A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach

Efficacy and Safety of Robotic Bilateral Axillo-Breast Approach Versus Robotic Gasless Axillary Approach for Thyroidectomy: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the comparative efficacy and safety of robotic thyroidectomy techniques, including the robotic bilateral axillo-breast approach (BABA) and the robotic gasless axillary approach (GAA).

DATA SOURCES

A comprehensive literature search was conducted across 5 major electronic databases (PubMed, Embase, Cochrane Library, Web of Science, and Scopus) to identify relevant studies published until May 2024.

REVIEW METHODS

Analysis was conducted using RevMan 5.4 software with pooled mean and rate ratios calculated with 95% CIs.

RESULTS

A total of 73 studies, comprising 70 eligible for meta-analysis, were included. Compared with robotic GAA, robotic BABA was associated with significantly longer operative time (pooled mean: 64.65 min, 95% CI: 51.77-77.53, P<0.00001), increased hospital stay (pooled mean: 1.24 d, 95% CI: 0.92-1.56, P<0.00001), and higher intraoperative bleeding (pooled mean: 44.90 mL, 95% CI: 26.99-62.81, P<0.00001). While no significant differences were observed in the rates of hypoparathyroidism, recurrent laryngeal nerve palsy, chyle leakage, seroma, hematoma, or infection, the incidence of Horner syndrome was significantly higher in the BABA group (pooled risk ratio: 0.01, 95% CI: 0.00-0.05, P=0.003).

CONCLUSIONS

Robotic BABA was associated with longer operative times, increased hospital stays, and higher intraoperative bleeding compared with Robotic GAA, although both techniques demonstrated comparable safety profiles for most outcomes. The higher incidence of Horner syndrome with BABA should be considered when selecting the optimal surgical approach for thyroidectomy.

Comparison of learning curves and related postoperative indicators between endoscopic and robotic thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) yield similar perioperative outcomes. This study investigated how the learning curve (LC) affects perioperative outcomes between ET and RT, identifying factors that influence the LC.

MATERIALS AND METHODS

Two researchers individually searched PubMed, EMBASE, Web of Science, and Cochrane Library for relevant studies published until February 2024. The Newcastle-Ottawa Scale assessed study quality. A random-effects model was used to compute the odds ratio and weighted mean difference (WMD). Poisson regression comparison of the number of surgeries (N LC ) was required for ET and RT to reach the stable stage of the LC. Heterogeneity was measured using Cochran's Q. Publication bias was tested using funnel plots, and sensitivity analysis assessed findings robustness. Subgroup analysis was done by operation type and patient characteristics.

RESULTS

This meta-analysis involved 33 studies. The drainage volume of ET was higher than that of RT (WMD=-17.56 [30.22, -4.49]). After reaching the N LC , the operation time of ET and RT was shortened (ET: WMD=28.15 [18.04-38.26]; RT: WMD=38.53 [29.20-47.86]). Other perioperative outcomes also improved to varying degrees. Notably, RT showed more refined central lymph node resection (5.67 vs. 4.71), less intraoperative bleeding (16.56 ml vs. 42.30 ml), and incidence of transient recurrent laryngeal nerve injury (24.59 vs. 26.77). The N LC of RT was smaller than that of ET (incidence-rate ratios [IRR]=0.64 [0.57-0.72]). CUSUM analysis (ET: IRR=0.84 [0.72-0.99]; RT: IRR=0.55 [0.44-0.69]) or a smaller number of respondents (ET: IRR=0.26 [0.15-0.46]; RT: IRR=0.51 [0.41-0.63]) was associated with smaller N LC . In RT, transoral approach (IRR=2.73 [1.96-4.50]; IRR=2.48 [1.61-3.84]) and retroauricular approach (RAA) (IRR=2.13 [1.26-3.60]; IRR=1.78 [1.04-3.05]) had smaller N LC compared to bilateral axillo-breast and transaxillary approach (TAA). In ET, the N LC of RAA was smaller than that of TAA (IRR=1.61 [1.04-2.51]), breast approach (IRR=1.67 [1.06-2.64]), and subclavian approach (IRR=1.80 [1.03-3.14]).

CONCLUSIONS

Rich surgical experience can improve surgical results of ET and RT. After reaching the N LC , the perioperative outcomes of RT are better than those of ET. Study subjects, surgical approaches, and analysis methods can affect N LC .

Current and Future of Robotic Surgery in Thyroid Cancer Treatment

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Endoscopic thyroidectomy via chest-collarbone approach versus conventional open thyroidectomy: a retrospective comparative study

OBJECTIVE(S)

Endoscopic thyroidectomy, such as axillary, areola and transoral approaches, offer the advantage of a good cosmetic outcome, but it requires a wider dissection field compared to open thyroidectomy. Recently, chest-collarbone approach thyroidectomy has been widely developed in China because of its shorter anatomical route compared to other endoscopic approaches. This study retrospectively evaluated endoscopic thyroidectomy via chest-collarbone approach in patients with thyroid nodules to determine its feasibility.

METHODS

A total of 46 patients with thyroid disease who underwent endoscopic thyroidectomy between January 2022 and December 2022 were enrolled in the study and randomly matched to patients with thyroid disease who underwent open thyroidectomy at the same time based on nodule size and pathology. Postoperative bleeding, hoarseness situation, hospital stay, postoperative drainage volume, laryngeal nerve palsy, hypoparathyroidism and wound infection were assessed in both groups.

RESULTS

Forty-four patients underwent endoscopic thyroidectomy successfully and two patients changed to open thyroidectomy. The amount of postoperative drainage for the endoscopic thyroidectomy group was 102.78 ± 28.04 mL, and which was 71.91 ± 19.20 for open thyroidectomy group (p < 0.001). The postoperative hospital stay for the endoscopic thyroidectomy group was 8.78 ± 2.57 days, and which was 7.22 ± 1.13 for open thyroidectomy group (p < 0.001). There was no significant difference in postoperative bleeding, hoarseness situation, and wound infection between the two groups. Laryngeal nerve palsy, supraclavicular nerve injury and hypoparathyroidism were not observed in any patient during this study.

CONCLUSION

Chest-collarbone endoscopic thyroid surgery is acceptable. This treatment improves in a good cosmetic outcome in patients with thyroid disease. To assess patients with preoperative nodule size and nature of the case is the impact of the success rate, which is particularly important.

Surgical outcomes of robotic thyroidectomy for thyroid tumors over 4 cm via the bilateral axillo-breast approach

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Oncologic outcomes and surgical completeness of remote-access thyroidectomy: a systematic review and network meta-analysis

BACKGROUND

The oncologic safety and surgical completeness of remote-access thyroidectomies are not yet clearly established. This study evaluates the oncologic outcomes and surgical completeness of three prevalent remote-access thyroidectomies: the gasless transaxillary approach (GTAA), bilateral axillo-breast approach (BABA), and transoral approach (TOA), in comparison with conventional transcervical thyroidectomy (CTT).

METHODS

Literature searches were conducted in PubMed, EMBASE, and the Cochrane Library databases, covering the period from 2000 to 2023. Network meta-analyses were performed on selected studies, focusing on recurrence and surgical completeness. Surgical completeness was assessed using stimulated serum thyroglobulin levels and the count of retrieved lymph nodes.

RESULTS

The review included 48 studies, encompassing a total of 16,356 patients. The number of retrieved lymph nodes was comparable among BABA, TOA, and CTT, while GTAA might be less effective. Stimulated serum thyroglobulin levels showed no significant differences across the four groups. However, the proportion of patients with stimulated thyroglobulin levels below 1.0 ng/mL was significantly lower in GTAA compared to the other groups. The overall recurrence rates were 1.31% for CTT, 0.89% for GTAA, 0.62% for BABA, and 0% for TOA, with no significant differences in recurrence rates when adjusted for follow-up duration.

CONCLUSIONS

This study demonstrated that the oncologic outcomes of GTAA, BABA, and TOA are comparable to those of CTT, based on recurrence rates. In terms of surgical completeness, BABA and TOA showed equivalence to CTT, whereas GTAA might be inferior to the other techniques.

Surgical safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy: a systematic review and meta-analysis

OBJECTIVES

To assess the safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy in thyroid tumor.

METHODS

Bilateral axillo-breast approach robotic thyroidectomy and other approaches (open thyroidectomy, transoral robotic thyroidectomy, and bilateral axillo-breast approach endoscopic thyroidectomy) were compared in studies from 6 databases.

RESULTS

Twenty-two studies (8830 individuals) were included. Bilateral axillo-breast approach robotic thyroidectomy had longer operation time, greater cosmetic satisfaction, and reduced transient hypoparathyroidism than conventional open thyroidectomy. Compared to bilateral axillo-breast approach endoscopic thyroidectomy, bilateral axillo-breast approach robotic thyroidectomy had greater amount of drainage, lower chances of transient vocal cord palsy and permanent hypothyroidism, and better surgical completeness (postopertive thyroblobulin level and lymph node removal). Bilateral axillo-breast approach robotic thyroidectomy induced greater postoperative drainage and greater patient dissatisfaction than transoral robotic thyroidectomy.

CONCLUSION

Bilateral axillo-breast approach robotic thyroidectomy is inferior to transoral robotic thyroidectomy in drainage and cosmetic satisfaction but superior to bilateral axillo-breast approach endoscopic thyroidectomy in surgical performance. Its operation time is longer, but its cosmetic satisfaction is higher than open thyroidectomy.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications

Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.

Remote-access robotic thyroidectomy: A systematic review

BACKGROUND

Recently, robotic surgery has been introduced as a new surgical approach to the thyroid.

OBJECTIVES

The primary objective of this systematic review is to critically examine safety and feasibility of the different robotic approaches.

METHODS

The literature on robotic thyroidectomy was systematically reviewed. Primary endpoints were surgery duration, length of hospital stay, complications, postoperative pain and cosmetic satisfaction.

RESULTS

Sixty-eight studies with a total of 14433 patients were included. Depending on the robotic approach used, operative duration ranged between 89 and 230 min and hospitalisation stay between 0.1 and 5.6 days. Complication rates varied between 7.3% and 29%. Postoperative pain visual analogue scores (VAS) ranged from 0.6 to 4.71.

CONCLUSION

Robotic thyroidectomy results in high cosmetic satisfaction and quality of life. No differences in complication rates between robotic and traditional approaches are observed, supporting safety and feasibility of these robotic techniques.

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Simple Summary

Transoral thyroidectomy accesses the thyroid gland through three incisions in the oral vestibule. The cosmetic outcome was excellent since no scar was observed on the body surface. However, it is challenging to create a working space using this new approach. Unconventional but severe complications can also occur. Our review summarizes the tips regarding working space creation in transoral thyroidectomy and tricks for preventing complications.

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Bilateral axillo-breast approach robotic thyroidectomy: review of a single surgeon's consecutive 317 cases

Background

Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) is one of the most popular remote-access approaches for thyroid surgery. This study aimed to evaluate the surgical outcomes of BABA RT.

Methods

Medical records of patients who underwent BABA RT between July 2008 and July 2016 were retrospectively reviewed. Surgeries were performed by one surgeon at one institution. Clinicopathological features and postoperative surgical outcomes were evaluated.

Results

A total of 317 patients were enrolled. The mean age was 40.0±9.7 years, and 287 (90.5%) were female. The mean tumor size was 1.02 cm. Papillary thyroid carcinoma (PTC) was most commonly seen (n=282, 88.8%), followed by benign nodules (n=33, 10.5%) and follicular thyroid carcinoma (n=2, 0.6%). Total thyroidectomy was performed in 202 (63.7%) patients, while unilateral lobectomy was performed in 113 (35.6%). Two patients (0.6%) had transient vocal cord palsy, but none showed permanent vocal cord palsy. Thirty-four (16.8%) patients developed hypoparathyroidism, 33 (16.3%) were transient and 1 (0.5%) was permanent. The mean operation time for total thyroidectomy and lobectomy was 264.9±52.4 and 203.4±47.6 min, respectively. A decrease in operation time in total thyroidectomy was observed in 49-51 cases (P=0.015). Four patients (1.4%) had local recurrence during the median follow-up of 61±23 months.

Conclusions

BABA RT can be performed safely in selected patients with thyroid nodules. The learning curve duration for BABA RT was 49-51 cases of total thyroidectomy.

Predictive factors for prolonged operative time of robotic thyroidectomy via bilateral axillo-breast approach: Analysis of 359 cases of differentiated thyroid cancer

OBJECTIVE

This study assessed the results of robotic thyroidectomy for differentiated thyroid cancer in early stage, to identify the predictive factors of operative time and complication rate.

METHODS

A patient cohort of 359 cases in total was involved in this retrospective study. The data of clinical characteristics and follow-up results were collected.

RESULTS

The cohort of patients involved was composed of 285 female patients and 74 male ones. The mean age was 34.91 ± 7.93 years old. The mean Body Mass Index (BMI) was 22.43 ± 3.47. The mean tumor size was 0.75 ± 0.56 cm, and the mean gland size was 4.68 ± 0.83 cm. Among all the specimen, the ratio of tumor invasion of gland capsule was 63/296, and the ratio of chronic thyroiditis was 110/249. 75 patients underwent total thyroidectomy + central compartment node dissection (CCND). 284 patients underwent Lobectomy + CCND. The ratio of central lymph node metastasis was 144/215 (40.1%). The mean number of lymph node dissected was 5.26 ± 4.09. The mean operative time was 96.53 ± 25.69 min. 21(5.8%) patients had hoarseness after operation. 22(29.3%) patients had hypocalcemia after total thyroidectomy. The inadvertent parathyroidectomy was found in 66(18.4%) cases. The surgical extent (unilateral/bilateral resection), BMI and gland size were found to have a significantly correlation with the operative time (p < 0.05) after multivariate analysis.

CONCLUSION

The surgical extent, BMI and gland size are found to be independent risk factors of prolonged operative time of robotic thyroidectomy. However, these factors are not associated with a higher complication rate.

Unilateral axilla-bilateral areola approach for thyroidectomy by da Vinci robot vs. open surgery in thyroid cancer: a retrospective observational study

Background

To compare the efficacy and safety of unilateral axilla-bilateral areola (UABA) approach for robot-assisted thyroidectomy with conventional open surgery in thyroid cancer patients.

Methods

The clinicopathological features and surgical outcomes of 194 thyroid cancer patients treated by robotic surgery using the UABA approach and 217 patients treated by open surgery in our department from January 2017 to August 2018 were analysed and compared.

Results

The operation time was longer in the robotic group than in the open surgery group. The patients' satisfaction with neck appearance was higher in the robotic group than in the open surgery group (91.2% vs. 21.6%, P<0.01). After total thyroidectomy and central lymph node dissection, the incidence of postoperative transient hypoparathyroidism and postoperative permanent hypoparathyroidism in the open surgery group was 29.7% (44/148) and 6.8% (10/148), higher than that [17.9% (27/151) and 2.0% (3/151)] in the robotic group (P<0.05 respectively). No significant difference was observed in the number of dissected lymph nodes or postoperative serum thyroglobulin (TG) levels or incidence of transient or permanent hoarseness of voice between the two groups. No recurrence or metastasis was found.

Conclusions

Compared with open surgery, UABA robotic surgery preserved the neck appearance and effectively reduced hypoparathyroidism by super-meticulous capsular dissection (SMCD).

Outcome Comparison between Endoscopic Transoral and Bilateral Axillo-Breast Approach Thyroidectomy Performed by a Single Surgeon

BACKGROUND

The transoral approach and the bilateral axillo-breast approach (BABA) are remote access approaches for endoscopic thyroidectomy. Both follow a symmetric design and use CO₂ insufflation to maintain the working space. The outcome differences between the techniques are rarely compared in the literature.

METHODS

All patients who underwent endoscopic transoral (n = 72) and BABA (n = 63) thyroidectomy between October 2018 and August 2020 by a single surgeon were retrospectively reviewed. The following peri-operative data were collected and compared: operative time, blood loss, postoperative drainage amount, hospital stay, pain score, number of retrieved lymph nodes, and complications.

RESULTS

Patients in the transoral group were younger (44.7 vs. 49.3 years, p = 0.022) and had smaller tumors (2.4 vs. 2.8 cm, p = 0.020) than those in the BABA group. The operative times were significantly longer in the transoral group than in the BABA group (lobectomy, 194.1 vs. 177.0 min, p = 0.026; total thyroidectomy, 246.0 vs. 214.3 min, p = 0.042). Nevertheless, the time difference became insignificant after completing the initial 20 cases of transoral thyroidectomy. The drainage fluid collected after the surgery was serosanguinous, and a lower drainage volume was observed in the transoral group than that in the BABA group (64.9 vs. 78.5 ml, p = 0.017). However, there was no significant difference regarding the blood loss, hospital stay, postoperative pain score, and lymph nodes retrieved. The rate of postoperative complications, such as hypoparathyroidism and vocal cord palsy was comparable between the two groups.

CONCLUSIONS

Transoral approach and BABA are comparable with regard to surgical outcomes. Selected patients may choose either technique based on their preferences.

Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy

BACKGROUND

Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods.

METHODS

A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve.

RESULTS

Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2.

CONCLUSIONS

The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.

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.

Impact of bedside assistant on outcomes of robotic thyroid surgery: A STROBE-compliant retrospective case-control study

The importance of bedside assistants has been well established in various robotic procedures. However, the effect of assistants on the surgical outcomes of thyroid surgery remains unclear. We investigated the effects of a dedicated robot assistant (DRA) in robotic thyroidectomy. We also evaluated the learning curve of the DRA.Between January 2016 and December 2019, 191 patients underwent robotic total thyroidectomy, all of which were performed by a single surgeon. The DRA participated in 93 cases, while non-dedicated assistants (NRAs) helped with 98 cases. Demographic data, pathologic data, operative times, and postoperative complications were recorded and analyzed.Robotic thyroidectomy was successful in all 191 patients, and none required conversion to the conventional open procedure. Mean operative time was shorter in the DRA group than in the NRA group (183.2 ± 33.6 minutes vs 203.1 ± 37.9 minutes; P < .001). There were no significant differences in terms of sex distribution, age, preoperative serum thyroid stimulating hormone level, or pathologic characteristics between the groups. Cumulative summation analysis showed that it took 36 cases for the DRA to significantly reduce operative time. Mean operative time decreased significantly in the subgroup including the 37th to the 93rd DRA cases compared with the subgroup including only the first 36 DRA cases (199.7 ± 37.3 minutes vs 172.8 ± 26.4 minutes; P < .001). NRA group showed no definite decrease of operation time, which indicated that the NRAs did not significantly deviate from the mean performance.Increased experience of the bedside assistant reduced operative times in the robotic thyroidectomy. Assistant training should be considered as a component of robotic surgery training programs.

Thyroid cancer surgery - in what direction are we going? A mini-review

The prevalence of thyroid cancer, especially in women, is increasing dramatically. Therefore, patients often undergo thyroidectomy upon diagnosis. However, the cosmetic outcome after surgery is of particular concern for many patients. Thus, minimally invasive procedures for treating thyroid disease have been established in recent decades. Total endoscopic and robotic procedures have been slowly and successively introduced while meeting all oncological criteria. Our analysis of the advantages and disadvantages of scarless surgical procedures suggests that the cosmetic aspects of these surgeries will continue to become more important. This review assesses the recent findings regarding the roles of endoscopic and robotic procedures in thyroid cancer surgery.

Comparison of the vessel sealer Extend® with harmonic ACE® in robotic bilateral axillary-breast approach thyroid surgery

Background

Harmonic ACE^® (Harmonic) Curved Shears are frequently used for vessel sealing in patients undergoing robotic thyroidectomy. Unlike other robotic devices with articulation, the Harmonic device can only move in a straight-forward direction without articulation. The recently introduced Vessel Sealer Extend^® (VSE) provides bipolar sealing and cutting with articulation movement. This study compared the VSE and Harmonic devices in robotic bilateral axillary-breast approach (BABA) thyroid surgery.

Methods

From December 2018 to March 2019, 35 consecutive patients underwent robotic BABA thyroidectomy, 20 using the VSE and 15 using the Harmonic device. Patient characteristics, pathologic results, and clinical outcomes, including complications, were evaluated.

Results

The characteristics of patients in the two groups were similar. Surgical time from robot docking to completion of lobectomy was longer in the VSE than in the Harmonic group (45.00±9.52 vs. 39.72±12.76 min; P=0.170). The number of camera cleanings during lobectomy was significantly lower in the VSE group (0.55±0.51 vs. 1.93±1.71; P=0.002). Intraoperative blood loss (53.00±43.29 vs. 28.67±41.03 mL; P=0.102), hospital stay after surgery (3.55±0.95 vs. 3.67±0.90 days; P=0.715), and pain scores on the first (2.85±0.37 vs. 2.93±0.26; P=0.458) and second (2.55±0.51 vs. 2.60±0.51; P=0.775) postoperative days were similar in the VSE and Harmonic groups. No patient experienced vocal cord palsy or postoperative bleeding.

Conclusions

VSE can be safely applied to robotic BABA thyroid surgery.

Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery

OBJECTIVE

Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.

METHODS

Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.

RESULTS

One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T² = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T² = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T² = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.

CONCLUSION

Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1603-1608, 2020.

Robotic thyroidectomy via bilateral axillo-breast approach: Experience and learning curve through initial 220 cases

OBJECTIVE

This study is aim to summarize the experience of robotic thyroidectomy via bilateral axillo-breast approach of our center and also to find out the learning curve of this technique.

METHODS

In total 220 initial patients who have undergone robotic thyroidectomy via bilateral axillo-breast approach from May 2015 to September 2017 were involved in this study. The data of operation time, clinical characteristics, surgical outcomes and oncological outcomes were collected. The moving average method is use to explore the learning curve.

RESULTS

All patients had undergone robotic thyroidectomy successfully without conversion to other surgical approaches. The mean age of the enrolled subjects was 34.4 ± 7.8 years old, while the sex ratio (male/female) was 38/182. There were 50 benign tumor cases and 170 malignant tumor cases. The mean total operation time was 105.3 ± 37.6 min. Lymph node metastasis was observed in 61 (35.9%) patients. The mean retrieved lymph node count was 5.1 ± 3.8 while the mean metastatic lymph node count was 0.7 ± 1.5. The operation time decreased significantly after about 30-35 cases and formed the plateau. After 80 cases, the operation time significantly decreased again.

CONCLUSION

For skilled endocrine surgeons, robotic thyroidectomy has proved to be safe and feasible, which could be applied extensively in patients strictly selected in high-volume centers, with a relatively short learning curve of about 30-35 cases. While the surgeons getting more experienced, this technique would be more efficient.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Quantitative Assessment of the Learning Curve for Robotic Thyroid Surgery

With the increased utilization of robot thyroidectomy in recent years, surgical proficiency is the paramount consideration. However, there is no single perfect or ideal method for measuring surgical proficiency. In this study, we evaluated the learning curve of robotic thyroidectomy using various parameters. A total of 172 robotic total thyroidectomies were performed by a single surgeon between March 2014 and February 2018. Cumulative summation analysis revealed that it took 50 cases for the surgeon to significantly improve the operation time. Mean operation time was significantly shorter in the group that included the 51st to the 172nd case, than in the group that included only the first 50 cases (132.8 ± 27.7 min vs. 166.9 ± 29.5 min; p < 0.001). On the other hand, the surgeon was competent after the 75th case when postoperative transient hypoparathyroidism was used as the outcome measure. The incidence of hypoparathyroidism gradually decreased from 52.0%, for the first 75 cases, to 40.2% after the 76th case. These results indicated that the criteria used to assess proficiency greatly influenced the interpretation of the learning curve. Incorporation of the operation time, complications, and oncologic outcomes should be considered in learning curve assessment.

Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature

INTRODUCTION

The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature.

METHODS

Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4).

RESULTS

All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high.

CONCLUSION

Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Meta-analysis Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy and Conventional Thyroidectomy

Objective. Despite gaining popularity, bilateral axillo-breast approach robotic thyroidectomy (BABA RT) remains controversial. We performed a meta-analysis to evaluate the safety and effectiveness of BABA RT compared with open thyroidectomy (OT) in thyroid disease. Methods. A literature search was conducted using various databases, including PubMed, Web of Science, and Cochrane Library, up to February 2018. Outcomes of interest included patient characteristics, surgical outcomes, adverse events, complications, and surgical completeness. Results. A total of 11 publications including 2733 patients (1070 in the BABA RT and 1663 in the open group) were finally selected for the meta-analysis. BABA RT was associated with an equivalent complication rate, including transient and permanent hypocalcemia, transient and permanent recurrent laryngeal nerve palsy, bleeding, chyle leakage, and seroma, as well as surgical outcomes including tumor size, length of hospital stay, total drain amount, and pain score. BABA RT was also associated with an equivalent surgical completeness, including total dose of radioactive iodine, proportion of stimulated thyroglobulin (sTg) <1.0 ng/mL, and level of sTg. Moreover, BABA RT involved longer operative times (weighted mean difference [WMD] = 110.13; P < .00001), smaller number of retrieved lymph nodes(WMD = −1.26, P = .003), and more cost (WMD = 5811.18; P < .00001) compared with OT. Conclusions. BABA RT is safe and feasible and provides similar perioperative outcomes and complications when compared with OT. However, BABA RT was associated with longer operating time, fewer retrieved lymph nodes, and more cost. Randomized clinical trials with large samples and longer follow-up data are needed to more rigorously examine this effect.

Fluorescence imaging-guided robotic thyroidectomy and central lymph node dissection

BACKGROUND

The purpose of this study was to evaluate the feasibility of complete central compartment node dissection (CCND) using fluorescence imaging (FI) during robotic thyroidectomy.

METHODS

A total of 110 patients underwent robotic thyroidectomy and CCND from August 2015 to June 2016; 55 patients underwent robotic surgery using FI (FI group) and the other 55 patients without it (control group). The FI group was injected with indocyanine green into the thyroid to enhance the identification of lymph nodes (LNs).

RESULTS

Indocyanine green-stained LNs were easily detected using FI. The number of harvested LNs was 7.0 in the FI group and 4.8 in the control group (P = 0.004). There was lower rate of transient hypocalcemia in the FI group (18.5%) than control group (26.7%), but there was no significant difference (P = 0.417). There were no other significant differences between the two groups.

CONCLUSIONS

The use of FI during robotic thyroidectomy facilitated the identification of LNs and guided complete CCND.

A comparison study of the transoral and bilateral axillo-breast approaches in robotic thyroidectomy

OBJECTIVES

Transoral robotic thyroidectomy (TORT) is a new remote access approach to avoid cervical incision. The purpose of this study is to compare two approaches used to avoid cervical incision: transoral approach and bilateral axillo-breast approach (BABA) in robotic thyroidectomy.

METHODS

A total of 90 patients were enrolled prospectively between September 2016 and April 2017. The BABA group had 43 and the TORT group had 47 patients, respectively. Parameters including clinicopathologic data, operative time, complications, laboratory data, hospital stay, postoperative pain, and cosmetic satisfaction were analyzed.

RESULTS

Complications were not different among the two groups. The operative time of TORT was longer than BABA until 15 cases of TORT were completed, but there was no difference after that. The Visual Analogue Scale score in TORT was lower than BABA in all the periods. TORT showed a higher cosmetic satisfaction after surgery. There was no infection or permanent mental nerve hypoesthesia in TORT.

CONCLUSION

Our study showed that TORT had less postoperative pain and a greater cosmetic satisfaction than the BABA. There were no significant differences in the postoperative surgical results between the two groups. TORT was comparable to the BABA in outcome with higher cosmetic satisfaction and less pain.

Preoperative information for thyroid surgery

The preoperative information necessary to communicate to the patient to obtain informed consent in thyroid surgery is not detailed in length in the current medical literature. Advances in technology and the advent of remote access approaches in thyroid surgery have increased the need for a detailed communication of risks, benefits and alternatives to achieve an informed consent. In this review article, we outline the indications for thyroid surgery, risks of thyroid surgery, different approaches to thyroidectomy, and possible consequences of using advanced technology using intraoperative nerve monitoring (IONM) as an example. A truly detailed informed consent in the modern age of thyroid surgery is crucial. This article not only details the risks, benefits and alternatives of thyroid surgery, but also incorporates new practices, guidelines and technologies to allow patients to achieve a comprehensive preoperative understanding of treatment recommendations.

Comparative Study between Robotic Total Thyroidectomy with Central Lymph Node Dissection via Bilateral Axillo-breast Approach and Conventional Open Procedure for Papillary Thyroid Microcarcinoma

BACKGROUND

A large proportion of the patients with papillary thyroid microcarcinoma are young women. Therefore, minimally invasive endoscopic thyroidectomy with central neck dissection (CND) emerged and showed well-accepted results with improved cosmetic outcome, accelerated healing, and comforting the patients. This study aimed to evaluate the safety and effectiveness of robotic total thyroidectomy with CND via bilateral axillo-breast approach (BABA), compared with conventional open procedure in papillary thyroid microcarcinoma.

METHODS

One-hundred patients with papillary thyroid microcarcinoma from March 2014 to January 2015 in Jinan Military General Hospital of People's Liberation Army (PLA) were randomly assigned to robotic group or conventional open approach group (n = 50 in each group). The total operative time, estimated intraoperative blood loss, numbers of lymph node removed, visual analog scale (VAS), postoperative hospital stay time, complications, and numerical scoring system (NSS, used to assess cosmetic effect) were analyzed.

RESULTS

The robotic total thyroidectomy with CND via BABA was successfully performed in robotic group. There were no conversion from the robotic surgeries to open or endoscopic surgery. The subclinical central lymph node metastasis rate was 35%. The mean operative time of the robotic group was longer than that of the conventional open approach group (118.8 ± 16.5 min vs. 90.7 ± 10.3 min, P < 0.05). The study showed significant differences between the two groups in terms of the VASs (2.1 ± 1.0 vs. 3.8 ± 1.2, P < 0.05) and NSS (8.9 ± 0.8 vs. 4.8 ± 1.7, P < 0.05). The differences between the two groups in the estimated intraoperative blood loss, postoperative hospital stay time, numbers of lymph node removed, postoperative thyroglobulin levels, and complications were not statistically significant (all P > 0.05). Neither iatrogenic implantation nor metastasis occurred in punctured porous channel or chest wall in both groups. Postoperative cosmetic results were very satisfactory in the robotic group.

CONCLUSIONS

Robotic total thyroidectomy with CND via BABA is safe and effective for Chinese patients with papillary thyroid microcarcinoma who worry about the neck scars.

Aesthetics in Thyroid Surgery: The Patient Perspective

Objectives

To define characteristics that influence patient perceptions of thyroidectomy scar cosmesis.

Study Design

Prospective cohort study.

Setting

Tertiary endocrine surgery practice in an academic medical center.

Subjects and Methods

Institutional review board–approved trial in which 136 subjects were recruited from a population of patients being seen for either thyroid or sinus surgery and evaluated standardized photographs, superimposed with computer-generated thyroidectomy scars of varying lengths (2, 4, and 6 cm) and widths (1 and 2 mm), and graded their perception of the scars using the observer scar assessment scale (OSAS) domains of the patient and observer scar assessment scale.

Results

There were 69 subjects in the thyroid group and 67 in the nonthyroid group. Controlling for width, longer scars were perceived as worse than shorter scars; controlling for length, thicker scars were perceived as worse than thinner scars ( P < .01). Beyond 2 cm, thick scars were judged to be worse than thin scars, even when they were shorter. There was no difference in the mean overall OSAS scores between surgery, sex, or age groups. Nonwhites tended to judge scars as being worse than whites did ( P < .01).

Conclusion

As expected, patients of all demographics prefer shorter scars compared with longer scars and thinner scars over thick scars. Ethnic differences in scar perception were identified and deserve additional study. Surgeons should endeavor to perform thyroid surgery through the smallest incision that allows the operation to be performed safely to minimize the cosmetic impact of the operation.

Bilateral axillo-breast approach robotic thyroidectomy: review of evidences

The bilateral axillo-breast approach (BABA) is one of the most popular contemporary remote-access thyroidectomy techniques. While the initial experiences with BABA endoscopic thyroidectomy (ET) were associated with some technical challenges and safety concerns, many limitations of the technique could now be substantially overcome by BABA robotic thyroidectomy (RT). In this review, the current literature evidences of BABA RT were analyzed. Data regarding the patient selection, the learning curve, and the comparison with open thyroidectomy (OT) and BABA ET were examined. Careful case selection for BABA RT should be undertaken according to factors related to the patient and the thyroid pathology. The learning curve of BABA RT was about 40 cases. Comparing to OT, BABA RT was comparable to OT for the complication profiles and most perioperative outcomes. But it was associated with longer operative time, higher cost and possibly inferior oncological control with lower number of central lymph node (LN) retrieved. When compared to BABA ET, BABA RT was comparable for most perioperative outcomes except longer operative time and higher cost. Yet, BABA RT was superior to BABA ET for better oncological control. BABA RT is a safe and effective procedure for most benign thyroid conditions and low-risk differentiated thyroid cancers (DTC).

Three-dimensional versus two-dimensional endoscopic-assisted thyroidectomy via the anterior chest approach: a preliminary report

OBJECTIVE

The objective of the study was to evaluate the safety and effectiveness of three-dimensional (3D) endoscopy for thyroidectomy and compare it to two-dimensional (2D) endoscopy. The major limitations of conventional endoscopy include its lack of depth perception and tactile feedback. The 3D endoscopy technique, which involves 3D imaging, is widely used. However, few reports have described the use of 3D endoscopic systems in thyroid surgery.

METHOD

In this single-institutional study, 103 consecutive patients who underwent endoscopic thyroidectomy between July 2013 and April 2014 were enrolled. Of these, 32 patients chose 3D endoscopy, and 71 patients chose 2D endoscopy and were used as a control group. All patients were stratified by type of operation.

RESULT

All 103 patients underwent a successful endoscopic-assisted thyroidectomy with no conversion to open surgery. There were no differences in operation time, intraoperative bleeding, postoperative drainage, the number of lymph nodes (LNs) dissected, major complications, and hospital stays. During a median follow-up of 28.0 months, no patients experienced a recurrence of thyroid cancer.

CONCLUSION

Our preliminary report demonstrates that 3D endoscopy achieved the same level of safety and effectiveness as 2D endoscopy in endoscopic-assisted thyroidectomies. Additionally, 3D endoscopy provided good depth perception and allowed the surgeon to easily recognize critical anatomical landmarks. Further large-scale studies, preferably prospective randomized control trials, are required to confirm this finding.

Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy with Open Thyroidectomy for Graves' Disease

BACKGROUND

There is an ongoing debate about whether robotic thyroidectomy (RT) is appropriate for Graves' disease. The aim of this study was to compare the safety of bilateral axillo-breast approach (BABA) RT with that of open thyroidectomy (OT) in patients with Graves' disease.

METHODS

From January 2008 to June 2014, 189 (44 BABA RT and 145 OT) patients underwent total thyroidectomy for Graves' disease. Recurrence of Graves' disease, intraoperative blood loss, hospital stay, and complication rates including recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism were analyzed between BABA RT and OT groups, after propensity score matching according to age, gender, body mass index, surgical indication, the extent of operation, excised thyroid weight, and follow-up period.

RESULTS

No patient experienced recurrence of Graves' disease after median follow-up of 35.0 months. Intraoperative blood loss (151.8 ± 165.4 mL vs. 134.5 ± 75.4 mL; p = 0.534) and hospital stay (3.4 ± 0.7 day vs. 3.3 ± 0.7 day; p = 0.564) were not different between BABA RT and OT groups. Complication rates including transient RLN palsy (11.4 vs. 11.4%; p = 1.000), transient hypoparathyroidism (18.2 vs. 20.5%; p = 0.787), permanent RLN palsy (0 vs. 2.3%; p = 0.315), and permanent hypoparathyroidism (2.3 vs. 2.3%; p = 1.000) were also comparable between groups.

CONCLUSIONS

BABA RT for Graves' disease showed comparable surgical completeness and complications to conventional OT. BABA RT can be recommended as an alternative surgical option for patients with Graves' disease who are concerned about cosmesis.

Surgical safety and oncological completeness of robotic thyroidectomy for thyroid carcinoma larger than 2 cm

BACKGROUND

The safety of robotic thyroidectomy (RT) for small-sized thyroid carcinomas has been well established. The surgical outcomes of bilateral axillo-breast approach RT for thyroid carcinomas larger than 2 cm were evaluated and compared with those of open thyroidectomy (OT).

METHODS

The medical records of patients who underwent total thyroidectomy or hemithyroidectomy followed by completion thyroidectomy for differentiated thyroid carcinomas measuring 2-4 cm were retrospectively reviewed.

RESULTS

The study included 86 patients who underwent RT (n = 21) or OT (n = 65) with mean ages of 30.8 and 51.6 years, respectively. The mean tumor size was 2.8 cm in both groups. There were no significant differences between the RT and OT groups in vocal cord palsy rate (transient, 19.0 vs. 9.2 %; permanent, 0 vs. 1.5 %), postoperative hypoparathyroidism rate (transient, 19.0 vs. 33.8 %; permanent, 4.8 vs. 1.5 %), and the number of retrieved central lymph nodes in papillary thyroid carcinoma patients (6.4 ± 3.5 vs. 6.1 ± 3.9, respectively). The proportion of the patients with serum stimulated thyroglobulin level of <1.0 ng/ml at the initial radioactive iodine treatment was 64.7 % (11/17) for RT group and 66.0 % (35/53) for OT group (p = 0.920). There were three patients (1 RT and 2 OT) who had a biochemical incomplete response, and there was no case of anatomical recurrence or mortality during the median follow-up period of 40.2 months.

CONCLUSION

RT is a safe and oncologically sound treatment option for differentiated thyroid carcinomas measuring 2-4 cm in a selected group of patients. The role of RT should be evaluated in correlation with technological advances and increased experience.

Surgical outcomes of robotic thyroidectomy vs. conventional open thyroidectomy for papillary thyroid carcinoma

Background

The purpose of this study was to compare the surgical outcomes of robotic thyroidectomy (RT) using bilateral axillo-breast approach (BABA) with conventional open thyroidectomy (OT) in papillary thyroid carcinoma patients.

Methods

Between January 2009 and December 2013, 815 patients who had received thyroidectomy for papillary thyroid carcinoma were enrolled. Of these, 126 patients received RT and 689 patients underwent OT. Age, gender, body mass index, extent of surgery, tumor size, multiplicity, bilaterality, extrathyroidal extension, and tumor stage were used for the propensity score matching analysis. One hundred and nine patients were selected in each group, and surgical outcomes were compared between the two groups.

Results

The RT group showed a significantly longer operating time (290.6 ± 74.4 vs. 107.9 ± 30.8 min, P < 0.001). However, the mean hospital stay after surgery (3.6 ± 0.8 vs. 3.4 ± 1.2 days, P = 0.293), postoperative complication rates (major and minor, P = 0.754 and P = 0.852), and pain score (postoperative day, P = 0.669; postoperative day 1, P = 0.952) were comparable between the two groups. There was no difference in the number of metastatic lymph nodes, but the mean number of retrieved lymph nodes in the RT group was lesser than that in the OT group (3.5 ± 3.5 vs. 5.3 ± 5.2, P = 0.002).

Conclusions

Robotic thyroidectomy via the BABA may be a safe and acceptable surgical technique. But, further development that resolves the limitation of central node dissection is needed.

Comparison of the Quality of Life for Thyroid Cancer Survivors Who Had Open Versus Robotic Thyroidectomy

OBJECTIVES

The purpose of this study was to compare the quality of life (QoL) between conventional open and robotic total thyroidectomy in papillary thyroid carcinoma.

MATERIALS AND METHODS

From January 2011 to July 2013, 229 patients (112 robot and 117 open) were randomly selected. QoL, including overall satisfaction, cosmetic results, voice/sensory change, postoperative pain and impairment of swallowing, neck/shoulder movement, and physical/psychological activity, was recorded.

RESULTS

The follow-up period was 32.3 ± 6.3 months. The satisfaction levels of the overall and cosmetic results were 8.95 ± 1.23, 8.40 ± 1.20 and 3.86 ± 0.04, 3.21 ± 0.10 for robotic and open surgery, respectively; these differences were statistically significant (P = .006, <.001). The sensory change might be more noticeable with robotic thyroidectomy (P = .064). There were no differences in the results concerning other variables among the two groups.

CONCLUSION

Robotic thyroidectomy shows comparable results to conventional open thyroidectomy in terms of the postoperative long-term QoL.

Predictive factors for difficult robotic thyroidectomy using the bilateral axillo-breast approach

BACKGROUND

The purpose of this study was to identify predictors of difficult robotic thyroidectomy using the bilateral axillo-breast approach (BABA) for the management of patients with papillary thyroid carcinoma (PTC).

METHODS

We examined a database containing details of patients with PTC who had undergone robotic thyroidectomy with cervical lymph node dissection between July 2008 and June 2013. Patients were subgrouped into difficult thyroidectomy and non-difficult thyroidectomy to identify predictors associated with difficult thyroidectomy corresponding to the time of operation. Clinicopathologic characteristics, surgical outcomes, and postoperative morbidities were investigated.

RESULTS

Male sex was the only significantly different clinicopathologic factor between the 2 groups (p = .013). Other factors, such as age (p = .809) and body mass index (BMI; p = .202), were comparable between the 2 groups. The rates of postoperative complications, such as hypoparathyroidism, vocal cord palsy, and seroma, in the difficult thyroidectomy group were not significantly different from those in the non-difficult thyroidectomy group. There was no hematoma or wound infection. Male sex was the only independent factor associated with difficult thyroidectomy (odds ratio [OR] = 5.379; 95% confidence interval [CI] = 1.052-27.502; p = .043), according to the multivariate logistic regression model.

CONCLUSION

Male sex was the only predictive factor for difficult robotic thyroidectomy using BABA. Further evaluations should be performed to ascertain additional factors associated with difficult robotic thyroidectomy. © 2015 Wiley Periodicals, Inc. Head Neck 38: E954-E960, 2016.

Ethical issues in robotic-assisted transaxillary thyroidectomy

Like many new techniques in surgery, the use of robotic-assisted transaxillary thyroidectomy is an innovative approach to a common surgical treatment. However, the increased risks associated with the operation along with the increased costs make robotic-assisted transaxillary thyroidectomy an ethically problematic procedure to be utilized in contemporary health systems.