The application of subcapsular saline injection during bilateral axillo-breast approach robotic thyroidectomy: a preliminary report

The application of subcapsular saline injection to preserve the parathyroid gland during thyroidectomy

OBJECTIVE

To evaluate the clinical effect of subcapsular saline injection (SCASI) after total thyroidectomy.

METHODS

A total of 77 patients who underwent total thyroidectomy in our hospital from January 2020 to December 2021 were selected and divided into the SCASI group (n = 43) and the non-SCASI group (n = 34). The general clinical data of the patients were collected, and serum parathyroid hormone (PTH) and serum calcium levels were determined preoperatively, on the 1st postoperative day, and at 1 and 6 months after the operation. These data were compared between groups.

RESULTS

There was no significant difference in postoperative complications between the two groups. The PTH and serum calcium levels in the SCASI group were significantly higher than those in the non-SCASI group on the 1st postoperative day (t = 2.340, 5.208, both P < 0.05), and the PTH levels in the SCASI group at 1 month after the operation were higher than those in the non-SCASI group (t = 2.141, P < 0.05). In addition, the proportion of transient and permanent hypoparathyroidism in the SCASI group was significantly decreased (χ2 = 3.920, 3.948, P < 0.05).

CONCLUSION

Total thyroidectomy requires high surgical precision, and SCASI can reduce the incidence of temporary and permanent hypoparathyroidism.

Robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach

BACKGROUND

We conducted this study to report our novel robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach and compare it with a conventional transaxillary (CTA) approach using a retraction method for intraoperative and postoperative outcomes.

METHODS

We retrospectively analyzed 354 patients who underwent robotic thyroidectomy between January 2019 and April 2023. Of these patients, 143 underwent the procedure through the GOSTA approach, which involves a small incision of 3 cm along the axillary folds with both arms down and a gas-insufflation, from skin flap creation to the completion of thyroidectomy as a one-step single-port procedure without the need for a retractor. The remaining 211 patients underwent the CTA approach. We analyzed the GOSTA approach and compared the surgical outcomes of the GOSTA (n = 100) and CTA (n = 167) approaches in patients with differentiated thyroid cancer who underwent thyroid lobectomy.

RESULTS

Out of the 143 patients who underwent the GOSTA approach, 12 underwent total thyroidectomy and 9 underwent lateral neck lymph node dissection with total thyroidectomy. GOSTA-thyroid lobectomy was performed on 122 patients; of these, 100 were diagnosed with differentiated thyroid carcinoma. A comparative study with the CTA approach was only conducted in patients who underwent thyroid lobectomy. No significant differences were found in operative time, hospital stay, or complications between the two groups.

CONCLUSIONS

Despite proceeding in one-step with a single smaller incision, from skin flap creation to the completion of thyroidectomy, the GOSTA approach is as feasible and safe as the CTA approach. Additionally, the GOSTA approach allows for thyroidectomy without using a retractor and reduces the workload for the surgeon and assistants.

A Time Trend Analysis of 5,000 Robotic Thyroidectomies via Bilateral Axillo-Breast Approach

BACKGROUND

This study aimed to investigate the time trends of surgical outcomes in patients who underwent bilateral axillo-breast approach robotic thyroidectomy (BABA RT) over the last 14 years.

METHODS

From February 2008 to September 2021, we conducted a retrospective medical chart review of 5,011 consecutive patients who underwent BABA RT at three Seoul National University-affiliated hospitals. The patients were divided into three groups based on the main model of the da Vinci robotic surgical system to evaluate trends in surgical treatment strategies and outcomes after BABA RT.

RESULTS

Of the 5,011 patients (4,706 malignant and 305 benign), the most common histological subtype was papillary thyroid carcinoma (n = 4,584; 97.4%). The mean tumor size significantly increased from 0.8 cm to 1.2 cm (p < 0.05). The mean numbers of metastatic and harvested lymph nodes from the central neck dissection and the lateral neck dissection showed a significant difference and tendency to increase (from 0.9 to 1.6, 4.7 to 6.2, p < 0.05, and from 0.6 to 3.9, 5.3 to 17.9, p < 0.05), respectively, throughout the study period. Permanent hypoparathyroidism decreased from 3.4 to 2.9%. The rate of transient and permanent vocal cord palsy decreased from 15.2 to 2.7% and from 0.7 to 0.2%, respectively.

CONCLUSION

With advancements in robotic surgical systems and improvements in the BABA RT technique, surgical indications have expanded to include more advanced thyroid diseases, and surgical outcomes have improved over the last 14 years.

Bilateral axillo-breast approach robotic total thyroidectomy in a 5-year-old patient with intractable Graves' disease

Robotic thyroid surgeries in children are gaining popularity due to cosmetic advantages, but most previous studies include patients of school-age or older. We hereby introduce our case of a 5-year-old patient with Graves' disease to show key differences and similarities between pediatric and adult bilateral axillo-breast approach (BABA) robotic thyroidectomies. Despite the small body, no additional working space was needed and the flap creation was performed as similarly done in adults. The anatomy was not much different, except that the parathyroid tissues were easily identified due to low body fat, and the prominent thymus covered most of the level VI area. The patient did not experience postoperative complications such as hypoparathyroidism or vocal cord palsy. Postoperative wounds showed excellent results with minimal scars. BABA robotic thyroidectomy can be performed safely in pediatric patients and may be considered an alternative option for conventional open thyroidectomy in children.

Endoscopic parathyroidectomy: a retrospective review of 27 cases

BACKGROUND

Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP).

METHODS

Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection.

RESULTS

Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids.

CONCLUSION

Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.