A Time Trend Analysis of 5,000 Robotic Thyroidectomies via 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.

Impact of Large Thyroid Nodules (≥4 cm) on Surgical Outcomes Following Endoscopic Thyroidectomy Through the Bilateral Axillo-Breast Approach

OBJECTIVE

Endoscopic thyroidectomy through the bilateral axillo-breast approach (BABA) is predominantly used in cases involving low-risk thyroid malignancies and benign nodules measuring <4 cm. However, the efficacy and safety of this technique in larger goiters remain underexplored.

METHODS

This retrospective study compared perioperative data and pathologic outcomes among patients who underwent endoscopic BABA thyroidectomy categorized on the basis of the size of the dominant nodule (<4 vs ≥4 cm).

RESULTS

Among the 113 included patients, 81 (72%) had a dominant nodule measuring <4 cm (group 1) and 32 (28%) presented with a nodule measuring ≥4 cm (group 2). Group 2 experienced longer operative times, greater blood loss, and higher drainage volumes than group 1. However, pain scores and length of postoperative hospital stay were similar between the groups. None of the patients required conversion to open surgery. The incidence rates of vocal cord palsy and hypoparathyroidism did not differ significantly between groups. In group 2, three patients developed seroma (9%) and one exhibited delayed bleeding (3%). Pathologic examination revealed that 6 patients (19%) in group 2 had malignant neoplasms; 3 were identified in the dominant nodule, whereas the remaining 3 were identified in separate, smaller nodules. Throughout the mean follow-up period of 43 months, no recurrence or metastasis was reported.

CONCLUSIONS

Endoscopic BABA thyroidectomy is a viable option for patients with large thyroid nodules (≥4 cm); however, this technique requires careful execution.

Chinese expert consensus on transoral vestibular approach robotic thyroidectomy and parathyroidectomy (version 2024)

The transoral robotic thyroidectomy (TORT) has been increasingly adopted for minimally invasive thyroid surgery and it has proved to have better cosmetic results and comparable surgical outcomes with open operations. Most reports on TORT are case series, or single center, small-sample controlled, retrospective studies, and clinical guidelines have not been established so far. To better promote the standardized implementation and widespread adoption of TORT in China, the expert panel have organized thyroid minimally invasive surgery experts and some robotic thyroidectomy experts in China jointly formulate the Chinese expert consensus on transoral vestibular approach robotic thyroidectomy and parathyroidectomy (2024 edition) based on the latest relevant literature and clinical experiences from multiple centers. This consensus aims to provide guidance and reference for colleagues.

One-Year Clinical Experience of Single-Port and Multi-Port Robotic Thyroid Surgery in a Single Institution

Background: With the advent of da Vinci SP, surgical methods using da Vinci SP are becoming popular in thyroid surgery. The authors previously reported on a new surgical method called the single-port robotic areolar (SPRA) approach, which evolved from the previous bilateral axillary breast approach (BABA). This paper reports a comparative analysis of SPRA and BABA over one year. Methods: The data on SPRA and BABA thyroid surgery performed at the authors' hospital from December 2022 to December 2023 were analyzed. Results: 111 SPRA and 159 BABA surgeries were performed. SPRA was performed overwhelmingly on women (1 man vs. 110 women), and the body mass index (BMI) was lower in SPRA patients (23.63 ± 3.49 vs. 25.71 ± 4.39, p < 0.001). The proportion of total thyroidectomy was significantly higher in BABA patients, and a modified radical neck dissection (MRND) was only performed using the BABA method. The time for flap formation before robot docking was significantly shorter in SPRA patients (12.08 ± 3.99 vs. 18.34 ± 5.84 min, p < 0.001). Postoperative drain amount was also significantly lower in SPRA patients (53.87 ± 35.45 vs. 81.74 ± 30.26 mL, p < 0.001). Hospital stay after surgery was significantly shorter with SPRA (3.04 ± 0.48 vs. 3.36 ± 0.73 days, p < 0.001). Thyroglobulin levels after a total thyroidectomy (0.06 ± 0.13 vs. 0.45 ± 0.78, p = 0.002) and stimulated Tg level before the RAI (1.03 ± 0.74 vs. 5.01 ± 13.63, p = 0.046) were significantly lower in the SPRA group. No significant differences were observed between the two groups according to the postoperative complications, including vocal cord palsy and hypoparathyroidism. Conclusions: Based on the authors' experience, SPRA is a less invasive robot thyroid surgery method than BABA.

Outcomes of bilateral axillo-breast approach robotic parathyroidectomy versus open parathyroidectomy for primary hyperparathyroidism: a single-institution retrospective study

Purpose

Bilateral axillo-breast approach robotic parathyroidectomy (BABA-RP) aims to remove overactive or enlarged parathyroid glands with no visible neck collar incision. In this study, we compared the safety and surgical outcomes of BABA-RP vs. those of an open surgery group to ascertain whether BABA-RP is a safe and feasible surgical approach for patients with primary hyperparathyroidism (pHPT).

Methods

This single-institution retrospective cohort study included 74 patients with primary HPT who underwent open parathyroidectomy (n = 37) or BABA-RP (n = 37) at our institution between November 2014 and March 2023. Patient demographics, biochemical cure rates, operative time, blood loss rates, and complication rates were examined and compared.

Results

The patients in the BABA-RP group were younger and had a longer mean operative time. Regarding complication events, 2 patients in the open surgery group and 1 patient in the BABA-RP group had transient hypoparathyroidism. All 74 patients achieved biochemical cure at <6 months, regardless of the approach used. Two patients in the BABA-RP group and 1 patient in the open surgery group had carcinoma on surgical pathology. All 3 patients with parathyroid carcinoma remained recurrence-free at 1-year follow-up.

Conclusion

Compared with the open procedure, BABA-RP is a safe and feasible procedure that provides an excellent biochemical cure rate for patients with pHPT and has superior cosmetic benefits with equivalent surgical outcomes.

Comparison of transoral vestibular robotic thyroidectomy with traditional low-collar incision thyroidectomy

Transoral vestibular robotic thyroidectomy can really make the patient's body surface free of scar. This study aimed to compare the surgical and patient-related outcomes between the transoral vestibular robotic thyroidectomy and traditional low-collar incision thyroidectomy. The clinical data of 120 patients underwent transoral vestibular robotic thyroidectomy (TOVRT) or traditional low-collar incision thyroidectomy (TLCIT) were collected from May 2020 to October 2021. Propensity score matching analysis was used to minimize selection bias. All these patients were diagnosed with papillary thyroid carcinoma (PTC) through ultrasound-guided fine-needle aspiration prior to surgical intervention and surgical plan was tailored for each patient. An intraoperative recurrent laryngeal nerve (RLN) detection system was used in all patients, whose RLNs were identified and protected. We performed transoral vestibular robotic thyroidectomy with three intraoral incisions. Additional right axillary fold incisions were adopted occasionally to enhance fine reverse traction of tissue for radical tumor dissection. Clinical data including gender, age, tumor size, BMI, operation time, postoperative drainage volume and time, pain score, postoperative length of stay (LOS),number of lymph nodes removed, complications, and medical expense were observed and analyzed. Propensity score matching was used for 1:1 matching between the TOVRT group and the TLCIT group. All these patients accepted total thyroidectomy(or lobectomy) plus central lymph node dissection and all suffered from PTC confirmed by postoperative pathology. No conversion to open surgery happened in TOVRT group. The operative time of TOVRT group was longer than that of TLCIT group (P < 0.05). The postoperative drainage volume of TOVRT group was more than that of TLCIT group (P < 0.05). The drainage tube placement time of TOVRT group were longer than that of TLCIT group (P < 0.05). Significant differences were also found in intraoperative bleeding volume, pain score and medical expense between the two groups (P < 0.05). The incidence of perioperative common complications such as hypoparathyroidism and vocal cord paralysis in the two groups was almost identical (P > 0.05). However, there were some specific complications such as surgical area infection (one case), skin burn (one case), oral tear (two cases), and paresthesia of the lower lip and the chin (two cases) were found in TOVRT group. Obviously, the postoperative cosmetic effect of the TOVRT group was better than TLCIT group (P < 0.05). TOVRT is safe and feasible for low to moderate-risk PTC patients and is a potential alternative for patients who require no scar on their neck. Patients accepted TOVRT can get more satisfaction and have less psychologic injury caused by surgery.

Transoral endoscopic thyroidectomy vestibular approach vs. transoral robotic thyroidectomy: systematic review and meta-analysis

This study aimed to conduct a systematic review and meta-analysis to compare the surgical outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT). We carried out a systematic literature search of PubMed, Web of Science, Cochrane Library, and Google Scholar on studies comparing TOETVA and TORT until January 2023. A total of five articles published between 2018 and 2023 that matched the inclusion criteria were included in the systematic review and meta-analysis. The studies included 641 patients (394 TOETVA patients and 247 TORT patients). TOETVA group was associated with a significantly shorter operative time with a mean difference of 60.08 min [95% confidence interval (CI) - 83.95 to - 36.20; P < 0.001). Transient recurrent laryngeal nerve palsy was more common in the TOETVA group than the TORT group (OR 3.00; 95% CI 1.14-7.88; P = 0.03). There were no significant differences in the other outcomes, including the length of hospital stay, postoperative pain scores, number of central lymph nodes retrieved, permanent recurrent laryngeal nerve injuries, and transient and permanent hypoparathyroidism. The TOETVA group was associated with shorter operative time and more transient recurrent laryngeal nerve palsy than the TORT group. Each procedure has its benefits and limitations. The surgical approach should be determined by considering the patient's characteristics and preferences, as well as the surgeon's preference and area of expertise.

First Experience of Single-Port Robotic Areolar Approach Thyroidectomy

OBJECTIVES

Numerous minimally invasive thyroidectomy techniques have been developed and are actively utilized in hospitals around the globe. Herein, we describe a recently developed minimally invasive thyroidectomy technique that employs the da Vinci SP, and we present the preliminary clinical outcomes of single-port robotic areolar thyroidectomy (SPRA).

METHODS

A 3-cm semi-circular incision on the right areola and a small 8-mm incision on the left areola were created. Using hydro-dissection and an advanced bipolar device, a subcutaneous skin flap was created, extending from the areola to the thyroid cartilage. The da Vinci SP was then inserted through the incision in the right areola. Between December 2022 and March 2023, 21 SPRA procedures were conducted. Patients' medical records and surgical videos were subsequently reviewed.

RESULTS

Lobectomy was performed in 17 patients, isthmectomy in 2 patients, and total thyroidectomy in 2 patients. The mean flap time was 14.9±4.2 minutes and the console time was 62.4±17.1 minutes. The mean tumor size was 0.89± 0.65 cm and the number of retrieved lymph nodes was 3.94±3.98 (range, 0-12). There were no observed instances of vocal cord palsy or hypoparathyroidism.

CONCLUSION

We successfully developed and performed the novel SPRA for the first time worldwide. Unlike other robotic surgery.

METHODS

SPRA is less invasive and leaves no visible scars. This technique employs a sophisticated single-port robotic device. However, to assess the efficacy of this method, we need to analyze more cases and conduct comparative studies in the near future.

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.