A comparison of surgical morbidity and scar appearance between gasless, transaxillary endoscopic thyroidectomy (GTET) and minimally invasive video-assisted thyroidectomy (VAT)

Patient satisfaction and operator proficiency in gasless transaxillary endoscopic thyroidectomy under IONM: a retrospective cohort study

Background

This study aims to evaluate the surgical safety and effectiveness of gasless transaxillary endoscopic thyroidectomy (GTET), assess patients' short-term perceptions and long-term outcomes, and delineate the learning curve and key surgical techniques of the operators.

Materials and methods

Clinicopathological and postoperative follow-up data from patients with unilateral thyroid cancer in the same period were collected. These patients were divided into the GTET group and the traditional open surgery group to compare and analyze the differences and explore the factors affecting the learning curve of GTET.

Results

Patients who chose GTET had better general health and thyroid conditions than those in the open group, and the quality of postoperative life was better in the GTET group than in the open group, with the main differences between the two groups being appearance and neck and shoulder function. The GTET learning curve in this study peaked at 19 cases, with slight differences between left and right, and a larger sample size is still needed to explore the factors affecting the learning curve.

Conclusions

GTET has a reliable safety and efficacy profile for patients with unilateral thyroid cancer. Intraoperative nerve monitoring (IONM) techniques require some adaptation in GTET. In some respects, patients' postoperative experience and quality of life are superior to those of conventional open surgery. There is a learning curve for GTET, but large samples are still needed to explore its true significance.

Correlation between surgical position and neck pain in patients undergoing thyroidectomy: a prospective observational study

BACKGROUND

Thyroid diseases are one of the most common health problems worldwide. Although they represent a necessary step in order to perform thyroidectomy, hyperextension of the neck can potentially increase postoperative pain. The aim of this study is to determine a correlation between the degree of neck hyperextension on the operative table and the postoperative pain in patients undergoing open thyroidectomy.

METHODS

Patients were prospectively enrolled from the cohort of patients operated at the Endocrine Surgery Unit of the University Hospital of Pisa, between May and July 2021. Both of patients who underwent total thyroidectomy or hemi-thyroidectomy were recruited. The following data were analysed in order to find a correlation with postoperative pain at 24 h: age, gender, type of surgery, BMI, operative time, and degree of neck extension.

RESULTS

Overall, 195 patients were enrolled. A direct, statistically significant correlation emerged between the degree of neck hyperextension and the postoperative pain 24 h after surgery, regardless of the pain of the surgical wound (p < 0.001; beta 0.270).

CONCLUSIONS

A direct correlation emerges between neck tilt angle and postoperative neck pain. Moreover, total thyroidectomy (TT) predisposes more to postoperative neck pain, considering the type of surgery.

Analysis of trends and status of evaluation methods in thyroid scar

Background

The incidence of thyroid cancer has increased over the decades, and patients prefer short thin scars after thyroidectomy due to their cosmetic visibility. Several scar assessment methods have been used to determine the most cosmetically optimal surgical method, but a widely accepted measurement tool is still lacking. This study investigates the usage status in the thyroid scar scale according to time, region, and study method.

Methods

The authors searched for articles on thyroid scars published between January 2000 and September 2022 in the PubMed database. The study included clinical studies that mentioned thyroid scar and scar scale, excluding articles that did not evaluate neck scars. Statistical analysis was performed using IBM SPSS Statistics 29.

Results

A total of 35 studies were included. Among them, 17 used the Vancouver Scar Scale (VSS), 17 used the Patient and Observer Scar Assessment Scale (POSAS), four used the Manchester Scar Scale (MSS), and four used the Stony Brook Scar Evaluation Scale (SBSES). VSS and POSAS were the most commonly used scar evaluation methods. VSS tended to be used frequently in Asia, while POSAS was used frequently in Europe and in randomized controlled trials.

Conclusion

VSS and POSAS are popular thyroid scar assessment methods, with regional variations. Standardization is needed for meaningful comparisons. Patient's subjective evaluations should be considered, given the cosmetic importance of thyroid scars.

Parathyroidectomy for solitary parathyroid adenoma via trans-areola single site endoscopic approach: Results of a case-match study

BACKGROUND

This study aimed to establish the standardized procedure of trans-areola single site endoscopic parathyroidectomy (TASSEP), and to compare the performance of TASSEP with that of conventional open parathyroidectomy (COP).

METHODS

This study enrolled 40 patients with primary hyperparathyroidism (PHPT) who underwent TASSEP, and included 40 of 176 PHPT patients who underwent COP based on propensity score matching. The retrospective analysis was conducted based on prospectively collected data. Perioperative outcomes, including surgical profile, surgical burden and cosmetic results and follow-up were reported. The learning curve was described using a cumulative sum (CUSUM) analysis.

RESULTS

40 TASSEPs were completed successfully without conversions or severe complications. There was no statistically significant difference in operation time between TASSEP and COP groups (80.83 ± 11.95 vs. 76.95 ± 7.30 min, p = 0.084). Experience of 17 cases was necessitated to reach the learning curve of TASSEP. Postoperative pain score and traumatic index (C-reactive protein and erythrocyte sedimentation rate) in TASSEP were apparently lower than those in COP group (p < 0.05). During the proliferation and stabilization phases, TASSEP was associated with significantly better incision recovery and cosmetic scores. Postoperative serum calcium and PTH levels throughout the follow-up period indicated satisfactory surgical qualities in both groups.

CONCLUSION

Based on precise preoperative localization and intraoperative planning facilitated by three-dimensional (3D) virtual modeling, TASSEP can be feasibly performed on selected patients with satisfactory success rates and low complication rates, providing preferable cosmetic results and alleviating the surgical burden to a certain extent.

Clinical analysis of a new multifunctional instrument set for gasless endoscopic thyroidectomy with two different approaches

BACKGROUND

Following the rapid development of endoscopic thyroidectomy techniques, various surgical procedures have been developed (e.g., transoral, submandibular, areolar, axillary, retroauricular, and combined procedures), and each of these procedures has its own advantages. In recent years, gasless endoscopic thyroidectomy has emerged as a feasible procedure, and it has replaced traditional CO2 insufflation approaches because of advantages such as stable cavity construction, pollution reduction, resource saving, and risk reduction. However, each gasless procedure requires special instruments for cavity construction, and this results in enormous wastage of medical resources. In the present study, we introduced a set of instruments developed by our team. This set of instruments is designed to be compatible with the current gasless endoscopic thyroidectomy approaches, including transoral, submandibular, transareolar, transaxillary, retroauricular, combined, and lateral cervical lymph node dissection. Here, we introduced this set of instruments for two gasless endoscopic thyroidectomy procedures (transaxillary and transareolar). Following the incorporation of this set of instruments in regular clinical practice, it could be used for more gasless endoscopic thyroidectomy procedures in the future.

OBJECTIVE

To investigate the feasibility, safety, and efficacy of the self-developed instruments for gasless endoscopic thyroidectomy in two different approaches.

METHODS

A total of 180 patients diagnosed to have papillary thyroid carcinoma (PTC) between January 2020 and April 2022 were retrospectively investigated. The patients were assigned to a gasless transaxillary group (group A) and a gasless transareolar group (group B). The same gasless endoscopic-assisted instruments were used for both groups. The clinical characteristics, treatment results, and complications were compared between the two groups.

RESULTS

All 180 patients were successfully operated. The extent of surgical resection in all patients was the same: "unilateral glandular lobectomy + isthmus combined with ipsilateral central zone lymph node dissection." There were 130 and 50 patients in group A and group B, respectively; one patient in the former group was converted to open surgery due to intraoperative bleeding. No significant difference was observed between the two groups in terms of gender, age, body mass index (BMI), education level, and proportion of concomitant Hashimoto's thyroiditis (P > 0.05). The establishment of cavity time was significantly longer in group A than in group B (35.62 ± 5.07 min vs. 17.46 ± 2.55 min, P < 0.01). The number of lymph nodes cleared was slightly less in group A than in group B (4.06 ± 2.93 vs. 4.52 ± 2.38, P = 0.07). Moreover, the two groups showed no significant differences (P > 0.05) in the total operative time (145.54 ± 45.11 min vs. 143.06 ± 46.70 min), tumor size (0.68 ± 0.46 cm vs. 0.71 ± 0.49 cm), postoperative hospital stay (4.08 ± 1.48 days vs. 3.72 ± 1.07 days), vocal cord paralysis [4 (3.1%) vs. 2 (4%)], postoperative swallowing discomfort [24 (18.5%) vs. 5 (10%)], and postoperative recurrence and satisfaction scores (3.27 ± 1.52 vs. 3.28 ± 1.53).

CONCLUSION

Although the two approaches of gasless endoscopic surgery have different operative paths and different time periods for cavity construction, both approaches are similar in terms of the principle of cavity construction, safe and reliable postoperative efficacy, and good cosmetic effect. Therefore, the same set of instruments can be used to complete the surgery in both approaches, thus saving medical resources and facilitating the popularization of this technology.

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.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique

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.

Comparison of Tissue Adhesive Glue with Subcuticular Absorbable Suture for Skin Closure Following Thyroid Surgery: A single-blinded randomised controlled trial

Objectives

This study aimed to compare the skin closure time, postoperative pain and the scar outcome between tissue adhesive and sub-cuticular sutures in thyroid surgery.

Methods

This study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, a tertiary care hospital in India from March 2017 to December 2019. Adult patients undergoing thyroid surgery were included while those with previous neck surgery, history of keloids/hypertrophic scars and those undergoing concomitant neck dissections were excluded. Following platysma closure, patients were randomised into two groups (tissue adhesive and subcuticular sutures) using the Serially Numbered Opaque Sealed Envelopes technique. A sample size of 64 in each group was calculated for this prospective, single-blinded and randomised controlled trial. The primary outcome was the skin closure time. The secondary outcomes were postoperative pain at 24 hours and scar scoring at 1^st and 3^rd postoperative month. Statistical analysis was done using SPSS software.

Results

A total sample of 124 patients were included in this study, with 61 patients assigned to the suture group and 63 assigned to the tissue adhesive group. The median skin closure time and postoperative pain was significantly lower in the tissue adhesive group as compared to the suture group (P <0.01). There was no statistically significant difference in scar outcome at the 1^st or 3^rd months between both groups (P = 0.088 and 0.137, respectively). There were no wound-related complications in either group. When a subgroup analysis was conducted, no difference was seen in the scar outcome or wound-related complications in patients with comorbidities. There were no instances of allergic contact dermatitis to the tissue adhesive.

Conclusion

The use of tissue adhesive leads to lower operative time and less postoperative pain in thyroid surgeries. The scar outcome is comparable between tissue adhesives and subcuticular sutures.

Comparison of Postoperative Scarring in Asian Women After Supra-brow and Sub-brow Blepharoplasty: A Retrospective Study

BACKGROUND

Supra-brow and sub-brow blepharoplasty are two types of upper eyelid blepharoplasties that are commonly performed in middle-aged Asian women to correct skin laxity of the upper eyelid; the postoperative scar formation of the two procedures may be different. Therefore, we designed this retrospective study to explore the differences in postoperative scarring between patients receiving supra- or sub-brow blepharoplasty.

METHODS

We identified 52 patients who underwent supra-brow blepharoplasty and 54 patients who underwent sub-brow blepharoplasty. For each patient, the scar quality was assessed using photographs, the Observer Scar Assessment Scale (OSAS), and the Patient Scar Assessment Scale (PSAS) 1 year following surgery.

RESULTS

For OSAS, higher scores for pigmentation, thickness, relief, pliability, surface, and overall opinion were observed in patients who underwent supra-brow blepharoplasty (p < 0.05) except for the "vascular score" (p = 0.148). The average overall opinion scores of the supra- and sub-brow blepharoplasty were 3.90 ± 0.41 and 2.33 ± 0.48, respectively, indicating that acceptance of postoperative scars in patients who underwent supra-brow blepharoplasty was worse than that in patients who underwent sub-brow blepharoplasty. Significantly higher scores were observed in all items of PSAS items for patients with supra-brow blepharoplasty (p < 0.05).

CONCLUSIONS

The postoperative scars in patients who underwent supra-brow blepharoplasty were more obvious than those in sub-brow blepharoplasty. From the perspective of postoperative scar formation, sub-brow blepharoplasty may be a more suitable choice for patients.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transaxillary gasless endoscopic hemithyroidectomy versus conventional open hemithyroidectomy: early single-centre experience

Conventional open thyroidectomy is defined as a gold standard in thyroid gland disease treatment. However, progressive surgery methods such as endoscopic technique provide better structure visualisation and improved cosmetic effect. Our study aim is to compare conventional open (COH) and endoscopic transaxillary hemithyroidectomy (TAH) and define the learning curve for TAH procedure. We retrospectively analysed 107 COH and 65 TAH cases. Patients' demographic data and surgery results were compared. Also, surgeon learning curve analysis using cumulative sum (CUSUM) was performed for the duration of the surgery. TAH was applied to younger female patients with lower thyroid gland volume. COH group patients were hospitalised for longer in comparison with TAH (p < 0.05). Mean TAH surgery time was longer (78.1 min, SD = 22.6) compared with COH (66.7 min, 15.3) (p < 0.05). Overall complication rate was comparable between groups. There was a tendency towards a lower unintentional parathyroidectomy rate in TAH group. TAH group results showed significantly longer surgery time for patients whose body mass index (BMI) was over 30 (kg/m²), compared to whose BMI was below 30 (kg/m²) (p = 0.004). Shortest endoscopic surgery time (64.9 ± 12.45 min) was achieved between 41 and 50 cases. CUSUM analysis showed that surgery time decreased after the 30th TAH case. TAH approach compared to COH results in longer surgery time, shorter hospital stay and comparable rate of postoperative complications. However matched pair studies are necessary to clarify the results. After thirty cases, the surgeon became proficient in transaxillary endoscopic thyroid surgery.

Scar satisfaction assessment after conventional thyroidectomy: follow-up results

Objective

With the introduction of remote access thyroidectomy questions regarding patient satisfaction after trans-cervical thyroidectomy has been raised in several publications. As far as neck scars are concerned, patient satisfaction in the early post-operative period and long term are different. This study assessed patient satisfaction regarding their neck scar in the early post-operative period and at long term follow-up.

Methods

Retrospective study. Patients underwent total thyroidectomy by single surgeon. Scar satisfaction scores assessed at different time intervals (< 6 weeks, 6 months, 2 years and 5 years after procedure). Scores of patients aged < 35 years and > 35 years were compared. Patient and observer scar assessment scales (PSAS, OSAS) and patient satisfaction score (PSS) were used.

Results

595 patients were included (443 females and 152 males, age 19-77 years). Improvement was observed in the PSAS (13.5 ± 2.3 at 6 weeks; to 4.32 ± 1.37 at 5 years; p < 0.05) and OSAS (7.32 ± 1.35 to 4.18 ± 1.51; p < 0.05). PSS improved over time from 1.8 ± 0.8 to 0.92 ± 0.66 (p < 0.05). The satisfaction scores were higher in patients < 35 years (p = 0.003). The scores indicated excellent patient satisfaction and are similar to those published in the literature regarding minimally invasive surgery (MIS).

Conclusions

Proper incision placement and suturing resulted in excellent patient satisfaction regarding scars after conventional thyroidectomy.

Thyroidectomy for thyroid cancer via transareola single-site endoscopic approach: results of a case-match study with large-scale population

BACKGROUND

Due to technical challenges, single-site endoscopic thyroidectomy (SSET) is seldom reported and has been attempted in only limited cases. This large-scale study aimed to compare the clinical outcomes of standardized transareola SSET (TASSET) with those of conventional open thyroidectomy (COT) for thyroid cancer.

METHODS

The data were prospectively collected, and case-match study was performed at a ratio of 1:1 according to age, sex, body mass index, lesion size, number of lesion foci, lesion side, recurrent laryngeal nerve (RLN) exploration and pathology. Two hundred eligible patients underwent TASSET, and the same number of patients was selected for propensity score matching from 2256 patients who underwent COT. Perioperative data, including surgical profile, oncological and traumatic burdens, and cosmetic satisfaction, were analyzed.

RESULTS

No significant differences were observed in blood loss or drainage between TASSET and COT groups. There were no differences in operation time between TASSET and COT (106.39 ± 28.44 vs 102.55 ± 23.10 min, p = 0.154). A total of 3.63 ± 1.82 lymph nodes (LNs) were retrieved from CND with 0.96 ± 1.42 positive in TASSET. In COT, the total and positive LN yields were 3.77 ± 1.91 and 0.99 ± 1.40 (p = 0.445, p = 0.802). Cancer recurrence was not observed in either group. There were no differences in the occurrence of permanent and transient hoarseness or RLN injuries. Postoperative flap seroma or hematoma occurred in 12 TASSET patients and 58 COT patients (p < 0.001). The pain score, CRP level and ESR in TASSET group were lower than those in COT group. TASSET yielded significantly better incision recovery and cosmetic scores than did COT at both the proliferation and stabilization stages.

CONCLUSIONS

TASSET is technically feasible and yields enhanced recovery with minimally invasive and cosmetic advantages without compromising the level of safety or cancer eradication.

Postoperative quality of life and cosmetic outcome between minimally invasive video-assisted thyroidectomy and bilateral axillo-breast approach robotic thyroidectomy: a single center retrospective cohort study

Different approaches to endoscopic thyroidectomy utilize incisions that result in inevitable physical trauma to patients since postoperative tissue fibrosis and scars will influence their quality of life for a lifetime. Over the past few years, most studies have discussed the safety concerns of different kinds of endoscopic thyroidectomy; conversely, there has been less discussion on postoperative quality of life. Because most patients undergoing thyroidectomy for cancer or benign diseases are likely to have long-term survival, it is essential to study the cosmetic outcome of patients' scars from minimally invasive video-assisted thyroidectomy (MIVAT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy on quality of life. From July 2015 to December 2017, 95 patients-60 who underwent MIVAT and 35 who underwent BABA robotic thyroidectomy-were retrospectively studied. Patient demographics, operative indications, pathologic findings, pain scores after surgery, complications, perception of scars, and overall satisfaction were compared between the two groups. The cosmetic outcome and overall satisfaction were evaluated at least 2 years after the operation using the patient scar assessment questionnaire and the 36-item short form health survey (SF-36). There was no statistically significant difference in scar perception between the two groups. However, in the SF-36, the MIVAT group had better satisfaction than the BABA robotic group regarding general health, vitality, mental health, and health change. MIVAT and BABA robotic thyroidectomy can be safely performed in selected patients, and patients who underwent MIVAT had better postoperative qualities of life than those who underwent the BABA robotic approach.

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.

The Influence of Cosmetic Concerns on Patient Preferences for Approaches to Thyroid Lobectomy: A Discrete Choice Experiment

Background: Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. Methods: A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. Results: The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. Conclusions: The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.

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.

Characteristics of the parathyroid gland in endoscopic thyroidectomy with the application of an image enhancement system

BACKGROUND

To assist surgeons in identifying and preserving the parathyroid gland (PTG) in endoscopic thyroidectomy (ET), we have summarized the characteristics of the PTG and the surrounding tissues in ET by applying the Storz Professional Image Enhancement System (SPIES).

METHODS

From November 2014 to May 2016, 182 patients with 613 suspected PTGs were included in our study. The shape, color, area, and density of surface blood vessels (SBVs); whether they were encapsulated with adipose tissue; and whether congestion was present during the operation were summarized. The κ coefficient of interobserver agreement in assessing the area and the density of SBVs of suspected PTGs with and without Spectra A (SA) and Spectra B (SB) modalities were calculated. Multiple binary logistic regression analyses were performed to determine the predictive value of different characteristics for detecting the PTG in ET with the application of SPIES.

RESULTS

With visual identification and histopathological results as reference standards, 291 targeted tissues were identified as PTGs, 256 as adipose tissue, 43 as lymph nodes, and 23 as thyroid tissue. The κ coefficients of interobserver agreement in assessing SBV density with or without the SA and SB modalities were 0.944 ± 0.013 and 0.859 ± 0.021, respectively, and those in assessing SBV area were 0.937 ± 0.014 and 0.841 ± 0.022, respectively. In the comparison between PTGs and other tissues, multiple binary logistic regression analysis revealed that shape, color, SBV density, congestion, and whether tissue was encapsulated with adipose tissue were independent predictive factors of PTGs.

CONCLUSION

With the application of SPIES, the shape, color, density of SBVs, adipose tissue encapsulation, and congestion were independent factors that predicted PTGs in ET. The SA and SB modalities of SPIES could improve the reliability of SBV density and area classifications in targeted tissues.

Single-incision endoscopic thyroidectomy by the axillary approach with gas inflation for the benign thyroid tumor: retrospective analysis for a single surgeon's experience

BACKGROUND

Trans-axillary endoscopic thyroid surgery offers the advantage of a good cosmetic outcome; however, it requires a wider dissection field compared to the other endoscopic approaches or open surgery. Therefore, it might cause severe postoperative pain occasionally. To reduce the dissection field required, we perform trans-axillary single-incision endoscopic thyroidectomy (SIET) with gas inflation. The aim of this study was to present a single surgeon's experience with SIET and to investigate the learning curve of SIET.

METHODS

Between June 2009 and September 2014, a total of 105 patients who underwent hemithyroidectomy for benign thyroid tumor via an SIET procedure were included in the present study. All of the procedures were performed by the same surgeon. Each patient's operative outcomes were collected and retrospectively analyzed. The cumulative summation (CUSUM) analysis was used to assess the learning curve of SIET.

RESULTS

No mortality or serious morbidity was observed during the study period. The adverse postoperative outcomes included wound hematoma (2 cases; 1.9 %), transient skin paresthesia (5 cases; 4.76 %), transient voice change (5 cases; 4.76 %), skin pigmentation (1 case; 0.9 %), and fibrous band of wound (1 case; 0.9 %). The overall mean operative time was 105 min, and the mean operative time in the experienced phase was 95 min. CUSUM analysis showed a decreasing trend at the 35th patient, suggesting that more than 35 cases were needed for the surgeon to gain proficiency. In 76.19 % of the cases, patients showed extreme satisfaction with the cosmetic results.

CONCLUSION

Our results showed reasonable surgical outcomes compared to previous studies on endoscopic thyroidectomy. The SIET procedure is safe and feasible for benign thyroid tumors and has an acceptable learning curve for surgeons who are proficient in conventional endoscopic thyroidectomy.

A survey of preferences regarding surgical approach to thyroid surgery

BACKGROUND

Transaxillary thyroidectomy (TAT) has gained popularity in East Asian countries; however, to date there have been no attempts to evaluate the preferences regarding TAT in the US population. The aim of this study is to assess the preferences and considerations associated with TAT in an American cohort.

METHODS

Self-administered surveys were distributed to 966 adults at various locations in a single state. Questions assessed preferences for the surgical approach, acceptable risks and extra costs, and willingness to pursue TAT despite reduced cancer treatment efficacy.

RESULTS

The response rate was 84 %, with a mean age of 40 ± 17 years. The majority of respondents were female. Of the respondents, 82 % preferred TAT to a cervical thyroidectomy (CerT), all risks being equal; 51 % of the respondents were willing to accept a 4 % complication rate with TAT, and 16 % stated they would agree to pay up to an additional $US5,000 for the TAT approach. When presented with thyroid cancer, 20 % of all respondents still preferred TAT, even if it would not cure their disease. Patients preferring TAT over CerT were younger, female, more willing to accept complications and spend additional money, and, most significantly, preferred the TAT approach, even if it was less likely to cure their cancer.

CONCLUSIONS

Although this survey presents a hypothetical question for people who do not have thyroid disease, the majority of respondents preferred TAT over CerT. Furthermore, a substantial number were willing to accept higher complication rates and increased costs for TAT.

Quality of scar after total thyroidectomy: a single blinded randomized trial comparing octyl-cyanoacrylate and subcuticular absorbable suture

Objective. To compare the quality of resulting scar at 6 weeks after total thyroidectomy with the use of the tissue adhesive octyl-cyanoacrylate or subcuticular absorbable suture for the closure of cervicotomy. Material and Methods. There are 50 patients undergoing a cervicotomy for total thyroidectomy. Twenty-five patients were randomly assigned to closure with tissue adhesive and 25 with subcuticular absorbable suture. At week 6 the scar was evaluated by blinded assessors with the Italian version of POSAS questionnaire, a validated wound scale composed of an observer's and a patient's subscale. Results. Assessment of scar appearance showed a statistically significant difference (p = 0. 038) in favor of subcuticular suture with respect to tissue adhesive on observer's assessment. The difference on patients' self-assessment was not significant. A multivariate analysis of six qualitative features of scars showed a significant influence on assessment for hyperpigmentation and relief of scar. The Italian version of POSAS proved to be reliable. Conclusion. Though tissue adhesive represents a valid method of skin closure, subcuticular absorbable suture provides a better aesthetic outcome in small cervical incisions in the early phase after thyroid surgery.