscopic lobectomy and conventional open lobectomy were performed in 73 and 99 patients with papillary thyroid microcarcinoma, respectively. HRQoL was assessed at 1, 3, 6, and 12 months after surgery using the Thyroid Cancer-Specific Quality of Life Questionnaire. The cosmetic outcomes were assessed 12 months after surgery using the Patient and Observer Scar Assessment Scale (POSAS).

RESULTS

No significant difference was observed in the surgical results between the two groups. However, the data showed that the average operative time and postoperative hospital stay of the transaxillary group were longer than those of the open group (p < 0.001). Both groups showed similar changes in the QOL scores over time. However, the transaxillary group had fewer complaints of the throat or oral problems at 1 month postoperatively than the open group (p < 0.001). During the follow-up, the cosmetic results of scars in the transaxillary group were significantly better than those in the open group (p < 0.05). Patients who underwent transaxillary endoscopic lobectomy had higher overall satisfaction with their scar appearance, determined using POSAS, at 12 months postoperatively.

CONCLUSIONS

The current findings suggest that transaxillary endoscopic lobectomy may offer better cosmetic and HRQoL outcomes.

Learning curve for endoscopic thyroidectomy using video-assisted neck surgery: retrospective analysis of a single surgeon's experience of 100 cases

BACKGROUND

Endoscopic thyroidectomy offers excellent cosmetic outcomes, but requires a period of time for surgeons to become proficient. We examined the learning curve for the first 100 cases experienced by a single surgeon using a video-assisted neck surgery (VANS) subclavian approach.

METHODS

We retrospectively studied 100 patients (99 women, 1 man; mean age, 36.2 years) with both benign and malignant thyroid diseases treated between 2016 and 2020.

RESULTS

Preoperative diagnosis was papillary thyroid carcinoma (PTC) in 36 cases and other (non-PTC) in 64 cases. All patients underwent lobectomy, with unilateral central node dissection added for patients with PTC. Mean operative time was 125 min for non-PTC cases and 129 min for PTC cases (p = 0.43), with blood loss of 33.8 ml and 7.6 ml, respectively (p = 0.01). Recurrent laryngeal nerve paralysis (RNP) was observed in 12 patients (12%) and hemorrhage in 2 patients (2%). Comparing the first 30 cases with the last 70 cases, no significant differences in operative time or blood loss were evident, although tumor size of non-PTC cases was significantly greater among later cases (32.4 mm vs. 39.5 mm, p = 0.039). RNP was significantly decreased in later cases (26.7% vs. 5.7%, p = 0.003). Multivariate analysis revealed tumor size as a significant risk factor for increased blood loss, and increased experience correlated significantly with the decrease in RNP.

CONCLUSIONS

In VANS, a certain surgical level was reached after experiencing 30 cases.

Single-Port Access Endoscopic Thyroidectomy via Axillary Approach for the Benign Thyroid Tumor: New Aspects from Vietnam

Background

This study aims to describe our new experience with single-port totally endoscopic thyroidectomy via the axillary approach in patients with unilateral thyroid benign tumors. In parallel with that, we also discuss here the challenges and novelty highlights we have confronted and solved and the details of our operative technique.

Methods

Between August 2018 and May 2020, the study involved 54 patients who underwent a single-port single-incision endoscopic thyroidectomy via the axillary approach for benign thyroid tumor at the National Hospital of Endocrinology (Hanoi, Vietnam). Surgical patient indications were in working age, goiter classification of grade 1 or grade 2, the thyroid with mononuclear or multinucleated, lesion diameter of less than 4 cm, unilateral thyroid benign lesion and no previous history of neck surgery or irradiation.

Results

No mortality was observed. Morbidities included transient voice change in 8 patients, swallowing disorders in 2 patients, transient skin paresthesia in 2 patients and wound hematoma in 2 patients. Mean amount of postoperative drainage was 70.2 mL, mean duration of postoperative drainage was 2.7 days, and mean postoperative hospital day was 6.6 days. Mean total operation time was 66.0 minutes and mean blood loss was 13.3 mL. Regarding medium-term follow-up outcomes following surgery, we recorded the hypothyroidism in 3 patients (5.6%) and the hypocalcemia in 1 case (1.8%). Most patients felt normal neck movement and sensation (79.6%), 3 patients were painful (5.6%) and 8 those were numb (14.8%). We saw the soft incision scar in 35 patients (64.8%), convex scar in 14 patients (25.9%), and hard scar in 5 patients (9.3%).

Conclusion

Single-port endoscopic thyroidectomy via axillary approach is a safe and feasible treatment option for removing benign thyroid tumor, delivering favorable surgical outcomes with ideal cosmetic effect and reduction in injury to the anterior neck tissue.

Novel robot-assisted thyroidectomy by a transaxillary gas-insufflation approach (TAGA): a preliminary report

Background

Robot-assisted transaxillary approaches to thyroidectomy have been well described. They have an advantage over the breast approach in that a circumareolar incision is avoided. However, they require a single long axillary incision to accommodate all 3 robotic arms and provide adequate visualization of the area around the thyroid. The purpose of this study was to test the feasibility of the robot-assisted transaxillary gas-insufflation approach (TAGA) and to attempt reducing the size of the scar.

Methods

We evaluated 47 patients who underwent robot-assisted thyroid lobectomy via TAGA from July 2015 to Aug 2017. The following variables were studied: patients' demographics, operative time according to each operation step, volume of drainage, duration of hospitalization, and perioperative complications.

Results

The mean age of all patients was 42.4±9.1 years. The mean total volume of drainage was 195.4±70.9 mL, and the duration of postoperative stay was 3.0±1.1 days. Two cases (4.3%) of transient vocal cord palsy and 2 cases (4.3%) of seroma were identified postoperatively. There was no post-operative cosmetic problem at the skin incisions made in the axilla.

Conclusions

Robot-assisted thyroid lobectomy via TAGA is technically feasible while achieving good cosmetic results. TAGA can be an alternative robot-assisted method for thyroidectomy.

TransOral Endoscopic Thyroidectomy via Submental and Vestibular Approach: A Preliminary Report

Purpose: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA), with its excellent cosmetic effect, has become increasingly popular worldwide. Nonetheless, anatomic obstacles have limited its development to a certain extent. Here, we present our preliminary outcomes of transoral endoscopic thyroidectomy via submental and vestibular approach (TOETSMVA), which can overcome those limitations. Methods: From November 2019 to March 2020, we performed TOETSMVA in 21 consecutive patients with thyroid carcinoma at Zhongshan Hospital, Xiamen University. A 1.5-cm lateral incision was made at two fingers below the mandible; two 5-mm incisions were made in the vestibule near the first molars; TOETSMVA was completed through these incisions. The demographic data and surgical outcomes of the patients were retrospectively reviewed. Results: Twenty-one patients with a mean age of 37.5 ± 10.4 years were incorporated into this study. Fourteen patients had papillary thyroid micro-carcinomas, two had papillary thyroid carcinomas, and five had benign nodules. Eight patients had lymph node metastases. All surgeries were performed successfully without conversion to open thyroidectomy. The mean operation time was 138.8 ± 33.2 min; the average hospital stay was 3.3 ± 0.8 days. No patients developed cutaneous paralysis in the midline chin region. Transient recurrent laryngeal nerve paralysis was observed in one patient. There was no evidence of postoperative bleeding, infection, tetany, or other complications. Conclusion: TOETSMVA was shown to be a safe and advisable alternative for selected patients. This approach can overcome the limitations of TOETVA without sacrificing cosmetic results.

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.

Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach

Importance

Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars.

Objective

To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT).

Design, Setting, and Participants

This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias.

Main Outcomes and Measures

Operative time, blood loss, and complications related to thyroid surgery.

Results

Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group.

Conclusions and Relevance

The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.

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.

Comparison of endoscopic thyroidectomy via a modified axillo-breast approach with the conventional breast approach for treatment of unilateral papillary thyroid microcarcinoma

Endoscopic thyroidectomy (ET) via an axillo-breast (ABA), axillary or breast approach (BA) is effective for treatment of unilateral papillary thyroid microcarcinoma (PTMC). However, several disadvantages still exist, including inconvenience for using endoscopic instruments and poor cosmetic results. Here, we introduced a modified ABA (MABA) to overcome these disadvantages and evaluated its therapeutic outcomes by comparison with conventional BA.Fifty-five patients undergoing ET via MABA (n = 22) or BA (n = 33) for PTMC were retrospectively enrolled between June 2012 and June 2015. Surgical outcomes, including the operation time, blood loss, amount of drainage, number of dissected lymph nodes, complications, cosmetic satisfaction and prognosis (recurrence and survival), were analyzed.The operation time (87.1 ± 9.3 min vs 93.2 ± 8.3 min; P = .014) and drainage tube removal time (4.4 ± 1.0 days vs 5.1 ± 1.1 days; P = .018) were shorter in the MABA group than those in the BA group. There was less postoperative drainage (54.3 ± 35.7 mL vs 137.6 ± 87.0 mL; P < .01) in the MABA group compared with the BA group. No significant differences in the blood loss (15.9 ± 7.5 mL vs 19.2 ± 11.7 mL, P = .243) and the number of dissected lymph nodes (1.8 ± 1.5 vs 2.3 ± 2.1, P = .309) were observed between the 2 groups. Subcutaneous ecchymosis occurred more frequently in the BA group than that in the MABA group (33.3% vs 9.1%; P = .038). Patients treated by MABA were more satisfied with their cosmetic results than those undergoing BA (100% vs 81.8%; P = .034). At the last follow-up time, all patients were alive although 1 patient in the BA group developed cervical lymph node recurrence ipsilateral to the original tumor at 4 years after surgery. Multivariate logistic regression analysis showed MABA surgery was a protective factor for postoperative complications (OR = 0.209, 95% confidence interval [CI] = 0.054-0.817, P = .024).ET via the MABA strategy may be a good choice for unilateral PTMC because of shorter operation time, fewer complications, greater cosmetic satisfaction, and excellent prognosis.

Single-incision endoscopic thyroidectomy for papillary thyroid cancer: A pilot study

BACKGROUND

Recently, we have reported single incision endoscopic thyroidectomy using an axillary approach with gas inflation (SIET) in cases with benign thyroid tumors to reduce post-operative pain and invasiveness of the conventional endoscopic thyroidectomy. The aim of this study was to present our experiences with SIET for papillary thyroid cancer (PTC).

METHODS

Patients who were diagnosed with histologically papillary thyroid carcinoma (≤1 cm) with single, unilateral, and intra-thyroidal lesion and without clinical lymph node metastasis were included. We analyzed clinico-pathological characteristics, surgical outcomes, and oncologic adequacy of the SIET procedure.

RESULTS

Between January 2011 and July 2012, a total of 75 patients underwent hemi-thyroidectomy with ipsilateral central lymph node dissection via SIET. The mean tumor size was 0.5 cm and 4.1 ± 2.43 central lymph nodes were removed. Of the patients, 98.3% were satisfied with their surgical wound post-operatively and no critical post-operative complications occurred during the study, except for one case of post-operative bleeding. There was one case of disease recurrence, which occurred in the contra-lateral cervical lymph node region 6 months after SIET. This patient underwent completion thyroidectomy with selective neck dissection.

CONCLUSION

The SIET is a safe and acceptable procedure for PTC with a reduced dissection field, less post-operative pain, and more cosmetic satisfaction than conventional endoscopic thyroid surgery.