Advanced Approaches for Thyroid Surgery

Safety and Feasibility of Robotic Transaxillary Thyroidectomy for Graves' Disease: A Retrospective Cohort Study

BACKGROUND

Despite the increase in experience and understanding of robotic thyroidectomy, its application for Graves' disease (GD) remains controversial. This study aimed to assess the safety and feasibility of robotic transaxillary thyroidectomy (RTT) for GD in comparison with the conventional open thyroidectomy (open group: OG) approach.

METHODS

A total of 192 patients who underwent surgical resection for GD were retrospectively reviewed. Among them, 51 patients underwent RTT and the remaining 141 patients were in the conventional OG.

RESULTS

All robotic operations were performed successfully without open conversion. Patients who underwent RTT were significantly younger (P < 0.001) and predominantly of the female sex. Operative time was longer for RTT than for the OG (182.5 ± 58.1 vs. 112.0 ± 29.5; P < 0.001). The mean intraoperative blood loss was not statistically different between RTT and the OG (113.3 ± 161.6 vs. 95.3 ± 209.1, P = 0.223). The mean weight of the resected thyroid was reduced in those who underwent RTT compared with open thyroidectomy (P = 0.033). The overall complication rate for RTT and open thyroidectomy was not significantly different (33.3% vs. 22.7%, P = 0.135). In RTT, the most common complication was transient hypocalcemia (21%). Permanent hypocalcemia and recurrent laryngeal nerve injury occurred in only one patient in each group. The weight of the resected thyroid was not related to the incidence of complications in patients receiving RTT.

CONCLUSIONS

Considering excellent cosmesis, findings of this study support the safety and feasibility of RTT. Nevertheless, it should be performed by expert surgeons with extensive robotic surgery experience.

Thyroid cancer surgery - in what direction are we going? A mini-review

The prevalence of thyroid cancer, especially in women, is increasing dramatically. Therefore, patients often undergo thyroidectomy upon diagnosis. However, the cosmetic outcome after surgery is of particular concern for many patients. Thus, minimally invasive procedures for treating thyroid disease have been established in recent decades. Total endoscopic and robotic procedures have been slowly and successively introduced while meeting all oncological criteria. Our analysis of the advantages and disadvantages of scarless surgical procedures suggests that the cosmetic aspects of these surgeries will continue to become more important. This review assesses the recent findings regarding the roles of endoscopic and robotic procedures in thyroid cancer surgery.

A Comparison of Robotic Versus Open Thyroidectomy for Papillary Thyroid Cancer

OBJECTIVES

This study investigated the potential advantages of robotic thyroidectomy and determined whether it is safe and complete compared with conventional open surgery in patients with papillary thyroid cancer.

MATERIALS AND METHODS

A total 376 consecutive patients who underwent total thyroidectomy and central neck dissection for papillary thyroid cancer from February 2013 to July 2014 were retrospectively reviewed. Postoperative complication rates and surgical completeness were compared between the robotic and open groups.

RESULTS

Transient hypoparathyroidism was higher in the open group (10.5%) compared with the robotic group (2.8%; P=0.042). There were no differences in mean number of retrieved or metastatic lymph nodes. The mean values of stimulated thyroglobulin level were acceptably low in both groups. There was no difference in the proportion of patients with stimulated thyroglobulin levels <1 ng/mL.

CONCLUSION

Our study results show that outcomes of robotic thyroidectomy may be similar to that of conventional thyroidectomy, with possible better preservation of the parathyroid blood supply.

Initial experience with robotic gasless transaxillary thyroidectomy for the management of graves disease: comparison of conventional open versus robotic thyroidectomy

PURPOSE

The aim of this study was to report on our initial experiences with robotic gasless transaxillary thyroidectomy for the management of Graves disease (GD).

METHODS

Among 257 patients with benign thyroid diseases who underwent thyroidectomy, 16 patients who underwent thyroidectomy for GD were analyzed from January 2009 to December 2010. These patients included 7 individuals who underwent robotic gasless transaxillary thyroidectomy (robot group; RG) and 9 who underwent conventional open thyroidectomy (open group; OG). Regardless of the type of surgery, all patients underwent subtotal thyroidectomy. The clinical characteristics and surgical outcomes of the 2 groups were compared.

RESULTS

Patients in the RG were significantly younger at the time of surgery compared with those in the OG (P=0.028). The mean operative time was 171.29±18.88 minutes for the RG and 89.44±7.08 minutes for the OG (P=0.001). The mean weight of the resected glands was 77.43±12.29 g for the RG and 85.56±20.37 g for the OG (P=0.896). The RG had a significantly shorter mean hospitalization period of 3.0±0 days compared with 3.78±0.22 days of the OG. The mean number of times analgesics were used for pain control were 2.43±0.29 for the RG and 4.0±0.52 for the OG (P=0.039). No cases in the RG were converted to open thyroidectomy. During a mean follow-up period of 14.43±1.49 months for the RG, no patients continued antithyroid drugs or developed recurrent GD.

CONCLUSIONS

Robotic gasless transaxillary thyroidectomy is a technically feasible and safe procedure for the patients with GD that results in a scarless outcome on the neck. This procedure can be a promising alternative for endoscopic or conventional open thyroidectomy for the management of GD.

Systematic review and meta-analysis of robotic vs conventional thyroidectomy approaches for thyroid disease

OBJECTIVE

This study compared postoperative technical, quality-of-life, and cost outcomes following either robotic or open thyroidectomy for thyroid nodules and cancer.

DATA SOURCES

PubMed, Ovid MEDLINE, EMBASE, ISI Web of Science, and the Cochrane Central Register of Controlled Trials.

REVIEW METHODS

We examined relevant controlled trials, comparative effectiveness studies, and cohort studies for eligible publications. We calculated the pooled relative risk for key postoperative complications, mean differences for operative time, and standardized mean differences for length of stay (LOS) using random effects models. Quality-of-life outcomes were summarized in narrative form.

RESULTS

The meta-analysis comprised 11 studies with 726 patients undergoing robotic transaxillary or axillo-breast thyroidectomy and 1205 undergoing open thyroidectomy. There were no eligible cost-related studies. Mean operative time for robotic thyroidectomy exceeded open thyroidectomy by 76.7 minutes, while no significant difference in LOS was identified. There were no significant differences in hematoma, seroma, recurrent laryngeal nerve injury, hypocalcemia, or chyle leak rates. The systematic review included 12 studies. Voice, swallowing, pain, and paresthesia outcomes showed no significant differences between the 2 approaches. The robotic cohort reported higher cosmetic satisfaction scores, although follow-up periods did not exceed 3 months and no validated questionnaires were used.

CONCLUSIONS

Transaxillary and axillo-breast robotic and open thyroidectomy demonstrate similar complication rates, but robotic approaches may introduce the risk of new complications and require longer operative times. Robotic thyroidectomy appears to improve cosmetic outcomes, although longer follow-up periods and use of validated instruments are needed to more rigorously examine this effect.

Anesthetic implications for robot-assisted transaxillary thyroid and parathyroid surgery: a report of twenty cases

Gasless transaxillary robot-assisted endoscopic thyroid surgery has recently been proposed and developed in South Korea and the United States. Perianesthetic implications and their evolution for 20 patients scheduled to undergo this innovative surgical technique are presented. The anesthetic considerations focus on the length of surgery due to the learning curve, the risk of the ipsilateral arm posture, and postoperative pain evaluation and management.

Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006

BACKGROUND

Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time.

METHODS

Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures.

RESULTS

The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006.

CONCLUSIONS

From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.

Criteria for Laparoscopic Advanced Surgery in Semi-Equipped Setup (CLASS): Feasibility Study Based on Institutional Experience

Laparoscopic and Minimally invasive techniques have become a routine practice for various surgical disorders in present times. Though, advanced laparoscopic procedures are feasible they are largely restricted to fewer centers due to lack of advanced instrumentation, finances and expertise at most of them. In this context, we conducted a feasibility study to evolve definite criteria for performing advanced laparoscopic surgeries in resource restricted set-ups. We present our experience with 25 cases of advanced laparoscopic procedures using conventional laparoscopic instruments. We evaluated the clinico-investigative profile and operative details of all the patients. We classified the surgical expertise, laparoscopic instrumentation, surgical set ups and patient factors systematically to evolve the criteria for feasibility of advanced laparoscopicsurgery. Out of the 22 eligible patients for the study, various laparoscopic surgeries performed were - Fundoplication (4), Cystogastrostomy (3), Endoscopic thyroidectomy (7), Thoracoscopic Thyroidectomy (2), Adrenalectomy (5) and Retroperitoneal paraganglioma excision (1). There was no mortality and two morbidities in the form of hypercarbia and a tracheo-cutaneous fistula in 2 cases of endoscopic thyroidectomy. According to the criteria, we propose our surgical set up falls in to Grade 3, for which this criteria fits in. This study demonstrates the feasibility of advanced laparoscopic procedures in semi-equipped set-up, preferably by employing institute specific criteria of CLASS.

Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon

OBJECTIVE

The objective of the study was to describe our experience with modifications of the Miccoli minimally invasive thyroidectomy.

DESIGN

Planned analysis of a prospectively maintained database was undertaken after Institutional Review Board approval.

METHODS

Demographic and surgical data were obtained and analyzed with attention to age, sex, pathology, incision lengths, and complications.

RESULTS

From a single-surgeon series of 785 consecutive thyroidectomies, 178 patients were identified who underwent an endoscopic minimally invasive thyroidectomy. A series of modifications of the classic Miccoli technique evolved over a period of 4 years and include presurgical factors (patient marking in holding area, intubation with laryngeal EMG tube using videolaryngoscope, rotation of operating table away from anesthesia), intraoperative principles (use of operative loupes, slave monitor, laryngeal nerve monitoring, and novel instrumentation; identification of the medial cleft and ligation of superior pedicle bundle using ultrasonic technology; avoidance of clips), and postoperative techniques (deep extubation, laryngeal endoscopy, outpatient management, and oral calcium supplementation).

CONCLUSIONS

A minimally invasive endoscopic thyroidectomy is possible even in a practice with moderate surgical volumes by using several techniques that facilitate the performance of this procedure. A high success rate and low complication rate can be achieved, resulting in improved patient satisfaction.

Robotic thyroidectomy: a framework for new technology assessment and safe implementation

Robotic thyroidectomy is a new approach to thyroid surgery that offers the benefit of eliminating the anterior neck incision utilized in traditional approaches. Although no level I evidence exists to strongly support a robotic approach to thyroid surgery, initial non-randomized reports of robotic surgical approaches, in a variety of surgical specialty areas such as cardiothoracic, urologic, gynecologic and head and neck surgery suggest possible advantages of robot assisted techniques. These include platform and instrument stability, tremor reduction, articulating end effectors, three-dimensional, magnified imaging, and improved surgeon ergonomics. Potential negatives associated with robotic surgery include its expense, the lack of haptic feedback, instrument limitations, and the implicit learning curve. Robotic thyroidectomy introduces new potential risks, not typically associated with thyroid surgery. These risks are related to a new approach to the surrounding anatomy and are also associated with the learning curve. The introduction of new technology to any surgery mandates a rational framework for initial assessment and safe implementation. A New Technology Task Force was convened to draft guiding principles which may serve as a framework for the safe implementation of emerging technologies in thyroid surgery. This document suggests initial minimum steps that surgeons should consider during initial implementation of robotic thyroidectomy.

Robotic thyroid surgery: an initial experience with North American patients

OBJECTIVE

To review the initial experience of gasless transaxillary robot-assisted endoscopic thyroid surgery in a series of patients and describe modifications of the technique for the North American patients, selection criteria, and other issues related to this technology.

METHODS

Retrospective review of the first 31 consecutive cases at a single institution.

RESULTS

Thirty-one patients underwent robotic thyroid surgery. Twenty thyroid lobectomies and 11 total thyroidectomies were performed. Improvements in the length of time to perform components of the procedure were noted from the early group of cases to later group of cases. No major or permanent complications occurred.

CONCLUSIONS

Robotic thyroid surgery is feasible in North American patients and can be safely performed. The procedure has potential complications and a definite learning curve exists for both surgeons and operating room staff. Training methods need to be validated to ensure safe adoption. More studies need to be performed to further evaluate the relative benefits of this technique.

Minimally invasive thyroidectomy in the treatment of well differentiated thyroid cancers: indications and limits

PURPOSE OF REVIEW

To summarize recent papers in the literature with respect to minimally invasive thyroidectomy and discuss indications and limits of the endoscopic/video-assisted treatment of differentiated thyroid carcinoma.

RECENT FINDINGS

During the 1990s, with the general tendency to develop minimally invasive operations, an endoscopic approach was applied to neck surgery for both parathyroidectomy and thyroidectomy. The most wide spread minimally invasive technique for thyroidectomy is minimally invasive video-assisted thyroidectomy (MIVAT).

SUMMARY

Papillary carcinoma is the main indication for MIVAT, this cancer usually being found in normal glands of young women. In contrast, for locally invasive carcinomas, lymph node metastasis or both, the procedure must be immediately converted to the conventional technique. MIVAT also is not indicated for the treatment of medullary and anaplastic carcinomas. Recent prospective randomized studies clearly demonstrate that MIVAT allows the same clearance to be achieved at the thyroid bed level and the same outcome as with the conventional technique, when dealing with 'low-risk' papillary carcinoma. At the same time, patients can benefit from the main advantages of this minimally invasive technique: less postoperative pain, faster postoperative recovery and excellent cosmetic outcome.