The current status of endoscopic thyroidectomy in Korea

Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: A network meta-analysis

BACKGROUND

To assess the surgical outcomes of various minimally invasive and remote-access surgical approaches for thyroid cancer patients.

METHODS

We collected studies from January 2020 to July 2022 in 6 databases. Pairwise and network meta-analyses were performed for outcomes and complications of 9 minimally invasive interventions (minimally invasive video-assisted, endoscopic or robotic bilateral axillo-breast approach, endoscopic or robotic postauricular, endoscopic or robot transaxillary approach, transoral endoscopic thyroidectomy vestibular approach or robotic thyroidectomy) and conventional thyroidectomy (control).

RESULTS

Multiplicity and bilaterality of cancer, lymph node metastasis, and coincidence of thyroiditis showed no significant difference between minimally invasive interventions and control. However, larger tumor size (robotic bilateral axillo-breast approach standardized mean difference -1.3989, 95% confidence interval [-2.1717 to -0.6262]), higher body mass index (robot transaxillary approach standardized mean difference -0.5350, 95% confidence interval [-0.9557 to -0.1144], robotic bilateral axillo-breast approach standardized mean difference -0.2301, 95% confidence interval [-0.4389 to -0.0214]), and frequent extrathyroidal extension (robotic bilateral axillo-breast approach standardized mean difference 0.7435, 95% confidence interval [0.5602-0.9869]) were observed in control. In surgical outcomes and adverse effects, there was no significant difference in hospitalization or retrieved lymph node number between minimally invasive interventions and control. However, longer operative time was observed in the robotic bilateral axillo-breast approach(standardized mean difference 6.5393, 95% confidence interval [5.0476-8.0309]) and transoral robotic thyroidectomy (standardized mean difference 5.4946, 95% confidence interval [2.9984-7.9907]) groups than in control. In surgical completion, the rate of low postoperative serum thyroglobulin, postoperative thyroglobulin level, and postoperative radioactive iodine ablation dose showed no significant difference between minimally invasive interventions and control.

CONCLUSION

Minimally invasive thyroidectomy did not show inferior results compared to conventional thyroidectomy despite the longer operative time. Surgeons need to prudently consider all aspects of patients to determine the proper surgical approach for thyroid cancer.

Recent progress of robotic head and neck surgery using a flexible single port robotic system

We performed robotic neck surgery through a transoral or retroauricular approach (RA) using the DaVinci SP and analyzed our experiences to evaluate the feasibility and safety of this system for performing RA neck surgeries. A total of 63 patients were enrolled in this study, consisting of 37 males and 26 females. All operations were successfully completed without significant complication in 63 patients with head and neck tumor. Using DaVinci SP, it is easy to insert three robotic arms into a long and narrow working space because all robotic arms and an endoscope are inserted through a single arm. Using the navigation function of the DaVinci SP, the endoscopic arm could be made into the shape of a "cobra" to secure proper visualization of the surgical site, which helps surgeons identify specific anatomic structures such as cranial nerve or vessels. We did not have any cases where robotic surgery was converted to open surgery due to severe bleeding or technical issues during surgery. The mean operative time was 207 min and the average hospital stay was 6.9 days. The time required for docking the surgical robot was within 10 min on average for DaVinci SP, which was much simpler and faster than that of the previous Si/Xi system. Based on our early experiences performing robotic head and neck surgery using the DaVinci SP, we confirmed that the system provided advanced technical advantages over the previous Si/Xi system in performing robotic surgery.

Surgical outcomes of different approaches in robotic assisted thyroidectomy for thyroid cancer: A systematic review and Bayesian network meta-analysis

BACKGROUND

The aim of the study was to assess the feasibility, safety, and potential benefits of four approaches of robotic assisted thyroidectomy (RT). The approaches mentioned above are also compared with traditional open thyroidectomy (OPEN).

MATERIALS AND METHODS

Medline, Embase, Cochrane library (CENTRAL) and Web of Science databases were searched up to 13th Dec 2019. Data of surgical outcomes and complications were extracted to conduct the statistical analyses.

RESULTS

A total of 30 studies with 6622 patients were included. Ten were prospective study and 1 declared prospective randomized comparative study. The number of retrieved lymph nodes (LNs) in central compartment were similar between gasless transaxillary approach (GAA), bilateral axillo-breast approach (BABA) and transoral approach (OA). OPEN retrieved more LNs than BABA and OA. More metastatic LNs were seen in GAA and BABA than OA, as was for OPEN. The operation time was significantly shorter in GAA and gasless unilateral transaxillary approach (GUAA) than BABA and OA, while shortest for OPEN. Lower incidence of transient hypoparathyroidism was found in BABA than OPEN. No significant difference was observed in other indexes.

CONCLUSIONS

BABA, GAA, GUAA and OA in RT appear to be feasible and safe for patients with thyroid cancer with unique benefits. Surgical outcomes of different approaches were not identical for operation time, cosmetic effects, central neck dissection. Surgeons would consider more about patients' will.

Trans oral endoscopic thyroidectomy (TOETVA): First French experience in 90 patients

OBJECTIVE

Thyroidectomy techniques using extracervical approaches have grown in popularity for about 20 years and their feasibility has now been demonstrated. We wanted to evaluate one of these new approaches: the anterior vestibular endoscopic approach (TOETVA). The aim of this study was to evaluate the results of an initial series patients who underwent an anterior trans-vestibular endoscopic oral thyroidectomy.

METHODS

From February 2018 to September 2020, this technique was offered to patients aged 18 to 70, ASA I or II, who presented with an indication for thyroid surgery and who wished to avoid cervical scars. The approach was through the anterior vestibule of the mouth and the specimen was extracted either transorally or via the axilla depending on its size. Apart from the first ten cases, all patients underwent recurrent nerve neuromonitoring. The patients were operated on by two surgeons experienced in thyroid surgery. All the patients had follow-up visits on D15, D30 and at 2 months. The pre- and intra-operative data, length of stay and complications were evaluated.

RESULTS

A total of 90 consecutive patients (87 women) aged 46±12.4 years (18 to 69) with a mean BMI of 24.4±4 were included. The indications for surgery included 11 papillary cancers, 5 oncocytic nodules, 15 toxic nodules, 13 cases of Graves disease and 46 symptomatic goiters and/or nodules. The mean pre-operative diameter of the nodules was 3.61±1.99 (0.44 to 7.3) cm. The interventions performed were 44 lobo-isthmectomies, 41 total thyroidectomies and 5 isthmectomies. The mean operating time was 134±45min (40 to 255). On D1, the post-operative ionized calcium was 1.09±0.11mmol/L (4.3685±0.44mg/dL) (normal 0.8-1.15mmol/L) (3.206-4.609mg/dL)) and the total serum calcium was 2.07±0.11mmol/L 8.296±0.44mg/dL (normal 2.2-2.5mmol/L) (8.817-10.019mg/dL). Five patients underwent conversion from endoscopic to open cervical approach (5.5%). The complications were seven cases of transient recurrent nerve palsy (7.8%), eight cases of hypoparathyroidism (19%) including six transient and two permanent, one skin burn and 26 cases of transient chin numbness related to the electrocautery (29%). Ten patients (11%) presented with transient post-operative skin ecchymosis that resolved within 7-10 days. A spontaneous pneumo-mediastinum was observed on chest CT in three patients and evolved favorably. No hematoma, or surgical site infection, or complications related to axillary extraction were observed. All the patients declared themselves satisfied post-operatively and at the end of the follow-up.

CONCLUSION

The TOETVA route of entry is a safe and reliable technique in well-selected patients wishing to avoid a cervical scar.

Comparison of surgical outcome between conventional open thyroidectomy and endoscopic thyroidectomy through axillo-breast approach

Objective:

Minimally invasive thyroidectomy can be categorized into either video-assisted method or remote access thyroidectomy (RAT). Although RAT provided excellent cosmetic results, some debate about the advantages and disadvantages remains in different countries. Thus, this study aimed to compare the surgical results between endoscopic thyroid surgery and conventional thyroidectomy.

Materials and Methods:

The study retrospectively reviewed the conventional and endoscopic thyroidectomy performed at our institution from September 2011 to July 2012. Overall, 30 patients were recruited for this study. The patients were divided into two groups: Group O (open group, n = 15) and Group E (endoscopic group, n = 15). Postoperative outcomes (including wound pain, swallowing disturbance, and chest wall paresthesia) and complications were analyzed and assessed.

Results:

The endoscopic group was associated with longer operation time and hospital stay. The visual analog scale (VAS) score of surgical wound pain was significantly higher in the open group in 1-week postoperation. However, the VAS score of swallowing disturbance was significantly higher in the endoscopic group in 1-week postoperation. More than half of the patients (53%) had chest wall paresthesia within 1-month postoperation in the endoscopic group. No surgical complications occurred in both groups.

Conclusion:

Although endoscopic thyroidectomy provides excellent cosmetic results in thyroid surgery, higher immediate postoperative pain, and prolonged chest wall paresthesia compared with those in conventional surgery are a concern and warrant careful patient selection.

Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation

BACKGROUND

The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.

METHODS

Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.

RESULTS

The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).

CONCLUSIONS

The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.

Technique for endoscopic thyroidectomy with selective lateral neck dissection via a chest-breast approach

BACKGROUND

Endoscopic thyroidectomy has been widely accepted because it can effectively avoid neck scarring. However, there are seldom reports concerning completely endoscopic lateral neck dissection approaches. In this study, we introduced a technique for performing endoscopic thyroidectomy with lateral neck dissection via a chest-breast approach.

METHODS

We retrospectively reviewed 18 patients who underwent endoscopic total thyroidectomy along with levels II, III, IV, and VI dissection. All major outcomes, such as cosmetic effect, operative time and complications, etc., were analyzed. In addition, another 20 patients who underwent traditional open surgery (open group) were enrolled in the study to conduct a contrasting analysis between patients treated with the endoscopic technique (endoscopic group) and open group patients, in terms of demographic data and main operative outcomes, to evaluate the feasibility of this technique.

RESULTS

All 18 endoscopic surgery cases were successfully performed, and no patient was converted to the open procedure intra-operatively. There were no significant differences between the two groups regarding age (P = 0.209), Body Mass Index (P = 0.479), sex (P = 0.218), drainage time (P = 0.153), operation time (P = 0.065), intra-operative blood loss (P = 0.139), post-operative pain (P = 0.114), and number of dissected lateral lymph nodes (II: P = 0.201; III + IV: P = 0.107). The mean total and lateral lymph nodes dissection (LLND) time in the endoscopic group were longer than those of the open group (P = 0.002; 235 ± 35 vs. 182 ± 20 min, P = 0.000; 125 ± 21 vs. 80 ± 14 min, P = 0.000). The primary lesion diameter of the endoscopic group was smaller than that of the open group (1.7 ± 0.8 vs. 2.9 ± 1.3 cm, P = 0.002). The scores for cosmetic satisfaction in the endoscopic group were higher than those in the open group (8.3 ± 0.7 vs. 4.4 ± 0.9, P = 0.000). Among the complications, there was no significant difference between the two approaches in transient vocal cord paresis (1/18 vs. 0/20, P = 0.474), transient hypoparathyroidism (4/18 vs. 4/20, P = 1.000), post-operative lymphatic leakage (1/18 vs. 3/20, P = 0.606), and intra-operative large blood vessel injury (2/18 vs. 0/20, P = 0.218). There was no incidence of uncontrolled bleeding, mental nerve injury, permanent hypoparathyroidism, permanent recurrent laryngeal nerve (RLN) injury, skin bruise on the neck, asphyxia/dyspnea or other complications like tracheal injury, esophageal injury, etc., nor was there any death or recurrence in either of the two groups during the short follow-up period.

CONCLUSION

It is feasible to perform LLND (levels II, III, IV, and VI) with endoscopic thyroidectomy via a chest-breast approach. In particular, this technique avoids a large scar on the patient's neck and has well operative outcomes compared with open surgery. Accordingly, this technique may offer one more option for selective patients.

Postsurgical Outcomes and Surgical Completeness of Robotic Thyroid Surgery: A Single Surgeon's Experience on 700 Cases

BACKGROUND

Advanced technology and understanding of robotic surgical system have rendered robotic thyroid surgery more expanding. The aim of this study was to identify the periodic changes in postsurgical outcomes of robotic thyroid surgery performed by a single surgeon.

METHODS

We conducted a retrospective review of 700 robotic thyroid surgery cases using gasless trans-axillary approach.

RESULTS

All patients underwent successful operations without conversion to open surgery, and were mostly younger than 45 years, female, less-extended thyroid surgery and lymph node dissection, and thyroid cancer. The median follow-up period was 67 months (12-99 months). Regarding technical outcomes, the operation time declined steeply after 100 consecutive cases, and reached 120.0-132.7 minutes for thyroid lobectomy and 162.9-174.1 minutes for total thyroidectomy (TT). The most common complication was transient hypoparathyroidism (43.7%), whose incidence decreased steeply to a range of 9.1% to 25.0% after 300 consecutive cases. Regarding surgical completeness for thyroid cancer, an average of seven lymph nodes was retrieved through central compartment node dissection without fluctuation over time. The proportion of the patients with serum stimulated thyroglobulin levels <10 ng/mL at the time of radioactive iodine remnant ablation after TT and <1 ng/mL 6-12 months after the first remnant ablation ranged between 86.4%-100% and 66.7%-100%, respectively, without significant fluctuation.

CONCLUSION

For properly selected patients, robotic thyroid surgery is useful surgical option with reliable technical outcome and surgical completeness and cosmetic benefit.

Application of Straight Line Tunnel With Less Subcutaneous Separation in Transthoracic Endoscopic Thyroidectomy

The objective of this paper was to evaluate the value of straight-line tunnel application in transthoracic endoscopic thyroidectomy. Forty patients were given 3-port transthoracic endoscopic thyroidectomy from March 2011 to June 2014. Preoperative diagnoses found 20 cases of nodular goiter, 16 cases of adenoma, and 4 cases of thyroid calcification. We used a metal rod to free skin flap in a straight way toward the neck, and a straight-line tunnel was created to obtain a good view. All 40 cases involving endoscopic thyroidectomy were performed successfully, 28 were performed with unilateral subtotal thyroidectomy, 5 were performed with unilateral thyroidectomy, 5 were performed with bilateral partial thyroidectomy, and 2 were performed with radical thyroidectomy for carcinoma. One is anaplastic thyroid carcinoma (ATC) and the other is follicular thyroid carcinoma. Operation time was 78.5 ± 18.6 minutes, intraoperative blood loss was 40.2 ± 15.6 mL, intraoperative flap-freeing time was 14.3 ± 3.8 minutes, and the diameter of the thyroid tumor was 3.8 ± 2.5 cm. Postoperative hospital stay was 3.5 ± 2.0 days. One patient got voice hoarseness and recovered in 3 months. Two patients suffered from transient hypocalcemia and recovered without treatment. No subcutaneous effusion or seroma was observed. No recurrence was found during the 12- to 36-month (mean: 28 months) follow-up. One patient felt chest numbness 3 months after the surgery. Thirty-two patients were very satisfied with the cosmetic appearance and 8 patients were satisfied. The application of straight-line tunnel in transthoracic endoscopic thyroidectomy is a simple, safe, feasible procedure with less trauma, seroma, and skin contraction.

Robotic thyroidectomy versus conventional open thyroidectomy for differentiated thyroid cancer: meta-analysis

Objective:

To conduct a meta-analysis to compare the short-term outcomes of robotic thyroidectomy and conventional open thyroidectomy for differentiated thyroid cancer.

Methods:

Medline, Embase, Science Citation Index Expanded and the Cochrane Library databases were searched for relevant literature. The evaluated endpoints were intra-operative and post-operative outcomes.

Results:

Twelve eligible, non-randomised comparative studies involving 2513 patients were included, with 923 patients in the robotic thyroidectomy group and 1590 patients in the conventional open thyroidectomy group. Meta-analysis results revealed that robotic thyroidectomy was associated with significantly longer operative time and a lower number of retrieved central lymph nodes, as compared with conventional open thyroidectomy. No significant differences were found between robotic thyroidectomy and conventional open thyroidectomy in terms of post-operative outcomes.

Conclusion:

Robotic thyroidectomy appears to be a feasible and safe surgical procedure for patients with differentiated thyroid cancer. However, more high-quality randomised clinical trials should be undertaken to confirm these findings.

Nationwide multicenter survey for current status of endoscopic thyroidectomy in Korea

Objectives

We evaluated the current status of endoscopic thyroidectomy procedures in Korea in terms of indications, contraindications, advantages, disadvantages, complications, and limitations of each approach.

Methods

An email survey, consisting of 15 questions, was sent to 29 experienced endoscopic thyroidectomy surgeons.

Results

The most commonly used approach was the gasless transaxillary approach (66.7%), followed by the bilateral axillo-breast approach with gas insufflation (23.8%). The most common indication was less than 1 cm, single papillary thyroid cancer. The role of endoscopic thyroidectomy is not still established; some consider it a novel procedure (34.8%), others a transition to robotic thyroidectomy (34.8%).

Conclusion

Our results shed light on the general consensus of opinions about endoscopic thyroidectomy, such as the advantages, disadvantages, complications, limitations, and even its future role.

Surgical outcomes of robotic thyroid surgery using a double incision gasless transaxillary approach: analysis of 400 cases treated by the same surgeon

BACKGROUND

The purpose of this study was to evaluate the surgical outcomes of 400 cases of robotic thyroid surgery using a double incision gasless transaxillary approach.

METHODS

We analyzed 400 patients who underwent a robot-assisted thyroidectomy performed by a single surgeon.

RESULTS

All patients underwent successful operations without conversion to open surgery. Transient hypoparathyroidism was the most common complication (51.7%) and permanent hypoparathyroidism occurred in only 2 patients (1.4%). The mean number of retrieved central lymph nodes was 6.5 ± 4.4 for ipsilateral central compartment node dissection and 8.4 ± 5.1 for bilateral central compartment node dissection. The proportion of patients with stimulated thyroglobulin (sTg) levels at the time of remnant ablation <10 ng/mL and sTg levels 6 to 12 months after the first ablation <1 ng/mL was 84.9% and 88.3%, respectively.

CONCLUSION

Robotic thyroid surgery is technically safe and may be a surgical option for patients with well-differentiated thyroid cancer.

Endoscopic thyroidectomy via a transaxillary approach is a safe procedure in patients with breast augmentation

INTRODUCTION

Breast augmentation with implants is a common cosmetic procedure. Some endoscopic thyroid procedures can pose a risk of damage to the augmented breast. The aim of this study was to evaluate the safety of transaxillary gasless endoscopic thyroidectomy in patients with augmented breast.

MATERIALS AND METHODS

Between January 2009 and December 2010, 120 patients underwent endoscopic thyroidectomies. Of those, 6 patients had previously undergone breast augmentation. Augmented breasts were evaluated preoperatively and postoperatively in terms of shape and stability.

RESULTS

All patients were female, and the mean age was 40.8 years. All patients received breast augmentation with silicone cohesive gel 2 to 10 years prior to thyroidectomy. Postoperatively, the authors found that there were no changes to the breasts in terms of anterior-posterior projections and internal angles. The augmented breasts remained stable.

CONCLUSIONS

Endoscopic thyroidectomy via a transaxillary approach is safe and effective for patients who have undergone silicone breast implant augmentation.

Operative technique of endoscopic thyroidectomy: a narration of general principles

Endoscopic thyroidectomy is fast becoming a reality with increasing experience in endocrine surgery. Many techniques of minimally invasive video-assisted thyroidectomy through cervical and extra-cervical routes such as chest wall, transaxillary, trans-oral, post-auricular, trans-luminal approach have been attempted. At present anterior chest wall or trans-axillary routes are favourite extra-cervical routes. In this context, we describe our operative technique of endoscopic thyroidectomy through chest wall to highlight the surgical steps of practical importance.

Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients

OBJECTIVE

To confirm the merits of robotic thyroid surgery by comparing the surgical outcomes of robotic-assisted and conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients.

BACKGROUND

Robot-assisted surgical techniques are widely utilized, and substantially, overcome the limitations of conventional endoscopic surgery. Furthermore, recently, robotic procedures were introduced to the thyroidectomy field.

METHODS

From November 2001 to July 2009, 1150 patients with PTMC underwent endoscopic thyroidectomy using a gasless, trans-axillary approach. Of these patients, 580 underwent a robotic procedure (the robotic group; RG) and 570 a conventional endoscopic procedure (the conventional endoscopic group; EG). These 2 groups were retrospectively compared in terms of their clinicopathologic characteristics, early surgical outcomes, and surgical completeness.

RESULTS

Total thyroidectomy was performed more frequently in the RG. Although mean operation times were not statistically different, the mean number of central nodes retrieved was greater in the RG than in the EG. Mean tumor size were not significantly different in the 2 groups, but the RG showed more frequent central node metastasis and capsular invasion. Tumor and nodal statuses in the RG were more advanced than in the EG. Regarding postoperative complications, transient hypocalcemia was more frequent in the RG, but other complication frequencies were not significantly different in the 2 groups. Postoperative serum thyroglobulin levels were similar in 2 groups, and short-term follow-up (1 year) revealed no recurrence by sonography and no abnormal uptake during radioactive iodine therapy in either group.

CONCLUSIONS

The application of robotic technology to endoscopic thyroidectomy could overcome the limitations of conventional endoscopic surgery during the surgical management of PTMC.