Minimally invasive video-assisted thyroidectomy: experience of 300 cases

A Randomized Comparison of Carbon Nanoparticles in Endoscopic Lymph Node Dissection Via the Bilateral Areola Approach for Papillary Thyroid Cancer

OBJECTIVE

We assess the value of carbon nanoparticles (CNP) staining in patients undergoing endoscopic thyroidectomy and central compartment lymph node (CLN) dissection via the bilateral areola approach [endoscopic thyroidectomy via bilateral areola approach (ETBAA)].

METHODS

This was a prospective randomized study. Three hundred two consecutive early-stage thyroid cancer patients eligible for ETBAA were recruited at the Division of Thyroid Surgery, China-Japan Union Hospital, Jilin University, China. CLN were mapped and retrieved under the guidance of stained or unstained CNP. The location, detection rates, positive nodes, and number of stained lymph nodes were compared.

RESULTS

ETBAA patients were randomly divided into a CNP group (n=152) and a control group (n=150). In the CNP group, the imaging of lymphatic flow could be observed in 1016 (95.9%) lymph nodes, whereas 43 (4.1%) were unstained. The mean number of stained lymph nodes in each procedure was 6.68 (range, 3 to 12). The total number of dissected lymph nodes was 1059 in the CNP group and 872 in the control group (P=0.00). There was a significant difference of inadvertent parathyroidectomy between the 2 groups: 0.5% versus 3.9% in lobectomy (P=0.035) and 0.6% versus 5.2% in total thyroidectomy (P=0.012). However, the rates of hypoparathyroidism were not significantly different (P>0.05). There were no cases of CNP-related adverse effects.

CONCLUSIONS

The lymphatic navigation by CNP increases the number of detected CLN without the involvement of radioactive isotopes. However, CNP did not lower hypocalcemia, did not improve parathyroid hormone range, and there was no significant difference in the percentage of metastatic lymph nodes between the 2 groups.

Modified version of minimally invasive open thyroidectomy using an unilateral incision

BACKGROUND/OBJECTIVE

Open thyroidectomy has been the standard approach for patients undergoing thyroidectomy. However, this approach leads to prominent scars, hypesthesia, paresthesia, and uncomfortable sensations. We aimed to describe our modified technique of minimally invasive open thyroidectomy (MIT) and to compare the results with those of conventional thyroidectomy.

METHODS

This study included 880 patients who underwent surgery between January 2016 and December 2016. Modified MIT was performed in 249 patients (28.3%), and conventional thyroidectomy was performed in the remaining 631 patients.

RESULTS

Lobectomy was performed in the majority of cases (MIT 204 [81.9%] vs. conventional 429 [67.9%]). There were no significant differences in complications between the two approaches (6 [2.4%] vs. 8 [1.3%]). Patients who underwent surgery using the minimally invasive approach had a shorter operative time (77.99 ± 34.5 vs. 91.23 ± 36.58 min) and were discharged earlier (2.4 ± 0.8 vs. 3.2 ± 0.8) than those who underwent conventional thyroidectomy.

CONCLUSION

Modified MIT is a safe alternative to standard open thyroidectomy and allows the performance of bilateral total thyroidectomy with proper central compartment neck dissection.

LEVEL OF EVIDENCE

2b.

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.

Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews

Background:

We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure.

Materials and Methods:

PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test.

Results:

The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups.

Conclusions:

TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.

Minimally invasive video-assisted thyroidectomy in Asian patients: experience from Singapore

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) although well established in Europe has not yet gained widespread acceptance in Asia. We describe our learning experience in the first reported series of 105 cases from Singapore.

METHODS

A retrospective analysis of outcomes in 105 patients who underwent MIVAT from April 2011 to 2018 was performed. The inclusion criteria were - symptomatic benign thyroid pathologies and follicular lesions or neoplasms needing a hemi-thyroidectomy. A thyroid lobe volume less than 35 mL was used as cut-off. Patients underwent surgeon-performed thyroid ultrasound with biopsy of solid nodules. All cases were operated by one surgeon using standard Miccoli technique with energy device used in all cases.

RESULTS

From a total of 424 patients with nodular goitres undergoing thyroidectomy, 105 (24%) symptomatic eligible patients underwent the MIVAT procedure (M:F - 23:82). The mean incision lengths at start and completion were 1.7 cm (range 1.5-2 cm) and 2.4 cm (range 2-2.7 cm), respectively. Mean operating time was 97 min (range 59-160 min). There were four conversions (3.8%) in the first 25 cases and four patients (3.8%) experienced transient hoarseness with full recovery. Visual analogue pain scores at 6 and 24 h post-operatively were 2.7 and 1.1, respectively. Scar satisfaction was reported as excellent (75%), satisfactory (23%) and poor (2%).

CONCLUSION

Although technically more demanding, MIVAT is a safe and useful operation in a thyroid surgeon's armamentarium. The limitation of goitre size, however, allows only a small percentage of symptomatic patients to undergo this procedure.

Transoral endoscopic selective lateral neck dissection for papillary thyroid carcinoma: a pilot study

BACKGROUND

Transoral endoscopic thyroid surgery via the vestibular approach (TOETVA) has been gradually accepted worldwide due to its scar-free effect on the neck. Even central cervical lymphadenectomy has been performed in some cases of papillary thyroid carcinoma (PTC). However, there are few reports involving lateral neck dissection with TOETVA. In this study, we attempted to perform selective lateral neck dissection (SLND) for PTC via a transoral vestibular approach.

METHODS

This prospective study was conducted from January 2016 to December 2018 in twenty PTC patients with unilateral T1 tumors without capsular invasion and patients with abnormal level III and IV lymph nodes who underwent SLND via a transoral vestibular approach.

RESULTS

Endoscopic surgery was successfully accomplished in all 20 PTC patients. The mean age was 29.2 ± 5.5 (20-41) years. The mean operation time was 146.0 ± 18.7 (114-193) min. The average postoperative hospital stay was 6.8 ± 1.3 (5-10) days. The mean number of removed nodes was 7.4 ± 2.5 (4-12) in the central neck and 10.9 ± 2.8 (6-16) in the lateral neck, and the positive yield amounts were 2.0 ± 1.2 (0-4) and 2.7 ± 1.9 (0-6), respectively. No major complications occurred except for 1 case of transient unilateral recurrent laryngeal nerve palsy and two cases of effusion in the operative area. No evidence of persistent or recurrent disease was observed in these patients during a mean follow-up of 24.3 ± 9.1 (6-36) months. The cosmetic results and protection of personal privacy of this procedure were excellent.

CONCLUSION

Endoscopic SLND via the transoral vestibular approach is feasible, safe, and effective for selected PTCs. A multicenter large comparative study is necessary.

Minimally invasive video-assisted thyroidectomy: a critical analysis of long-term cosmetic results using a validated tool

INTRODUCTION

Since its first publication in 1997, minimally invasive video-assisted thyroidectomy (MIVAT) has developed into the predominant minimally invasive surgery of the thyroid. A major advantage over conventional thyroid surgery is the superior cosmetic result. However, there are still few data comparing the long-term cosmetic results of the two methods. This paper compares the long-term cosmetic results of the two methods, based on follow-up assessments.

METHODS

Between 2004 and 2011, 143 preselected patients underwent a MIVAT in our department. Additionally, 134 patients underwent a conventional thyroidectomy in our hospital in 2011. A total of 117 patients from the MIVAT group and 102 patients from the conventional thyroidectomy group received follow-up assessments after 23.1 and 23.6 months, respectively, using the patient and observer scar assessment scale.

RESULTS

The measurable cervical scar length averaged 1.9 cm in the MIVAT group and 3.9 cm in the conventional group (P < 0.001). Some 11.1% of the patients in the MIVAT group and 7.1% of the patients in the conventional group had developed keloid (P = 0.391). The patient scar assessment score was 10.4 for the MIVAT group compared with 9.9 for the conventional thyroidectomy group (P = 0.691) and the observer scare assessment score was 8.6 for MIVAT compared with 9.9 for conventional thyroidectomy (P = 0.011).

CONCLUSION

In the patient assessment instrument, conventional thyroidectomy had a small advantage over MIVAT in the cosmetic long-term results. This difference between the two groups was, however, not significant. Our result contradicts short-term cosmetic results of published randomized studies with improvement for MIVAT. The Observer Score demonstrates a significant advantage of the MIVAT.

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.

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.

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 Endoscopic Surgery of Thyroglossal Duct Cysts

PURPOSE

Thyroglossal duct cysts (TGDCs) may cause cosmetic defects or more serious impairments if left untreated. Our study was designed to examine the potential advantage of endoscopic surgery performed on TGDCs, especially the ability to completely resect the branches and to affect the cosmetic appearance.

PATIENTS AND METHODS

Thirty-two patients from Beijing Tongren Hospital, Beijing, China, diagnosed with TGDCs were selected. Seventeen patients with TGDCs underwent traditional Sistrunk's surgery, and 15 patients underwent endoscopic cystectomy.

RESULTS

All patients had complete resection and were followed up from 6 months to 4 years. None had a recurrence after endoscopic resection. However, patients in the traditional surgery group had a 5.9% (1/17) rate of recurrence. The incision length was approximately 2.1 cm in the endoscopic group compared with 5.2 cm in the traditional group. The mean time for the endoscopic operation was 97.7 minutes compared with 51.6 minutes in the traditional surgical procedure. The average length of hospital stay was 6.7 days in the endoscopic group compared with 9.7 days in the traditional group.

CONCLUSIONS

Endoscope-assisted small-incision thyroglossal duct cystectomy is an efficient method. It causes fewer cosmetic defects and also decreases operative time. It will likely become the new standard procedure for patients with TGDCs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

New endoscopic thyroidectomy with the transareola single-site approach: a comparison with the bilateral areolar approach

PURPOSE

We developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas. Here, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the bilateral areolar approach (BAA).

METHODS

From September 2009 to December 2011, 129 patients with benign thyroid tumors were enrolled in the study. Of these patients, 51 patients underwent endoscopic thyroidectomy by TASSA and 78 patients by BAA. The TASSA technique was performed using one 10 mm trocar and one 5 mm trocar through circumareolar incisions using conventional endoscopic instruments. The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions.

RESULTS

Comparing TASSA with BAA, there were significant differences in the mean operative time (141.96 ± 19.85 vs. 98.14 ± 14.15 min) for lobectomy (P<0.05) and in the subcutaneous dissection area (101.00 ± 6.33 vs. 132.51 ± 5.25 cm, P<0.05). However, there were no significant differences in the duration of hospitalization, amount of drainage, occurrence of postoperative complications, and postoperative pain. All the patients were satisfied with the cosmetic result in the 2 groups.

CONCLUSIONS

Endoscopic thyroidectomy using the TASSA procedure is feasible and safe, and affords the advantages of minimal invasiveness and excellent cosmesis results compared with other approaches including BAA. The 2 procedures are technically more challenging procedures, which may become alternative procedures for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis.

Minimal-access video-assisted thyroidectomy for benign disease: a retrospective analysis of risk factors for postoperative complications

BACKGROUND

Minimal-access video-assisted thyroidectomy (MIVAT) has now become a widespread technique in the treatment of benign thyroid disease. No studies systematically investigate risk factors for postoperative complications. The aim of our study was to investigate possible risk factors for postoperative complications in MIVAT in patients with benign disease.

METHODS

One-hundred eighty-nine patients who underwent MIVAT for benign disease were retrospectively identified in a prospectively-maintained institutional register of thyroid surgery. Exclusion criteria were: (1) thyroid volume>45 mL; (2) malignant disease; (3) prior neck surgery; (4) prior neck irradiation; (5) nodule size>3 cm; (6) intrathoracic component; (7) follow-up<1 year. Age, sex, comorbidities, body mass index, existence of symptoms, duration of disease evolution, thyroid volume, hyperthyroidism, thyroiditis, and the duration of surgery were analyzed as risk factors for complications. We applied both bivariate and multivariate logistic regression analyses in order to identify risk factors associated with postoperative complications.

RESULTS

Complications were presented by 28 patients (14.8%). The variables associated as independent risk factors with these complications were hyperthyroidism (OR = 4.31; P = 0.003) and thyroiditis (OR = 3.59; P = 0.035). Age, sex and thyroid volume up to 45 mL do not seem to be independent risk factors.

CONCLUSIONS

In endocrine surgery units, two independent risk factors for postoperative complications could be identified in MIVAT patients: hyperthyroidism and thyroiditis. Surgeons operating on patients presenting these factors should be aware of the potential augmented risk in order to correctly adapt intraoperative and postoperative care.

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

Minimally invasive compared with conventional thyroidectomy for nodular goitre

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

Endoscopic thyroidectomy is safe in patients with a high body mass index

BACKGROUND

Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. However, the impact of obesity on the safety of minimally invasive video-assisted thyroidectomy (MIVAT) has not been well defined. We sought to determine the relationship between obesity and the risk of complications in patients undergoing MIVAT.

METHOD

A prospectively maintained database of all thyroid surgeries performed from January 2006 through June 2012 was searched and all cases of MIVAT were identified. Patients were stratified into three body mass index (BMI) groups according to the National Institutes of Health classification for obesity: normal (BMI ≤ 24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI ≥ 30 kg/m(2)). The total number of complications was compared among the three groups, and MIVAT patients were also compared to a cohort of patients undergoing conventional thyroid surgery.

RESULTS

There were 233 MIVATs performed on 223 patients. The mean overall BMI for the study population was 25.4 kg/m(2). There were 123 procedures (52.8%) in the normal group, 76 procedures (32.6%) in the overweight group, and 34 procedures (14.6%) in the obese group. Complications included 1 case of cellulitis (0.4%), 6 cases of temporary hypocalcemia (2.6%), and 6 cases of transient vocal fold paresis (2.6%). No patients suffered permanent hypocalcemia or a permanent recurrent laryngeal nerve injury. There were 9 complications in the normal group (7.3%), 4 complications in the overweight group (5.3%), and no complications in the obese group. Due to the low number of complications in this series, the overweight and obese groups were combined into a high BMI group for further analysis. Statistical analysis using simple logistic regression models revealed that there was no significant difference in the number of complications in patients with a high BMI compared with patients with a normal BMI (odds ratio [OR] 0.48 [confidence interval (CI) 0.14-1.63], p=0.2). The MIVAT group had fewer overall complications than the conventional thyroidectomy group.

CONCLUSIONS

Overweight and obese patients undergoing MIVAT in this series were not at an increased risk for surgical complications. The MIVAT procedure may be considered safe in patients with a high BMI, who may derive particular benefit from a minimally invasive approach.

Experience of 1166 thyroidectomy without use of prophylactic antibiotic

BACKGROUND

Although the procedure requires a small surgical incision and a short duration, incision infection rate is very low in thyroidectomy; however, doctors still have misgivings about infection events.

AIM

We retrospectively analyzed the prevention of incision infection without perioperative use of antibacterial medications following thyroidectomy.

MATERIALS AND METHODS

1166 patients of thyroidectomy were not administered perioperative antibiotics. Unilateral total lobectomy or partial thyroidectomy was performed in 68.0% patients with single-side nodular goiter or thyroid adenoma. Bilateral partial thyroidectomy was performed in 25.5% patients with nodular goiter or Graves' disease. The mean time of operation was 80.6 ± 4.87 (range: 25-390) min.

RESULTS

Resuturing was performed in two patients of secondary hemorrhage from residual thyroid following bilateral partial thyroidectomy. Temporally recurrent nerve paralysis was reported following right-side total lobectomy and left-side subtotal lobectomy in a nodular goiter patient. One case had suppurative infection in neck incision 5 days after bilateral partial thyroidectomy.

CONCLUSIONS

Thyroidectomy, which is a clean incision, involves a small incision, short duration, and minor hemorrhage. If the operation is performed under strict conditions of sterility and hemostasis, antibacterial medications may not be required to prevent incision infection, which reduces cost and discourages the excessive use of antibiotics.

Minimally invasive video-assisted versus minimally invasive nonendoscopic thyroidectomy

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

Hybrid-type endoscopic thyroidectomy (HET: Tori's method) for differentiated thyroid carcinoma including invasion to the trachea

Background

Endoscopic thyroidectomy (ET) or robotic thyroidectomy is yet to be applied to thyroid carcinoma invasive to the trachea and to wide lymph node node metastasis. On the other hand, small-incision thyroidectomy lacks sufficient working space and clear vision. The author has newly developed hybrid-type endoscopic thyroidectomy (HET) to overcome these problems.

Methods

From March 2011 to February 2012, HET was performed for 85 patients. Clinicopathologic characteristics were analyzed. To evaluate the superiority of HET for malignancy representatively, conventional lobectomy with central compartment node dissection (CCND) performed 1 year previously was compared with HET. In lobectomy and node dissection, a single skin incision (1.5 cm) is made above the clavicle, with a port incision (5 mm) made 3 cm below the clavicle. Then CCND is performed directly through the incision by lifting up the isthmus. To obtain sufficient working space for the lobectomy, the strap muscles are taped and pulled toward the head, then hung by the cradle. The thyroid lobe is retracted to the midline with a retractor, followed by isolation of the inferior laryngeal nerve and transection of the inferior thyroid vessels with the monitor of the scope. Lateral lymph nodes dissection can be performed at the same time, if necessary. In total thyroidectomy, the same procedure is performed at the opposite side. The scalpel can be used to shave through each incision in case of tracheal invasion.

Results

Of the 85 cases, 62 were malignant, involving papillary thyroid carcinoma (PTC), and 23 were benign. Total thyroidectomy was performed for 22 of the PTC cases and CCND for 49 of the cases. Shaving for tracheal invasion was performed for eight patients. No mortality, complications, recurrence, or metastasis was found 1–2 years after the operation. Compared with conventional thyroidectomy, HET was superior in blood loss, visual analog scale, and postoperative hospital stay.

Conclusion

The author’s method (Tori’s method) might be less invasive, cosmetically excellent, and moreover, safe and feasible for differentiated thyroid carcinoma including invasion to the trachea.

Trans-areola single-site endoscopic thyroidectomy: pilot study of 35 cases

BACKGROUND

Endoscopic thyroidectomy via thoracic/breast approach is an acceptable and successful technique in Asia. This technique has the advantage of better cosmesis compared with open or even video-assisted thyroidectomy. Unfortunately, because of the need for three separate ports, conventional endoscopic thyroidectomy usually involves significantly more tissue dissection, and thus more injury to patients, limiting the popularity of this technique. We herein present 35 cases of trans-areola single-site endoscopic thyroidectomy (TASSET), which was first performed in 2009.

METHODS

Thirty-five patients who underwent TASSET for thyroid nodules from September 2009 to March 2011 were evaluated. The surgical outcomes of the surgery were retrospectively analyzed, including conversion, operative time, estimated blood loss, complications, length of stay, and patient satisfaction.

RESULTS

Thirty-one of the 35 patients (88.5%) underwent successful TASSET, with subtotal lobectomy being the most common procedure. Median operative time for the surgery was 153.65 min (range 100-190 min). Estimated blood loss ranged from 20 to 40 mL. Length of postoperative stay ranged from 2 to 4 days (average 2.5 days). Visual analog scale scores were 0 to 4 without administration of analgesics. The complication rate was low (8.6%) and included one case of transient recurrent laryngeal nerve (RLN) palsy, one case of subcutaneous seroma, and one case of tracheal injury. All patients were satisfied with the cosmetic outcome after mean follow-up of 8 months.

CONCLUSIONS

TASSET is feasible and safe, with great cosmetic benefits and less injury than other procedures. It may become an alternative procedure for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis.

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

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