Development of a surgical training model for bilateral axillo-breast approach robotic thyroidectomy

Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications

Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.

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.

Comparison of the Postoperative Outcomes of the Mini-Flap Bilateral Axillo-Breast Approach (BABA) and Conventional BABA Robot-Assisted Thyroidectomy

The bilateral axillo-breast approach (BABA) for robot-assisted thyroidectomy has some advantages over other minimally invasive thyroidectomies. However, some people do not consider this as a minimally invasive thyroidectomy because of the wider surgical skin flap. Thus, we devised mini-flap BABA robot-assisted thyroidectomy and analyzed the postoperative outcomes. The clinical records of 44 patients undergoing BABA robot-assisted thyroidectomy using a conventional flap or mini-flap were evaluated retrospectively. There were no significant group differences in clinicopathological characteristics. The operating and flap making times were shorter in the mini-flap group (206.18 ± 31.09 vs. 178.90 ± 34.43 min, p = 0.009; 38.85 ± 2.73 vs. 32.21 ± 8.62 min, p = 0.003, respectively). The total drainage amount was smaller in the mini-flap group (196.57 ± 81.40 vs. 150.74 ± 40.80 mL, p = 0.027). The numeric rating scale score and number of analgesics were lower at 2 h postoperatively in the mini-flap group (5.52 ± 0.87 vs. 4.57 ± 1.31, p = 0.006; 0.95 ± 0.22 vs. 0.65 ± 0.49, p = 0.012, respectively). There was no significant group difference in immediate oncological outcomes (p = 1.000). Mini-flap BABA robot-assisted thyroidectomy minimized the surgical flap and improved surgical outcomes. Therefore, it is a form of minimally invasive thyroidectomy. However, long-term follow-up of oncological outcomes is needed.

Modified Larssen solution (MLS)-fixed cadaver model for transoral endoscopic thyroidectomy vestibular approach (TOETVA) education: a feasibility study

BACKGROUND

Training formats for transoral endoscopic thyroidectomy vestibular approach (TOETVA) are limited. Our aim was to create and investigate a TOETVA training model for general and ENT surgeons.

METHODS

A total of 15 modified Larssen solution (MLS) human cadavers were used in the study. A day duration TOETVA human cadaver workshops were offered in two years consecutive. Post-training verbal and online questionnaires were applied to all trainers to evaluate course structure and program, organoleptic characteristics of MLS-fixed human cadavers, and TOETVA training effectiveness. Cost assessment is included in the study.

RESULTS

Ninety-eight participants, i.e., 14 trainers and 84 hands-on (HO) and observer (OB) trainees, attended the workshops, completed the tasks assigned, and fulfilled the questionnaires. Implementation of all steps of TOETVA was approved positively by 89.8% of all participants, 94.4% of HO, and 83.3% of OB trainees. Regarding human cadaver and teaching quality, 10.8 ± 0.8 (10-12) human cadavers were "practical" by 13.2 (94.5%) of the trainers, and by 33.3 (92.5%) of the trainees for all steps of TOETVA. The cadavers were stored for 4.53 years and used 6.27 times repeatedly for endoscopic workshops and research studies. TOETVA workshop cost with repeatable use of MLS-fixed human cadaver is half of other performed TOETVA workshops.

CONCLUSIONS

A TOETVA human cadaver workshop model has not been reported yet. Our findings suggest the feasibility of MLS-fixed human cadaver model for training of TOETVA, preserve the organoleptic properties necessary for the implementation of surgical steps, and reduce the cost.

Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.

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.

Evaluation of Surgical Skills during Robotic Surgery by Deep Learning-Based Multiple Surgical Instrument Tracking in Training and Actual Operations

As the number of robotic surgery procedures has increased, so has the importance of evaluating surgical skills in these techniques. It is difficult, however, to automatically and quantitatively evaluate surgical skills during robotic surgery, as these skills are primarily associated with the movement of surgical instruments. This study proposes a deep learning-based surgical instrument tracking algorithm to evaluate surgeons’ skills in performing procedures by robotic surgery. This method overcame two main drawbacks: occlusion and maintenance of the identity of the surgical instruments. In addition, surgical skill prediction models were developed using motion metrics calculated from the motion of the instruments. The tracking method was applied to 54 video segments and evaluated by root mean squared error (RMSE), area under the curve (AUC), and Pearson correlation analysis. The RMSE was 3.52 mm, the AUC of 1 mm, 2 mm, and 5 mm were 0.7, 0.78, and 0.86, respectively, and Pearson’s correlation coefficients were 0.9 on the x-axis and 0.87 on the y-axis. The surgical skill prediction models showed an accuracy of 83% with Objective Structured Assessment of Technical Skill (OSATS) and Global Evaluative Assessment of Robotic Surgery (GEARS). The proposed method was able to track instruments during robotic surgery, suggesting that the current method of surgical skill assessment by surgeons can be replaced by the proposed automatic and quantitative evaluation method.

Simulations and simulators in head and neck endocrine surgery

Simulations and simulators have become an increasingly important tool in trainee education across many surgical disciplines, particularly for robotic and minimally invasive procedures. Thyroidectomy and parathyroidectomy are common procedures performed across multiple surgical disciplines, however, there is limited literature regarding training models/simulators for these operations. This is despite the advent and growing popularity of remote-access thyroidectomy techniques, where simulators may provide significant value in trainee education and safe implementation. Here we review the literature regarding available simulations/simulators in head and neck endocrine surgery for both conventional transcervical approaches and newer remote-access thyroidectomy techniques.

Transoral robotic thyroidectomy versus conventional open thyroidectomy: comparative analysis of surgical outcomes using propensity score matching

BACKGROUND

Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).

METHODS

We retrospectively reviewed and compared the medical records of consecutive patients who underwent TORT or OT for thyroid carcinoma from March 2009 to January 2018. Propensity score matching using 10 clinico-pathologic factors was used to generate two matched cohorts, each composed of 186 patients.

RESULTS

The study included 372 patients who underwent TORT (n = 186) or OT (n = 186). Mean age, tumor size, and gender were not different between both groups. The two groups showed similar surgical outcomes, except for a longer operative time for TORT. There was one patient with immediate postoperative bleeding in the TORT group. The patient underwent re-operation for hemostasis with endoscopic approach. In the OT group, one patient had wound seroma, which was treated by several rounds of needle aspiration without infection. Vocal cord palsy was present in one patient in the TORT group, which was recovered in 3 months.

CONCLUSIONS

TORT could be performed safely and had comparable surgical outcomes with OT in the selected patients. TORT may be a suitable operative alternative for patients who do not want to leave scars on the neck.

Application of a Perception Neuron® System in Simulation-Based Surgical Training

While multiple studies show that simulation methods help in educating surgical trainees, few studies have focused on developing systems that help trainees to adopt the most effective body motions. This is the first study to use a Perception Neuron^® system to evaluate the relationship between body motions and simulation scores. Ten medical students participated in this study. All completed two standard tasks with da Vinci Skills Simulator (dVSS) and five standard tasks with thyroidectomy training model. This was repeated. Thyroidectomy training was conducted while participants wore a perception neuron. Motion capture (MC) score that indicated how long the tasks took to complete and each participant’s economy-of-motion that was used was calculated. Correlations between the three scores were assessed by Pearson’s correlation analyses. The 20 trials were categorized as low, moderate, and high overall-proficiency by summing the training model, dVSS, and MC scores. The difference between the low and high overall-proficiency trials in terms of economy-of-motion of the left or right hand was assessed by two-tailed t-test. Relative to cycle 1, the training model, dVSS, and MC scores all increased significantly in cycle 2. Three scores correlated significantly with each other. Six, eight, and six trials were classified as low, moderate, and high overall-proficiency, respectively. Low- and high-scoring trials differed significantly in terms of right (dominant) hand economy-of-motion (675.2 mm and 369.4 mm, respectively) (p = 0.043). Perception Neuron^® system can be applied to simulation-based training of surgical trainees. The motion analysis score is related to the traditional scoring system.

Bilateral Axillo-Breast Approach to Endoscopic Thyroidectomy in a Porcine Model

Traditional surgical training methods to teach young doctors have changed because of the emergence of animal models. The present article summarizes a protocol for bilateral axillo-breast approach (BABA) endoscopic thyroidectomy in a pig model. All procedures were approved by the local ethics committee and the pigs were anesthetized by a veterinarian. Formation of the flap involved skin marking, hydrodissection, blunt dissection and, finally, trocar insertion. BABA endoscopic thyroidectomy is performed by midline division, identification of the thyroid, thyroidectomy and, finally, surveillance of bleeding. Four cases of endoscopic thyroidectomy using porcine models were performed using the BABA approach. The mean weight of the pigs was 60 kg, and the mean operation time was 74.3 minutes. All surgeries were completed without complications. Surgical training for BABA endoscopic thyroidectomy using a porcine model is a valuable education method for young surgeons who need practice before performing surgery on human patients.