Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients

Impact of Multi-point Nursing Strategies Under a Clinical Problem-Solving Framework on Adverse Events Associated With Thyroid Nodule Resection

The impact of multi-point nursing strategies drawing on a problem-solving clinical framework to examine adverse events associated with thyroid nodule resection was investigated. Patients (n = 98) who underwent thyroid nodule resection were divided into observation and control groups. Patients in the control group received conventional care, and patients in the observation group received a multi-point care strategy under a clinical problem-solving framework. The length of stay (p < .001), hospitalization cost (p < .001), nursing satisfaction scores (p < .001) of the observation group were longer or higher and statistically significant. The incidence of complications in the observation group (8.16%) was lower than that in the control group (22.45%). The incidence of adverse events in the observation group (2.04%) was lower than that in the control group (14.29%), and statistically significant (p < .05). The multi-point nursing strategy using a clinical problem-solving framework provided evidence that it shortened the length of stay, reduce hospitalization costs, improve psychological status, increase nursing satisfaction, and reduce complications and adverse events in patients undergoing thyroid nodule resection.

Feasibility and Safety of transoral robotic parathyroidectomy: Initial experience with a new approach for parathyroid surgery

BACKGROUND

We present the initial outcomes of transoral robotic parathyroidectomy (TORP) using the transoral vestibular approach in patients with primary hyperparathyroidism (PHPT).

METHOD

A retrospective case series analysis was performed on patients diagnosed with PHPT between October 2016 and July 2019 who underwent transoral robotic surgery for parathyroidectomy.

RESULTS

Thirteen patients (five males and eight females) successfully underwent TORP at our institution from October 2016 to July 2019. Eight patients underwent TORP alone, and five underwent TORP combined with transoral robotic thyroidectomy for papillary thyroid carcinoma. No intra- or postoperative complications were observed. Serum levels of parathyroid hormone, total calcium, and ionized calcium decreased to normal postoperatively and continued to decrease during the follow-up period.

CONCLUSION

This study suggests that TORP holds promise for the treatment of patients with PHPT with the advantages of the robotic procedure, including dynamic visualization and meticulous dissection.

Current and Future of Robotic Surgery in Thyroid Cancer Treatment

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Vestibular approach for thyroid surgery: a comprehensive review

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an innovative technique in thyroid surgery. This review compiles current research on TOETVA, covering its development, anatomical challenges, techniques, selection of suitable patients, results, complications, and future advancements. We performed a comprehensive literature review on PubMed, EMBASE, and Cochrane databases for articles published up to 15th March 2024. The search strategy included a combination of terms focused on "vestibular approach" and "thyroidectomy". The review underscores the necessity for preoperative planning and careful patient selection to reduce risks and enhance outcomes. It discusses the unique anatomical challenges of TOETVA, such as avoiding mental nerve damage and the complexities involved in creating a subplatysmal space. Outcomes of TOETVA, including surgical duration, complication rates, and recovery times, are compared favorably to traditional methods. The approach is particularly noted for high patient satisfaction and superior cosmetic results. Complications specific to TOETVA, like infection, bleeding, and potential harm to the recurrent laryngeal nerve, are recognized. Future research directions are discussed as well. In summary, TOETVA is a promising alternative for thyroidectomy with excellent cosmetic outcomes and patient satisfaction. Success relies on selective patient criteria, surgical expertise, and continuous research to refine the approach.

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy

INTRODUCTION

Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA).

MATERIALS AND METHODS

Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab.

RESULTS

The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34).

CONCLUSIONS

TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Re-do transoral robotic thyroidectomy is feasible: preliminary results of the surgical feasibility and efficacy of completion transoral robotic thyroidectomy: cohort study

BACKGROUND

Transoral robotic thyroidectomy (TORT) has proven to be a safe and effective procedure with favourable surgical and cosmetic outcomes, but its application in completion thyroidectomy procedures remains to be established. In this study, the authors present our experience with completion TORT, assessing its surgical feasibility and efficacy. between February 2017 and August 2023.

METHODS

The authors conducted a retrospective analysis of consecutive patients who underwent completion TORT after an initial TORT procedure between February 2017 and August 2023.

RESULTS

A total of 10 patients (three males and seven females) were included in the study, with a mean age of 42.2±13.5 years. The indications for completion thyroidectomy included five cases of aggressive initial lesions and five cases of metachronous papillary thyroid carcinoma detected in the remnant lobe. The median interval between the initial and completion TORT procedures was 6.5 months. Flap dissection time showed no significant difference between the initial TORT and completion TORT operations (43.3±7.5 vs. 36.2±11.2, P =0.125). However, the mean console time (127.9±42.6 vs. 86.4±26.3 min, P =0.019) and mean total operation time (206.7±65.9 vs. 146.0±34.9 min, P =0.021) were significantly longer during the initial TORT procedure than during the completion TORT procedure. Two patients experienced transient hypoparathyroidism, which resolved within four weeks postoperatively. No other complications, such as vocal cord palsy, mental nerve injury, or bleeding, were observed. The median follow-up period was 21.5 months, and no recurrences were detected in any of the patients.

CONCLUSIONS

Our study demonstrates that re-do TORT is feasible, showing excellent cosmetic results and minimal adverse effects. Completion TORT may be considered a viable option for selected patients who require completion thyroidectomy after an initial TORT procedure.

Global trends in research of endoscopic thyroidectomy from 2013 to 2022: a scientometric and visualization analysis

Introduction

Recently, endoscopic thyroidectomy has been developed and applied to thyroid surgery to achieve minimized neck scar formation and enhanced aesthetic outcomes. Our scientometric research in this paper offers a thorough overview of endoscopic thyroidectomy from 2013 to 2022.

Methods

All pertinent articles on endoscopic thyroidectomy were obtained from the Web of Science Core Collection Database. The data on the number of citations and publications, most prolific countries and institutions, significant authors and journals, top themes, and keywords were analyzed by Biblioshiny, CiteSpace, and VOSviewer.

Results

There were 758 publications, all of that were found from 2013 to 2022. The output of the annual publication showed an upward trend. A series of cases report by Anuwong et al. published in 2016 received the most citations. The country with the most articles published articles was South Korea, and the two countries with the most collaboration were South Korea and the United States. The most productive journal was Surgical Endoscopy and Other Interventional Techniques. Dionigi G, Kim HY, and Anuwong A were the writers with the most articles published, the highest h- and g-indices, and the strongest link strength, respectively. The keywords "endoscopic thyroidectomy", "surgical", "thyroidectomy", "robotic thyroidectomy", "experience", and others were most used.

Conclusion

The innovative surgical technique, transoral endoscopic thyroidectomy vestibular approach (TOETVA), leaves no scars and produces optimal cosmetic results. However, the long-term oncologic results for thyroid cancer performed with this approach are still missing. This scientometric analysis can offer valuable insights into the present research standing and key focal points in this domain, enabling researchers to gain a precise understanding of the state-of-the-art research in this area.

Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Gasless Transaxillary Endoscopic Thyroidectomy for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless transaxillary endoscopic thyroidectomy (GTET) are 2 newly applied technologies. This study is to compare the 2 approaches from the aspects of effectiveness and safety.

MATERIALS AND METHODS

A total of 339 patients who underwent TOETVA or GTET with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2022. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, and postoperative outcomes.

RESULTS

The operative time of the TOETVA group was significantly longer than the GTET group (141.39±16.11 vs. 98.45±12.24, P <0.05). The TOETVA group had advantages over GTET group when the reduction of parathyroid hormone was compared (19.18±17.43 vs. 23.07±15.72, P <0.05). Meanwhile, more parathyroids were detected in central neck specimens in GTET group (40/181 vs. 21/158, P <0.05). TOETVA had an advantage on total number of central lymph nodes over GTET (7.65±3.11 vs. 4.99±2.45, P <0.05), whereas the number of positive central lymph nodes was similar ( P >0.05). No differences were found between the 2 groups on other data.

CONCLUSIONS

TOETVA and GTET are both safe and effective for unilateral papillary thyroid carcinomas. TOETVA has advantage on protection of inferior parathyroid glands and harvest of central lymph node dissection. Meanwhile, GTET can save more time compared with TOETVA. Surgeons and patients should freely choose the approaches based on their demands.

Three-Port Transoral Robotic Thyroidectomy in Papillary Thyroid Carcinoma

BACKGROUND

Although transoral thyroidectomy has become popular in thyroid surgery, transoral robotic thyroidectomy (TORT) has only been successfully applied in a very small number of medical centers worldwide.[1,2,3,4,5] In this video, we show a three-port TORT without an axillary incision for papillary thyroid carcinoma.

PATIENT AND METHODS

A 35-year-old female with cT1aN0M0 papillary thyroid carcinoma had a strong motivation to proceed with surgery but avoid external neck incisions. Thus, we decided to perform a hemithyroidectomy with isthmusectomy using a transoral robotic approach, employing the da Vinci Xi surgical system.

RESULTS

The operation was completed successfully without conversion to open surgery. The working space creation time, docking time, and console time were 30 min, 40 min, and 130 min, respectively. The pathological results were papillary thyroid carcinoma with 6- and 5-mm tumors. The patient was discharged 4 days after surgery without any complications such as bleeding, infection, mental nerve damage, permanent hoarseness, or hypoparathyroidism. The patient was completely satisfied with the cosmetic result.

CONCLUSION

Three-port TORT without an axillary incision is a promising approach with optimal cosmetic outcomes. For Vietnam, a developing country, success in the application of TORT using the new da Vinci Xi robotic platform for thyroid cancer is an important milestone in the development of thyroid surgery.

Robotic versus endoscopic transoral thyroidectomy in papillary thyroid cancer: A comparative analysis of surgical outcomes in 240 consecutive patients

BACKGROUND

This study compared the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) in papillary thyroid cancer (PTC).

METHODS

The TOETVA and TORT groups comprised 119 and 121 patients between November 2016 and May 2022. Clinico-surgical outcomes and operation times were retrospectively reviewed.

RESULTS

The TORT group showed a higher number of retrieved central compartment lymph nodes, shorter hospital stays, and lower pain score after 48 h than the TOETVA group. No significant difference was observed in the other postoperative complications, including permanent vocal cord palsy. Total operation, working space creation, and endoscopic or robotic surgery times of the TORT group were longer than those of the TOETVA group.

CONCLUSIONS

TORT and TOETVA are feasible and safe. TORT may have some advantages, such as central compartment node dissection, shorter hospital stays, and pain score after 48 h in PTC, despite a longer operative time.

Transoral endoscopic thyroidectomy with or without central neck dissection

PURPOSES

Minimally invasive thyroid surgeries are universally accepted. We report on one, transoral endoscopic thyroidectomy with or without central neck dissection.

METHODS

A case series of 103 patients were operated on between December 2018 and December 2021. We performed transoral endoscopic thyroidectomy vestibular approach (TOETVA) for 76 patients with a benign nodule, and 27 with papillary thyroid carcinoma (PTC). The patients with malignant nodules also underwent ipsilateral central neck dissection. The extent of surgery, operative time and operative complications were analyzed.

RESULT

No cases were converted to open surgery. Average tumor size was 3.8 ± 1.62 cm, mean operative time was 116.5 ± 41.7 min, median blood loss 40.1 ± 49 mL. There were 95 patients with lobectomy and 8 patients with total thyroidectomy. Temporary hoarseness occurred in 9 patients (8.7 %). No patients developed permanent hoarseness. Twelve patients had middle chin numbness.

CONCLUSION

The transoral endoscopic thyroidectomy vestibular approach, with or without central neck dissection, is a safe, effective and highly aesthetic treatment.

Novel suspension system for gasless transoral vestibular thyroidectomy

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is receiving increased attention, frequently due to growing requirements for cosmetic incisions. Here, we report our initial experience and discuss the safety and efficacy of the innovative surgical working space suspension system for gasless TOETVA.

METHODS

We retrospectively analyzed 75 consecutive patients for whom gasless TOETVA with our novel working space suspension system was used. This suspension system included self-developed retractors, a sterile bandage, and an anesthesia stand. We also improved some main surgical instruments in gasless TOETVA.

RESULTS

The study included 75 patients who successfully underwent thyroidectomy and central neck dissection via gasless TOETVA. The mean operating time was 143.27 ± 34.60 min. The mean number of retrieved lymph nodes was 8.00 ± 5.39. Conversion to open surgery did not occur, nor did patients exhibit serious postoperative complications. Postoperative complications included 4 cases of transient recurrent laryngeal nerve (RLN) palsy, 9 of transient hypoparathyroidism, and 3 of transient mental nerve injury. One patient with subcutaneous fluid after surgery recovered after aspiration. Another patient with submental minor perforation recovered well after suturing. There was no evidence of specific complications related to self-designed retractors.

CONCLUSION

The innovative working space suspension system for gasless TOETVA provided enough and stable working space and optimized the clarity of the surgical field without CO₂-related complications.

Comparative surgical outcomes of transoral endoscopic and robotic thyroidectomy for thyroid carcinoma: a propensity score-matched analysis

BACKGROUND

Surgical outcomes of patients with thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus transoral robotic thyroidectomy (TORT) were compared.

METHODS

Patients who underwent TOETVA or TORT between July 2016 and February 2022 were retrospectively analyzed. TOETVA and TORT groups were propensity score-matched (1:1) based on age, sex, body mass index, surgical extent, tumor size, and presence of thyroiditis.

RESULTS

A total of 185 patients underwent transoral thyroidectomy (142 TOETVA and 43 TORT). Final diagnoses consisted of 135 papillary and seven follicular thyroid carcinomas in the TOETVA group and 43 papillary thyroid carcinomas in the TORT group (p = 0.138). Mean operative time was shorter for the TOETVA group than the TORT group (106.3 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer for the TOETVA group than the TORT group (2.2 vs. 1.9 days, p = 0.031). After 1:1 propensity score matching, each group included 43 patients. Mean operative time was shorter in the TOETVA group than the TORT group (106.2 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer in the TOETVA group (2.3 vs. 1.9 days, p = 0.031). There was no significant difference in vocal cord palsy incidences between the groups (one transient, one permanent in the TOETVA group vs. none in the TORT group, p = 0.359). The learning curve was 71 cases for TOETVA and 25 cases for TORT.

CONCLUSION

TOETVA had shorter mean operative time, and TORT had shorter learning curve and shorter mean hospital stay. Surgeons should be familiar with the advantages and disadvantages of each procedure.

The global status and hotspots of research in the field of trans-oral endoscopic thyroidectomy (TOET) from 2008 to 2022

Purpose

In this study, the aim was to comprehensively analyze the current status, hotspots, and trends of trans-oral endoscopic thyroidectomy (TOET) through bibliometric analysis and by presenting the field atlas.

Methods

Web of Science Core Collection database was adopted to screen studies regarding TOET published between January 1, 2008 and August 1, 2022. The evaluation covered the criteria total number of studies, keywords, and contributions from countries/regions, institutions, journals, and authors.

Results

A total of 229 studies were covered. SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES is the largest publication in the field of TOET. The three countries that contributed the most studies were Korea, China, and the USA. The most frequently occurring core keywords in the field of TOET are vestibular approach, outcomes, experience, safety, robotic thyroidectomy, scar, video-assisted thyroidectomy and quality-of-life. The seven clusters were generated in this study: intraoperative monitoring of the laryngeal return nerve (# 0), learning curve (# 1), postoperative quality of life (# 2), central lymph node dissection and safety (# 3), complications (# 4), minimally invasive surgery (# 5), and robotic surgery (# 6).

Conclusion

The main research topics in the field of TOET place focuses on learning curves, laryngeal nerve monitoring, carbon dioxide gas bolus, chin nerve injury, surgical complications, and surgical safety. In the future, more academics will focus on the safety of the procedure and reducing complications..

Transoral thyroidectomy implemented by a novice surgeon: Efforts for safe implementation

Background

This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon.

Methods

We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy.

Results

Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome.

Conclusions

Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework.

Level of Evidence

Level 4.

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

Simple Summary

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

Abstract

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

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Simple Summary

Transoral thyroidectomy accesses the thyroid gland through three incisions in the oral vestibule. The cosmetic outcome was excellent since no scar was observed on the body surface. However, it is challenging to create a working space using this new approach. Unconventional but severe complications can also occur. Our review summarizes the tips regarding working space creation in transoral thyroidectomy and tricks for preventing complications.

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review

This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.

Application of robots in general surgery

Background: Application of robotic surgery in the field of general surgery has been increasing. This paper is an overview of the current uses and future perspectives of robotic surgery in four major divisions—endocrine, upper gastrointestinal, hepato-biliary-pancreatic (HBP), and colorectal surgery.Current Concepts: In endocrine surgery, cosmetic advantage is the highest priority when selecting a surgical approach for thyroidectomy. Currently, the transaxillary route is the most common approach. The introduction of the single-port system could maximize the advantages of this technique. In upper gastrointestinal surgery, the use of robots has the advantage of better retrieval of lymph nodes, less bleeding, earlier discharge, and less complications than the laparoscopic approach. However, a more prospective comparative trial is required to confirm those findings. In the HBP field, the indications of robotic surgery have expanded, starting with cholecystectomy to more challenging procedures, such as donor hepatectomy and pancreaticoduodenectomy. Meticulous dissection using robots could provide benefits to patients. In colorectal surgery, robotic surgery is an excellent technical tool for minimally invasive surgeries for rectal cancers, especially in male patients with narrow, deep pelvises. However, further studies are required to confirm the impact of robotic surgery on rectal cancers.Discussion and Conclusion: Robots are used to provide optimal surgical outcomes. Investigating new technologies and innovative surgical procedures is the highly important for a surgeon in the era of minimally invasive surgery.

Endoscopically-Assisted Scar-Free Midline Neck Mass Excision

Traditional open surgery is indicated for the treatment of selected tumor subsites in the head and neck. However, it can cause major cosmetic problems and functional pathologies. The endoscopically-assisted transoral approach is increasingly preferred in some surgical fields due to its superior cosmetic and functional outcomes. Nonetheless, endoscopically-assisted transoral approach is not yet standard in the head and neck due to their anatomical complexity. The transoral surgical approach has been used for head and neck masses since the 1960s, and its application continues to evolve with changing disease conditions and recent innovations in surgical instruments. The potential for wide application of transoral surgery continues to be investigated, with a focus on minimizing occurrence of the complications. This review presents details of the surgical procedure and postoperative clinical outcomes, as well as endoscopically-assisted scar-free techniques for the resection of midline neck masses.

The sensorimotor changes of the lower lip and chin after transoral endoscopic thyroidectomy vestibular approach

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) can lead to abnormal sensorimotor changes in the lower lip and chin because of its incision design. This study aimed to explore the surgical outcomes of these changes after TOETVA. A total of 122 patients who underwent TOETVA were reviewed. The original incision design was used for the 39 patients in group A and a modified incision design was used for the 83 patients in group B. The sensorimotor changes in the lower lip and chin were compared. Varying degrees of paresthesia of the lower lip and chin (PoLC) were noted in all group A patients. Approximately 20.5% of group B patients did not suffer from PoLC, and the degree of PoLC in group B was significantly lower (P < 0.001). Abnormal motor function of the lower lip was noted for 23.1% of the patients in group A and 2.4% of those in group B. The incision design plays an important role in the morbidity of sensorimotor changes in the lower lip and chin. Our modified incision design seems minimally invasive and feasible for patients who undergo TOETVA.

Vocal cord granuloma after transoral thyroidectomy using oral endotracheal intubation: two case reports

Background

Transoral thyroidectomy can be performed using nasal or oral intubation. Recently, we encountered two cases of vocal cord granuloma that were suspected to result from intraoperative compression by the oral endotracheal tube.

Cases presentation

Two women underwent transoral endoscopic thyroidectomy with oral endotracheal tubes fixed at the mouth angle. Their initial postoperative recovery was uneventful, but they developed hoarseness 2 months after the surgery. Subsequent strobolaryngoscopy revealed vocal cord granulomas at the side of contact of the endotracheal tube. One patient received medication and voice therapy, and her granuloma shrank significantly one month later. The other patient underwent granuloma resection. Thereafter, the symptoms improved in both the patients.

Conclusions

Oral intubation with tube placement at the mouth angle might result in the formation of vocal cord granulomas. Therefore, we suggest positioning the tube at the midline to avoid excessive irritation on one side of the vocal cord.

Prevention of transoral thyroidectomy complications: An analysis of surgical outcomes in 423 consecutive series

BACKGROUND

Although there are several publications on the new transoral robotic thyroidectomy technique, few have thoroughly reviewed its associated complications. This study analyzed the causes and prevention of transoral robotic thyroidectomy-specific complications and presented preventive measures.

METHODS

The medical records of patients who underwent transoral robotic thyroidectomy performed by a single surgeon between March 1, 2009 and April 30, 2019 were retrospectively analyzed. Patient demographic, clinical, and operative data were analyzed using descriptive statistics. We describe the transoral robotic thyroidectomy-related complications experienced at our institution and how to overcome them.

RESULTS

This study included a total of 423 patients who underwent transoral robotic thyroidectomy. The general surgical complications included immediate postoperative bleeding (2 cases) and delayed hematoma (3 cases). Chyle leakage and localized wound infection were found in 1 case each. Transient vocal cord palsy occurred in 4 cases, and 1 case developed transient hypoparathyroidism. The transoral robotic thyroidectomy-specific complications included zygoma bruise (2 cases), flap bruise (3 cases), chin flap perforation (2 cases), and oral commissure tearing (2 cases). The complications occurring when creating the flap included flap burns (4 cases), skin dimpling in the midline of the lower chin (2 cases), and hematomas in the intraoral trocar insertion sites (3 cases).

CONCLUSION

Surgeons familiar with thyroid surgery and experienced in robotic surgery can perform transoral robotic thyroidectomy without causing more complications than those seen with traditional surgery.

Transoral versus gasless transaxillary endoscopic thyroidectomy: a comparative study

This study aimed to compare the surgical safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless endoscopic thyroidectomy transaxillary approach (GETTA). This retrospective study assessed 150 patients managed with the TOETVA at the Yantai Yuhuangding hospital and 150 patients managed via the GETTA at the Zhenjiang Provincial People's Hospital. The procedures were compared in terms of workspace creation time, operating time, complications, post-operative complaints, cosmetic satisfaction, and the efficacy of central neck lymph-node dissection. There was no significant between-group difference in terms of post-operative complications. The average workspace creation and operating times were significantly shorter for GETTA than for TOETVA (P values for both < 0.001). The average number of lymph nodes dissected from the central compartment of the neck was higher in the TOETVA group than in the GETTA group (7.2 ± 4.6 vs. 3.9 ± 3.0, P < 0.001). The mean swallowing impairment index-6 scores at 1 month were significantly lower in the GETTA group than in the TOETVA group (1.5 ± 1.2 vs 2.6 ± 1.4, P < 0.001). Over 97% of all patients (both groups) were either satisfied or very satisfied with the cervical cosmetic outcomes at 3 months post-surgery (P = 0.099). TOETVA and GETTA are both safe procedures with good cervical cosmetic outcomes for well-selected patients. Although TOETVA is more efficacious in terms of central lymph nodes dissection, GETTA has a greater time-cost advantage.

Scarless Completion Thyroidectomy After Initial Transoral Approach for Differentiated Thyroid Cancer: How and When to Start?

BACKGROUND

With growing literature, the feasibility of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been confirmed as a valid method for managing differentiated thyroid cancer. Completion thyroidectomy (CT) is recommended in patients who have been diagnosed with differentiated thyroid cancer after unilateral lobectomy by TOETVA. In this retrospective study, the authors addressed the critical questions of how and when to do the second operation of CT to avoid a neck scar.

MATERIALS AND METHODS

The authors retrospectively reviewed our patients who had received TOETVA in our hospital from August 2016 to December 2019. Those who received CT after initial TOETVA as cTOETVA were further separated according to the approaching methods. Demographic data, operative variables, and postoperative variables were collected and analyzed.

RESULTS

A total of 97 patients were enrolled using TOETVA. Malignancies were present in 42 patients (43.3%) using TOETVA. There were 3 approaching methods of cTOETVA and separated into reopen transcervical approach (re-TCA), retransoral TOETVA (re-TOETVA), and transaxillary approach (TAA) groups. There were no significant complications among patients for cTOETVA. Of the 8 patients for the cTOETVA, 3 received re-TCA, 3 re-TOETVA, and 2 TAA.

CONCLUSIONS

The outcomes are encouraging and demonstrate the feasibility of scarless completion thyroidectomy after initial TOETVA. The re-TOETVA procedure should be completed within 14 days after the initial TOETVA procedure, TAA beyond 14 days, and re-TCA may be completed at any time. The cTOETVA techniques using re-TOETVA or TAA have better cosmetic results than re-TCA in oncological equivalency.

Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study

OBJECTIVE

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC.

MATERIALS AND METHODS

This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%).

RESULTS

The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up.

CONCLUSION

TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.

Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach

BACKGROUND

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure.

METHODS

Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT.

RESULTS

A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R² of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001).

CONCLUSIONS

We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.

Comparison of postoperative outcomes between bilateral axillo-breast approach-robotic thyroidectomy and transoral robotic thyroidectomy

Background

The use of robotic systems for thyroidectomy has increased as it enables more diverse approaches than the conventional open method. The aim of this study was to compare the clinical outcomes of Transoral Robotic Thyroidectomy (TORT) and Bilateral Axillo-Breast Approach-Robotic Thyroidectomy (BABA-RT).

Methods

This study was designed as a retrospective study. The included patients who underwent surgery by BABA-RT or TORT approach in our facility between 2008 and 2018. All surgeries were performed by one surgeon. Total thyroidectomy with central node dissection (CND) was performed only if tumors were >4 cm and had extrathyroidal extension, clinically apparent lymph node or distant metastases. In all other cases, lobectomy ± CND was performed.

Results

The group treated with TORT comprised 248 patients and the group that underwent BABA-RT had 316 patients. The number of retrieved lymph node (LN) was higher in the TORT group (4.9±4.4 vs. 4.2±4.9; P=0.01). There were no significant differences between the TORT and BABA-RT groups in concerns to the location of the tumor. Postoperative hospital stay was also shorter in the TORT group when compared with the BABA-RT group (2.8±0.90 vs. 3.4±0.97 days, P=0.012). Operative time was significantly shorter in the TORT group (204.11±40.19 vs. 243.78±57.16 min, P<0.01).

Conclusions

When comparing a total of 248 patients treated with TORT versus 316 with BABA-RT. TORT not only has advantages in better cosmetic outcomes with minimized postoperative scars, but also shows comparable, or even superior, surgical outcomes with shorter operation time than the BABA-RT procedure.

Surgical outcomes of minimally invasive thyroidectomy in thyroid cancer: comparison with conventional open thyroidectomy

Background

Minimally invasive thyroidectomy (MIT) is a safe method of performing thyroidectomy with notable benefits, such as improved cosmesis and reduced postoperative pain. The objective of this retrospective study was to report our experience with the technical feasibility of MIT, and compare its early surgical outcomes with those of conventional open thyroidectomy (COT) in patients with differentiated thyroid carcinoma (DTC).

Methods

A total of 617 patients who underwent MIT and 2,674 patients who underwent COT were reviewed between March 2006 and November 2017 at Yonsei University (Seoul, Korea). The mean follow-up duration was 41.2±19.7 months.

Results

The mean age of patients with DTC was 46.1±11.2 years. The mean operation time in the MIT group was significantly shorter than that of the COT group (63.5±26.2 vs. 85.3±36.8 minutes, P<0.001). The mean hospital stay was significantly shorter in the MIT group than it was in the COT group as well (2.7±0.6 vs. 3.1±0.8 days, P<0.001). There were significantly fewer painkillers used after surgery in the MIT group than in the COT group (1.2±0.5 vs. 2.7±1.6, P<0.001). The mean number of harvested LNs in the MIT group was significantly lower than that of the COT group (3.1±2.6 vs. 5.5±4.0, P<0.001).

Conclusions

This study demonstrated that MIT is technically feasible in patients with DTC. MIT is a valuable alternative operative technique to COT with good surgical outcomes and outstanding cosmetic results.

Complications of Transoral Thyroidectomy: Overview and Update

Transoral thyroidectomy via the vestibular approach has become popular worldwide, with advantages including less surgical morbidity, excellent postoperative cosmesis, and superior functional voice outcomes. Several studies have reported that the surgical outcomes of the transoral approach were comparable to those of the conventional transcervical approach in selected patients. However, unusual complications, such as CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been noted in transoral thyroidectomy. This paper aims to review and provide updated information on these complications and their management. Routine intraoperative neural monitoring is required to avoid laryngeal nerve palsy in the transoral approach. To prevent CO2 embolism, surgeons need to be careful not to injure the anterior jugular vein, and the CO2 insufflation pressure should be set as low as 4-6 mmHg. To avoid mental nerve injury, vestibular incisions should be placed in the safety zone, and dissection of the vestibular area and chin should be minimized. In conclusion, recognizing the possibility of complications and understanding their prevention and management are important for patient safety and the success of the transoral approach.

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases

BACKGROUND

North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA).

STUDY DESIGN

Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m², overweight 25-29.9 kg/m², and obese ≥ 30 kg/m² for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication.

RESULTS

Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively.

CONCLUSION

TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.

Surgical approaches to thyroid

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

Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews

Background:

We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure.

Materials and Methods:

PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test.

Results:

The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups.

Conclusions:

TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Transoral Chondrolaryngoplasty: Scarless Reduction of the Adam's Apple

The purpose of our study is to test the feasibility of transoral thyroid chondrolaryngoplasty using a similar approach to transoral thyroidectomy. This approach would allow for gender-affirming surgery while avoiding an external neck scar. We carried out our cadaveric feasibility study in an anatomy laboratory at an academic center. Five fresh cadavers were used for this study. We used a lower oral vestibular incision, along with retractors and an endoscope to dissect and gain access to the laryngeal prominence of the thyroid cartilage. Portions of the laryngeal prominence were then removed using scissors to achieve a satisfactory neck contour. Endoscopic as well as extracorporeal photographs were taken to demonstrate the approach. We were able to remove the laryngeal prominence successfully in all of our cadaveric specimens with this transoral approach.

Robotic thyroid surgery

Various remote access robotic thyroidectomy techniques have been developed using the da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA) to hide or avoid neck scarring and overcome the limitations of endoscopic thyroidectomy. Among those used today are the gasless transaxillary approach, the bilateral axillo-breast approach (BABA), the gasless postauricular facelift approach, and the transoral approach. Especially, the recently introduced transoral approach (including robotic and endoscopic procedures) is prominent and now popular worldwide. The most significant advantages of remote access robotic thyroidectomy are excellent postoperative cosmesis and voice outcomes. The important limitations to the adoption of robotic thyroidectomy are the difficult technique, high complication rate during the learning curve, and high cost. In addition, cultural differences, longer operative times, and medicolegal issues are a barrier to the diffusion of robotic thyroidectomy. However, remote access robotic thyroidectomy is feasible, and the outcomes are comparable to those of conventional transcervical thyroidectomy if performed by experienced surgeons in highly selected patients. This article reviews the evolution and recent advances in robotic thyroid surgery.

The pros and cons of additional axillary arm for transoral robotic thyroidectomy

Background

Transoral vestibular approach thyroidectomy using robotic system has advantages with articulating instrumentation. Transoral robotic thyroidectomy (TORT) can be done either using just two robot arms for instruments and an extra one for the endoscopic camera, or using three robot arms for instruments (third arm through axila) and an additional arm for the camera.

Pros of additional axillary arm for TORT

The 4th arm through an additional axillary port is mainly responsible for a counter-traction of strap muscles and thyroid tissue. The additional axillary port tract is also an excellent passage for the specimen removal with lower risk of disruption or fragmentation. Ultimately, these merits from the additional axillary arm allows TORT to be performed safely in a wide range of patient groups.

Cons of additional axillary arm for TORT

One of the issue with the additional axillary arm in TORT is that it leaves a cutaneous scar. Another issue to consider is the cost. In some places, robotic surgery operation fee varies with the number of arms used during the operation. Retraction of strap muscles through subcutaneous stitches applied after establishing the working space may make up for the lack of counter-traction.

Conclusion

TORT can be done safely with or without the transaxillary arm and surgeon may consider pros and cons based on multiple factors.

Minimally Invasive Approaches for Thyroid Surgery-Pitfalls and Promises

PURPOSE OF REVIEW

To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies.

RECENT FINDINGS

Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy

INTRODUCTION

The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA).

METHODS

The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued.

RESULTS

Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times.

CONCLUSIONS

The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.