Surgical treatment of low- and intermediate-risk papillary thyroid cancer with minimally invasive video-assisted thyroidectomy

The preferred surgical choice for intermediate-risk papillary thyroid cancer: total thyroidectomy or lobectomy? A systematic review and meta-analysis

BACKGROUND

The optimal surgical approach for intermediate-risk papillary thyroid carcinoma (IR-PTC) (according to ATA definition), whether total thyroidectomy (TT) or lobectomy (LT), has remained a contentious clinical gray area for several decades. This systematic review and meta-analysis aim to provide robust evidence and address this clinical dilemma comprehensively.

MATERIALS AND METHODS

A comprehensive literature search was conducted in Pubmed, Embase, Web of Science, and the Cochrane Library from 1st January 2009 to 29th December 2023 to evaluate the impact of different surgical options (TT or LT) on patients with IR-PTC. The primary outcomes included survival, recurrence rates, and postoperative complications. I2 and sensitivity analysis was used to explore the heterogeneity.

RESULTS

A total of 8 studies involving 2984 participants were included in this meta-analysis and systematic review. The results indicated that LT was a superior choice for mitigating complications compared to TT [risk ratio (RR), 0.32; 95% CI: 0.24-0.44, P <0.01], particularly for transient complications (RR, 0.24; 95% CI: 0.08-0.65, P <0.01), such as the transient parathyroid dysfunction (RR, 0.04; 95% CI: 0.01-0.15, P <0.01). However, TT did not increase the risk of recurrent laryngeal nerve palsy (RR, 0.78; 95% CI: 0.24-2.47, P =0.67), hemorrhage/seroma (RR, 0.77; 95% CI: 0.48-1.25, P =0.30), and permanent complications (RR, 0.18; 95% CI: 0.02-1.42, P =0.10). Besides, both LT and TT presented similar effect on survival outcomes (overall survival: RR, 1.00; 95% CI: 0.97-1.03, P =0.92, disease-specific survival: RR, 0.99; 95% CI: 0.97-1.02, P =0.69, recurrence-free survival: RR, 1.00; 95% CI: 0.96-1.05, P =0.86), recurrence (RR, 1.05; 95% CI: 0.76-1.46, P =0.76).

CONCLUSION

The present meta-analysis revealed that TT did not yield improved outcomes in IR-PTC patients, but was associated with an increased incidence of temporary complications. In light of these findings, it may be advisable to consider LT as the optimal choice for IR-PTC patients.

Mini-invasive video-assisted thyroidectomy vs robot-assisted transaxillary thryoidectomy: analisys and comparison of safety and outcomes

Thyroid surgery is characterized by large volumes and typically affects a young female population. Mini-invasive or remote access surgical techniques are born driven by the desire to improve aesthetic outcomes of the traditional technique, following technological advances that have upset the surgical world in the last 20 years. In our multicenter, retrospective observational study, we first compared an endoscopic technique with a robotic one: minimally invasive video-assisted thyroidectomy (MIVAT) and robot-assisted transaxillary thyroidectomy (RATT). We evaluated intraoperative features, complications, and cosmetic outcomes in a cohort of 609 patients. The efficacy and safety of these techniques are proven by a large literature and the comparison made in our study does not show inferiority of one technique compared to the other. Even the aesthetic results tend to be equal in the long term. It is desirable that further prospective and randomized studies are conducted to evaluate the outcomes of these procedures and the cost-benefit ratio.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Efficacy and Safety of Minimally Invasive Thyroid Surgery: A Network Meta-Analysis

OBJECTIVES

Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods.

DATA SOURCES

The PubMed, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar.

REVIEW METHODS

The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed.

RESULTS

EO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding.

CONCLUSION

It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470-2479, 2023.

Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC)

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.

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.

Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis

PURPOSE

Conventional thyroidectomy has been standard of care for surgical thyroid nodules. For cosmetic purposes different minimally invasive and remote-access surgical approaches have been developed. At present, the most used robotic and endoscopic thyroidectomy approaches are minimally invasive video assisted thyroidectomy (MIVAT), bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET), bilateral axillo-breast approach robotic thyroidectomy (BABA-RT), transoral endoscopic thyroidectomy via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy.

METHODS

A systematic search was conducted in Medline, Embase and Web of Science to identify original articles investigating operating time, length of hospital stay and complication rates regarding recurrent laryngeal nerve injury and hypocalcemia, of the different minimally invasive techniques.

RESULTS

Out of 569 identified manuscripts, 98 studies met the inclusion criteria. Most studies were retrospective in nature. The results of the systematic review varied. Thirty-one articles were included in the meta-analysis. Compared to the standard of care, the meta-analysis showed no significant difference in length of hospital stay, except a longer stay after BABA-ET. No significant difference in incidence of recurrent laryngeal nerve injury and hypocalcemia was seen. As expected, operating time was significantly longer for most minimally invasive techniques.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis comparing the eight most commonly used minimally invasive thyroid surgeries individually with standard of care. It can be concluded that minimally invasive techniques do not lead to more complications or longer hospital stay and are, therefore, not inferior to conventional thyroidectomy.

Recent Trends in Surgical Approach to Thyroid Cancer

Over the past decade, the incidence of thyroid cancer has rapidly increased worldwide, and thyroid surgery has become one of the most common performed surgical procedure. Even though conventional open thyroidectomy remains the gold standard, this approach leaves a neck scar which could be worrying mainly for young women. The recent progress in surgical technology, as well as patient cosmetic requests, have led to the development of alternative access to the thyroid lodge. Thus, alternative techniques have been established in order to potentially provide a more appealing cosmetic result, both with a minimally-invasive cervical or remote-access approach. However, the introduction of these new techniques was initially approached with caution due to technical challenges, the introduction of new complications and, above all, skepticism about the oncologic effectiveness. Among several alternative approaches proposed, the minimally invasive video-assisted thyroidectomy and the robot-assisted transaxillary thyroidectomy became popular and obtained the favor of the scientific community. Moreover, the recent introduction of the trans-oral endoscopic thyroidectomy with vestibular approach, although the safety and the efficacy are still under discussion, deserves particular attention since it represents the only technique truly scarless and provides the best cometic result. The purpose of this article is to provide an overview of the current main alternative approaches for the treatment of thyroid cancer with particular focus on the oncological effectiveness of the procedures.

Comparative study of gasless endoscopic selective lateral neck dissection via the anterior chest approach versus conventional open surgery for papillary thyroid carcinoma

BACKGROUND

Although there has been increasing interest in aesthetical approaches for treating patients with papillary thyroid carcinoma (PTC), there have been no studies comparing the safety and effectiveness of gasless endoscopic selective lateral neck dissection (SLND) via the anterior chest approach (ACA) with that of conventional open surgery (OPEN) for papillary thyroid carcinoma.

METHODS

A total of 91 patients with PTC who underwent either gasless endoscopic thyroidectomy, central compartment neck dissection and SLND via the ACA or conventional open surgery between Nov. 2008 to Dec. 2018 were included. Primary outcomes and demographic data were compared between the two groups.

RESULTS

Thirty-one patients were in the ACA group and 60 were in the OPEN group. The ACA group was younger and had a longer operative time but less intraoperative hemorrhage (P < 0.001 for all). There were no differences in other clinicopathological features. During the median follow-up of 48 months (ACA group) and 35 months (OPEN group), no recurrence on US/CT was found. The patients in the ACA group had better cosmetic results assessed postoperatively.

CONCLUSION

It appeared that gasless endoscopic selective lateral neck dissection via the anterior chest approach achieved comparable safety and effectiveness as conventional open surgery for PTC and resulted in better cosmetic results.

Comparison Between Total Thyroidectomy and Medical Therapy for Amiodarone-Induced Thyrotoxicosis

CONTEXT

It is not known whether total thyroidectomy is more favorable than medical therapy for patients with amiodarone-induced thyrotoxicosis (AIT).

OBJECTIVE

To compare total thyroidectomy with medical therapy on survival and cardiac function in AIT patients.

METHODS

Observational longitudinal cohort study involving 207 AIT patients that had received total thyroidectomy (surgery group, n = 51) or medical therapy (medical therapy group, n = 156) over a 20-year period. AIT types and left ventricular ejection fraction (LVEF) classes were determined at diagnosis of AIT. Cardiac and thyroid function were reevaluated during the study period. Survival was estimated using the Kaplan-Meier method.

RESULTS

Overall mortality and cardiac-specific mortality at 10 and 5 years, respectively, were lower in the surgery group than in the medical therapy group (P = 0.04 and P = 0.01, respectively). The lower mortality rate of the surgery group was due to patients with moderate to severely compromised LVEF (P = 0.005 vs medical therapy group). In contrast, mortality of patients with normal or mildly reduced LVEF did not differ between the 2 groups (P = 0.281 and P = 0.135, respectively). Death of patients with moderate to severe LV systolic dysfunction in the medical therapy group occurred after 82 days (interquartile range, 56-99), a period longer than that necessary to restore euthyroidism in the surgery group (26 days; interquartile range, 15-95; P = 0.038). Risk factors for mortality were age (hazard ratio [HR] = 1.036) and LVEF (HR = 0.964), whereas total thyroidectomy was shown to be a protective factor (HR = 0.210). LVEF increased in both groups after restoration of euthyroidism, above all in the most compromised patients in the surgery group.

CONCLUSIONS

Total thyroidectomy could be considered the therapeutic choice for AIT patients with severe systolic dysfunction, whereas it is not superior to medical therapy in those with normal or mildly reduced LVEF.

Video-Assisted Thyroidectomy for Papillary Thyroid Carcinoma: Oncologic Outcome in Patients with Follow-Up ≥ 10 Years

BACKGROUND

Video-assisted thyroidectomy (VAT) arisen as a valid treatment for selected patients with papillary thyroid carcinoma (PTC), but no data concerning long-term oncologic outcome are available. The primary aim of the study was to evaluate the oncologic outcome of patients who underwent VAT for PTC with a follow-up ≥ 10 years.

METHODS

The medical charts of all the patients who successfully underwent VAT for PTC were reviewed. The patients with a minimum follow-up period of 120-months were included. Patients with unifocal PTC ≤ 1 cm, in the absence of lymph node metastases, without gross extracapsular invasion and age < 45 years were considered "low-risk" patients and followed with ultrasound and serum thyroglobulin (sTg) on levothyroxine (LT4); the remaining patients underwent nuclear medicine evaluation.

RESULTS

Two hundred and fifty-seven patients, operated on between May 2000 and October 2006, were included. Postoperative complications included four transient recurrent palsies, 76 transient and 1 permanent hypocalcemia. One hundred and four low-risk patients were followed with ultrasound and sTg on LT4. At a mean follow-up of 136.6 months, mean sTg on LT4 was 0.1 ± 0.1 ng/ml. None of them showed recurrence. The remaining 153 patients underwent nuclear medicine evaluation. Among these 153, 62 did not undergo radioiodine ablation (RAI). At a mean follow-up of 150.8 months, mean sTg on LT4 was 0.1 ± 0.1 ng/ml. None of them showed recurrence. The remaining 91 patients underwent RAI. Mean pre-RAI sTg off-LT4 was 8.3 ± 5.8 ng/ml, mean radioiodine uptake was 2.8 ± 4.4%. Among these 91, three pN1a patients developed a lateral neck node recurrence. No other recurrence was registered. At the latest follow-up mean sTg on LT4 in this subgroup of patients was 0.1 ± 0.2 ng/ml.

CONCLUSIONS

The long-term (≥ 10 years) oncologic outcome further demonstrates that VAT is a valid option for selected PTC patients.

Single-incision endoscopic thyroidectomy for papillary thyroid cancer: A pilot study

BACKGROUND

Recently, we have reported single incision endoscopic thyroidectomy using an axillary approach with gas inflation (SIET) in cases with benign thyroid tumors to reduce post-operative pain and invasiveness of the conventional endoscopic thyroidectomy. The aim of this study was to present our experiences with SIET for papillary thyroid cancer (PTC).

METHODS

Patients who were diagnosed with histologically papillary thyroid carcinoma (≤1 cm) with single, unilateral, and intra-thyroidal lesion and without clinical lymph node metastasis were included. We analyzed clinico-pathological characteristics, surgical outcomes, and oncologic adequacy of the SIET procedure.

RESULTS

Between January 2011 and July 2012, a total of 75 patients underwent hemi-thyroidectomy with ipsilateral central lymph node dissection via SIET. The mean tumor size was 0.5 cm and 4.1 ± 2.43 central lymph nodes were removed. Of the patients, 98.3% were satisfied with their surgical wound post-operatively and no critical post-operative complications occurred during the study, except for one case of post-operative bleeding. There was one case of disease recurrence, which occurred in the contra-lateral cervical lymph node region 6 months after SIET. This patient underwent completion thyroidectomy with selective neck dissection.

CONCLUSION

The SIET is a safe and acceptable procedure for PTC with a reduced dissection field, less post-operative pain, and more cosmetic satisfaction than conventional endoscopic thyroid surgery.

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB)

PURPOSE

The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals.

METHODS

This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up.

RESULTS

A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case.

CONCLUSIONS

The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Comparison of Robotic versus Conventional Selective Neck Dissection and Total Thyroidectomy for Papillary Thyroid Carcinoma

OBJECTIVE

To compare the surgical outcomes of robotic selective neck dissection (SND) with total thyroidectomy and conventional transcervical SND with total thyroidectomy.

STUDY DESIGN

Case series with chart review.

SETTING

University tertiary care facility.

SUBJECT AND METHODS

We retrospectively analyzed 66 patients who underwent total thyroidectomy with SND (≥3 levels of II-V) and bilateral central neck dissection for cN1b papillary thyroid carcinoma, of whom 41 underwent conventional SND and 25 of whom underwent robotic SND. Subjective pain, sensory change, and cosmetic satisfaction were evaluated regularly for 3 months with a questionnaire.

RESULTS

Compared with the conventional group, patients in the robotic group were younger (mean, 36.7 vs 47.5 years; P = .003) and more female dominant (96.0% vs 73.2%; P = .023). Mean total operative time was longer in the robotic group than the conventional group (298 vs 236 minutes; P < .001). Anterior chest pain was higher in the robotic group at postoperative 1 day (pain score, 1.88 vs 0.62; P = .011), 1 week (1.30 vs 0.43; P = .036), and 1 month (0.90 vs 0.18; P = .029). Postoperative cosmetic satisfaction was significantly superior in the robotic group.

CONCLUSION

Compared with conventional transcervical SND with total thyroidectomy, robotic SND with total thyroidectomy yields superior outcomes for cosmetic satisfaction, longer operative time, and higher chest pain in the short term. Further study with a larger number of patients is mandatory.

Minimally Invasive Video-Assisted Total Thyroidectomy (mi V.A.T.T.) - Case Series of 48 Patients

PURPOSE

The first report of miVATT was published in 1998 by Miccoli, leading to a revolution in the field of thyroid surgery. This prospective study aims to evaluate the technique with regard to our department's experience over a four-year period.

MATERIAL-METHODS

Between September 2009 and October 2013, 48 adult patients (37 females, 11 males) with a mean age of 41.3 (± 11.6) years underwent scheduled miVATT for benign thyroid lesions. Selection criteria included thyroid volume <15 ml and nodules not exceeding 3.5 cm of diameter. Thyroiditis, previous neck surgery and previous irradiation, mediastinal goiter and involvement in another clinical study constituted the exclusion criteria. The procedure we performed was miVATT as described by Miccoli with the only additions being the use of the Harmonic Scalpel and the fixation of the endoscope on a holding device. Also, no drains were applied.

RESULTS

No conversions to open surgery were needed. Operation time for total thyroidectomy was 71.23 min (± 23.81) with a mean hospitalization of 1.14 days (± 0.4). Five patients (10.4%) exhibited transient hypocalcemia, whereas there were no recurrent laryngeal nerve palsies. Post-operative pain was mild and the final aesthetic result was considered excellent by the patients.

CONCLUSION

miVATT is a safe and feasible alternative to the conventional thyroidectomy when performed in carefully selected patients by experienced surgeons.

Video-assisted surgery for thyroid cancer patients

BACKGROUND

Today is well known that endoscopic thyroidectomy could reach the same level of completeness as a conventional operation. We have been using minimally invasive video assisted thyroidectomy (MIVAT) as our favorite minimally invasive access to thyroid diseases from the late nineties.

METHODS

Our experience with MIVAT is represented by 2,413 cases between 1998 and 2014: in particular 821 patients were operated with a total thyroidectomy for a papillary carcinoma (34.0%). Furthermore 967 patients underwent a MVAT for the presence of an undetermined lesion (40.0%).

RESULTS

The conversion rate was very low: 24 patients (1.0%), mainly due to: unexpected posterior tracheal invasions (nine patients), involvement of lymph nodes not evident at echography (four patients), esophageal infiltration (three patients), strap muscles infiltration (three patients) and finally in five cases the presence of serious thyroiditis that had escaped to ultrasonographic evaluation.

CONCLUSIONS

The minimally MIVAT to treat malignant thyroid tumors has today a very clear indication for malignancies.

Minimally invasive video-assisted thyroidectomy: reflections after more than 2400 cases performed

BACKGROUND

The minimally invasive video-assisted approach was developed for primary hyperparathyroidism in 1997 and the year after for thyroid disease. Since then, the technique has been adopted worldwide, and indications moved from the initial benign disease to low-risk and intermediate-risk carcinoma, demonstrating a level of oncologic radicality comparable to the conventional open approach when inclusion criteria are strictly respected.

METHODS

Between 1998 and 2014, 2412 minimally invasive video-assisted thyroidectomies (MIVAT) were performed in our department. The indication for surgery in 825 patients (34.3 %) was a malignant tumor, in particular, a papillary carcinoma in 800 patients. Among them, 528 patients operated on between 2000 and 2009 had a mean complete follow-up of 7.5 (standard deviation, 2.3) years.

RESULTS

A total thyroidectomy was performed in 1788 patients (74.1 %) and a hemithyroidectomy in 564 (23.4 %). Also performed was central compartment lymphadenectomy in 31 patients (1.3 %) and parathyroidectomy for the presence of a solitary parathyroid adenoma in 29 (1.2 %). Mean duration of the procedure was 41 (standard deviation, 14) minutes. After a mean follow-up of 7. 5 years, 528 patients who underwent MIVAT for low-risk or intermediate-risk papillary carcinoma presented a cure rate of 85 % (undetectable thyroglobulin), comparable with the 80 % rate reported in patients who had undergone open thyroidectomy during the same period.

CONCLUSIONS

After a long experience and a considerable number of procedures performed in a single center, MIVAT is confirmed as a safe operation, with a complication rate comparable with open thyroidectomy. MIVAT offers a cure rate for the treatment of low-risk and intermediate-risk malignancies that is comparable with an open procedure when inclusion criteria are strictly respected.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile

BACKGROUND

Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety.

METHODS

A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed.

RESULTS

Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001).

CONCLUSION

MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Minimally invasive video-assisted thyroidectomy for papillary thyroid cancer: a prospective 5-year follow-up study

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) was initially introduced for the treatment of selected patients who met certain thyroid volume, nodule size and pathological criteria. Recent studies indicate that the completeness of resection of malignant nodules is comparable to that obtained with conventional thyroidectomy.

AIMS

To compare the 5-year outcomes in patients with papillary thyroid carcinoma (PTC) treated with MIVAT versus conventional thyroidectomy.

METHODS

In this prospective cohort study conducted over 2 years (July 2005-June 2007), 172 patients with node-negative, nonmetastatic PTC underwent either MIVAT (n = 67) or conventional thyroidectomy (n = 105). Study outcomes were 1) the cumulative dose of radioactive iodine (RAI) to achieve a disease-free state, defined as a stimulated serum thyroglobulin (Tg) level &lt;2 ng/mL with negative Tg antibody and no tumor on a whole-body scan or cross-sectional imaging, and 2) the 5-year serum Tg level.

RESULTS

The clinical parameters of the MIVAT and conventional thyroidectomy groups were comparable except for age (mean 43 ± 12 vs. 59 ± 17 years, respectively; p = 0.03) and operative time (mean 69 ± 24 vs. 53 ± 16 minutes, p = 0.02); the mean tumor size was similar between groups (1.3 ± 0.7 vs. 1.6 ± 0.9 cm, p = 0.14). Surgical morbidity was similar in both groups. Median follow-up was 5 years. RAI dose (mean 72 ± 38 vs. 96 ± 47 mCu, p = 0.34) and serum Tg at 5 years (mean 0.3 ± 0.2 vs. 0.5 ± 0.3 ng/mL, p = 0.30) were not significantly different between the MIVAT and conventional thyroidectomy groups.

CONCLUSIONS

MIVAT can be safely utilized in patients with localized PTC, providing comparable completeness of resection and oncological outcome to conventional thyroidectomy.

3D laparoscopic revision thyroidectomy through an anterior chest approach: a case report

The detection rate of differentiated thyroid cancers, especially the papillary subtype, is rapidly increasing, and these malignancies have an excellent prognosis. Surgery remains the cornerstone of treatment, and numerous innovations in surgical techniques have been made in the past decade. Laparoscopic thyroidectomy is being gradually recognized as a safe and effective surgical procedure with good cosmetic results. Revision thyroidectomy is routinely performed via the open approach and rarely via laparoscopy. Three-dimensional laparoscopy offers advantages over two-dimensional laparoscopy in terms of visualization of the operative field and surgical manipulation and has been used at multiple surgical sites, but is rarely used in thyroid surgery. We present the first case of three-dimensional laparoscopic revision thyroidectomy, which was successfully performed through an anterior chest approach in a young, unmarried woman who was pathologically confirmed to have papillary thyroid cancer after an initial laparoscopic partial thyroidectomy performed 10 days prior to the revision surgery.

Minimally invasive video-assisted thyroidectomy: experience of 200 cases in a single center

Introduction

Minimally invasive techniques in thyroid surgery including video-assisted technique originally described by Miccoli have been accepted in several continents for more than 10 years.

Aim

To analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and to evaluate the feasibility and effects of this method in a general department over a 4-year period.

Material and methods

Initial experience was presented based on a series of 200 patients selected for MIVAT at the General Surgery Department of Yantai Yuhuangding Hospital affiliated with Qingdao University during the period from May 2008 to June 2012. The enrolling criteria were rigorously observed. An above sternal incision with average length of 2.5 cm (1.5–3.0 cm) was made. Clinicopathologic characteristics, postoperative pain, length of hospital stay, cosmetic results and complications were retrospectively analyzed.

Results

All patients received general anesthesia. Thyroid unilateral lobectomy was successfully accomplished in 108 cases, total thyroidectomy in 84, and partial lobectomy in 8. Conversion to standard conventional thyroidectomy was required in 6 patients (3%) because of thyroiditis and bleeding. The mean lymph node yield of the cancer specimens was 3.6 per patient. Permanent unilateral recurrent laryngeal nerve (RLN) palsy occurred in 1 case (0.5%), transient unilateral RLN palsy in 6 patients (3.0%, complete recovery after 1–6 months), and transient hypocalcemia in 7 patients (3.5%). No definitive hypocalcemia was observed. No postoperative hematomas occurred. Postoperative pain was endurable. The cosmetic result was excellent in most cases.

Conclusions

The MIVAT is feasible and safe in selected patients, with better results comparable to conventional thyroidectomy. The MIVAT can also be performed in a general surgery department.

Minimally invasive compared with conventional thyroidectomy for nodular goitre

Since minimally invasive thyroidectomy was introduced in 1997, different surgical approaches to the thyroid have been described: the minimal neck incision and the anterior chest, areolar breast or axillary access. Whereas conventional open thyroidectomy is suitable for any thyroid disease, minimal neck incision thyroidectomy or extracervical scarless neck thyroidectomy are limited to small-volume disease. In 11 prospective randomized studies and six systematic reviews, minimally invasive video-assisted thyroidectomy via a central or lateral neck approach afforded better cosmesis in the first 3 months than conventional open thyroidectomy, with less postoperative pain for the first 48 h. Surgical morbidity did not differ in these limited studies. No head-to-head comparison is available for extracervical scarless neck thyroidectomy and conventional open thyroidectomy. Extracervical scarless neck thyroidectomy caused more postoperative pain and gave rise to complications not seen with minimal neck incision thyroidectomy or conventional open thyroidectomy. In the absence of evidence to the contrary, conventional open thyroidectomy continues to remain the gold standard for any nodular goitre.

Minimally invasive video-assisted versus minimally invasive nonendoscopic thyroidectomy

Minimally invasive video-assisted thyroidectomy (MIVAT) and minimally invasive nonendoscopic thyroidectomy (MINET) represent well accepted and reproducible techniques developed with the main goal to improve cosmetic outcome, accelerate healing, and increase patient's comfort following thyroid surgery. Between 2007 and 2011, a prospective nonrandomized study of patients undergoing minimally invasive thyroid surgery was performed to compare advantages and disadvantages of the two different techniques. There were no significant differences in the length of incision to perform surgical procedures. Mean duration of hemithyroidectomy was comparable in both groups, but it was more time consuming to perform total thyroidectomy by MIVAT. There were more patients undergoing MIVAT procedures without active drainage in the postoperative course and we also could see a trend for less pain in the same group. This was paralleled by statistically significant decreased administration of both opiates and nonopiate analgesics. We encountered two cases of recurrent laryngeal nerve palsies in the MIVAT group only. MIVAT and MINET represent safe and feasible alternative to conventional thyroid surgery in selected cases and this prospective study has shown minimal differences between these two techniques.

BRAF mutation status in papillary thyroid carcinoma: significance for surgical strategy

BACKGROUND

BRAF mutation is probably the only molecular marker acting as a risk factor that is available before surgery: for this reason, soon after it became quite widespread, it seemed an important tool as a guide towards an individualized surgical therapy in papillary thyroid carcinoma.

PURPOSE

Capsule invasion, multifocality, and lymph node involvement are the most important parameters influencing the choice of surgical strategy in front of small papillary cancers and, in more detail, of micro papillary carcinomas. The relationship between these parameters and the BRAF mutation are closely examined through the more recent literature. Capsular invasion seems to show the strongest correlation with the mutation and this has important correlations, thus suggesting that a more aggressive local surgery might be advisable, whereas the correlation between the mutation and lymph node involvement would be weaker, at least according to the most recent studies.

CONCLUSIONS

The personalization of surgical therapy, today, seems easier to achieve thanks to molecular testing. In particular, an important result could be in the short term reduction in the number of completion thyroidectomies following simple lobectomies. Also, post operative radioactivated iodine therapies should be more carefully evaluated and tailored according to BRAF status. A possible flow chart for the decision of the therapeutic approach is proposed in accordance to the results of the literature.

Endoscopic thyroidectomy for differentiated thyroid cancer

Endoscopic thyroidectomy is a relatively new approach in treating differentiated thyroid cancer. Since last decades, more and more endoscopic thyroidectomies have been performed. We review the indications and contraindications, methods, and postoperational complications of this surgical procedure. Lots of surgical approaches have been developed in endoscopic thyroidectomy for differentiated thyroid cancer. Compared to conventional thyroidectomy, scarless endoscopic thyroidectomy has a superior cosmetic result. And it also reduces the incidence of hypesthesia, paresthesia, or feelings of self-consciousness. However, the outcome depends, to a large extent, on the skill of the operator and the learning curve being relatively long. With the development of surgical equipments and skills, operation time and complications will be reduced. Indications of endoscopic thyroidectomy will be widened and it will be more and more performed.

Video-assisted versus conventional total thyroidectomy and central compartment neck dissection for papillary thyroid carcinoma

BACKGROUND

Although video-assisted (VA) thyroidectomy emerged as effective treatment for selected patients with papillary thyroid carcinoma (PTC), some concerns remain about obtaining adequate central neck node clearance. We compared patients who underwent VA and conventional total thyroidectomy (TT) and central compartment dissection (CCD) for PTC.

METHODS

A total of 52 consecutive patients successfully underwent VA-TT and VA-CCD for PTC (VA group) were compared to 52 controls who underwent conventional TT and CCD (C group) for PTC.

RESULTS

The two groups were matched for age (p = 0.75), sex (p = 0.07), and tumor size (p = 1.0). Operating time (p = 0.23), overall postoperative complications (p = 0.41), pT (p = 0.44), and pN (p = 0.84) were similar in the two groups. The mean number of removed nodes was similar (10.6 ± 4.6 in VA group vs. 12.2 ± 5.6 in C group) (p = 0.11).Mean postoperative serum thyroglobulin (sTg) off levothyroxine (LT4) suppressive treatment was 3.2 ± 5.0 ng/ ml in the VA group and 2.6 ± 7.4 ng/ml in the C-group (P = 0.67). Mean postoperative radioiodine uptake (RAIU) was similar in the two groups (1.5 ± 1.3 vs. 1.7 ± 1.3%) (p = 0.49). When pN1a patients alone were considered, no difference was found between the VA group (21 patients) and the controls (24 patients) concerning the mean number of removed nodes (10.3 ± 4.1 vs. 12.4 ± 5.6) (p = 0.16), the mean sTg off LT4 (4.4 ± 6.0 vs. 1.9 ± 2.7 ng/ml) (p = 0.07) and the mean RAIU (1.9 ± 1.5 vs. 1.7% ± 1.3%) (p = 0.63).

CONCLUSIONS

The results of VA-TT and CCD in selected cases of PTC appear to be comparable to those of conventional surgery. A longer follow-up and larger series are necessary to draw definitive conclusions concerning longterm outcomes.

Minimally invasive video-assisted thyroidectomy: seven-year experience with 240 cases

Introduction

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance in recent years as an alternative to conventional thyroid surgery.

Aim

Assessment of our 7-year experience with MIVAT.

Material and methods

A retrospective study of 240 consecutive patients who underwent MIVAT at our institution between 01/2004 and 05/2011 was conducted. The inclusion criterion was a single thyroid nodule below 30 mm in diameter within the thyroid of 25 ml or less in volume. The exclusion criteria were previous thyroid or parathyroid surgery, T2 or higher thyroid cancer, N1 stage, and thyroiditis. The Miccoli technique was used. The analysis included indications, eligibility rate, operative time, morbidity and cosmetic effects.

Results

Of 6,574 patients referred for thyroid surgery, 240 (3.6%) were eligible for MIVAT. In the final pathology report, there were 206 follicular adenomas, 21 papillary thyroid cancers, 9 cases of Graves’ disease and 4 follicular cancers. Reasons for exclusion were as follows: thyroid volume above 25 ml in 5401 (85.3%), thyroid cancer larger than stage T1 in 392 (6.2%), thyroiditis in 358 (5.6%), and previous neck surgery in 183 patients (2.9%). Minimally invasive video-assisted thyroidectomy operations consisted of 210 lobectomies and 30 total thyroidectomies, including 15 one-stage parathyroidectomies. Mean operative time was 38.6 ±15.1 min. Transient versus permanent recurrent laryngeal nerve injury was found in 8 (3.0%) vs. 2 (0.7%) nerves at risk, respectively. Cosmetic effects were assessed after 1 and 6 months of follow-up as very good or excellent by 89.6% and 95.8% of patients, respectively.

Conclusions

Minimally invasive video-assisted thyroidectomy is suitable for surgeons experienced in thyroid and video-assisted surgery. It is feasible for well-selected patients including cases of T1 thyroid cancer, Graves’ disease and concomitant parathyroid adenoma.

Evaluation of surgical completeness in endoscopic thyroidectomy compared with open thyroidectomy with regard to remnant ablation

PURPOSE

To assure the surgical completeness of the bilateral axillo-breast approach (BABA) endoscopic thyroidectomy (ET), we compared ET and open thyroidectomy (OT) by means of the radioactive iodine (RAI) uptake of remnant thyroid.

MATERIALS AND METHODS

From January 2003 to May 2007, 46 patients who had received RAI ablation after total thyroidectomy because of papillary thyroid microcarcinoma were enrolled. Of total, 25 patients underwent ET and the other 21 underwent OT. The RAI activity of remnant thyroid was measured by the neck-to-skull uptake ratio on the first postoperative RAI ablation scan. Stimulated thyroglobulin levels, the total number of RAI ablation sessions, and doses of RAI for completion of ablation were also compared.

RESULTS

There were no significant differences in regards of the RAI uptake ratio, the stimulated thyroglobulin level, the total number of RAI ablation sessions, and doses of RAI for completion of ablation, between ET and OT groups.

CONCLUSION

The completeness of the surgical removal by BABA ET was comparable with that of OT. The BABA ET might give a safe option for patients with low-risk thyroid cancer.

Surgical completeness of bilateral axillo-breast approach robotic thyroidectomy: comparison with conventional open thyroidectomy after propensity score matching

BACKGROUND

Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) has good postoperative and excellent cosmetic outcomes. To assess the surgical completeness of BABA RoT, it was compared to open thyroidectomy (OT) after propensity score matching of the cohorts.

METHODS

Between 2008 and 2010, 760 patients who underwent total thyroidectomy with central node dissection (CND) caused by papillary thyroid carcinoma (PTC) in Seoul National University Hospital were enrolled; 327 BABA robotic and 423 open method operations were performed. We selected 174 robotic and 237 open thyroidectomy patients who received radioactive iodine (RAI) ablation. Propensity score matching using 3 demographic and 5 pathologic factors was used to generate 2 matched cohorts, each composed of 108 patients.

RESULTS

The matched BABA RoT and OT cohorts were not different with regard to the RAI uptake ratio, stimulated thyroglobulin (Tg) levels, or proportion of patients with stimulated Tg levels <1.0 ng/mL on the first ablation. The number of RAI ablation sessions and RAI doses needed to achieve a complete ablation also did not differ significantly.

CONCLUSION

The surgical completeness of BABA RoT did not differ from OT. BABA RoT may be suitable for patients with PTC who prefer scarless neck surgery.

Advances in surgical therapy for thyroid cancer

Thyroid cancer is the most common malignancy of the endocrine system and its incidence has dramatically increased over the past three decades. Well-differentiated thyroid cancers (DTCs) are the main focus of this article, as they represent >90% of thyroid malignancies. This Review provides an overview of the controversies surrounding the optimal choice of surgery and extent of resection for patients with low-risk DTC or with papillary thyroid microcarcinoma, and the role of prophylactic central lymph node dissection. This Review also outlines the current surgical management of DTC and presents updated results for these techniques, along with important advances and current dilemmas in surgical approaches to treatment of these cancers. For example, endoscopic and robotic thyroidectomy are the two most recent innovations to present technical and other challenges to the endocrine surgeon; in addition, the risks as well as the advantages of same-day thyroid surgery, which has gained some acceptance, are detailed. Arguments for and against each approach are presented, along with supporting evidence. The authors' personal opinions are also provided for each topic.

Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update

Thyroid surgery during the last century was characterized by a development of Kocher's concepts: through a relentless work of surgeons from all over the world thyroidectomy reached a standard of quality in terms of overall results which was unimaginable in the first half of the XX century. The flattering data collected in the literature until the 90's were all concordant in assuming that there would be little space for a real improvement in the quality standard of thyroid surgery. The introduction of laparoscopic surgery, though, changed very quickly the attitude of surgeons towards their operative behavior and countless new mini-invasive techniques were soon proposed for almost any field of surgery. In 1994, Gagner published the first series of laparoscopic adrenalectomies. Soon after, parathyroid adenomas seemed to offer an ideal field of application of these new surgical concepts. The first report of an endoscopic parathyroidectomy was in 1996. One year later other videoscopic procedures were described whose results seemed quite encouraging so as to push surgeons to try the same access and the same technique also for operations on thyroid. During the following decade several endoscopic or video-assisted approaches were proposed for the removal of thyroid gland. This paper aims to evaluate the results of minimally invasive thyroid and parathyroid surgery through an extensive review of the literature, in particular as far as minimally invasive video-assisted thyroidectomy is concerned.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Minimally invasive video-assisted thyroidectomy 2.0: expanded indications in a tertiary care cancer center

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) advantages include a smaller incision, less extensive surgical dissection, improved visualization secondary to rigid fiberoptics, and decreased postoperative pain. The aims of our study were to report our experience using expanded indications of MIVAT.

METHODS

A retrospective chart review of a single surgeon's initial experience was carried out at a tertiary academic cancer center.

RESULTS

In all, 53 patients were identified, of whom 40 underwent total thyroidectomy and 13 underwent hemithyroidectomy. Thyroid volume, nodule size, incision length, and surgical time were all examined. Most common pathology was well-differentiated papillary thyroid cancer (69.8%): 42% of patients had evidence of thyroiditis found on pathology; 17% of patients had temporary vocal cord paralysis, with only 1 case of vocal cord paralysis persisting >6 months (1.9%). Six patients (11%) experienced temporary hypocalcemia, requiring postoperative calcium supplementation; no patients experienced permanent hypocalcemia.

CONCLUSIONS

The use of MIVAT with expanded indications shows complication rates comparable to those of traditional open thyroidectomy.

Video-assisted thyroidectomy for papillary thyroid carcinoma

Background. The results of video-assisted thyroidectomy (VAT) were evaluated in a large series of patients with papillary thyroid carcinoma (PTC), especially in terms of completeness of the surgical resection and short-to-medium term recurrence. Methods. The medical records of all patients who underwent video-assisted thyroidectomy for PTC between June 1998 and May 2009 were reviewed. Results. Three hundred fifty-nine patients were included. One hundred twenty-six patients underwent concomitant central neck node removal. Final histology showed 285 pT1, 26 pT2, and 48 pT3 PTC. Lymph node metastases were found in 27 cases. Follow-up was completed in 315 patients. Mean postoperative serum thyroglobulin level off levothyroxine was 5.4 ng/mL. Post operative ultrasonography showed no residual thyroid tissue in all the patients. Mean post-operative ¹³¹I uptake was 1.7%. One patient developed lateral neck recurrence. No other recurrence was observed.

Technological innovations in surgical approach for thyroid cancer

Over the last decade, surgeons have witnessed dramatic changes in surgical practice as a result of the introduction of new technological advancement. Some of these changes include refinement of techniques in thyroid cancer surgery. The development of various endoscopic thyroidectomy techniques, the addition of the da Vinci robot, and the use of operative adjuncts in thyroid surgery, such as intraoperative neuromonitoring and quick intraoperative parathyroid hormone, have made thyroid cancer surgery not only safer and better accepted by patients with thyroid cancer but also offer them more surgical treatment options.

Considerations for personalized surgery in patients with papillary thyroid cancer

BACKGROUND

Personalizing treatment for papillary thyroid cancer (PTC) requires a multidisciplinary approach. The surgical management of PTC has long been based on retrospective studies focusing on endpoints that are of debatable significance. There is considerable debate in the literature regarding the optimal initial treatment for PTC. Many of these issues are discussed in this review. These debates have hindered the development of a tailored treatment strategy.

SUMMARY

The ability to optimally personalize a surgical plan for the treatment of PTC is ultimately dependent on an understanding of the biological behavior of that individual patient's tumor. We are at the genesis of an age where molecular biology advances endeavor to profile a patient's tumor behavior. This review summarizes current strategies for managing PTC, where we are with personalizing surgery for these patients, and where we hope to go. Thyroid surgery is one of the newest fields for the application of minimally invasive techniques and can now be accomplished endoscopically or with robotic assistance in many patients who therefore may benefit from these alternative approaches.

CONCLUSION

When treating a patient with PTC, it seems prudent to weigh the many factors discussed in this review to individualize the most optimal surgical plan.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Surgical technique refinements in head and neck oncologic surgery

The head and neck region poses a challenging arena for oncologic surgery. Diseases and their treatment can affect a myriad of functions, including sight, hearing, taste, smell, breathing, speaking, swallowing, facial expression, and appearance. This review discusses several areas where refinements in surgical techniques have led to improved patient outcomes. This includes surgical incisions, neck lymphadenectomy, transoral laser microsurgery, minimally invasive thyroid surgery, and the use of vascularized free flaps for oromandibular reconstruction.