Transoral endoscopic selective lateral neck dissection for papillary thyroid carcinoma: a pilot study

A prospective study comparing the gasless endoscopic thyroidectomy trans-axillary approach to conventional open thyroidectomy: health and quality of life outcomes

BACKGROUND

The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL).

METHODS

This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS).

RESULTS

Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation.

CONCLUSIONS

Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.

Gasless Single-Incision Endoscopic Surgery via Subclavicular Approach for Lateral Neck Dissection in Patients with Papillary Thyroid Cancer

BACKGROUND

The technical difficulties and trauma of remote access methods in endoscopic surgery (ES) for lateral neck dissection (LND) can be daunting for most patients with papillary thyroid cancer (PTC) and surgeons. The purpose of study was to introduce gasless single-incision ES via a subclavicular approach (ESSA) and to explore its safety and efficacy for LND.

METHODS

Between January 2022 and February 2023, we retrospectively reviewed 17 patients with PTC who underwent ESSA for LND. In addition, 22 patients who received video-assisted ES (VAES) and 48 patients who underwent open surgery (OP) for LND during the same period were included. Clinicopathological characteristics, complications, and efficacy of the lymph node yield (LNY) were compared between the ESSA and the other two groups (VAES and OP).

RESULTS

The LNY from central and lateral neck dissection by ESSA was comparable to that by VAES (9.2 ± 8.1 vs. 9.5 ± 4.2, P = 0.986, and 33.5 ± 11.6 vs. 30.6 ± 9.2, P = 0.382, respectively) and OP (9.2 ± 8.1 vs. 11.0 ± 5.4, P = 0.420, and 33.5 ± 11.6 vs. 31.5 ± 7.9, P = 0.383, respectively). Swallowing impairment scores at 1 and 3 months were significantly lower after ESSA than those after VAES (1.8 ± 1.0 vs. 3.0 ± 1.2, P = 0.003, and 0.9 ± 0.8 vs. 1.7 ± 0.8, P = 0.006, respectively). The cosmetic satisfaction rate 1 month after surgery was significantly higher in the ESSA group than that in the VAES group (100 vs. 31.8%, P < 0.001).

CONCLUSIONS

ESSA is a safe and minimally invasive procedure that provides a scarless cervical appearance and has good efficacy for LND. Therefore, ESSA may be a feasible choice for selected patients with N1b PTC with cervical cosmetic needs.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Patterns of lymph node metastasis in level IIB and contralateral level VI for papillary thyroid carcinoma with pN1b and safety of low collar extended incision for neck dissection in level II

OBJECTIVE

To explore relevant clinical factors of level IIB and contralateral level VI lymph node metastasis and evaluate the safety of low-collar extended incision (LCEI) for lymph node dissection in level II for papillary thyroid carcinoma (PTC) with pN1b.

METHOD

A retrospective analysis was performed on 218 patients with PTC with pN1b who were treated surgically in the Head and Neck Surgery Center of Sichuan Cancer Hospital from September 2021 to May 2022. Data on age, sex, body mass index (BMI), tumor location, maximum tumor diameter, multifocality, Braf gene, T staging, surgical incision style, and lymph node metastasis in each cervical subregion were collected. The chi-square test was used for comparative analysis of relevant factors. All statistical analyses were completed by SPSS 24 software.

RESULT

Each subgroup on sex, age, BMI, multifocality, tumor location, extrathyroidal extension, Braf gene, and lymphatic metastasis in level III, level IV, and level V had no significant difference in the positive rate of lymph node metastasis in level IIB (P > 0.05). In contrast, patients with bilateral lateral cervical lymphatic metastasis were more likely to have level IIB lymphatic metastasis than those with unilateral lateral cervical lymphatic metastasis, with a statistically significant difference (P = 0.000). In addition, lymph node metastasis in level IIA was significantly associated with lymph node metastasis in level IIB (P = 0.001). After multivariate analysis, lymph node metastasis in level IIA was independently associated with lymph node metastasis in level IIB (P = 0.010). The LCEI group had a similar lymphatic metastasis number and lymphatic metastasis rate in both level IIA and level IIB as the L-shaped incision group (P > 0.05). There were 86 patients with ipsilateral central lymphatic metastasis (78.2%). Patients with contralateral central lymphatic metastasis accounted for 56.4%. The contralateral central lymphatic metastasis rate was not correlated with age, BMI, multifocality, tumor invasion, or ipsilateral central lymphatic metastasis, and there was no significant difference (P > 0.05). The contralateral central lymphatic metastasis in males was slightly higher than that in females, and the difference was statistically significant (68.2% vs. 48.5%, P = 0.041).

CONCLUSION

Lymphatic metastasis in level IIA was an independent predictor of lymphatic metastasis in level IIB. When bilateral lateral cervical lymphatic metastasis or lymph node metastasis of level IIA is found, lymph node dissection in level IIB is strongly recommended. When unilateral lateral cervical lymphatic metastasis and lymphatic metastasis in level IIA are negative, lymph node dissection in level IIB may be performed as appropriate on the premise of no damage to the accessory nerve. LCEI is safe and effective for lymph node dissection in level II. When the tumor is located in the unilateral lobe, attention should be given to contralateral central lymph node dissection because of the high lymphatic metastasis rate.

Robotic infraclavicular approach for minimally invasive neck dissection in head-neck cancers

Background

In the recent years, there has been a rapid increase in the use of robot assisted neck dissection (RAND) as an alternative method for conventional neck dissection. Several recent reports have emphasized upon the feasibility and effectiveness of this technique. However, substantial technical and technological innovation is still essential in spite of the availability of multiple approaches for RAND.

Materials and Methods

The present study describes a novel technique, i.e., Robotic Infraclavicular Approach for Minimally Invasive Neck Dissection (RIA MIND) used in head and neck cancers with the help of Intuitive da Vinci Xi Surgical System.

Results

After RIA MIND procedure, the patient was discharged on the third post operative day. Also, the total wound size was less than 3.5 cm which enhanced the patient recovery time and required minimal post operative care. The patient was further reviewed 10 days after the procedure for the removal of sutures.

Conclusion

RIA MIND technique was effective and safe for performing neck dissection for oral, head and neck cancers. However, additional detailed studies will be required for establishing this technique.

Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer

OBJECTIVE

We had previously reported endoscopic central and lateral neck dissection via breast combined with an oral approach for papillary thyroid cancer treatment. In this study, we optimized the procedure with Wu's seven steps to make the procedure quicker and easier.

METHODS

Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer are: (1) establish the working space, (2) isolate the sternocleidomastoid and internal jugular vein, (3) dissect the thyroid via breast approach, (4) dissect the central lymph nodes via oral approach, (5) dissect the inferior board of level IV via oral approach, (6) remove the tissues of levels IV, III, and II via breast approach, and (7) wash the working space and place drainage tubes. Twelve patients were assigned to the Wu's seven steps group, and 13 patients were assigned to the contrast group. The operative procedure of the contrast group was the same as Wu's seven steps except for a few key differences, such as that the central lymph nodes were dissected via breast approach first and the internal jugular vein(IJV) was dissected from the cricoid cartilage down to the venous angle.

RESULTS

The Wu's seven steps group had a short operation time and few injuries of the internal jugular vein. There were no statistical differences in other clinicopathological features or surgical complications.

CONCLUSION

It appears that Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer are effective and safe.

A novel hybrid approach for "Scarless" (at the neck) lateral neck dissection for papillary thyroid carcinoma: A case series and literature review

Lateral neck dissection (LND) is a necessary treatment for thyroid cancer with lateral lymph node metastasis. However, the defect created during open surgery leaves a visible scar on the neck. With advancements in surgical technology, many robotic and endoscopic surgical techniques have been reported as alternatives to open surgery. In this study, we present a case series demonstrating the successful application of a novel hybrid approach for endoscopic LND and a review of different surgical approaches for "scarless" (at the neck) LND. We performed endoscopic LND via a combined chest and transoral approach in 24 patients between January 2021 and March 2022. The surgery was completed successfully in all patients with an average operation time of 298.1 ± 72.9 min. The numbers of positive/retrieved lymph nodes at levels II, III-IV, and VI were 0.7 ± 0.9/8.4 ± 4.1, 3.6 ± 2.7/19.5 ± 6.8, and 4.9 ± 3.9/10.3 ± 4.5, respectively. Complications included transient hypoparathyroidism in 10 patients, transient recurrent laryngeal nerve injury in 1 patient, internal jugular vein (IJN) injury in 1 patient, IJN sacrifice due to cancer invasion in 1 patient, and chyle leak in 1 patient, and no cases of tumor recurrence were observed during follow-up. The present case series indicates that the combined chest and transoral approach is feasible and effective for performing LND. Our review of different approaches for "scarless" (at the neck) LND identified advantages and disadvantages for all techniques. Our novel approach has unique advantages, and thus, it can provide an ideal surgical procedure for specific papillary thyroid carcinoma patients.

Endoscopic thyroidectomy via the combined trans-oral and chest approach for cT1-2N1bM0 papillary thyroid carcinoma

BACKGROUND

Recent years there have been witnessed considerable advances in endoscopic selective lateral neck dissection (LND). However, dissection of lymph nodes at level IV and level VI via the chest approach is inherently challenging. In this study, we used combined trans-oral and chest approach for endoscopic thyroidectomy in patients with cT1-2N1bM0 papillary thyroid carcinoma (PTC).

METHODS

Clinical characteristics and surgical outcomes of ten patients with cT1-2N1bM0 PTC who underwent endoscopic thyroidectomy via combination of trans-oral and chest approach between September 2020 and September 2021 were retrospectively reviewed.

RESULTS

All 10 patients successfully underwent total thyroidectomy and selective LND via chest approach, while central neck dissection (CND) and supplementary dissection of lymph nodes at level IV were performed via the trans-oral approach. The mean number of positive/retrieved level II, III-IV, and VI lymph nodes were 0.6 ± 1.0/9.8 ± 5.0, 4.6 ± 2.8/23.1 ± 4.7, and 4.9 ± 3.4/10.3 ± 4.6, respectively. Four patients developed transient hypoparathyroidism which spontaneously resolved within 1 month. Five patients developed numbness of lateral neck and ear and one patient experienced limb lift restriction. No other complications or tumor recurrence occurred during follow-up.

CONCLUSION

It is feasible to perform total thyroidectomy, CND, and selective LND via combined trans-oral and chest approach, and satisfactory short-term outcomes were observed in this cohort. This approach may offer one more option for cT1-2N1bM0 PTC patients, especially those in whom metastatic lymph nodes at level IV or level VI are detected by preoperative examination.

Endoscopic lateral neck dissection via the breast and transoral approaches for papillary thyroid carcinoma: A preliminary report

PURPOSE

Complete lymph node dissection is essential for the management of papillary thyroid carcinoma (PTC) with lymph node metastasis (LNM). This work aimed to describe the feasibility of endoscopic lateral neck dissection via the breast and transoral approach (ELNDBTOA) in PTC patients and the necessity of the addition of the transoral approach.

METHODS

We included 13 patients with PTC and suspected lateral LNM who underwent ELNDBTOA at the Zhongshan Hospital, Xiamen University. Total thyroidectomy, ipsilateral central lymph node dissection, and selective neck dissection (levels IIA, IIB, III, and IV) were performed endoscopically via the breast approach. Residual lymph nodes were further dissected via the transoral approach.

RESULTS

The mean operation time was 362.1 ± 73.5 min. In the lateral neck compartments, the mean number of retrieved lymph nodes was 36.6 ± 23.8, and the mean number of positive lymph nodes was 6.8 ± 4.7. In further dissection via the transoral approach, lymph nodes in the lateral neck compartment were obtained in nine patients (9/13, 69.2%), and three patients (3/13, 23.1%) had confirmed lateral neck metastases. Transient hypocalcemia occurred in two patients (2/13, 15.4%), and three patients (3/13, 23.1%) developed transient skin numbness in the mandibular area. No other major complications were observed. There was no evidence of local recurrence or distant metastasis during the follow-up period (range, 24-87 months). All patients were satisfied with the good cosmetic outcome.

CONCLUSION

ELNDBTOA is an option with proven feasibility for select PTC patients with LNM, and the addition of the transoral approach is necessary to ensure complete dissection.

Feasibility of transoral robotic selective neck dissection with or without a postauricular incision for papillary thyroid carcinoma: A pilot study

Background

The study aimed to evaluate the feasibility of transoral robotic selective neck dissection (SND) with or without a postauricular incision for papillary thyroid carcinoma (PTC).

Methods

We studied 14 patients with PTC who underwent robotic SND via the transoral or combined transoral and postauricular approaches.

Results

The transoral approach was performed on 10 patients for dissection of levels III and IV. An additional postauricular incision was made on 4 patients for dissection of level II in addition to levels III, IV, and V. The operation was completed successfully in 13 patients, except 1 patient with the procedure conversion due to uncontrolled bleeding from the internal jugular vein. The mean numbers of removed lymph nodes in the lateral compartment were 23.1 ± 9.4 and 38.3 ± 8.5 in the transoral and combined groups. Transient recurrent laryngeal nerve palsy occurred in 1 patient, transient hypoparathyroidism in 3 patients, and chyle leakage in 1 patient. There were no hematomas, mental nerve injuries, surgical space infections, or CO₂ embolisms.

Conclusion

Transoral robotic SND is feasible with or without a postauricular incision.

Analysis of factors influencing cervical lymph node metastasis of papillary thyroid carcinoma at each lateral level

Objective

To analyze the clinicopathological characteristics of patients with papillary thyroid carcinoma (PTC) and its influence on the distribution of lymph node metastasis at each lateral level of the neck to guide precise treatment of the lateral area.

Methods

The clinicopathological data of patients with PTC initially diagnosed and treated at our hospital from February 2014 to September 2021 were collected; the metastatic status of each lateral level was recorded, and correlations were analyzed.

Results

A total of 203 patients were enrolled in this study. There were 67 males and 136 females, with an average age of 41.1 years. In the lateral cervical area, lymph node metastasis was found at level IIa in 81 patients (39.9%); level III, 171 patients (84.2%); level IV, 122 patients (60%); and level Vb, 18 patients (8.9%). Correlation analysis showed that age (r = 0.198, P < 0.01) and sex (r = 0.196, P < 0.01) were weakly correlated with the number of positive lymph nodes in the central region. The tumor size (r = 0.164, P < 0.05) was weakly correlated with lymph node metastasis at level IV. The presence of multiple tumor foci was weakly correlated with lymph node metastasis at level IIa (r = 0.163, P < 0.05) and Vb (r = 0.143, P < 0.05). The tumor location (r = − 0.168, P < 0.05) was weakly correlated with lymph node metastasis at level III. The number of positive lymph nodes in the central region (r = 0.189, P < 0.01) was weakly correlated with lymph node metastasis at level IV. Binary logistic regression analysis showed that the risk of metastasis of multifocal tumors was higher than that of unifocal tumors by 1.958 times at level IIa (P = 0.021, OR = 1.958) and 2.929 times at level Vb (P = 0.049, OR = 2.929). The higher the tumor was located, the higher the risk of metastasis at level III (P = 0.014, OR = 0.563). Every additional positive lymph node in the central region increased the risk of metastasis at level IV by 1.126 times (P = 0.009, OR = 1.126).

Conclusions

For patients with pathological evidence of lateral metastasis, standard dissection of level IIa through Vb is recommended; selective dissection requires careful consideration. Patients with multifocal tumors have a high risk of metastasis at levels IIa and Vb, which requires special attention during the operation.

Thyroidectomy Using the Lateral Cervical Small Incision Approach for Early Thyroid Cancer

Objective

Surgical resection is the main treatment for thyroid cancer, but while traditional open thyroidectomy improves prognosis, it also results in poor cosmetic outcomes. Therefore, we devised the lateral cervical small incision approach to thyroidectomy and will evaluate its efficacy.

Methods

The clinicopathological data of 191 patients who underwent unilateral thyroidectomy and isthmusectomy for early thyroid cancer were collected retrospectively. Of these, 100 patients underwent a traditional thyroidectomy using the median cervical approach (control group), and 91 patients underwent a thyroidectomy using the lateral cervical small incision approach (experimental group). The differences in perioperative prognosis, postoperative complications, and cosmetic outcomes between the two groups were evaluated.

Results

There was no significant difference in sex, age, tumor size, lymph node dissection, number of metastases, or postoperative complications between the experimental group and the control group (P > 0.05). There were significant differences in the duration of the operation; postoperative blood loss, drainage, and hospital stay; and scar color, blood circulation, hardness, and thickness between the groups (P < 0.05). The cosmetic outcomes of the incisions in the experimental group were more satisfactory than in the control group (P < 0.05).

Conclusion

When compared with traditional open thyroidectomy, the lateral cervical small incision approach has a lower incidence of complications, a better perioperative prognosis, and an improved cosmetic outcome.

Comparison of Supraclavicular Oblique Incision With Traditional Low Collar Incision Approach for Thyroidectomy in Differentiated Thyroid Cancer

Background

Various incisions and approaches for thyroidectomy have been developed to treat differentiated thyroid cancer (DTC). Supraclavicular oblique incision (SOI) thyroidectomy (SOIT) has been applied in DTC patients over the past ten years. However, the safety and efficacy of this approach were yet to be confirmed.

Aim

This study aimed to compare the surgical and patient-related outcomes between SOIT and traditional low collar incision thyroidectomy (TLCIT) in patients with DTC.

Methods

We retrospectively screened all patients with DTC who received thyroid lobectomy from October 2020 to October 2021. The surgical results and patient-related outcomes assessed at 1 and 6 months after surgery by questionnaire were compared between the SOIT and TLCIT groups.

Results

A total of 128 patients were included in this study, of whom 38 patients (30.5%) were operated on with SOIT and 89 patients (69.5%) with TLCIT. There was no significant difference in demographic characteristics and thyroid features between the two groups. Despite comparable operative time (61.9 ± 12.1 vs. 59.9 ± 15.0 min, p = 0.425), the SOIT group had a smaller neck incision (4.4 ± 0.7 vs. 5.0 ± 1.0 cm, p = 0.002), a shorter duration of postoperative drainage (2.4 ± 0.5 vs. 2.7 ± 0.9 days, p = 0.019), less volume of postoperative drainage (48.4 ± 24.6 vs. 60.3 ± 22.8 ml, p = 0.040), and shorter postoperative hospitalization (3.2 ± 0.5 vs. 3.6 ± 0.9 days p = 0.006), as compared with the TLCIT group. At 1-month follow-up after surgery, SOIT showed better performance in preventing hypoparathyroidism (p = 0.026) and abnormal neck sensation (p = 0.010) and in improving cosmetic satisfaction (p = 0.036) than TLCIT. At 6-month follow-up, SOIT was feedback with better cosmetic satisfaction (p < 0.001) and a lower percent of abnormal neck sensation (p = 0.031) or movement (p = 0.005).

Conclusion

Our study suggests that minimally invasive surgery using the SOI provides superior surgical and patient-related outcomes compared with surgery using a traditional low collar incision (TLCI) in patients with DTC.

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.

Scarless total thyroidectomy via transoral endoscopic vestibular approach: initial case series in a developing Asian country

Conventional open thyroidectomy may leave a visible scar postoperatively and can lead to impaired quality of life. Since 2016, the transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has gained popularity due to being a true 'scarless' procedure. However, minimally invasive thyroidectomy has not been widely adopted in the Philippines yet. From August 2019 to December 2019, nine patients (mean thyroid nodule size of 3.1 cm) underwent TOETVA with one open conversion due to adherent papillary cancer. Majority had a blood loss of <100 ml, whereas mean operative time was 149.8 ± 20.5 minutes. Five patients developed hypocalcemia (three transient), whereas two patients reported transient lower lip numbness. TOETVA is a safe and feasible novel procedure for both benign and malignant thyroid diseases. Care must be taken in selecting patients who opt for TOETVA, and that surgeons should reassess their limitations before implementing this technique in their surgical practice.

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.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches.

Methods

A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed.

Results

This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed.

Conclusions

Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).

Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach in an Endemic Region

Objective

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless method that enables thyroidectomyusing natural orifice of the body. The opinion which is even common among TOETVA performing surgeons is that this surgery involves a small percentage of thyroidectomy applied patients. In this study, based on the currently accepted exclusion criteria, we aimed to determine what percentage of patients, who underwent thyroidectomy in an endemic area are actually suitable for TOETVA.

Methods

Between January 2017 and December 2019, 1197 consecutive patients who underwent surgery for thyroid pathology in our clinic were analyzed retrospectively. Pre-operative evaluations were made according to the current exclusion criteria and as a result, patients with no previous neck surgery, no history of radiotherapy, no retrosternal thyroid extension, and none lymph node dissection operation been made and whose thyroid gland diameter is <10 cm and gland volume is not more than 45 ml, malignant nodule diameter is <2 cm, and benign nodule diameter is <4 cm are involved to this study by being considered appropriate for TOETVA procedure.

Results

According to the criteria, 513 patients (42.8%) were found suitable for TOETVA. A total of 421 (82%) of these patients were female and 92 (18%) were male. The mean age was 46.2±13.2. A total of 192 (37%) of these patients were operated due to the benign reasons, and 321 (63%) of these patients operated due to the malignancy or suspicion of malignancy. Average nodule size was 1.9 cm, and the average thyroid volume was 23.8 ml among benign patients. Whereas among malignant patients, the average nodule size was 1.7 cm and the average thyroid volume was 21.8 ml. A total of 462 (90.1%) of the patients were applied to the total thyroidectomy and 51 (9.9%) of the patients were applied to the hemithyroidectomy. In the same period, 29 patients operated through TOETVA and 4 patients operated through bilateral axillary breast approach thyroidectomy. When the final pathology, results of the patients were examined, papillary thyroid carcinoma was seen in 301 (58.7%) patients, benign pathologies were seen in 192 (37.4%) patients, and 20 (3.9%) patients were diagnosed with other pathologies (follicular thyroid carcinoma, poorly differentiated carcinoma and Hürthle cell neoplasia, etc.).

Conclusion

Although "patient willingness" factor could not be included in the study, TOETVA eligible patient repository is wider contrary to popular belief. In our humble opinion, TOETVA method is going to pursue its spread and become a part of the routine surgical training session due to its effectiveness in terms of credibility in today's world where cosmetic concerns gradually gain prominence.

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.

Application of lateral supraclavicular incision in unilateral thyroid papillary carcinoma surgery

INTRODUCTION

The standard approach to thyroidectomy is a collar incision via the anterior neck, and the neck scar has always been a source of worry for patients. Acceptable wound cosmetology has become a focus for thyroid surgeons.

OBJECTIVE

To verify the effectiveness and cosmetic results of thyroidectomy through a lateral supraclavicular incision.

METHODS

180 patients were randomly divided into two groups: a lateral supraclavicular approach and a conventional transcervical approach. The main outcomes included incision length, intraoperative blood loss, operative time, total drainage volume, hospitalization expense, early postoperative pain measured by visual analog scale, infection, and perceived cosmetic outcome.

RESULTS

There were no statistical significances between the two groups in terms of age, gender, nodule size, intraoperative blood loss, operative time, total drainage volume, hospital expense and postoperative complications, whereas there were significant differences in terms of incision length (5.2±1.04cm vs. 6.9±1.14cm, p<0.05).

CONCLUSIONS

The lateral supraclavicular incision is a safe and feasible approach for thyroidectomy. Compared with conventional approach, it provides a better cosmetic result.

Initial Experience With Robotic Modified Radical Neck Dissection Using the da Vinci Xi System Through the Bilateral Axillo-Breast Approach

Objectives.

The bilateral axillo-breast approach (BABA) to robotic thyroidectomy has been extended to modified radical neck dissection (MRND). This study assessed outcomes in patients who underwent robotic MRND through BABA using the da Vinci Xi system.

Methods.

The medical records of 40 patients who underwent total thyroidectomy, bilateral central neck dissection, and MRND from September 2018 to March 2020 were reviewed retrospectively, including 12 who underwent robotic surgery and 28 who underwent open surgery. All operations were performed by a single endocrine surgeon.

Results.

The operation time was significantly longer in the robotic group than in the open group (277.08±32.64 vs. 191.43± 60.43 minutes, respectively, P<0.01), but the number of retrieved lymph nodes did not differ significantly (32.58± 9.31 vs. 34.54±10.90, respectively, P=0.569). The incidence of transient hypoparathyroidism was significantly lower in the robotic group (16.7% [2/12] vs. 53.6% [15/28], P=0.041). The mean hospital stay was shorter (3.92±0.90 vs. 4.71±1.63 days) and the pain score on the first postoperative day was lower (2.92±0.29 vs. 3.18±0.67) in the robotic group. Six of the 12 patients (50%) in the robotic group had stimulated thyroglobulin levels <1.0 ng/mL.

Conclusion.

Robotic MRND through BABA has several advantages, including excellent cosmetic outcomes and a lower incidence of transient hypoparathyroidism than is the case for open MRND. Robotic MRND through BABA may be a promising surgical approach compared with conventional open MRND.