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La Via L, Zanghì A, Cavallaro A, Di Vita M, Maniaci A, Cocuzza S, Cappellani A, Di Majo S. Vestibular approach for thyroid surgery: a comprehensive review. Front Surg 2024; 11:1423222. [PMID: 38948483 PMCID: PMC11211391 DOI: 10.3389/fsurg.2024.1423222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
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.
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Affiliation(s)
- Luigi La Via
- Department of Anesthesia and Intensive Care, University Hospital Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Antonio Zanghì
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania, Italy
- Centro di Ricerca in Chirurgia Delle Sindromi Malformative Complesse Della Transizione e dell’Età Adulta, University of Catania, Catania, Italy
| | - Andrea Cavallaro
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Maria Di Vita
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Antonino Maniaci
- Faculty of Medicine and Surgery, University of Enna “Kore”, Enna, Italy
| | - Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania, Italy
| | - Alessandro Cappellani
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Simone Di Majo
- Residency Program in General Surgery, University of Catania, Catania, Italy
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Zhang D, Sun H, Kim HY, Chai YJ, Tufano RP, Wu CW, Pino A, Anuwong A, Dionigi G. Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy. Surg Laparosc Endosc Percutan Tech 2024; 34:248-258. [PMID: 38767568 DOI: 10.1097/sle.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/27/2022] [Indexed: 05/22/2024]
Abstract
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.
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Affiliation(s)
- Daqi Zhang
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Hoon Yub Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery Center, KUMC Thyroid Center Korea University, Anam Hospital
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Che-Wei Wu
- Department of Otorhinolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Antonella Pino
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS
| | - Angoon Anuwong
- Department of Surgery, Minimally Invasive and Endocrine Surgery Division, Police General Hospital, Bangkok, Thailand
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS
- Department of Pathophysiology and Transplantation, University of Milan, Italy
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Karimov Z, Kim SM, Turk Y, Dionigi G, Moscoso ES, Ozdemir M, Frattini F, Ozgul S, Makay O. Complication and conversion outcomes in transoral endoscopic thyroidectomy vestibular approach (TOETVA): a retrospective multicenter propensity score-matched cohort study. Updates Surg 2024; 76:227-238. [PMID: 38095833 DOI: 10.1007/s13304-023-01721-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/29/2023] [Indexed: 01/24/2024]
Abstract
Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a scarless thyroid surgery used as an alternative to open conventional surgery. Our aim was to investigate possible risk factors for complications and conversion during TOETVA. The study was conducted internationally by centres from Turkiye, the Republic of Korea, Italy, and Peru. A total of 406 patients who underwent TOETVA and were ≥ 18 years of age were included in the study. Demographic, pre-, intra-, and postoperative data were collected and compared between the groups with/without complication/conversion to identify possible predictors of complication/conversion. Subsequently, patients with complication/conversion were matched by the hospital, age, sex, and American Society of Anesthesiologists classification score using a propensity score (PSM) of 1:3 to eliminate confounding differences. Results were reported for the un-matched and matched groups. Complications occurred in 11 (2.7%) patients. High body mass index (26.4 ± 3.4 vs. 23.3 ± 3.7, p = 0.007), larger tumor size (1.7 ± 1.3 cm. vs. 1.1 ± 1.0 cm, p = 0.012), larger thyroid volume (20.0 ± 9.2 vs. 12.8 ± 8.5, p = 0.007) and long operation time (127.8 ± 45.0 min. vs. 97.7 ± 38.5 min., p = 0.008) were significantly associated with complications in un-matched analyses. Older age (42.7 ± 8.0 vs. 34.9 ± 9.2, p = 0.023), high BMI (26.7 ± 3.2 vs. 23.3 ± 3.7, p = 0.012), and longer operation time (160.1 ± 54.1 min. vs. 97.4 ± 37.8, p = 0.001) were significantly related to conversion in un-matched analyses. However, significance was lost after PSM for both complication and conversion. The data from this study conducted on TOETVA cases do not suggest a risk factor for complications and conversion with PSM.
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Affiliation(s)
- Ziya Karimov
- Medicine Program, Ege University Faculty of Medicine, Izmir, Turkey
| | - Seok-Mo Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Yigit Turk
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifco), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Murat Ozdemir
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey
| | - Francesco Frattini
- Division of Surgery, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifco), Milan, Italy
| | - Semiha Ozgul
- Department of Biostatistics and Medical Informatics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ozer Makay
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey.
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Yap RV, Buenafe AA, Tankiatsy J, Bejasa MM, Mahani IN, Calayag G. Carbon dioxide embolism during transoral endoscopic thyroidectomy: A case report and literature review. Asian J Endosc Surg 2023; 16:774-780. [PMID: 37550828 DOI: 10.1111/ases.13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 06/29/2023] [Indexed: 08/09/2023]
Abstract
The creation of the surgical space in transoral endoscopic thyroid surgery may put the anterior jugular vein at risk for injury and possibly lead to carbon dioxide (CO2 ) embolism. Although rare, CO2 embolism is potentially fatal. We report a case of a 67-year-old female who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) for a benign thyroid disease. Intraoperatively, the anterior jugular vein was inadvertently lacerated. The end-tidal (Et)CO2 , O2 saturation, heart rate, and blood pressure suddenly decreased. The patient eventually became asystole. Cardiopulmonary resuscitation was performed with a return of spontaneous circulation (ROSC). We successfully ligated the injured vessel and terminated the procedure. A literature review of CO2 embolism during transoral thyroid surgery is presented, focusing on presentation, management, and prevention. Since TOETVA is still in preliminary clinical application, especially in developing countries, CO2 embolism may not be uncommon during the initial phase of the learning curve. Surgeons and anesthesiologist should be aware of this possibility.
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Affiliation(s)
- Ralph Victor Yap
- Unified Minimally Invasive Surgery Training, Quezon City, Philippines
| | - Alfred Allen Buenafe
- Unified Minimally Invasive Surgery Training, Quezon City, Philippines
- Philippine Center for Advanced Surgery, Cardinal Santos Medical Center, San Juan, Philippines
- Section of Minimally Invasive Surgery, Cardinal Santos Medical Center, San Juan, Philippines
| | - James Tankiatsy
- Unified Minimally Invasive Surgery Training, Quezon City, Philippines
| | | | | | - Glenford Calayag
- Unified Minimally Invasive Surgery Training, Quezon City, Philippines
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Jiang J, He G, Chu J, Li J, Lu X, Jiang X, Xie L, Gao L, Zhang D. Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique. Front Oncol 2023; 13:1115927. [PMID: 37324008 PMCID: PMC10264817 DOI: 10.3389/fonc.2023.1115927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 04/20/2023] [Indexed: 06/17/2023] Open
Abstract
Background The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO2)-related complications. Herein, we proposed a new technique without CO2 called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA. Methods We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded. Results Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery. Conclusions Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.
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Wang Y, Luo Y, Wu G, Lin S, Fu Y. Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer. Surg Endosc 2023:10.1007/s00464-023-09910-1. [PMID: 37010605 DOI: 10.1007/s00464-023-09910-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/26/2023] [Indexed: 04/04/2023]
Abstract
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.
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Affiliation(s)
- Yuanyuan Wang
- Department of Thyroid Surgery, Zhengzhou University First Affiliated Hospital, Zhengzhou, 450000, China
| | - Yezhe Luo
- Department of General Surgery, ZhongShan Hospital of Xiamen University, Xiamen, 361004, China
| | - Guoyang Wu
- Department of General Surgery, ZhongShan Hospital of Xiamen University, Xiamen, 361004, China.
| | - Suqiong Lin
- Department of General Surgery, ZhongShan Hospital of Xiamen University, Xiamen, 361004, China
| | - Yilong Fu
- Department of General Surgery, ZhongShan Hospital of Xiamen University, Xiamen, 361004, China
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Jiang J, He G, Chu J, Li J, Lu X, Zhang D. Novel suspension system for gasless transoral vestibular thyroidectomy. Surg Endosc 2023; 37:1070-1076. [PMID: 36109361 DOI: 10.1007/s00464-022-09528-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 07/31/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Jinxi Jiang
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China
| | - Gaofei He
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China
| | - Junjie Chu
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China
| | - Jianbo Li
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiaoxiao Lu
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China
| | - Deguang Zhang
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou, People's Republic of China.
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Sheng X, Liu J, Fang J, Zheng X, Wang S. En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma. Front Endocrinol (Lausanne) 2023; 14:1130791. [PMID: 36923227 PMCID: PMC10009257 DOI: 10.3389/fendo.2023.1130791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/08/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma. OBJECTIVE This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma. METHODS This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed. RESULTS All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51 cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision. CONCLUSION The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.
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Affiliation(s)
- Xuren Sheng
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Jianjun Liu
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Jing Fang
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Xucai Zheng
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Shengying Wang
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
- *Correspondence: Shengying Wang,
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Kuang P, Wang Y, Wu G, Luo Y, Fu J, Yan W, Lin S, Hong X, Lin F, Lin E, Fu Y. Endoscopic lateral neck dissection via the breast and transoral approaches for papillary thyroid carcinoma: A preliminary report. Front Surg 2022; 9:997819. [PMID: 36386534 PMCID: PMC9663646 DOI: 10.3389/fsurg.2022.997819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/26/2022] [Indexed: 06/22/2024] Open
Abstract
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.
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Affiliation(s)
- Penghao Kuang
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Yuanyuan Wang
- Department of Thyroid Surgery, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Guoyang Wu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Yezhe Luo
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jinbo Fu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Wei Yan
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Suqiong Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xiaoquan Hong
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Fusheng Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Ende Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Yilong Fu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
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Akritidou E, Douridas G, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas NI. Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review. In Vivo 2022; 36:1-12. [PMID: 34972695 DOI: 10.21873/invivo.12671] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Ellada Akritidou
- Department of Surgery, Thriassio General Hospital, Athens, Greece; .,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
| | | | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Lee SH, Moorthy R, Nagala S. OUP accepted manuscript. Br J Surg 2022; 109:497-502. [PMID: 35576381 DOI: 10.1093/bjs/znac072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework. METHODS A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework. RESULTS Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration). CONCLUSION There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.
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Affiliation(s)
- Shen-Han Lee
- Department of Otorhinolaryngology, Hospital Sultanah Bahiyah, Kedah, Malaysia
| | - Ram Moorthy
- Department of Otolaryngology-Head and Neck Surgery, Royal Berkshire Hospital, Reading, UK
- Department of Otolaryngology-Head and Neck Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Sidhartha Nagala
- Department of Otolaryngology-Head and Neck Surgery, Royal Berkshire Hospital, Reading, UK
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Long SM, Ali K, Tufano RP, Banuchi VE. Airway injury from transoral endoscopic thyroidectomy vestibular approach. Head Neck 2021; 44:E6-E10. [PMID: 34729859 DOI: 10.1002/hed.26909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/17/2021] [Accepted: 10/07/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel technique that eliminates a cervical scar. This procedure carries unique risks, and data on outcomes are needed as more cases are performed. METHODS We describe two cases of airway injury during the TOETVA. A description of the procedure and management of the injuries is outlined. RESULTS In one case, a 3-mm injury in the thyrohyoid membrane was identified. The TOETVA was converted to an open approach due to significant inflammation in the setting of Graves' and the repair was performed while open. In the second case, a fracture occurred from the thyroid notch to Broyle's ligament without avulsion. A primary repair was endoscopically performed. CONCLUSIONS Airway injury is a possible complication of both open thyroidectomy and TOETVA. For TOETVA, trauma is most likely to occur in the midline during Hegar dilation and trocar placement through the central incision.
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Affiliation(s)
- Sallie M Long
- Department of Otolaryngology - Head and Neck Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Khalid Ali
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Victoria E Banuchi
- Department of Otolaryngology - Head and Neck Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
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Multimodal Assessments of Altered Sensation after Transoral Endoscopic Thyroidectomy. World J Surg 2021; 46:600-609. [PMID: 34704148 DOI: 10.1007/s00268-021-06356-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Transoral endoscopic thyroidectomy, a novel technique, uses oral vestibule as the entry point and leaves no scar on the body surface. However, because the incisions are close to the mental nerve, nerve damage and the associated sensory impairment are concerning. Herein, we evaluated sensory alteration after transoral endoscopic thyroidectomy and determined factors associated with the prolonged sensory alteration. METHODS Patients who underwent transoral endoscopic thyroidectomy were enrolled. Sensation over the lower lip, chin, and neck was evaluated before and after the surgery. A self-assessment questionnaire, Semmes-Weinstein monofilament test, and two-point discrimination test were used to subjectively and objectively evaluate sensory changes. RESULTS Fifty-one patients were enrolled; most of them reported altered sensation, with chin (72.5%) being the most common site, followed by lower lip (52.9%), upper neck (33.3%), and lower neck (5.9%) on postoperative day 2. The sensory disturbance resolved within 3 months. Factors associated with prolonged sensory alteration are male sex and old age. Fourteen patients (27.5%) experienced mild drooling from the mouth, which was usually self-limiting in 1 month. Sensory impairments in light touch pressure threshold and two-point discrimination were significant in the chin and neck on postoperative day 2 and at 1 week. The ability to discern two-point was also compromised in the lower lip on postoperative day 2. All these significant changes normalized to preoperative baseline at 1 month. CONCLUSIONS There was an altered sensation after transoral endoscopic thyroidectomy with the most common and disturbed in the chin. Sensory impairment was usually transient and recovered in 3 months.
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Cohen O, Tufano RP, Anuwong A, Shaha AR, Olsen KD, Zafereo M, Rinaldo A, Mäkitie AA, Nixon IJ, Russell JO, Ferlito A, Khafif A. Transoral endoscopic vestibular approach for thyroidectomy and parathyroidectomy - From promise to practice. Am J Otolaryngol 2021; 42:103022. [PMID: 33838355 DOI: 10.1016/j.amjoto.2021.103022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/28/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To describe the evolution and recent series on transoral endoscopic vestibular approach thyroidectomy and parathyroidectomy (TOET/PVA). DATA SOURCES PubMed, Google Scholar. REVIEW METHODS Review of the available English literature. RESULTS TOET/PVA may offer several advantages over other remote access thyroidectomy approaches and has been adopted by many centers worldwide with excellent success rates. Indications include benign disease and early thyroid cancer patients. Complication rate is comparable to the trans-cervical approach. The suggested framework has been validated in recent studies and its feasibility confirmed. CONCLUSION TOET/PVA has now been used to treat thousands of patients worldwide due to low cost, short learning curve and excellent cosmetic outcomes. Further studies will be necessary to demonstrate oncologic non-inferiority and also the true value that is added by the approach.
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15
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Park JO, Lee DH, Kim MR, Kim SY, Han JH, Sun DI. Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to carbon dioxide gas insufflation: A comparative analysis of 131 cases. Oral Oncol 2021; 121:105463. [PMID: 34343782 DOI: 10.1016/j.oraloncology.2021.105463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
Although transoral endoscopic thyroid surgery affords several advantages, the use of carbon dioxide (CO2) gas to create and maintain the working space may cause complications such as subcutaneous emphysema and a CO2 embolism. We have used a self-retaining retractor as an alternative to CO2 gas insufflation for some time; we here report its feasibility and safety. We reviewed the medical records of 131 patients who underwent transoral endoscopic thyroid lobectomy; we compared the "CO2 group" and the "retractor" group. All thyroid tumors were completely removed with negative surgical margins. No major complication occurred in the retractor group. Two major events occurred in the CO2 group: one case of permanent vocal cord palsy and one CO2 embolism. Significant subcutaneous emphysema of the neck and chest were noted in 17.7% of CO2 group patients, but in no retractor group patient. Wound infection occurred in one patient in each group but improved after appropriate management. The total operation times from incision to suture did not differ significantly between the two groups (p = 0.514). Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to CO2 gas insufflation is feasible and safe. The superiority of transoral endoscopic thyroidectomy would be emphasized by avoiding CO2 gas insufflation, thus eliminating the risk of CO2 gas-related complications.
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Affiliation(s)
- Jun-Ook Park
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Dong-Hyun Lee
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Mi Ra Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Inje University of Korea, Republic of Korea
| | - Sang-Yeon Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Inje University of Korea, Republic of Korea
| | - Jae Hong Han
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Dong-Il Sun
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea.
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Tang JX, Wang L, Nian WQ, Tang WY, Xiao JY, Tang XX, Liu HL. Asymptomatic carbon dioxide embolism during transoral vestibular thyroidectomy: A case report. World J Clin Cases 2021; 9:4024-4031. [PMID: 34141762 PMCID: PMC8180200 DOI: 10.12998/wjcc.v9.i16.4024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/19/2021] [Accepted: 03/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic thyroidectomy has obvious advantages over conventional surgical techniques in terms of postoperative cosmetic outcome. Although the incidence of carbon dioxide embolism (CDE) during endoscopic thyroidectomy is very low, it is potentially fatal. The clinical manifestations of CDE vary, and more attention should be paid to this disorder.
CASE SUMMARY A 27-year-old man was scheduled for thyroidectomy by the transoral vestibular approach. The patient had no other diseases or surgical history. During the operation, he developed a CDE following inadvertent injury of the anterior jugular vein. The clinical manifestation in this patient was a transient sharp rise in end-tidal carbon dioxide, and his remaining vital signs were stable. In addition, loud coarse systolic and diastolic murmurs were heard over the precordium. The patient was discharged on day 4 after surgery without complications.
CONCLUSION A transient sharp rise in end-tidal carbon dioxide is considered a helpful early sign of CDE during endoscopic thyroidectomy.
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Affiliation(s)
- Jia-Xi Tang
- Department of Anesthesiology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Ling Wang
- Department of Phase I Clinical Trial Ward, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Wei-Qi Nian
- Department of Phase I Clinical Trial Ward, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Wan-Yan Tang
- Department of Phase I Clinical Trial Ward, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Jing-Yu Xiao
- Department of Anesthesiology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Xi-Xi Tang
- Department of Anesthesiology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing 400030, China
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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve. J Clin Med 2021; 10:jcm10040863. [PMID: 33669741 PMCID: PMC7922263 DOI: 10.3390/jcm10040863] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3–3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.
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18
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Pros and Cons of Transoral Endoscopic Thyroidectomy Via Vestibular Approach: A Comparative Study. Surg Laparosc Endosc Percutan Tech 2020; 31:331-336. [PMID: 33252576 DOI: 10.1097/sle.0000000000000875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/11/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The objective of this study was to explore the feasibility and safety of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) compared with endoscopic thyroidectomy via bilateral areola approach (ETBAA) in the treatment of patients with benign thyroid nodules. MATERIALS AND METHODS From January 2017 to December 2018, 60 patients who received TOETVA were enrolled as the research group; 65 patients who underwent ETBAA were included as the control group. A retrospective study was performed using the clinical data for these cases. All patients were diagnosed with benign nodules by preoperative examinations. Parameters including surgical trauma, complications, cosmetic satisfaction, and postoperative discomfort were compared between the 2 groups. RESULTS All operations were completed without incident. There were significant differences in operation time (137.8±18.7 vs. 95.7±17.2 min), intraoperative blood loss (16.8±9.1 vs. 24.6±16.6 mL), drainage volume (123.1±20.9 vs. 153.6±40.2 mL), C-reactive protein level (7.2±5.2 vs. 9.0±4.7 mg/L), drainage time (3.2±0.6 vs. 3.9±1.3 d), postoperative hospital stay (3.3±0.8 vs. 4.1±1.5 d), and sense of skin tension on the neck (0% vs. 10.8%) between the TOETVA and ETBAA groups (P<0.05). There were no significant differences in pain score, incidence of recurrent laryngeal nerve injury, transient hypoparathyroidism, infection, inadvertent parathyroidectomy, or swallow discomfort between the 2 groups. The cosmetic satisfaction score in the TOETVA group was significantly higher than that in the ETBAA group at 1 month after surgery (9.8±0.5 vs. 9.4±0.9, P<0.05), but at 3 months after the operation, the difference was not statistically significant. CONCLUSIONS TOETVA was accompanied by less surgical trauma and skin tension on the neck than ETBAA, and the cosmetic effect of this approach was better than that of ETBAA in the early postoperative period. TOETVA for benign thyroid nodules is safe and feasible. However, there are disadvantages with TOETVA, such as a long surgical period. More cases and further research are needed to delve further into this approach.
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Ryu CH, Seok J, Jung YS, Ryu J. Novel robot-assisted thyroidectomy by a transaxillary gas-insufflation approach (TAGA): a preliminary report. Gland Surg 2020; 9:1267-1277. [PMID: 33224801 DOI: 10.21037/gs-20-450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Robot-assisted transaxillary approaches to thyroidectomy have been well described. They have an advantage over the breast approach in that a circumareolar incision is avoided. However, they require a single long axillary incision to accommodate all 3 robotic arms and provide adequate visualization of the area around the thyroid. The purpose of this study was to test the feasibility of the robot-assisted transaxillary gas-insufflation approach (TAGA) and to attempt reducing the size of the scar. Methods We evaluated 47 patients who underwent robot-assisted thyroid lobectomy via TAGA from July 2015 to Aug 2017. The following variables were studied: patients' demographics, operative time according to each operation step, volume of drainage, duration of hospitalization, and perioperative complications. Results The mean age of all patients was 42.4±9.1 years. The mean total volume of drainage was 195.4±70.9 mL, and the duration of postoperative stay was 3.0±1.1 days. Two cases (4.3%) of transient vocal cord palsy and 2 cases (4.3%) of seroma were identified postoperatively. There was no post-operative cosmetic problem at the skin incisions made in the axilla. Conclusions Robot-assisted thyroid lobectomy via TAGA is technically feasible while achieving good cosmetic results. TAGA can be an alternative robot-assisted method for thyroidectomy.
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Affiliation(s)
- Chang Hwan Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Republic of Korea
| | - Jungirl Seok
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Republic of Korea
| | - Yuh-Seog Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Republic of Korea
| | - Junsun Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Republic of Korea
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Tae K. Complications of Transoral Thyroidectomy: Overview and Update. Clin Exp Otorhinolaryngol 2020; 14:169-178. [PMID: 33211953 PMCID: PMC8111399 DOI: 10.21053/ceo.2020.02110] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/15/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
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21
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Moreno Llorente P, A Gonzales Laguado E, Alberich Prats M, Francos Martínez JM, García Barrasa A. Surgical approaches to thyroid. Cir Esp 2020; 99:267-275. [PMID: 33069356 DOI: 10.1016/j.ciresp.2020.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 01/03/2023]
Abstract
Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIXth 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.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España.
| | - Erick A Gonzales Laguado
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
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Tartaglia F, Giuliani A, Sorrenti S, Ulisse S. Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews. J Minim Access Surg 2020; 16:315-322. [PMID: 32978350 PMCID: PMC7597888 DOI: 10.4103/jmas.jmas_123_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - Alessandro Giuliani
- Department of Environment and Health, Superior Institute of Health, Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
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Han S, Kwon TK, Chai YJ, Park J, Lee DY, Lee KE, Kim HY, Hwang KT, Yi KH. Functional Voice and Swallowing Outcome Analysis After Thyroid Lobectomy: Transoral Endoscopic Vestibular Versus Open Approach. World J Surg 2020; 44:4127-4135. [DOI: 10.1007/s00268-020-05731-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
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Tae K, Lee DW, Bang HS, Ahn YH, Park JH, Kim DS. Sensory change in the chin and neck after transoral thyroidectomy: Prospective study of mental nerve injury. Head Neck 2020; 42:3111-3117. [DOI: 10.1002/hed.26351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 01/29/2023] Open
Affiliation(s)
- Kyung Tae
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine Hanyang University Seoul South Korea
| | - Dong Won Lee
- Department of Otolaryngology—Head and Neck Surgery, School of Medicine Catholic University of Daegu Daegu South Korea
| | - Hyang Sook Bang
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine Hanyang University Seoul South Korea
| | - You Hern Ahn
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
| | - Jung Hwan Park
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
| | - Dong Sun Kim
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
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Abstract
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.
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Zhang D, Sun H, Tufano R, Caruso E, Dionigi G, Kim HY. Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy. Oral Oncol 2020; 108:104755. [PMID: 32526656 DOI: 10.1016/j.oraloncology.2020.104755] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/24/2020] [Accepted: 04/27/2020] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China.
| | - Hui Sun
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China.
| | - Ralph Tufano
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Ettore Caruso
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy.
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy.
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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Fernandez-Ranvier G, Meknat A, Guevara D, Taye A, Suh H, Inabnet WB. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Single-institution Experience of the First 50 Cases. Surg Innov 2020; 27:439-444. [PMID: 32496175 DOI: 10.1177/1553350620927611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has evolved from a novel procedure to a cosmetically appealing alternative to the traditional open thyroidectomy. TOETVA is limited to only high-volume centers with the hope to expand and demonstrate the safety, reproducibility, and application for the correct patient with thyroid disease. We present our experience with the first 50 TOETVA procedures performed at our institution. Methods. From September 2016 to June 2018, we performed 50 transoral endoscopic thyroidectomies via the vestibular approach for a variety of thyroid pathologies. Outcomes were analyzed from a prospectively maintained database. Patients were treated for a different range of thyroid pathologies. Results. A total of 12 (24%) patients underwent total thyroidectomy, whereas 38 (76%) patients underwent a subtotal thyroidectomy or thyroid lobectomy. The mean surgical time was 149 ± 40.0 (90-256) minutes for lobectomy and 217.6 ± 33.3 (175-276) minutes for total thyroidectomy. Of our 50 patients, 16 (32%) had postoperative transient lower lip numbness with an average time to recovery of 23.8 (.43-48) weeks, with 1 (2%) patient having persistent, but improving, lower lip numbness beyond the 6-month follow-up. There were 13 (26%) patients with transient chin numbness with an average time to recovery of 15.7 (2-48) weeks. Two (4%) patients had transient recurrent laryngeal nerve (RLN) injury with hoarseness, whereas 1 (2%) patient had permanent injury. Conclusion. The TOETVA is a safe and reproducible procedure. For selected patients, this technique is a viable alternative to conventional thyroidectomy.
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Affiliation(s)
| | - Aryan Meknat
- Department of Surgery, Mount Sinai Hospital, 5925Icahn School of Medicine at Mount Sinai, USA
| | - Daniela Guevara
- Department of Surgery, Mount Sinai Hospital, 5925Icahn School of Medicine at Mount Sinai, USA
| | - Aida Taye
- Department of Surgery, Mount Sinai Hospital, 5925Icahn School of Medicine at Mount Sinai, USA
| | - Hyunsuk Suh
- Department of Surgery, Mount Sinai Hospital, 5925Icahn School of Medicine at Mount Sinai, USA
| | - William B Inabnet
- Department of Surgery, 12252University of Kentucky College of Medicine, USA
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Evaluation of the efficacy of postoperative antibiotic treatment in transoral endoscopic thyroidectomy: a prospective randomised controlled trial. Br J Oral Maxillofac Surg 2020; 58:334-340. [PMID: 31982170 DOI: 10.1016/j.bjoms.2020.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/03/2020] [Indexed: 02/06/2023]
Abstract
Transoral endoscopic thyroid surgery (TOET) is a new, minimally-invasive approach that does not result in a scar in the anterior neck. To prevent infection of the surgical site from oral cavity flora into the thyroidectomy area, postoperative antibiotics are generally given orally for 3-7 days. However, there is no clinical evidence to support this approach. This study was an open-label, randomised, controlled trial to evaluate the clinical usefulness of postoperative antibiotics given orally to patients having TOET. Patients were randomly assigned to receive amoxicillin-clavulanate 625mg orally three times a day for a week after operation (treated group) or no antibiotics (untreated group). Fifty patients - 25 treated and 25 untreated - were enrolled. Maximum body temperature, pulse rate, white blood cell count, and C-reactive protein concentrations did not differ between the two groups. Evaluation of the surgical site showed no significant differences between them. Seven patients in the treated group developed nausea, vomiting, and diarrhoea compared with none in the untreated group. The results suggest that postoperative oral antibiotics are not essential after TOET. Large-scale prospective series are required to confirm this finding.
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Fernandez Ranvier G, Meknat A, Guevara DE, Llorente PM, Vidal Fortuny J, Sneider M, Chen YH, Inabnet W. International Multi-institutional Experience with the Transoral Endoscopic Thyroidectomy Vestibular Approach. J Laparoendosc Adv Surg Tech A 2020; 30:278-283. [PMID: 31951503 DOI: 10.1089/lap.2019.0645] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background: Surgical approaches to thyroidectomies have undergone a rapid evolution over the past three decades. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is currently the latest remote access procedure for the treatment of benign and malignant thyroid disease. The purpose of this article is to present the results of TOETVA from five different international institutions. Materials and Methods: From 2016 to 2019, 152 TOETVA procedures were performed on 149 patients at five separate international institutions. Outcomes were analyzed from a prospectively maintained database. There were 12 (8%) men and 137 (92%) women with mean ages of 41.5 ± 10.3 (27-69) and 46.9 ± 1.8 (17-78), respectively. Results: There were 3 (2%) cases that required conversion from the endoscopic approach to an open procedure. A thyroid lobectomy was performed in 111 (73.0%) cases, total thyroidectomy in 38 (25.0%) cases whereas a completion thyroidectomy in 3 (2.0%) cases. Mean operative times were 161.8 ± 42.4 (83-304) minutes for the lobectomy, 213.4 ± 71.7 (120-430) minutes for the total thyroidectomy, and 136.7 ± 109.8 (64-263) minutes for the completion thyroidectomy. The final pathology report revealed 107 (70.4%) benign nodules, 44 (28.9%) nodules with underlying papillary thyroid carcinoma, and 1 (0.7%) case with Hurthle cell carcinoma. Of the 152 cases, 7 (4.7%) patients developed temporary hypoparathyroidism. There were 5 (3.3%) patients who developed transient recurrent laryngeal nerve (RLN) injury and 3 (2.0%) with persistent injury of the RLN. Temporary lower lip numbness was noted in 51 (33.6%) patients whereas 1 (0.7%) patient was noted to have persistent numbness. We reported 57 (38.5%) patients with temporary chin numbness, 9 (5.9%) patients with skin injuries, and 2 (1.3%) with tracheal perforation. Conclusion: To date, the literature and the outcomes from these 5 international institutions have determined that, in select patients, TOETVA can be as safe and efficacious as the traditional trans-cervical technique for the treatment of specific thyroid pathologies.
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Affiliation(s)
- Gustavo Fernandez Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aryan Meknat
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York
| | - Daniela E Guevara
- Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jordi Vidal Fortuny
- Department of Surgery, Swiss Medical Network, Clinique de Genolier and Clinique Valére, Genolier, Switzerland
| | - Mark Sneider
- Department of Surgery, United Hospital Allina Health, St. Paul, Minnesota
| | - Yu-Hsien Chen
- Department of Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
| | - William Inabnet
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
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Pace-Asciak P, Russell JO, Shaear M, Tufano RP. Novel Approaches for Treating Autonomously Functioning Thyroid Nodules. Front Endocrinol (Lausanne) 2020; 11:565371. [PMID: 33250857 PMCID: PMC7673400 DOI: 10.3389/fendo.2020.565371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/05/2020] [Indexed: 11/13/2022] Open
Abstract
Benign thyroid nodules are exceedingly common in the adult population. Only a small percentage of nodules are toxic or autonomously functioning thyroid nodules (AFTNs). The options clinicians have for treating the symptoms of hyperthyroidism include anti-thyroidal medications, radioactive iodine, or surgery. Depending on the patient population treated, these options may not be suitable or have inherent risks that are undesirable to the patient. On the other hand, untreated hyperthyroidism can lead to osteoporosis, atrial fibrillation, emotional lability, and neurological consequences. Thus, we present a review of two novel safe and effective approaches for treating AFTN; one surgical (transoral endoscopic thyroid surgery) and one non-surgical (radiofrequency ablation), as a means for expanding our treatment armamentarium.
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A prospective, randomized controlled study of the safety and efficacy of gasless bilateral axillo-breast approach (BABA) robotic thyroidectomy. Surg Endosc 2019; 34:4846-4856. [PMID: 31848757 DOI: 10.1007/s00464-019-07262-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/11/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND During bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT), carbon dioxide (CO2) gas is insufflated into the operative cavity, not only triggering hemodynamic and metabolic changes, but also inducing postoperative pain and gas embolism. Here, we explored whether the new gasless BABA RoT approach was as safe and efficacious as conventional robotic surgery using CO2 insufflation. PATIENTS AND METHODS We performed a prospective, randomized controlled trial comparing conventional BABA RoT to gasless BABA RoT (CO2 group, n = 14; gasless group, n = 14). All clinicopathological and oncological outcomes were evaluated. The hemodynamic parameters [heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and cardiac index (CI)] and metabolic parameters [partial pressure of carbon dioxide (PaCO2) and pH] were measured at baseline; 30, 60, 90, and 120 min after CO2 insufflation; and 30 min after desufflation. Pain parameters [numeric rating scale (NRS) score, number of analgesics (NA), and bottom hit count (BHC)] were measured at 2, 24, 48, and 72 h after surgery. RESULTS We found no statistically significant differences between the two groups in terms of any demographic or baseline characteristic. The clinicopathological and oncological outcomes did not differ significantly between the two groups, but the operation time was longer for the gasless group (187.50 ± 42.64 vs. 212.50 ± 35.88 min; P = 0.028). In terms of the hemodynamic, metabolic, and pain parameters, the pH fell significantly less in the gasless group (P = 0.047), but there were no significant between-group differences in the HR, MAP, CO, CI, PaCO2, NRS, NA, or BHC. No safety concerns arose. CONCLUSION The new, gasless BABA RoT technique employing the da Vinci robotic surgical system is safe. Although metabolic changes during operation are thereby minimized, gasless BABA RoT should be used carefully when engaging in thyroid surgery; more experience is required.
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Suh I, Viscardi C, Chen Y, Nwaogu I, Sukpanich R, Gosnell JE, Shen WT, Seib CD, Duh QY. Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique. J Surg Res 2019; 243:123-129. [DOI: 10.1016/j.jss.2019.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Fernandez-Ranvier G, Meknat A, Guevara DE, Inabnet WB. Transoral Endoscopic Thyroidectomy Vestibular Approach. JSLS 2019; 23:e2019.00036. [PMID: 31719772 PMCID: PMC6830499 DOI: 10.4293/jsls.2019.00036] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Remote-access thyroid surgery has gained popularity and has advanced significantly over the past two decades, given the patient desire to avoid cosmetically displeasing scarring. It has only been recently that natural-orifice transluminal endoscopic surgery (NOTES) techniques have been geared for thyroidectomies. The transoral endoscopic thyroidectomy vestibular approach has been categorized as a NOTES procedure-given the approach to the thyroid gland via incisions in the oral cavity. Our aim is to provide a review of the current literature on the transoral endoscopic thyroidectomy vestibular approach (TOETVA), to present the worldwide experience of this novel procedure, and to outline whether individual patients have characteristics that would make the procedure feasible for this technique. METHODS A literature review was done to compile articles detailing the international experience with TOETVA. Our experience combined with what has been published in the literature was used to establish which pathological and patient characteristics make this particular technique feasible for a thyroidectomy. RESULTS We detail in the provided tables both feasibility for this surgical technique and the international experience. CONCLUSION TOETVA represents the latest remote-access endoscopic technique for the excision of the thyroid gland. TOETVA is being performed at various international institutions and multiple hospitals in the United States.
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Affiliation(s)
- Gustavo Fernandez-Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aryan Meknat
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York, USA
| | - Daniela E Guevara
- Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William B Inabnet
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Russell JO, Razavi CR, Shaear M, Chen LW, Lee AH, Ranganath R, Tufano RP. Transoral Vestibular Thyroidectomy: Current State of Affairs and Considerations for the Future. J Clin Endocrinol Metab 2019; 104:3779-3784. [PMID: 30860578 PMCID: PMC6656420 DOI: 10.1210/jc.2019-00116] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/06/2019] [Indexed: 12/30/2022]
Abstract
CONTEXT The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a recently described procedure for surgical management of select thyroid pathology that avoids a cutaneous scar. TOETVA is far from the first described remote-access approach to the thyroid. In fact, numerous such techniques have been described over the past 20 years, although none has gained widespread implementation in North America or Europe. However, with its rapid growth worldwide and excellent outcomes to date, TOETVA may succeed where these prior techniques have failed. EVIDENCE ACQUISITION The English literature was reviewed using the following keywords: transoral thyroidectomy, remote-access thyroidectomy, minimally invasive thyroidectomy, and TOETVA. Because three systematic reviews of this technique were recently conducted, this manuscript does not seek to provide a fourth. Rather, we summarize salient findings from these reviews and focus on candidates for the procedure, technique-specific characteristics that have led to early success with TOETVA, and prospects for the future. EVIDENCE SYNTHESIS TOETVA is the only thyroidectomy approach obviating the need for a cutaneous incision, and it offers several advantages over previously described remote-access thyroidectomy techniques. These include a favorable anatomic surgical perspective, a comparatively short learning curve, no requirement for expensive instrumentation, and a broad inclusion criterion. These characteristics have facilitated the excellent surgical outcomes to date. CONCLUSIONS TOETVA is a suitable surgical option with proven safety and feasibility for a carefully selected patient population. The potential value of the procedure outside enhanced cosmesis continues to be defined.
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Affiliation(s)
- Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher R Razavi
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammad Shaear
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lena W Chen
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Lee
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rohit Ranganath
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Park YM, Kim DH, Moon YM, Lim JY, Choi EC, Kim SH, Holsinger FC, Koh YW. Gasless transoral robotic thyroidectomy using the DaVinci SP system: Feasibility, safety, and operative technique. Oral Oncol 2019; 95:136-142. [DOI: 10.1016/j.oraloncology.2019.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/27/2019] [Accepted: 06/02/2019] [Indexed: 01/29/2023]
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Park JO, Wang SG, Park D, Bae IH, Lee JC, Lee BJ, Shin SC. The Feasibility of a Prototype Thyroidoscope for Gasless Transoral Endoscopic Thyroidectomy: A Preclinical Cadaver Study. J Laparoendosc Adv Surg Tech A 2019; 29:953-957. [DOI: 10.1089/lap.2019.0107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Jun-Ook Park
- Department of Otolaryngology, Head and Neck Surgery, Catholic University College of Medicine, Seoul, Republic of Korea
| | - Soo-Geun Wang
- Department of Otorhinolaryngology, Head and Neck Surgery, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Dahee Park
- Department of Otorhinolaryngology, Head and Neck Surgery, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In-Ho Bae
- Department of Otorhinolaryngology, Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jin-Choon Lee
- Department of Otorhinolaryngology, Head and Neck Surgery, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology, Head and Neck Surgery, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Sung-Chan Shin
- Department of Otorhinolaryngology, Head and Neck Surgery, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
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Transoral endoscopic thyroidectomy for thyroid carcinoma: outcomes and surgical completeness in 150 single-surgeon cases. Surg Endosc 2019; 34:861-867. [DOI: 10.1007/s00464-019-06841-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
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Transoral endoscopic thyroid surgery in a Korean population. Surg Endosc 2019; 33:2104-2113. [DOI: 10.1007/s00464-018-6481-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/11/2018] [Indexed: 12/11/2022]
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Gasless transoral endoscopic thyroidectomy vestibular approach (gasless TOETVA). Surg Endosc 2019; 33:3034-3039. [PMID: 31087173 DOI: 10.1007/s00464-019-06826-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/03/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been the subject of increasing interest from several institutions around the world over the last 2 years. Recently, we successfully performed TOETVA in live human patients without CO2 gas using our newly designed retractable blade. METHODS We reviewed the medical records of 15 consecutive patients who underwent gasless TOETVA using a self-retaining retractor. RESULTS We successfully performed 13 thyroid lobectomies and 2 total thyroidectomies in 15 patients. No patient exhibited serious postoperative complications such as recurrent laryngeal nerve palsy and permanent hypocalcemia. One patient developed transient hypocalcemia but recovered within 2 months. No patient developed a wound infection; furthermore, no visible scar or dimpling was evident on the neck of any patient. CONCLUSION Gasless TOETVA provides enough working space and good visibility to perform thyroid surgery without any risk of CO2 gas-related complications.
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Park JO, Kim MR, Park YJ, Kim MS, Sun DI. Transoral endoscopic thyroid surgery using robotic scope holder: Our initial experiences. J Minim Access Surg 2019; 16:235-238. [PMID: 31031326 PMCID: PMC7440021 DOI: 10.4103/jmas.jmas_12_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background : Transoral thyroid surgery represented by the da Vinci system is attracted attention and performed by several institutions. However, the current available da Vinci system still has some limitations to be improved for transoral thyroid surgery including high cost of equipment and expendables, larger diameter scope and instruments and no tactile sensation. It triggered us interest in more easily available robotic scope holder. Soloassist II (AktorMed GmbH, Barbing, Germany) is an active endoscope holder system which is controlled by a joystick. It has total six joints: three joints which are controlled by computer, one is controlled by manual and two act as a gimbal joint following the movement of the main body. Materials and Methods We tried transoral endoscopic thyroidectomy using Soloassist II (AktorMed GmbH, Barbing, Germany) in December 2017 in our hospital. Results We successfully performed four thyroid lobectomies in four patients with Soloassist II. We refined and described surgical procedures in each step using video clips. It provided an excellent vibration-free stable surgical view which enabled fatigue-free work, without shaking or tilting the horizon. The surgeon could perform transoral endoscopic thyroid surgery with only one assistant surgeon. Docking and preparation time for Soloassist was within 10 min in all four patients. The setup and dismantling could be performed parallel to the usual workflow. No complication was reported by any patient. Conclusions : The robotic scope holder (Soloassist II) seems to be safe and feasible equipment for performing transoral endoscopic thyroid surgery. Several possible advantages could be expected with this robotic scope holder.
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Affiliation(s)
- Jun-Ook Park
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Mi Ra Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Haeundae Paik Hospital, Inje University of Korea, Busan, South Korea
| | - Yeong Jun Park
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Haeundae Paik Hospital, Inje University of Korea, Busan, South Korea
| | - Min-Sik Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dong-Il Sun
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Tae K, Lee DW, Song CM, Ji YB, Park JH, Kim DS, Tufano RP. Early experience of transoral thyroidectomy: Comparison of robotic and endoscopic procedures. Head Neck 2018; 41:730-738. [DOI: 10.1002/hed.25426] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/03/2018] [Accepted: 09/21/2018] [Indexed: 01/20/2023] Open
Affiliation(s)
- Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery; College of Medicine, Hanyang University; Seoul South Korea
| | - Dong Won Lee
- Department of Otolaryngology-Head and Neck Surgery; College of Medicine, Hanyang University; Seoul South Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery; College of Medicine, Hanyang University; Seoul South Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery; College of Medicine, Hanyang University; Seoul South Korea
| | - Jung Hwan Park
- Department of Internal Medicine; College of Medicine, Hanyang University; Seoul South Korea
| | - Dong Sun Kim
- Department of Internal Medicine; College of Medicine, Hanyang University; Seoul South Korea
| | - Ralph P. Tufano
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
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Cottrill EE, Funk EK, Goldenberg D, Goyal N. Transoral Thyroidectomy Using A Flexible Robotic System: A Preclinical Cadaver Feasibility Study. Laryngoscope 2018; 129:1482-1487. [PMID: 30284264 DOI: 10.1002/lary.27543] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS Traditionally, most thyroid surgery utilizes a curvilinear cervical incision with a resulting permanent scar. Minimally invasive and remote access thyroid surgery techniques continue to evolve. Transoral approaches through a vestibular incision have been developed at several centers throughout the world, obviating the need for a cutaneous incision and optimizing aesthetics. To date this technique has been performed using rigid endoscopes or a linear robotic platform. The goal of this study was to test the feasibility of a novel flexible robotic system to perform a transvestibular thyroidectomy in a preclinical cadaver model. STUDY DESIGN Preclinical feasibility study. METHODS Right and left thyroid lobectomies were successfully performed via a transvestibular approach in four cadavers. RESULTS A single vestibular incision between bilateral mental nerves allowed entrance of the flexible robot in a subplatysmal plane in both male and female cadavers. The recurrent laryngeal nerves and parathyroids were identified and preserved. The flexible three-dimensional camera allowed excellent visualization and could be easily repositioned for optimal visualization of right and left structures. The flexible and wristed instruments enabled an atraumatic approach and allowed for precise surgical technique. CONCLUSIONS The transoral vestibular approach to the central neck is a promising technique for thyroidectomy with optimal cosmesis and can be successfully accomplished using this novel flexible robotic system. Improvements in visualization and access offered by this system may improve application of this technique. LEVEL OF EVIDENCE NA Laryngoscope, 129:1482-1487, 2019.
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Affiliation(s)
- Elizabeth E Cottrill
- Department of General Surgery, Division of Otolaryngology-Head and Neck Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania.,Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, U.S.A
| | - Emily K Funk
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, CA, U.S.A
| | - David Goldenberg
- Department of General Surgery, Division of Otolaryngology-Head and Neck Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Neerav Goyal
- Department of General Surgery, Division of Otolaryngology-Head and Neck Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
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Tae K, Ji YB, Song CM, Ryu J. Robotic and Endoscopic Thyroid Surgery: Evolution and Advances. Clin Exp Otorhinolaryngol 2018; 12:1-11. [PMID: 30196688 PMCID: PMC6315214 DOI: 10.21053/ceo.2018.00766] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.
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Affiliation(s)
- Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Junsun Ryu
- Department of Otolaryngology-Head and Neck Surgery, Center for Thyroid Cancer, National Cancer Center, Goyang, Korea
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Camenzuli C, Schembri Wismayer P, Calleja Agius J. Transoral Endoscopic Thyroidectomy: A Systematic Review of the Practice So Far. JSLS 2018; 22:e2018.00026. [PMID: 30275676 PMCID: PMC6158973 DOI: 10.4293/jsls.2018.00026] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives Thyroid disease largely affects young females, but the incidence is also increasing among males. In an effort to avoid the scarring of the neck that is synonymous with conventional thyroidectomy, endoscopic techniques have been developed over the years. The transoral endoscopic approach is the latest of these innovations that promises a scarless surgical outcome. This review evaluates whether this technique is safe and feasible in live patients and outlines the outcomes in published literature so far. Database PubMed, Medline, BioMed Central, Cochrane Library, OVID and Web of Science were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting strict inclusion and exclusion criteria. Sixteen studies were included in the final analysis. Discussion This systematic review presents cases of 785 patients. Surgeons in 15 of the studies used a completely vestibular approach, whereas those in the remaining 2 used the floor of the mouth for primary access. Conversion to open surgery took place in 1.3%. In total, 4.3% of patients experienced transient laryngeal nerve palsy, whereas 0.1% had permanent recurrent incidences of the condition. Transient hypocalcemia occurred in 7.4% of cases, with no recorded permanent cases. Carbon dioxide embolism occurred in 0.6% of cases, and another 0.6% had a deep-seated neck infection. The complication rates within the review were deemed acceptable and the overall technique feasible. A prospective randomized controlled trial was proposed to compare this technique with conventional thyroidectomy.
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Affiliation(s)
- Christian Camenzuli
- Department of Anatomy, Faculty of Medicine and Surgery, Biomedical Sciences, University of Malta, Msida, Malta
| | - Pierre Schembri Wismayer
- Department of Anatomy, Faculty of Medicine and Surgery, Biomedical Sciences, University of Malta, Msida, Malta
| | - Jean Calleja Agius
- Department of Anatomy, Faculty of Medicine and Surgery, Biomedical Sciences, University of Malta, Msida, Malta
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Sun H, Dionigi G. Endoscopic thyroid surgery requires surgeons, patient candidacy & neural monitoring. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2018. [DOI: 10.2217/ije-2018-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, PR China
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood & Childhood ‘G. Barresi’, Division for Endocrine & Minimally Invasive Surgery, University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
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