Safety of video-assisted thyroidectomy versus conventional surgery

An institutional experience of intraoperative neurophysiological monitoring application in robotic thyroidectomy: a retrospective case-control study

Purpose

Intraoperative neurophysiological monitoring (IONM) has been introduced in thyroid surgery to prevent injury of the recurrent laryngeal nerve (RLN). However, its effectiveness remains controversial in robotic thyroidectomy (RT). This study aimed to compare the surgical outcome of RT in patients with and without the application of IONM.

Methods

This retrospective case-control study included 100 patients who underwent total thyroidectomy via robotic bilateral axillo-breast approach in a tertiary center. A study group of 50 patients who had IONM during RT was compared to a control group of 50 patients who underwent RT with nerve visualization alone.

Results

The sex ratio (4:45 vs. 7:43, P = 0.538), mean age (39.3 ± 7.1 years vs. 37.5 ± 10.4 years, P = 0.304), and body mass index (23.1 ± 2.6 kg/m2 vs. 22.2 ± 3.9 kg/m2, P = 0.215) were comparable between the IONM and control groups. Pathologic features including tumor size (0.8 cm vs. 0.9 cm, P = 0.283), extrathyroidal extension (58.0% vs. 24.0%, P = 0.316), lymph node metastasis (30% vs. 34%, P = 0.668), and number of lymph nodes (5.3 vs. 5.3, P = 0.668) showed no differences. There was no permanent RLN palsy, postoperative bleeding, and wound complications. Transient hypoparathyroidism was observed in 12 (24.0%) and 14 (28.0%), permanent hypoparathyroidism in 0 (0%) and 1 (2.0%), and transient RLN palsy was observed in 3 (6.0%) and 3 (6.0%), respectively.

Conclusion

We did not demonstrate a clear advantage of IONM in RT. Controversies regarding the effectiveness of IONM is not closed.

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.

Video-Assisted Thyroidectomy Using a Surgical Energy Device: Initial Experience in a Japanese Single-Center Cohort

Objective

Video-assisted thyroidectomy (VAT) was approved for coverage under the Japanese public health insurance system in 2016. In our department, we introduced VAT in 2018, and we have since been performing the procedure with the assistance of surgical energy devices. We herein summarize our cases undergoing VAT, including a review of points to consider when introducing the procedure, and characteristics of the surgical energy devices.

Methods

We enrolled 24 patients (14 women and 10 men; age: 24-83 years; mean: 59.0 years) with thyroid/parathyroid tumors who underwent VAT between January 2018 and March 2021 at our department. The medical records of the patients were reviewed, and demographic data, clinical characteristics, histological type, treatment outcomes, and complications were analyzed.

Results

The surgical energy devices used were LigaSure® in the first 4 cases, Acrosurg®. Scissors S17 in the next 13 cases, and Acrosurg®. Revo S15 in the latest 7 cases. The operation time (range: 72-250 min; mean: 147 min), intraoperative blood loss (range: 5-370 mL; mean: 33 mL), indwelling time of wound drain (range: 2-6 days; mean: 3.5 days), and hospitalization period (range: 3-8 days; mean: 5.5 days) were within acceptable ranges. In this study, it is suggested that Acrosurg®. Revo S15 can shorten the indwelling time and the hospitalization period. There were no serious complications, but 1 patient developed transient vocal cord paralysis, which improved 3 months after surgery. It was suggested that the microwave energy devices, Acrosurg®. Scissors S17 and Acrosurg®. Revo S15, may be more effective with respect to sealing/hemostasis/coagulation capacity and controllability than the high-frequency electrosurgical device, LigaSure®.

Conclusion

Based on this initial experience, VAT using surgical energy devices appeared to be a safe, effective, and minimally invasive procedure for the treatment of thyroid/parathyroid tumors. Further studies confirming these early findings are needed.

Current therapeutic options for low-risk papillary thyroid carcinoma: Scoping evidence review

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

Single-Port Access Endoscopic Thyroidectomy via Axillary Approach for the Benign Thyroid Tumor: New Aspects from Vietnam

Background

This study aims to describe our new experience with single-port totally endoscopic thyroidectomy via the axillary approach in patients with unilateral thyroid benign tumors. In parallel with that, we also discuss here the challenges and novelty highlights we have confronted and solved and the details of our operative technique.

Methods

Between August 2018 and May 2020, the study involved 54 patients who underwent a single-port single-incision endoscopic thyroidectomy via the axillary approach for benign thyroid tumor at the National Hospital of Endocrinology (Hanoi, Vietnam). Surgical patient indications were in working age, goiter classification of grade 1 or grade 2, the thyroid with mononuclear or multinucleated, lesion diameter of less than 4 cm, unilateral thyroid benign lesion and no previous history of neck surgery or irradiation.

Results

No mortality was observed. Morbidities included transient voice change in 8 patients, swallowing disorders in 2 patients, transient skin paresthesia in 2 patients and wound hematoma in 2 patients. Mean amount of postoperative drainage was 70.2 mL, mean duration of postoperative drainage was 2.7 days, and mean postoperative hospital day was 6.6 days. Mean total operation time was 66.0 minutes and mean blood loss was 13.3 mL. Regarding medium-term follow-up outcomes following surgery, we recorded the hypothyroidism in 3 patients (5.6%) and the hypocalcemia in 1 case (1.8%). Most patients felt normal neck movement and sensation (79.6%), 3 patients were painful (5.6%) and 8 those were numb (14.8%). We saw the soft incision scar in 35 patients (64.8%), convex scar in 14 patients (25.9%), and hard scar in 5 patients (9.3%).

Conclusion

Single-port endoscopic thyroidectomy via axillary approach is a safe and feasible treatment option for removing benign thyroid tumor, delivering favorable surgical outcomes with ideal cosmetic effect and reduction in injury to the anterior neck tissue.

Long-term cosmetic results of video-assisted thyroidectomy: a comparison with conventional surgery

PURPOSE

We present the long-term cosmetic results of the video-assisted thyroidectomy (MIVAT) in comparison to the conventional operation.

METHODS

Forty-eight patients (four males, 44 females; mean age 47.4 ± 12.5 years) constituted the video-assisted group (VA-Group). These were compared with 48 patients (10 males, 38 females; mean age 47.4 ± 12.5 years) operated by conventional surgery (C-Group). The patients were selected from all thyroid operations performed between January 2016 and June 2017. Patient Scar Assessment Scale (PSAS) and Observer Scar Assessment Scale (OSAS) were used for the evaluation performed by an independent surgeon. Both scales contained six items scored numerically on a ten-step scale ranging from 1 (normal skin) to 10 (worst result). Moreover, photos of all scars were taken and analyzed by six team surgeons using modified OSAS.

RESULTS

The mean follow-up time was 31.7 ± 6.4 months for the MIVAT group and 32.9 ± 4.6 months for the conventional group (p = 0.39). The mean scar length in the VA-Group was 2.6 cm vs. 3.8 cm in the C-Group (p < 0.0001). The total score of PSAS was 9.93 (6-35) for MIVAT and 9.72 (6-29) for conventional thyroidectomy (p = 0.22). The total OSAS score by the independent surgeon showed a better cosmetic outcome for conventional surgery (13.19 vs. 12.33; p = 0.01). The total OSAS score by the six team surgeons did not differ between both groups in five of six ratings; one surgeon favored MIVAT (12.2 vs. 13.6; p = 0.04).

CONCLUSIONS

This study does not find cosmetic advantages of minimally invasive video-assisted thyroidectomy compared to conventional thyroidectomy.

Endoscopic Thyroidectomy in Anterior Chest Approach Versus Open Thyroidectomy for Patients with Papillary Thyroid Carcinomas, a Retrospective Study

Background: To compare the endoscopic thyroidectomy (ET) with the open thyroidectomy (OT) for patients with papillary thyroid carcinomas and share our experience of central lymph nodes dissection and recurrent laryngeal nerve exposure. Materials and Methods: From January 2015 to July 2017, 197 patients were enrolled in our hospital. Among them, 85 underwent ET and 112 underwent OT. The mean age of the patients was 38.15 ± 11.72 years in ET group and 47.79 ± 10.51 years in OT group. Unilateral thyroidectomy was performed in 47 patients of ET group and 63 patients of OT group. Bilateral thyroidectomy was performed in 38 patients of ET group and 49 patients of OT group. Intraoperative information, including operation time, hemorrhage, tumor size, capsular invasion, central LN metastasis, number of retrieved lymph nodes, hospital stay, cost, postoperative complication, and cosmetic satisfaction, was compared between the two groups. Results: The operation time of ET group was significantly longer (P < .05). There were no significant differences between the two groups in postoperative complications (P > .05). The patients in ET group were more satisfied with the cosmetic effects (P < .05). Conclusion: ET was a safe and effective alternative operation method for selected patients with papillary thyroid carcinomas.

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 Magnification Techniques and Direct Vision in Thyroid Surgery: A Systematic Review and Meta-Analysis

Background and Objectives: The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. Methods and Materials: Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Results: Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11-1.35), I² = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09-1.09), I² = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. Conclusion: The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small.

Minimally Invasive Video-Assisted Thyroidectomy: Analysis of Complications From a Systematic Review

BACKGROUND

Nowadays, minimally invasive video-assisted thyroidectomy (MIVAT) is considered a safe and effective option. However, its complication rate has not been specifically discussed yet. The aim of this systematic review was enrolling a large number of studies to estimate early and late complications (transient and definitive, uni- and bilateral laryngeal nerve palsy; transient and definitive hypocalcemia; cervical hematoma; hypertrophic or keloid scar) of MIVAT compared with conventional technique.

METHODS

The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in PubMed and Embase. Search terms were "minimally invasive," "video-assisted," and "thyroidectomy." We enrolled randomized clinical trials, nonrandomized trials, and noncontrolled trials.

RESULTS

Thirty-two articles were considered suitable. Complication rate of MIVAT was quite similar to conventional technique: only one randomized trial found a significant difference concerning overall skin complication, and a single trial highlighted hypocalcemia significantly increased in MIVAT, concerning serologic value only. No difference concerning symptomatic nor definitive hypocalcemia was found.

CONCLUSIONS

We can confirm that MIVAT is a safe technique. It should be adopted in mean-high-volume surgery centers for thyroidectomy, if a strict compliance with indication was applied.

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.

Morbidity from minimally invasive video-assisted thyroidectomy: a general review

Minimally invasive video-assisted thyroidectomy (MIVAT) is known and used worldwide, it combines the advantages associated with endoscopic magnification with those due with traditional surgery. In selected patients, it should be considered a safe and valid alternative. Indeed, a lot of comparative studies have demonstrated the advantages of MIVAT in terms of low rate of complications, reduced postoperative pain, improved cosmetic results and higher patient satisfaction over traditional surgery. Anyway, for obtaining the best results, with similar or even less complication rate than traditional surgery, surgeons should be well trained, acquired confidence with a smaller surgical incision and with the use of endoscopic instruments.

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.

Minimally Invasive Video-Assisted Thyroidectomy: Almost a Decade of Experience at an Academic Center

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance as an alternative to conventional thyroidectomy. This technique results in less bleeding, postoperative pain, shorter recovery time, and better cosmetic results without increasing morbidity. We retrospectively assessed outcomes in 583 patients having MIVAT from May 2005 to September 2014. The study population was divided into groups according to periods: 2005 to 2009 and 2010 to 2014. Operative data, complications, and length of stay were collected and compared. Total thyroidectomy was undertaken in 185, completion thyroidectomy in 49, and hemithyroidectomy in 349. Malignancy was present in 127 (21.8%). Mean incision was 3.4 ± 0.7 cm and estimated blood loss was 23.7 ± 21.7 mL. Mean operative time was 86.5 ± 39.3 minutes for all operations, 78.5 ± 37.0 minutes for hemithyroidectomy, 70.9 ± 30.1 minutes for completion thyroidectomy, and 106.8 ± 41.3 minutes for total thyroidectomy. Postoperatively, 56 (9.6%) had unilateral vocal cord dysfunction, which resolved except for one case (0.17%). Fifty-nine patients (10.1%) developed hypocalcemia, but only three cases (0.51%) became permanent. Only one patient required readmission. In conclusion, MIVAT results in short operative times, minimal blood loss, and few complications and is safely performed in an academic institution.

Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation

Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient's right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.

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.

Short and long-term cosmesis of cervical thyroidectomy scars

Introduction Multiple surgical approaches to the thyroid gland have been described via cervical or extracervical routes. Improved cosmesis, patient satisfaction, reduced pain (procedure dependent) and early discharge have all been reported for minimally invasive approaches with similar safety profiles and long-term outcomes to conventional surgery. This review summarises the current evidence base for improved cosmesis with minimally invasive cervical approaches to the thyroid gland compared with conventional surgery. Methods A systematic review was undertaken. The MEDLINE(®), Embase™ and Cochrane databases were searched for relevant articles. Results A total of 57 papers thyroid papers were identified. Of those, 20 reported some form of cosmetic outcome assessment. There were 6 randomised controlled trials with 412 patients (evidence level 2B), 7 cohort studies with 3,073 patients (level 3B) and 7 non-comparative case series with 1,575 patients (level 4). There was significant heterogeneity between studies in terms of wound closure technique, timing of scar assessment and scar assessment scales (validated and non-validated). Most studies performed early scar assessments, some using non-validated scar assessment tools. Conclusions Assessment of cosmesis is complex and requires rigorous methodology. Evidence from healing/remodelling studies suggests scar maturation is a long-term process. This calls into question the value of early scar assessment. Current evidence does not support minimally invasive surgical approaches to the thyroid gland if improved long-term cosmesis is the goal.

Minimally invasive video-assisted thyroidectomy: Ascending the learning curve

BACKGROUND:

Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. The aim of this report is to point out some aspects of the learning curve of the video-assisted thyroid surgery, through the analysis of our preliminary series of procedures.

PATIENTS AND METHODS:

Over a period of 8 months, we selected 36 patients for minimally invasive video-assisted surgery of the thyroid. The patients were considered eligible if they presented with a nodule not exceeding 35 mm and total thyroid volume <20 ml; presence of biochemical and ultrasound signs of thyroiditis and pre-operative diagnosis of cancer were exclusion criteria. We analysed surgical results, conversion rate, operating time, post-operative complications, hospital stay and cosmetic outcomes of the series.

RESULTS:

We performed 36 total thyroidectomy and in one case we performed a consensual parathyroidectomy. The procedure was successfully carried out in 33 out of 36 cases (conversion rate 8.3%). The mean operating time was 109 min (range: 80-241 min) and reached a plateau after 29 MIVAT. Post-operative complications included three transient recurrent nerve palsies and two transient hypocalcemias; no definitive hypoparathyroidism was registered. The cosmetic result was considered excellent by most patients.

CONCLUSIONS:

Advances in skills and technology allow surgeons to easily reproduce the standard open total thyroidectomy with video-assistance. Although the learning curve represents a time-consuming step, training remains a crucial point in gaining a reasonable confidence with video-assisted surgical technique.

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.

Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT)

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance among surgeons as its feasibility has been well documented. The aim of this systematic review with meta-analysis has been to assess and validate the safety and feasibility of MIVAT when compared to conventional thyroidectomy (CT) and to verify other potential benefits and drawbacks.

METHODS

A literature search for prospective randomized trials comparing MIVAT and CT was performed. Trials were reviewed for the primary outcome measures: overall morbidity, recurrent laryngeal nerve palsy, postoperative hypocalcemia, and postoperative hematoma; and for the secondary outcome measures: operative time, conversion to standard procedure, intraoperative blood loss, intraoperative drain insertion, nodule size and thyroid weight, postoperative pain evaluation, length of hospital stay, patient satisfactory score, and cosmetics results. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables.

RESULTS

Nine prospective randomized studies comparing MIVAT and CT were analyzed. Overall, 581 patients were randomized to either MIVAT (289, 49.7 %) or CT (292, 50.3 %). The primary outcome measures of MIVAT were comparable with those of CT without statistically significant difference. Patients who underwent MIVAT experienced significantly less pain than those operated on conventionally during the whole postoperative period. Patient satisfactory score significantly favored MIVAT (9.0 vs. 6.8, SMD = -3.388, 95 % CI = -5.720 to -1.057). Operative time was significantly longer in MIVAT (75.2 vs. 59.2 min, SMD = 1.246, 95 % CI = 0.227-2.266).

CONCLUSIONS

MIVAT is a safe and feasible alternative for the removal of small-volume benign thyroid disease and low-risk papillary thyroid carcinomas showing better cosmetics results and less postoperative pain but significantly longer operative time when compared to CT. New multicenter randomized studies are needed to evaluate the technique in more complex circumstances such as intermediate-risk thyroid cancer, lymph node removal, thyroiditis, and Graves' disease.

Comparative study comparing endoscopic thyroidectomy using the axillary approach and open thyroidectomy for papillary thyroid microcarcinoma

BACKGROUND

Endoscopic thyroidectomy has been applied prudently to malignant thyroid tumors. The purpose of our study was to compare the surgical outcomes of endoscopic thyroidectomy (ET) and conventional open thyroidectomy (COT) for micropapillary thyroid carcinoma.

METHODS

From October 2002 to December 2008, 78 patients underwent unilateral lobectomy and isthmectomy with central lymph node dissection for papillary thyroid microcarcinoma. Of these, 37 patients underwent ET and 41 patients COT. Surgical outcomes, including operation time, number of retrieved lymph nodes, postoperative complication rate and patients' satisfaction with the cosmetic results, were analyzed.

RESULTS

The mean age of the patients was 42.3 ± 7.6 years in the ET group and 49.0 ± 10.8 years in the OT group (P = 0.003). The operation time was shorter in the COT group (112.3 ± 14 min) than in the ET group (138.4 ± 36.9 min, P< 0.01). However, there were no significant differences in tumor size (0.5 ± 0.231 vs. 0.41 ± 0.264 cm, P = 0.116), number of retrieved lymph nodes (3.63 ± 2.1 vs. 3.82 ± 3.28, P = 0.78) or postoperative hospital stay (3.35 ± 0.94 vs. 3.17 ± 1.16 days, P = 0.457). Patients in the ET group experienced more pain than those in the COT group at 1 and 7 days after the operation as evaluated by a visual analog scale (P = 0.037, 0.026). Cosmetically, patients in the ET group were very satisfied with the operative procedure according to the questionnaire we used (1.43 ± 0.55 vs. 3.21 ± 0.72, P< 0.001). The mean follow-up period was 54.3 months in the ET group and 47.4 months in the COT group, and each group exhibited one case of tumor recurrence detected at the other thyroid lobe within 2 years.

CONCLUSIONS

Large series of prospective studies and long-term follow-up are needed, but the results of ET using the axillary approach for micropapillary thyroid carcinoma were not inferiortothose using COT, and it might be a safe and feasible procedure with good cosmetic results.

Minimally invasive video-assisted thyroidectomy for the early-stage differential thyroid carcinoma

Background

Minimally invasive video-assisted thyroidectomy (MIVAT), the modified Miccoli’s thyroid surgery, is the most widespread minimally invasive technique and has been widely used for treatment of thyroid disease. This study aimed to verify the potential benefits of the modified Miccoli’s thyroid surgery, determine the feasibility of the MIVAT for early-stage differential thyroid carcinoma and evaluate the likelihood of the surgical method as a standard operation for early malignant thyroid carcinoma.

Methods

A total of 135 patients were retrospectively compared which included two groups of patients: the first group underwent the conventional thyroidectomy; the other group underwent MIVAT. Patients with thyroid nodule smaller than 20 mm and without previous neck surgery were included while those with wide-ranging and distant metastases of cervical tissues, or any suspected thyroid nodal metastases were excluded for analysis. MIVAT and the central compartment (level VI) lymph nodes dissection (LND) were considered as a new treatment method for this retrospective study. In addition to the comparison of surgical outcomes between the new treatment and the conventional thyroid surgery, other surgical parameters including operative time, operative volume of hemorrhage, incisional length, postoperative volume of drainage, length of hospitalization, accidence of hoarse voice, accidence of bucking, accidence of hypocalcemia and peak angle of cervical axial rotation were also compared.

Results

Out of 135 patients, 111 patients underwent conventional thyroid surgery and 24 patients underwent MIVAT plus level VI LND for treatment of early-stage differential malignant carcinoma. Patients who received the new surgical treatment had significantly shorter incisional length (3.1 cm vs. 6.9 cm, p < 0.0001), shorter operative time (109 min vs. 139 min, p = 0.014) and fewer operative hemorrhage (29.5 ml vs. 69.7 ml, p < 0.0001) when compared to the conventional treatment. Postoperative peak angle of cervical axial rotation of patients treated with MIVAT was less than those treated with conventional surgery (L: 31.5° vs. 39.0°, p < 0.0001; R: 31.5° vs. 38.0°, p < 0.0001). Incisional wound infection, postoperative hoarse voice, bucking and hypocalcemia were not observed in all patients. Postoperative analgetica was not required as well.

Conclusions

Compared with conventional thyroid surgery for early-stage differential thyroid carcinoma, the new surgical treatment could be considered as an alternative surgical method for treatment of early-stage thyroid carcinoma since it was feasible, safe and clinically effective with better surgical and cosmetic outcomes.

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.

Video-assisted loboisthmectomy by the subclavicular approach. A case report

The main advantage of minimally invasive thyroidectomy is a good cosmetic effect. Minimally invasive video-assisted thyroidectomy (MIVAT) is performed without gas insufflation in contrast to endoscopic thyroidectomy. In general, MIVAT is carried out through an incision in the middle part of the neck, not covered with clothes. The MIVAT thyroid lobectomy can also be done through the subclavicular approach. We describe a case of a 19-year-old female patient with a tumour of the left side of the neck. Thyroid ultrasound scan (UST) with thyroid fine-needle aspiration and cytological examination (FNAC) were performed. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and anti-tyreoperoxidase (ATPO) were checked. Video-assisted hemithyroidectomy was performed through an incision below the left clavicle. Intraoperative pathology examination of the specimen was carried out. The UST showed a solitary 13 mm × 23 mm nodule in the left lobe of the thyroid, the FNAC showed benign pathology. Thyroid function tests were normal (TSH 0.90 mIU/l; FT3 4.70 pmol/l). Video-assisted hemithyroidectomy was done through the incision below the left clavicle. Histopathological examination proved thyroid hyperplasia nodosum. There were no intra- or postoperative complications. The patient was discharged on the second day. Clinical and cosmetic outcomes 2 months after surgery were good. Minimally invasive video-assisted thyroid lobectomy performed via the subclavicular area is feasible and provides good cosmetic outcomes.

New endoscopic thyroidectomy via a unilateral axillo-breast approach with gas insufflation: Preliminary report

BACKGROUND

Invasiveness of endoscopic thyroidectomy has been in debate. The purpose of this study was to introduce new endoscopic thyroidectomy via a unilateral axillo-breast approach (UABA) with gas insufflation to lessen invasiveness.

METHODS

We performed 68 cases of hemithyroidectomy via a UABA with gas insufflation from January to July 2011. The following variables were studied: operation time, pain score, drainage amount, drainage day, perioperative complications, pathological outcomes, and cosmetic satisfaction.

RESULTS

Mean postoperative pain visual analogue scale (VAS) scores were 2.75 ± 0.93 and 2.07 ± 0.79 at 1 and 3 days after surgery. The mean amount of drainage over the first 3 postoperative days was 144.35 ± 51.64 mL, and the mean time to drain removal was 3.75 ± 0.81 days. Two cases (2.9%) of transient vocal cord palsy and 2 cases (2.9%) of seroma were identified. All patients were satisfied with the cosmetic results.

CONCLUSION

Endoscopic thyroidectomy via a UABA with gas insufflation is a feasible and less invasive option for selected patients.

Minimally invasive video-assisted versus conventional open thyroidectomy: a systematic review of available data

PURPOSE

Minimally invasive video-assisted thyroidectomy (MIVAT) is now emerging as a novel and less invasive procedure for thyroid diseases. This study conducted a systematic review of the available data to evaluate the safety and efficacy of this new technique over conventional procedure.

METHODS

A systematic literature search was performed on Medline, Embase, and The Cochrane Library. Randomized controlled trials comparing the MIVAT with open thyroidectomy were selected and meta-analyzed.

RESULTS

Nine RCTs involving 730 patients were included and all were restricted to patients with a thyroid nodule no larger than 4 cm and surgery did not involve lymph node dissection. Both procedures were of similar efficacy in nodule resection. Open surgery had a 1.6 times higher rate of postoperative complications than the novel technique, with no significant difference (P = 0.08), especially in transient recurrent nerve palsy (OR = 0.93, P = 0.87). Although longer operative time was required for MIVAT (MD = 15.0 min, P < 0.00001), patients experienced less postoperative pain, especially in the early postoperative period (MD = -11.52, P = 0.0003). There was also a shorter incision length (MD = -2.36 cm, P < 0.00001), better cosmetic results and greater patient satisfaction in the novel technique group (WD = 2.59; P < 0.00001).

CONCLUSIONS

MIVAT is a feasible, practical, and safe alternative with better cosmetic benefits, and it can be performed with an ease of manipulation that is similar to that of conventional neck surgery.

Current surgical status of thyroid diseases

Thyroid nodules are a common clinical problem for surgeons. The clinical importance of nodules is the need to exclude thyroid cancer, which occurs in 5%–15% of patients. If fine needle aspiration cytology is positive, or suspicious for malignancy, surgery is recommended. During the past decade, with the tendency to develop smaller incisions, an endoscopic approach has been applied to thyroid surgery, called minimally invasive video-assisted thyroidectomy. This approach was immediately followed by other minimally invasive or scarless neck techniques, such as the breast approach, axillary-breast approach, and robot-assisted method. All these techniques follow the same principles of surgery and oncology. This review presents the current surgical management of the thyroid gland, including the surgical techniques and compares them by describing benefits and drawbacks of each one.

Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: a cost-effective analysis

OBJECTIVE

To compare the cost of minimally invasive video-assisted thyroidectomy (MIVAT) with conventional thyroidectomy.

STUDY DESIGN

A cost-effectiveness study and chart review.

SETTING

Academic university hospital.

SUBJECTS AND METHODS

Pediatric and adult patients referred to the Department of Otolaryngology-Head and Neck Surgery for suspicious thyroid nodules, goiters, or known carcinomas. A tertiary care hospital's billing department was queried for all hemithyroidectomies and total thyroidectomies completed by the Department of Otolaryngology-Head and Neck Surgery between January 5, 2006, and November 1, 2007. The charges, including surgery, hospital, pathology, and anesthesia, for minimally invasive video-assisted thyroidectomy (MIVAT) and traditional or minimally invasive open thyroidectomies meeting MIVAT inclusion criteria were then reviewed retrospectively and compared statistically.

RESULTS

A total of 185 thyroidectomies were performed, 50.3 percent of which met criteria for MIVAT. Length of stay (days) was significantly shorter for patients undergoing MIVAT hemithyroidectomy (mean difference -0.8; 95% confidence interval [95% CI] -1.08 to -0.52) and not significantly different between groups for total thyroidectomy (mean difference 0.1; 95% CI -0.36 to 0.56). Mean anesthesia cost (U.S.$) was similar between groups for hemi- and total thyroidectomies. MIVAT mean pathology cost was significantly less than open thyroidectomy for hemithyroidectomy (mean difference -89.9; 95% CI -179.01 to -0.79) and approached significance for total thyroidectomy. There was no significant difference in hospital cost and total cost for hemithyroidectomy and total thyroidectomy.

CONCLUSION

In a group of matched cohorts, the cost of MIVAT appears to be equal to that of open thyroidectomy.

Surgical treatment of thyroid diseases in elderly patients

BACKGROUND

We evaluated the safety of thyroid surgery in elderly patients, in whom surgical procedures usually are considered more hazardous than in younger patients.

METHODS

The medical records of all the patients who were aged 70 years or older who had undergone thyroid surgery between January 1998 and June 2008 were reviewed.

RESULTS

A total of 320 patients were included. The preoperative diagnosis was multinodular goiter in 171 cases, toxic goiter in 59 cases, suspicious or indeterminate thyroid nodule in 60 cases, and thyroid carcinoma in 30 patients. Total thyroidectomy was performed in 283 patients, thyroid lobectomy in 15 patients, and a completion thyroidectomy was performed in 22 patients. The final histology showed thyroid cancer in 86 patients and benign disease in 234.

CONCLUSIONS

Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach.

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.

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.

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.

Extrathyroidal implantation of thyroid tumor cells after needle biopsy and other invasive procedures

BACKGROUND

Implantation of thyroid cells (ITC) into extrathyroidal locations is a rare complication of thyroid fine-needle biopsy (FNB) and thyroid surgery. Here we review the prevalence, likely pathogenesis, treatment, and likely ways to minimize this complication of invasive thyroid procedures and present an illustrative patient.

SUMMARY

Tumor aggressiveness more likely leads to ITC after FNB. Large needle size may be associated with increased risk of ITC. Number of passages during biopsy, excessive suction, needle withdrawal without releasing suction, and injection of tumor cells during biopsy may be associated with ITC after FNB. This statement is based on rational hypotheses. Cutting or rupture of a thyroid nodule during surgery leads to ITC into extrathyroidal soft tissue.

CONCLUSIONS

ITC occurs rarely with needles smaller than 23 gauge. Some authorities suggest the use of gentle suction and release suction during extraction and a reduced number of passes based on entirely theoretical grounds. In conventional surgery, lobectomy for all thyroid nodules rather than nodulectomy or partial lobectomy should be performed. If endoscopic surgery is performed on larger nodules, the surgeon should take great care to avoid rupturing the tumor.

Minimally invasive, video-assisted thyroidectomy: first experience from the United Kingdom

INTRODUCTION

Minimally-invasive, video-assisted thyroidectomy (MIVAT) was developed to reduce scarring/trauma associated with cervical incisions used in open thyroidectomy. Results from various centres have been published internationally but none from the UK. This study reports the first results from the UK and compares them with other centres. We also aim to compare the results of a single-surgeon experience in a small/moderately-sized hospital to those of larger tertiary centres.

PATIENTS AND METHODS

Retrospective analysis of a single surgeon experience in a district general hospital

RESULTS

The cohort was 55 patients (52 female, 3 male), mean age 48 years (range, 21-77 years) who had 64 MIVAT procedures. There were 49 hemithyroidectomies (HTs), 2 isthmusectomy, 4 total thyroidectomies (TTs) and 9 completion thyroidectomies (CTs) with median operating time of 86 min (IQR 66-110 min). Individual operating times were HT 85 min (IQR 60-110 min); TT 130 min (IQR 100-140 min) and CT 77 min (IQR 70-98 min). Median operating time was shorter in the second half of this series (76 min vs 92 min; P < 0.001). Length of stay was < 1 day in 92%. Conversions occurred in 6.3% with no haematoma or re-operation. Transient voice change was present in 7 (11%), permanent unilateral recurrent laryngeal nerve palsy in 2 (3%), and transient hypocalcaemia in 2 (3%).

CONCLUSIONS

The first results from the UK are similar to those of other international centres. A single-surgeon practice can obtain results comparable to larger tertiary centres provided there is sufficient case-load. MIVAT is safe and effective, but has a steep learning curve with rapid improvement observed within first 30 cases. Future studies should focus on objective assessment of scar/cosmesis and cost-effectiveness. MIVAT is an acceptable alternative to open surgery in highly selected patients.

Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO(2) insufflation

BACKGROUND

Our objective was to evaluate the anatomic basis for robotic-assisted transaxillary thyroidectomy and to determine its feasibility in a prospective clinical trial.

METHODS AND RESULTS

Using the da Vinci Surgical Robotic System, we performed 5 cadaveric dissections, via transaxillary approach without gas insufflation. Once the safety and feasibility of this approach had been demonstrated in cadavers, it was utilized to perform a thyroid lobectomy in a patient. The da Vinci system provided excellent visualization of the recurrent and superior laryngeal nerves, parathyroid glands, and paratracheal lymphatics. After the 5 cadaver dissections, the procedure time diminished from >90 minutes to <30 minutes.

CONCLUSION

Robotic-assisted transaxillary thyroidectomy is feasible with proper instrumentation and an understanding of the surgical anatomy. Based on this preclinical laboratory study and our experience in 1 patient, further evaluation of this approach in the setting of a prospective clinical trial is warranted to determine standardized criteria identifying patients who would benefit from this approach.

Standard versus video-assisted thyroidectomy: objective postoperative pain evaluation

BACKGROUND

This prospective, randomized study was designed to objectively demonstrate that minimally invasive video-assisted thyroidectomy (MIVAT) improves postoperative pain compared with standard thyroidectomy, via the dosage of biochemical mediators measured before and after surgery.

METHODS

Forty-nine patients undergoing total thyroidectomy were allotted to MIVAT (n = 23) or traditional thyroidectomy (OPEN) (n = 26) groups. At hospitalization (T0), interleukin (IL)-1, -2, -4, -6, -10, -3, tumor necrosis factor (TNF)-α, TGF-β, and MCP-1 were measured. The basal pain tolerance also was evaluated by VAS. Blood samples for interleukin measurement and VAS evaluations were obtained from all patients in the recovery room (T1) and 24 h after surgery (T2).

RESULTS

At T0, the MIVAT and the OPEN groups were not different in terms of basal pain tolerance and biochemical profile. At T1, VAS scores were significantly higher (p = 0.04), whereas TGF-β (p = 0.03) and MCP-1 (p = 0.03) levels were significantly lower in the OPEN than in the MIVAT group. No significant difference was demonstrated for other interleukins. A significant inverse relationship between VAS and TGF-β was demonstrated and confirmed through the correlation (p = 0.003) and regression (p = 0.003, p < 0.0001, R (2) = 0.172) coefficients; the stepwise regression also demonstrated that TGF was the most predictive factor of postoperative pain (p = 0.0038) through an inverse relationship. No statistically significant difference has been demonstrated at T2.

CONCLUSIONS

TGF-β serum levels immediately after surgery seem to correlate with pain evaluation, confirming that reduced postoperative distress is an objective outcome of MIVAT. This result confirms the results of studies based only on subjective pain evaluations.

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

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) was introduced in the clinical practice to treat small benign thyroid nodules. This method has recently been demonstrated to produce the same completeness as a conventional thyroidectomy in patients with papillary thyroid cancer (PTC). The low number of treated cases and the limited follow-up of these patients represent the major limitations of these studies.

OBJECTIVE

The aim of the study was to compare the outcome of two groups of PTC patients, one treated with MIVAT and the other with conventional thyroidectomy, after a median follow-up of 5 yr.

STUDY GROUP

A total of 221 PTC patients were enrolled in this study according to the following criteria: 171 were treated with MIVAT (group A), and 50 were treated with conventional thyroidectomy (group B).

RESULTS

The outcome and the cumulative (131)I activity administered to achieve curative status were compared. After a mean follow-up of 3.6 +/- 1.5 yr (range, 1-8 yr; median, 5 yr), no differences were found between group A and group B. A similar rate of permanent hypoparathyroidism and/or nerve cord palsy was found in both groups.

CONCLUSION

We demonstrated that PTC patients operated on with MIVAT had a good outcome after 5 yr. This was similar to the outcome of patients treated with conventional thyroidectomy and the same degree of exposure to (131)I. These results, together with the evidence of a similar degree of completeness and rate of complications between the two surgical techniques, show that MIVAT is a valid option to treat low- and intermediate-risk PTC patients.