Robotic thyroidectomy versus conventional open thyroidectomy for thyroid cancer: a systematic review and meta-analysis

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.

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

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

The distribution of robotic surgery in general and visceral surgery departments in Switzerland - a nationwide inquiry

Objectives

Since its introduction as a clinical technique, robotic surgery has been extended to different fields of surgery. However, the indications as well as the number of robotic procedures varied in different institutions. The aim of this investigation was to evaluate the current use of robotic surgery in general and digestive surgery in Switzerland.

Methods

All Swiss surgical departments that are recognized training institutes for postgraduate training in surgery by the Swiss Institute of Medical Education (SIWF) were queried with a detailed questionnaire regarding the use of robotic surgery techniques and were analyzed regarding hospital size and type of hospital.

Results

Ninety-three departments were queried, and 67 % (n=63) answered the survey. Fifty-eight were public, and five were private institutions. Seventeen (26 %) of the queried departments used robotic surgery in digestive surgery. Four out of 17 (23 %) of the departments that performed robotic surgery were private hospitals, while 13 (77 %) were public institutions. In the majority of departments, robotic surgery of the rectum (n=12; 70.6 %) and colon (n=11; 64.7 %) was performed, followed by hernia procedures (n=8; 47.1 %) and fundoplication (n=7; 41.2 %). Less frequently, pancreatic resections (n=5; 29.4 %), cholecystectomy (n=4; 23.5 %), adrenalectomy (n=4; 23.5 %), gastric bypass (n=3; 17.7 %), gastric sleeve (n=3; 17.7 %), hepatic procedures (n=2; 11.7 %), or small bowel resections (n=1; 5.9 %) were performed as robotic procedures. More than 25 procedures per year per department were performed for hernia surgery (n=5 departments), gastric bypass (n=2 departments), cholecystectomy, fundoplication, and colon surgery (each n=1 department).

Conclusions

The number and range of robotic procedures performed in Switzerland varied widely. Higher accreditation for general surgery or subspecialization of visceral surgery of the department was positively associated with the use of robotic techniques, reflecting an unequal availability of robotic surgery.

Comparison of surgical outcomes of transoral robotic and endoscopic thyroidectomy: A systematic review and network meta-analysis

This study aimed to compare surgical outcomes of transoral robotic thyroidectomy (TORT) and transoral endoscopic thyroidectomy vestibular approach (TOETVA), concurrently compared with conventional transcervical thyroidectomy (CTT). A network meta-analysis, comprising 23 studies, was performed in this study. The operative time of the CTT group was significantly shorter than that of the TOETVA and TORT groups. The hospital stay of the TOETVA group was significantly longer than that of the CTT group. Rates of transient recurrent laryngeal nerve palsy and total complications were higher in association with TOETVA than with TORT. No significant differences were found between the three groups in intraoperative blood loss, retrieved lymph nodes, postoperative pain, and other complications. Cosmetic satisfaction was significantly superior with TORT and TOETVA than with CTT. Compared with CTT, TOETVA and TORT showed superior cosmesis but no significant difference in surgical outcomes except for operative time and hospital stay.

Comparison of Robotic Versus Conventional Open Thyroidectomy for Recurrent Laryngeal Nerve Safety: A Systematic Review and Meta-Analysis

This review aims to investigate the safety of recurrent laryngeal nerve (RLN) by comparing robotic thyroidectomy (RT) versus open thyroidectomy (OT) in Western and Asian populations. Two main outcomes of this review were (1) the safety of RLN comparing the robotic and OT assessing transient and permanent laryngeal nerve (PLN) palsy as a postoperative complication in each surgical procedure and (2) the safety of RLN comparing the robotic and OT assessing transient and permanent laryngeal nerve (PLN) palsy as a postoperative complication between studies conducted in USA/Europe and Asia. We searched relevant literature in electronic databases such as PubMed, MEDLINE, Cochrane CENTRAL, ScienceDirect, and Cumulative Index to Nursing & Allied Health (CINAHL) up to September 2022. Further research was performed during January 2024 in the Scopus database. Two primary outcomes were set: transient RLN palsy and permanent RLN palsy, comparing RT and OT. In this review, 18 non-randomized studies were included. A statistically significant difference between robotic and conventional OT was not observed either in transient RLN or in permanent RLN palsy. The odds ratio (OR) for the overall comparison of transient RLN palsy was 1.18, and the 95% confidence interval (95% CI) was 0.80-1.74. The subgroup analysis for transient RLN palsy between USA/Europe studies was OR 1.28, and the 95% CI was 0.64-2.58. The subgroup analysis for transient RLN palsy between Asian studies was OR 1.14, and the 95% CI was 0.72-1.82. The OR for the overall comparison of permanent RLN palsy was OR 0.90, and the 95% CI was 0.38-2.15. The subgroup analysis for permanent RLN palsy between USA/Europe studies was OR 0.45, and the 95% CI was 0.07-2.97. The subgroup analysis for permanent RLN palsy between Asian studies was OR 1.13, and the 95% CI was 0.42-3.05. Heterogeneity I2 was 0% in all outcomes. The Mantel-Haenszel method fixed effect was used. First, RT and open conventional thyroidectomy have comparable safety for RLN, although the analysis showed no statistically significant results. Second, no statistically significant results were found for RLN safety in either USA/Europe or Asian studies. Considering that there is not a statistically significant difference between the two approaches for RLN safety, and due to the limited number of studies from Western countries, the results should be considered with caution. Important factors such as the patient's body characteristics, the existing thyroid pathology, and the surgical approach should be kept in mind. More comparable studies are needed on the Western population.

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.

Safety and surgical outcomes of single-port trans-axillary robot-assisted thyroidectomy: Experience from a consecutive series of 300 patients

Since the introduction of the single-port (SP) robotic system, SP trans-axillary robot-assisted thyroidectomy (SP-TART) has been performed. We aimed to evaluate the safety and surgical outcomes of SP-TART in a consecutive series of 300 cases. We analyzed 300 patients with thyroid disease who underwent SP-TART from October 2021 to May 2023 in St. Mary's Hospital in Seoul, Korea. We analyzed the patients' clinicopathological characteristics and perioperative outcomes according to surgical extent. Of the 300 cases analyzed, 250 patients underwent less than total thyroidectomy (LTT), 31 patients underwent total thyroidectomy (TT), and 19 patients underwent TT with modified radical neck dissection (TT c mRND). The mean operative times for LTT, TT, and for TT c mRND were 69.8 ± 23.6, 104.2 ± 30.7, and 223.7 ± 72.4 min, respectively. Complications, including postoperative bleeding, transient hypoparathyroidism, and vocal cord palsy, were observed in nine, six, and six LTT, TT, and TT c mRND cases. The SP-TART method is a safe and feasible surgical option with a short operative time, good surgical outcome, and excellent cosmetic results.

Surgical methods of total thyroidectomy for differentiated thyroid cancer: a systematic review and Bayesian network meta-analysis

BACKGROUND

Emerging remote-access surgical methods are utilized to treat differentiated thyroid cancer. The study aimed to compare the surgical integrity, safety, efficacy, and postoperative experience of patients among common surgical methods.

METHODS

The PubMed, Medline, Cochrane Library, Web of Science, and EMBASE databases were searched from their inception until March 2023. Pairwise meta-analysis and Bayesian network meta-analysis were performed. The surface under the cumulative ranking curve (SUCRA) was used to illuminate the probability that each method would be the best for each outcome.

RESULTS

Thirty-two studies comprising 7042 patients were included. Robotic bilateral axillo-breast approach (RBABA) and robotic gasless transaxillary approach (RGAA) retrieved fewer lymph nodes (LNs) than open thyroidectomy (OT). RBABA showed a significantly lower permanent recurrent laryngeal nerve (RLN) palsy rate than OT. According to SUCRA values, endoscopic transoral approach (EOA) ranked the highest in retrieved LNs (0.84), the proportion of stimulated serum thyroglobulin less than 1.0 ng/ml (0.77), and the pain score (0.77). Endoscopic bilateral areola approach (EBAA) ranked the highest in the transient RLN palsy rate (0.72). The endoscopic gasless transaxillary approach (EGAA) ranked the highest in the transient hypoparathyroidism rate (0.78). RBABA ranked the highest in the rate of permanent RLN palsy (0.94) and hypoparathyroidism (0.77). OT ranked the highest in operative time (0.92).

CONCLUSIONS

Each surgical method of total thyroidectomy has benefits and limitations. EOA performed the best in maintaining surgical integrality and reducing the pain score, while taking a long operative time. Generally, RBABA showed the best advantage in protecting parathyroid glands and RLN but with the longest operative time. OT had the best advantage in operative time. Therefore, OT and EOA are ideal methods for patients with a higher risk of central LN metastasis. RBABA and EOA may not be suitable for elderly patients or those with high anesthesia risk.

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

OBJECTIVES

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Is transoral endoscopic thyroidectomy safe for total thyroidectomy compared to open thyroidectomy? A propensity-score matched cohort study with papillary thyroid carcinoma

BACKGROUND

Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has become increasingly popular in the treatment of papillary thyroid cancer (PTC). This study aimed to describe the safety and feasibility of total thyroidectomy between the TOETVA and open thyroidectomy (OT) approaches for the treatment of patients with PTC.

METHODS

We retrospectively reviewed 780 consecutive patients suffering from PTC that had undergone total thyroidectomy using TOETVA (n = 107) and OT (n = 673) between April 2016 and December 2021 at our institute. Afterward, a total of 101 matched patients' surgical outcomes were compared using propensity score matching (PSM) analysis.

RESULTS

Before PSM, the patients in the TOETVA group were younger (p < 0.001), had a lower body mass index (p < 0.001) and a greater female population (p < 0.001). After PSM, the TOETVA group was associated with significantly longer operative time (p < 0.001), greater blood loss (p < 0.001), total drainage amount (p < 0.001), higher C-reaction protein level (p < 0.001), better cosmetic satisfaction (p < 0.001) and quality of life (p < 0.001) and lower scar self-consciousness (p < 0.001). There was no statistical difference between the groups in the rate of parathyroid autotransplantation and bilateral lymph node dissection, the positivity of lymph node metastasis, number of dissected lymph nodes and positive lymph nodes, multifocality, postoperative level of blood calcium and parathyroid hormone (PTH), rate of PTH < 15 ng/mL, visual analog scale score, duration of hospital stay, complications, mean thyroid stimulating hormone (TSH)-stimulated Tg level before radioactive iodine, mean Tg level without TSH stimulation, and the proportion of serum Tg level of <1.

CONCLUSION

TOETVA is a safe and feasible technique for better cosmetic effects and similar surgical outcomes compared to conventional open surgery for the studied patients that required total thyroidectomy.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The learning curve for single-port transaxillary robotic thyroidectomy (SP-TART): experience through initial 50 cases of lobectomy

The new da Vinci® single-port (SP) robotic system, which utilizes a smaller incision and work space compared to the previous versions, is suitable for thyroidectomy. This study aimed to evaluate the learning curve for SP transaxillary robotic thyroidectomy (SP-TART) in a single-center. Fifty consecutive patients who underwent SP-TART between October 2021 and April 2022 in Seoul St. Mary's Hospital in Seoul, Korea, were included in this retrospective analysis. We examined the clinicopathological characteristics and short-term surgical outcomes and assessed the learning curve for SP-TART using cumulative summation analysis. The mean operation time was 57.8 ± 14.1 min, and the mean tumor size was 1.0 ± 0.7 (range, 0.3-3.7) cm. The patients were discharged approximately 2 days after surgery, and only two (4%) patients developed postoperative complications, including drainage-site bleeding and surgical site infection. Risk factors for long operation time were thyroiditis, amount of blood loss, and lymph node metastasis. The learning curve for SP-TART was 20 cases for the experienced robotic surgeon. SP-TART is technically feasible and safe with a short incision length and short operation time. It is a valuable alternative operative option with good surgical outcomes and outstanding cosmetic results.

A Comparison of the Bilateral Axillo-breast Approach (BABA) Robotic and Open Thyroidectomy for Papillary Thyroid Cancer After Propensity Score Matching

BACKGROUND

We aimed to investigate the potential advantages of bilateral axillo-breast approach (BABA) robotic thyroidectomy over conventional open surgery and to determine whether it is a safe and complete surgical procedure compared with open surgery in patients with papillary thyroid cancer.

PATIENTS AND METHODS

We retrospectively reviewed the records of 315 consecutive patients (robotic, n=54; open, n=261) who underwent total thyroidectomy and central neck dissection for papillary thyroid cancer from March 2013 to June 2014. Postoperative complication rate and surgical completeness were analyzed between patients who underwent BABA robotic thyroidectomy (robotic group) and those who chose open thyroidectomy (open group) after propensity score matching according to age, sex, body mass index, tumor size, extrathyroidal extension, and lymph node (LN) metastasis.

RESULTS

Transient hypoparathyroidism was higher in the open group than in the robotic group (13.0% vs. 1.9%; P =0.029). No difference was observed in the mean number of retrieved LNs and metastatic LNs. The mean level of stimulated thyroglobulin was acceptably low in both groups, and there was no difference in the proportion of patients who had stimulated thyroglobulin levels <1 ng/mL between the groups ( P =0.543).

CONCLUSIONS

Our results show that the outcomes of BABA robotic thyroidectomy may be comparable to those of conventional open thyroidectomy, with possibly better preservation of blood supply to the parathyroid glands, without sacrificing surgical completeness.

Comparison of the Robotic Bilateral Axillo-Breast Approach and Conventional Open Thyroidectomy in Pediatric Patients: A Retrospective Cohort Study

Background: Operations for pediatric thyroid nodules are more complicated, and usually lead to longer scars, which may impair life quality in the long term. Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) may provide a better alternative to conventional open thyroidectomy (COT) for pediatric thyroid nodules. Our study aimed at comparing the surgical and oncological outcomes of BABA RT and COT in pediatric patients. Methods: The data of 49 pediatric patients who consecutively underwent BABA RT or COT (20:29) between July 1998 and November 2021 in our center were retrospectively analyzed, including demographics, surgery extent, surgical outcomes, pathological characteristics, and oncological outcomes. Results: All BABA RT procedures were completed successfully without conversion to open operation. The BABA RT group consisted of 5 benign and 15 malignant cases, while the COT group consisted of 19 benign and 10 malignant cases. The operation time, drain removal time, and number of lymph nodes harvested by central lymph node dissection or lateral lymph node dissection were equivalent in the BABA RT and COT groups. Notably, the postoperative hospital stay of the BABA RT group was shorter than that of the COT group (8.5 [interquartile ranges (IQRs): 3] vs. 11 [IQR: 8] days, p = 0.008). The aesthetic score of the BABA RT group was much higher than that of the COT group (9 [IQR: 1] vs. 6 [IQR: 1], p < 0.001). There was no significant difference between the BABA RT and COT groups in hypoparathyroidism rate (transient, 5 vs. 4; permanent, 1 vs. 0). There was one case of chyle leakage in the COT group and no other complications in any group, such as recurrent laryngeal nerve injury. With a median follow-up of 101 (IQR: 189) months, one case of local relapse and one case of pulmonary metastasis in the COT group were documented. Conclusion: In the hands of experienced surgeons, robotic BABA thyroidectomy can be a safe and effective option for both benign and malignant thyroid nodules in children, including those with lymph node metastasis. Robotic BABA thyroidectomy can offer a better and faster postoperative course and a much better cosmetic result, which is crucial for pediatric thyroid patients.

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

Simple Summary

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

Abstract

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

Robot-assisted Nipple-sparing Mastectomy With Immediate Breast Reconstruction: An initial Experience of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG)

OBJECTIVE

The aim of this study was to present the results of early experience of robot-assisted nipple sparing mastectomy (RANSM).

BACKGROUND

RANSM improves cosmetic outcomes over conventional nipple-sparing mastectomy. However, data on the feasibility and safety of the RANSM are limited.

METHODS

Patients who underwent RANSM with immediate breast reconstruction as part of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) from November 2016 to January 2020 were enrolled. clinicopathologic characteristics, perioperative complications, and operation time were collected.

RESULTS

Overall, 73 women underwent 82 RANSM procedures conducted by 11 breast surgeons at 8 institutions. The median patient age was 45.5 years old (20-66 years), and 52 (63.4%) patients were premenopausal. Invasive breast cancer was noted in 55 cases (40 cases were stage i, 11 cases were stage ii, and 4 cases were stage iii, respectively) and ductal carcinoma in-situ was recorded in 20 cases. Of those, 3 patients with BRCA1/2 mutation carriers underwent contralateral risk-reducing RANSM. The median length of hospitalization was 12.0 days (5.0-24.0 days). The incision location was the mid-axillary line and the median incision length was 50.0 mm (30.0-60.0 mm). Median total operation time, median total mastectomy time, and median reconstruction time was 307.0 minutes (163.0-796.0 minutes), 189.5 minutes (97.5-325.0 minutes), and 119.5 minutes (45.0-689.0 minutes). Only 2 cases (2.5%) required reoperation. Nipple ischemia was found in 9 cases (10.9%) but only 1 case (1.2%) required nipple excision given that 8 cases (9.7%) resolved spontaneously. Skin ischemia was observed in 5 cases (6.1%) and only 2 (2.4%) cases needed skin excision whereas 3 cases (3.6%) resolved spontaneously. There was no conversion to open surgery orcases of mortality. The mean time for mastectomy among surgeons who performed more than 10 cases was 182.3 minutes (± 53.7, minutes) and 195.4 minutes (± 50.4, minutes).

CONCLUSION

This was the first report of RANSM conducted in the KoREa-BSG. RANSM is technically feasible and acceptable with a short learning curve. Further prospective research to evaluate surgical and oncologic outcomes is needed.

Comparison of cosmetic outcomes between remote‐access and conventional thyroidectomy: A review of the current literature

Objective

The pursuit of an esthetically pleasing scar following open thyroid surgery has led to the development of endoscopic thyroidectomy through remote incisions placed in several locations outside the neck. The objective of this study is to review the recent literature and compare the incision site appearance and patient satisfaction with the cosmetic outcome after extracervical and conventional thyroidectomy.

Methods

The English literature published since 2010 was searched through the PubMed/Medline database for studies comparing the cosmetic outcomes between remote-access endoscopic and conventional thyroidectomy using a form of scar assessment scale.

Results

A total of 9 relevant papers fulfilled the eligibility criteria including 1486 patients. Among them, 595 patients underwent endoscopic thyroidectomy through several remote-access approaches and 891 patients were assigned to the conventional group. Only one randomized-controlled trial was identified, whereas among the rest, four were prospective and four were retrospective nonrandomized cohorts. Regarding the extracervical modifications performed in the endoscopic groups, the axillary approach was performed in three studies and the breast approach in four studies, while the retroauricular facelift technique and the transoral vestibular method were applied in one study, respectively.

Conclusions

Evaluation of the wound appearance and patient satisfaction with the cosmetic outcome at various time points during the follow-up highlighted the superiority of the extracervical approaches over the conventional cervicotomy. Considering these findings, remote-access techniques could possibly be the ideal surgical method for patients with high esthetic requirements, providing an excellent appearance of the thoroughly exposed neck.

Postsurgical complications after robot-assisted transaxillary thyroidectomy: critical analysis of a large cohort of European patients

In the last decade, robot-assisted trans-axillary thyroidectomy has spread rapidly and has been proven to be a safe and effective procedure. However, several case series have reported new complications that have led to criticism regarding this approach. This study analyzed the incidence of complications in a large cohort of European patients. We enrolled all patients who underwent robot-assisted trans-axillary thyroidectomy from 2012 to 2020 at the University Hospital of Pisa Department of Endocrine Surgery. We analyzed complications and divided them into 2 groups. Group A included conventional complications, such as transient or permanent recurrent laryngeal nerve palsy, transient or permanent hypocalcemia, hemorrhage, and tracheal injury. Group B included unconventional complications, such as brachial plexus palsy, track seeding, seroma, great vessels injury, and skin flap perforation. There were 31 postsurgical complications (5.7%). Group A included 25 complications (4.6%): transient and permanent recurrent laryngeal nerve palsy occurred in 7 patients (1.3%) and in 1 (0.2%), respectively; transient and permanent hypocalcemia occurred in 9 patients (1.7%) and in 1 (0.2%), respectively. Postoperative bleeding occurred in 6 patients (1.1%) and tracheal injury in 1 (0.2%). Group B included 6 complications (1.1%): 1 patient with brachial plexus injury (0.2%), 1 with track seeding (0.2%), and 4 with seroma (0.7%). Robotic trans-axillary thyroidectomy is a safe approach with a risk of postoperative complications comparable to the conventional technique. Almost all complications after a novel introduction are anecdotal. With an accurate patient selection, high-volume institutions with experienced surgeons can perform this technique safely.

Anti-adhesive effect and safety of a thermosensitive adhesion barrier (Mediclore) for thyroid surgery: a double-blinded randomized controlled trial

Purpose

Methods

Results

Conclusion

Identification of circulating biomarkers for differentiating patients with papillary thyroid cancers from benign thyroid tumors

BACKGROUND

This study aimed to identify the potential circulating biomarkers of protein, mRNAs, and long non-coding RNAs (lncRNAs) to differentiate the papillary thyroid cancers from benign thyroid tumors.

METHODS

The study population of 100 patients was classified into identification (10 patients with papillary thyroid cancers and 10 patients with benign thyroid tumors) and validation groups (45 patients with papillary thyroid cancers and 35 patients with benign thyroid tumors). The Sengenics Immunome Protein Array-combined data mining approach using the Open Targets Platform was used to identify the putative protein biomarkers, and their expression validated using the enzyme-linked immunosorbent assay. Next-generation sequencing by Illumina HiSeq was used for the detection of dysregulated mRNAs and lncRNAs. The website Timer v2.0 helped identify the putative mRNA biomarkers, which were significantly over-expressed in papillary thyroid cancers than in adjacent normal thyroid tissue. The mRNA and lncRNA biomarker expression was validated by a real-time polymerase chain reaction.

RESULTS

Although putative protein and mRNA biomarkers have been identified, their serum expression could not be confirmed in the validation cohorts. In addition, seven lncRNAs (TCONS_00516490, TCONS_00336559, TCONS_00311568, TCONS_00321917, TCONS_00336522, TCONS_00282483, and TCONS_00494326) were identified and validated as significantly downregulated in patients with papillary thyroid cancers compared to those with benign thyroid tumors. These seven lncRNAs showed moderate accuracy based on the area under the curve (AUC = 0.736) of receiver operating characteristic in predicting the occurrence of papillary thyroid cancers.

CONCLUSIONS

We identified seven downregulated circulating lncRNAs with the potential for predicting the occurrence of papillary thyroid cancers.

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.

Surgical outcomes of different approaches in robotic assisted thyroidectomy for thyroid cancer: A systematic review and Bayesian network meta-analysis

BACKGROUND

The aim of the study was to assess the feasibility, safety, and potential benefits of four approaches of robotic assisted thyroidectomy (RT). The approaches mentioned above are also compared with traditional open thyroidectomy (OPEN).

MATERIALS AND METHODS

Medline, Embase, Cochrane library (CENTRAL) and Web of Science databases were searched up to 13th Dec 2019. Data of surgical outcomes and complications were extracted to conduct the statistical analyses.

RESULTS

A total of 30 studies with 6622 patients were included. Ten were prospective study and 1 declared prospective randomized comparative study. The number of retrieved lymph nodes (LNs) in central compartment were similar between gasless transaxillary approach (GAA), bilateral axillo-breast approach (BABA) and transoral approach (OA). OPEN retrieved more LNs than BABA and OA. More metastatic LNs were seen in GAA and BABA than OA, as was for OPEN. The operation time was significantly shorter in GAA and gasless unilateral transaxillary approach (GUAA) than BABA and OA, while shortest for OPEN. Lower incidence of transient hypoparathyroidism was found in BABA than OPEN. No significant difference was observed in other indexes.

CONCLUSIONS

BABA, GAA, GUAA and OA in RT appear to be feasible and safe for patients with thyroid cancer with unique benefits. Surgical outcomes of different approaches were not identical for operation time, cosmetic effects, central neck dissection. Surgeons would consider more about patients' will.

Unilateral axilla-bilateral areola approach for thyroidectomy by da Vinci robot vs. open surgery in thyroid cancer: a retrospective observational study

Background

To compare the efficacy and safety of unilateral axilla-bilateral areola (UABA) approach for robot-assisted thyroidectomy with conventional open surgery in thyroid cancer patients.

Methods

The clinicopathological features and surgical outcomes of 194 thyroid cancer patients treated by robotic surgery using the UABA approach and 217 patients treated by open surgery in our department from January 2017 to August 2018 were analysed and compared.

Results

The operation time was longer in the robotic group than in the open surgery group. The patients' satisfaction with neck appearance was higher in the robotic group than in the open surgery group (91.2% vs. 21.6%, P<0.01). After total thyroidectomy and central lymph node dissection, the incidence of postoperative transient hypoparathyroidism and postoperative permanent hypoparathyroidism in the open surgery group was 29.7% (44/148) and 6.8% (10/148), higher than that [17.9% (27/151) and 2.0% (3/151)] in the robotic group (P<0.05 respectively). No significant difference was observed in the number of dissected lymph nodes or postoperative serum thyroglobulin (TG) levels or incidence of transient or permanent hoarseness of voice between the two groups. No recurrence or metastasis was found.

Conclusions

Compared with open surgery, UABA robotic surgery preserved the neck appearance and effectively reduced hypoparathyroidism by super-meticulous capsular dissection (SMCD).

Post-Operative Complications and Nipple Necrosis Rates Between Conventional and Robotic Nipple-Sparing Mastectomy

Purpose

This study is to directly compare surgical outcomes between conventional nipple-sparing mastectomy (CNSM) and robot-assisted nipple-sparing mastectomy (RNSM).

Materials and Method

For this case–control study, 369 cases of 333 patients who underwent CNSM or RNSM with immediate reconstruction between November 2016 and January 2019 at Severance Hospital in Seoul, Republic of Korea were reviewed. Patients with stage IV breast cancer (n = 1), receiving neoadjuvant chemotherapy (n = 43), or subjected to previous operations (n = 14) or radiotherapy on the breasts were excluded. The main outcomes were comparing rates of post-operative complications, of high-grade post-operative complications as defined by the Clavien-Dindo classification, and nipple necrosis between the CNSM and the RNSM groups.

Results

A total of 311 cases, including 270 CNSMs and 41 RNSMs, were analyzed. The rates of post-operative nipple necrosis (p = 0.026, 2.4 vs. 15.2%) and of high-grade post-operative complications (p = 0.031, 34.8 vs. 17.1%) in the RNSM group were significantly lower than those in the CNSM group.

Conclusion

RNSM was associated with lower rates of high-grade post-operative complications and nipple necrosis than CNSM for patients with small breast volumes and less ptotic breasts.

Ultrasound-Guided Radiofrequency Ablation Versus Surgical Resection for the Treatment of T1bN0M0 Papillary Thyroid Carcinoma in Different Age Groups

PURPOSE

We aimed to compare the efficacy and safety of radiofrequency ablation (RFA) to that of surgical resection (SR) in patients with T1bN0M0 papillary thyroid carcinoma (PTC) in different age groups.

METHODS

Totally, 204 patients with an isolated, solitary, intrathyroidal T1bN0M0 PTC, who underwent either RFA (n=94) or SR (n=110) between April 2014 and December 2019, were retrospectively enrolled and were divided into two subgroups according to age (<45 years, ≧45 years). Patients with pathologically aggressive or advanced lesions were excluded from the study. Tumor progression and procedural complications were the primary and secondary endpoints, respectively. Tumor recurrence in situ, newly discovered tumors, lymph node involvement, or distant metastases indicated tumor progression. Complications included pain, fever, voice change, choking, numbness in the limbs, and cardiac events. Incidence rates of all endpoint events were compared between different age subgroups.

RESULTS

There were no significant differences in age, sex, and tumor size between the treatment groups. While the RFA group incurred less cost and experienced significantly shorter operative duration than the SR group, no significant differences were observed in incidences of both tumor progression and complications. Further, subgroup analysis of patients <45 years versus those ≧45 years showed no significant differences in the incidence of tumor progression and complications within or between different treatment groups. Older patients in the SR group incurred higher hospital costs than younger counterparts, but this difference was not observed in the RFA group.

CONCLUSIONS

Our results indicated that RFA had a similar prognosis as that of SR but was associated with lower overall cost in both young (<45 years) and middle-aged patients (≧45 years) with T1bN0M0 PTC. Therefore, RFA may be an effective and safe alternative to surgery for the treatment of patients with T1bN0M0 PTC.

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.

Personalized treatment for differentiated thyroid cancer: current data and new perspectives

More conservative and personalized treatment options have been developed in recent years to face the rising diagnosis of low-risk differentiated thyroid carcinoma (DTC). The present review describes the change towards a more risk-adapted management either in the treatment or in the follow-up of DTC. Particular attention is given to the innovations introduced by the latest guidelines for low-risk tumors, starting from the most appropriate extension of surgery up to the postoperative management. The emerging role of active surveillance for low-risk microcarcinoma is discussed, as well as the development of percutaneous strategies in the setting of malignant thyroid disease. The recent use of approved new systemic target therapies for advanced radioiodine refractory thyroid cancer is reported, together with the description of new compounds in trial. Finally, we provide some considerations to improve the risk evaluation in a presurgical setting, especially related to the rising role of genetics, to enable better risk-based cancer management and personalized treatment choices.

Robotic surgery versus open surgery for thyroid neoplasms: a systematic review and meta-analysis

PURPOSE

Robotic surgical system has been gradually applied in thyroid neoplasms as a novel treatment for years, with presenting some superiorities as well as limitations. To compare the effectiveness and safety of robotic surgery with open surgery for the patients with thyroid neoplasms, this review was conducted METHODS: We performed electronic search in CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray, and Sciencepaper Online databases and manual search in specific online databases and according to the reference list of relevant papers to get all the studies that compared the effectiveness and safety of robotic surgery with that of open surgery for patients with thyroid neoplasms. Last update was conducted in March 2020. Randomized-controlled trials, case-control studies, cohort studies, and cross-sectional surveys were all included.

RESULTS

In this review, 59 studies were included: two RCTs, 15 NRSs, 40 cohort studies, and two cross-sectional studies. Robotic surgery was found to be associated with longer operative duration, less retrieved lymph nodes, higher postoperative thyroglobulin before radioactive iodine ablation, similar complication incidence but less blood loss, better functional recovery, and higher cosmetic satisfaction compared to open surgery.

CONCLUSIONS

Robotic surgery is a safe and feasible approach with remarkable superiority in reducing intraoperative damage and improving patients' quality of life compared to open surgery for thyroid neoplasms. Meanwhile, this procedure is also associated with long operative duration, insufficient removal of neck lymph nodes, which need to be given careful consideration.

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

•

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

•

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

•

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

Introduction

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

Presentation of case

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

Conclusion

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

Preoperative scar perception study comparing 'scarless' in the neck endoscopic thyroidectomy with open thyroidectomy: a cross-sectional study

INTRODUCTION

Open thyroidectomy is the most common approach to thyroid surgery. However, 'scarless' (in the neck) endoscopic thyroidectomy, consisting of endoscopic and robotic surgery, is progressively being adopted for its perceived cosmetic benefits. This study aims to determine the patient's preferred surgical approach and to identify the factors that influence their decision.

MATERIALS AND METHODS

A pilot study consisting of 100 patients with a surgical thyroid disorder were prospectively recruited from a single tertiary centre. An interviewer-administered survey was conducted. Demographic, socioeconomic status, scar perception and an adapted body image scale were evaluated to identify factors that shaped the patient's perception of the surgical approach.

RESULTS

The mean age of participants was 54.5 ± 13.0 years; 72% were women and 87% Chinese. Of the 100 patients, 75 patients considered scarless endoscopic thyroidectomy as their preferred surgical approach while 25 patients opted for open thyroid surgery. Improvement in scar perception score between scarless endoscopic thyroidectomy and open thyroid surgery is associated with an increased willingness to choose scarless endoscopic thyroidectomy. The mean body image scale score was 6.9 ± 2.8, indicating no statistical difference between the surgical approaches. On multivariate analysis, improvement in scar perception score (odds ratio 3.38, 95% confidence interval 1.11-10.29) and having surgeon recommendation (odds ratio 6.38, 95% confidence interval 1.80-22.63) were independently associated with interest in scarless endoscopic thyroidectomy.

CONCLUSION

Patients interest in undergoing scarless endoscopic thyroidectomy is driven by improved scar perception and surgeon's recommendation compared with open thyroid surgery.

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

OBJECTIVE

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

STUDY DESIGN

Retrospective analysis.

SETTING

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Robotic lateral cervical lymph node dissection via bilateral axillo-breast approach for papillary thyroid carcinoma: a single-center experience of 260 cases

To evaluate the feasibility and safety of robotic lateral cervical lymph node dissection via BABA, 260 thyroid cancer patients with suspected level II, III, IV, and Vb lymph node metastasis were selected. The lateral cervical compartment was exposed by splitting the sternocleidomastoid muscle longitudinally, and separating between the strap muscles and the anterior margin of the sternocleidomastoid muscle. The procedure was completed in 260 patients. Mean time for robotic lateral node dissection took 80 ± 21 min. The wound catheter was removed 6.3 days. Postoperative transient symptomatic hypocalcemia was observed in 51 patients, transient hoarseness in three, seroma in three, chyle leakage in two, and tracheal injury in one. 124 patients were confirmed to have lymph node metastasis on final pathological report. Average postoperative hospital stay was 6.5 days. Robotic lateral neck dissection by BABA is the acceptable operative alternative for thyroid cancer patients who wished to keep their surgical history private.

Making the Jump: A Qualitative Analysis on the Transition From Bedside Assistant to Console Surgeon in Robotic Surgery Training

OBJECTIVE

To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training.

DESIGN

Qualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019.

SETTING

An urban, academic, multihospital general surgery residency program with a robust robotic surgery program.

PARTICIPANTS

Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews.

RESULTS

Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console.

CONCLUSIONS

Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

Robotic Neck Surgery in the Pediatric Population

Introduction:

Thyroid, parathyroid, and thymus surgeries are traditionally performed via a cervical approach. However, robot-assisted procedures can provide a safe alternative for neck surgeries. We report our experiences with robotic transaxillary and retroauricular approaches in pediatric patients.

Case Presentation:

We conducted a retrospective review of pediatric patients who underwent robot-assisted neck surgery by a single surgeon between April 2010 and May 2017. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated.

Management and Outcomes:

Nine surgeries in 7 female patients were reviewed (mean age, 16.0 ± 1.58 years; mean body mass index, 22.5 ± 0.75). Two thyroid lobectomies, 2 complete thyroidectomies, 1 subtotal thyroidectomy, 1 thyroid lobectomy with thymectomy, 2 subtotal parathyroidectomies with thymectomy, and 1 dermoid cyst excision were performed. Two surgeries with the retroauricular approach had a mean surgical time of 142.0 ± 6.13 minutes. Seven surgeries with the transaxillary approach had a mean surgical time of 146.1 ± 21.01 minutes. There were no reported conversions, permanent vocal cord paralysis, permanent hypoparathyroidism, hematoma, or seroma. There was 1 case (11%) of temporary shoulder hypoesthesia and 2 cases of temporary vocal cord paresis (22%).

Discussion:

This series on robot-assisted neck surgeries in children describes procedures performed with robotic transaxillary and retroauricular approaches. In the hands of a high-volume surgeon the techniques are feasible and safe options for operations in the neck in a select group of pediatric patients.

Meta-analysis Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy and Conventional Thyroidectomy

Objective. Despite gaining popularity, bilateral axillo-breast approach robotic thyroidectomy (BABA RT) remains controversial. We performed a meta-analysis to evaluate the safety and effectiveness of BABA RT compared with open thyroidectomy (OT) in thyroid disease. Methods. A literature search was conducted using various databases, including PubMed, Web of Science, and Cochrane Library, up to February 2018. Outcomes of interest included patient characteristics, surgical outcomes, adverse events, complications, and surgical completeness. Results. A total of 11 publications including 2733 patients (1070 in the BABA RT and 1663 in the open group) were finally selected for the meta-analysis. BABA RT was associated with an equivalent complication rate, including transient and permanent hypocalcemia, transient and permanent recurrent laryngeal nerve palsy, bleeding, chyle leakage, and seroma, as well as surgical outcomes including tumor size, length of hospital stay, total drain amount, and pain score. BABA RT was also associated with an equivalent surgical completeness, including total dose of radioactive iodine, proportion of stimulated thyroglobulin (sTg) <1.0 ng/mL, and level of sTg. Moreover, BABA RT involved longer operative times (weighted mean difference [WMD] = 110.13; P < .00001), smaller number of retrieved lymph nodes(WMD = −1.26, P = .003), and more cost (WMD = 5811.18; P < .00001) compared with OT. Conclusions. BABA RT is safe and feasible and provides similar perioperative outcomes and complications when compared with OT. However, BABA RT was associated with longer operating time, fewer retrieved lymph nodes, and more cost. Randomized clinical trials with large samples and longer follow-up data are needed to more rigorously examine this effect.

Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA): experiência inicial no Brasil

RESUMO Objetivo: apresentar a experiência inicial no Brasil com a tireoidectomia transoral endoscópica por abordagem vestibular (TOETVA). Métodos: estudo prospectivo de pacientes submetidos à TOETVA no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Regional do Oeste, Chapecó, Santa Catarina. Foram candidatos para o estudo os pacientes entre 18 e 65 anos de idade, ASA I e II, com volume glandular de até 35cm3e nódulos de até de 4cm. Dados dos pacientes, dos nódulos, tempo cirúrgico, complicações, e tempo de internação foram registrados. Resultados: nove pacientes foram operados entre maio de 2017 e abril de 2018. Todos eram mulheres, com idades entre 33 e 64 anos. O tamanho do nódulo variou de 1cm a 4cm. Dois pacientes eram portadores de neoplasia maligna e a tireoidectomia total foi feita em oito casos. Sete pacientes tiveram uma internação de apenas um dia. Um paciente sofreu uma complicação menor na pele, mas não ocorreram lesões dos nervos laríngeos recorrentes ou hipoparatireoidismo definitivo. Conclusão: a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos.

Comparison of short-term oncologic outcome of robotic thyroid surgery using dynamic risk stratification: A propensity score-matched comparison study

BACKGROUND

The long-term oncologic outcome of robotic surgery for thyroid cancer is not well established. The aim of this study was to predict the long-term oncologic outcome of robotic surgery by using dynamic risk stratification in classic papillary thyroid carcinoma.

METHODS

A total of 444 propensity score-matched pairs of patients with papillary thyroid carcinoma treated with robotic surgery and conventional open surgery were classified into 4 response-to-therapy categories. The results were compared between the robotic surgery and open surgery groups.

RESULTS

The median follow-up duration was 60 months. After propensity score matching, the robotic surgery group showed less extensive thyroid surgery and lymph node dissection and a higher proportion of patients who underwent radioactive iodine remnant ablation than the open surgery group; however, the dynamic risk stratification did not differ between the 2 groups (P = .086).

CONCLUSION

The long-term oncologic outcome of robotic surgery is expected to be comparable with that of open surgery based on the dynamic risk stratification.

Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience

OBJECTIVES

Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising.

STUDY DESIGN

This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6-12 months later and at the last available visit.

RESULTS

A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk).

CONCLUSION

In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

Well-differentiated thyroid cancer and robotic transaxillary surgery at a North American institution

BACKGROUND

Recent studies from Asia have reported the safety and feasibility of robotic-assisted thyroid surgery. In the United States, several small series and case reports have been published, mostly regarding treatment of benign disease. The aim of our study is to report the safety and feasibility of robotic surgery for well-differentiated thyroid cancer patients at a North American institution.

MATERIALS AND METHODS

We performed a retrospective cohort study using a prospectively collected single-center clinical database at Tulane University Medical Center. We included all well-differentiated thyroid cancer patients who underwent robotic-assisted or conventional cervical approach thyroid surgery with or without lymph node dissections at our institution from January 2015 to June 2017. Patient demographics and perioperative data were collected and analyzed.

RESULTS

A total of 144 surgeries for thyroid cancer were performed; 35 (24.3%) were robotic-assisted. There were no significant differences in estimated blood loss, operative times, complication rates, specimen sizes, positive microscopic margins, number of lymph nodes removed with associated lymph node dissections, patient follow-up duration, or clinical recurrence rates between the two groups. Overall length of stay was shorter for robotic-assisted surgery, at 0.6 ± 0.9 d, versus 1.1 ± 1.2 d for conventional open surgery (P = 0.009). For robotic-assisted surgery, 19 patients (54.3%) were discharged on the day of procedure, and only one patient was admitted as inpatient to the hospital (2.9%).

CONCLUSIONS

Robot-assisted thyroid surgery is a safe, feasible, and oncologically sound approach for a select group of well-differentiated thyroid cancer patients. However, long-term studies are needed.

Postsurgical Outcomes and Surgical Completeness of Robotic Thyroid Surgery: A Single Surgeon's Experience on 700 Cases

BACKGROUND

Advanced technology and understanding of robotic surgical system have rendered robotic thyroid surgery more expanding. The aim of this study was to identify the periodic changes in postsurgical outcomes of robotic thyroid surgery performed by a single surgeon.

METHODS

We conducted a retrospective review of 700 robotic thyroid surgery cases using gasless trans-axillary approach.

RESULTS

All patients underwent successful operations without conversion to open surgery, and were mostly younger than 45 years, female, less-extended thyroid surgery and lymph node dissection, and thyroid cancer. The median follow-up period was 67 months (12-99 months). Regarding technical outcomes, the operation time declined steeply after 100 consecutive cases, and reached 120.0-132.7 minutes for thyroid lobectomy and 162.9-174.1 minutes for total thyroidectomy (TT). The most common complication was transient hypoparathyroidism (43.7%), whose incidence decreased steeply to a range of 9.1% to 25.0% after 300 consecutive cases. Regarding surgical completeness for thyroid cancer, an average of seven lymph nodes was retrieved through central compartment node dissection without fluctuation over time. The proportion of the patients with serum stimulated thyroglobulin levels <10 ng/mL at the time of radioactive iodine remnant ablation after TT and <1 ng/mL 6-12 months after the first remnant ablation ranged between 86.4%-100% and 66.7%-100%, respectively, without significant fluctuation.

CONCLUSION

For properly selected patients, robotic thyroid surgery is useful surgical option with reliable technical outcome and surgical completeness and cosmetic benefit.

Comparison of Postoperative Neck Pain and Discomfort, Swallowing Difficulty, and Voice Change After Conventional Open, Endoscopic, and Robotic Thyroidectomy: A Single-Center Cohort Study

Background: The objective of this study was to compare the postoperative neck pain and discomfort, swallowing difficulty, and voice change after conventional open thyroidectomy (COT), endoscopic thyroidectomy (ET), or robotic thyroidectomy (RT) performed by a single surgeon. Methods: From January 2013 to December 2017, 254 patients underwent COT, ET, or RT performed by a single surgeon and completed a postoperative symptom survey conducted in the outpatient clinic by three nurses. The survey collected information on postoperative neck pain and discomfort, swallowing difficulty, and voice change. Results: Of the 254 patients, 169 underwent COT, 32 underwent ET, and 53 underwent RT. The mean age in the COT, ET, and RT groups was 50.1, 44.5, and 41.6 years, respectively. The mean interval between thyroidectomy and survey in the COT, ET, and RT groups was 42.7, 50.2, and 9.2 months, respectively. Postoperative neck pain was significantly higher in the ET and RT groups than in the COT group (p = 0.026). The average neck impairment index score in the RT group was significantly higher than that in the COT group (p < 0.001). There were no significant differences in pain scale scores, swallowing difficulty, swallowing impairment index, voice change, and voice hand index among the three groups. Conclusions: There were no significant differences in postoperative voice change or swallowing difficulty among the COT, ET, and RT groups, whereas neck pain and discomfort were more common after ET and RT than COT.

Advances in Robotic Transaxillary Thyroidectomy in Europe

PURPOSE OF REVIEW

The robotic surgical approach for minimally invasive thyroid surgery has been well described from the Korean surgeons and shows a wide spread diffusion in Asian area. This paper gives a systematic review aiming to pointed out the interest and the way of behaving of the European surgeons about the role of the robotic thyroidectomy (RT).

RECENT FINDINGS

A literature search was performed using Pubmed, MEDLINE, Cochrane and ClinicalTrials.gov databases, including only papers wrote from european surgeons enrolling patients operated in Europe. Outcomes of interest included patients characteristics, patients position, surgical devices, surgical technique, surgical outcomes, and complications. Eighteen studies have been included in the analysis, published from 2011 to 2017. An overall number of 1108 patients were treated in studies included. In the 44.4% of studies (eight trials), the Kuppersmith position was chosen, whereas in the 22.2% (four trials), the Chung position was selected, with a mean length on axilla skin incision of 5.8 ± 1.5 cm. Considering the characteristics of the surgical technique, the mean total surgical time was 166.8 ± 36.6 min (including total thyroidectomy and loboisthmectomy together), divided three consecutive phases, such as mean working space was 50.7 ± 21.8 min, mean docking time 16.0 ± 11.9 min and mean console time 102.87 ± 38.8 min. Considering the complications, only 50% of studies included reported data about acute complications. In particular, the most frequent was hypocalcemia, occurring in 32 cases (2.9%). RLN palsy occurred in 29 patients (2.6%), definitive in 13.8% of these cases and transient in 86.2%. Only nine studies reported the discharge time, with a mean of 2.4 ± 1.2 days after surgery.

SUMMARY

Despite the papers included in the study show a different way of collecting data, the transaxillary approach for robotic thyroidectomy for European patients is both feasible and safe. This procedure has to be carried out by surgeons expert in thyroid surgery with knowledge in robotic procedure. In the future, the incoming of dedicated instruments could improve and developed this technique.