Standard versus video-assisted thyroidectomy: objective postoperative pain evaluation

Mini-invasive video-assisted thyroidectomy vs robot-assisted transaxillary thryoidectomy: analisys and comparison of safety and outcomes

Thyroid surgery is characterized by large volumes and typically affects a young female population. Mini-invasive or remote access surgical techniques are born driven by the desire to improve aesthetic outcomes of the traditional technique, following technological advances that have upset the surgical world in the last 20 years. In our multicenter, retrospective observational study, we first compared an endoscopic technique with a robotic one: minimally invasive video-assisted thyroidectomy (MIVAT) and robot-assisted transaxillary thyroidectomy (RATT). We evaluated intraoperative features, complications, and cosmetic outcomes in a cohort of 609 patients. The efficacy and safety of these techniques are proven by a large literature and the comparison made in our study does not show inferiority of one technique compared to the other. Even the aesthetic results tend to be equal in the long term. It is desirable that further prospective and randomized studies are conducted to evaluate the outcomes of these procedures and the cost-benefit ratio.

Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review

This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.

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

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

Minimally invasive video-assisted thyroidectomy (MIVAT)

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain.

Methods

The authors conducted a retrospective analysis about patients who underwent MIVAT between 1998 and 2019 in the Endocrine Surgery Unit of the University Hospital in Pisa. Indications and contraindications are mentioned and strictly followed.

Results

Total thyroidectomy was performed in 1,862 cases (69%) and hemithyroidectomy was performed in 763 cases (28.3%). Conversion occurred in 43 cases (1.6%). In 188 cases (7%) a postoperative transient hypoparathyroidism was reported, whereas definitive hypoparathyroidism was reported in 12 cases (0.4%). Thirty-eight patients (1.4%) suffered from a definitive postoperative recurrent laryngeal nerve palsy. No definitive bilateral recurrent laryngeal nerve palsy occurred.

Conclusions

From our multi-years' experience which spreads over 20 years, we can reaffirm the concept that MIVAT is a safe procedure which is not burdened by an increase complications rate or additional costs. Furthermore, this technique offers advantages in terms of cosmetic results and post-operative pain.

Indications, benefits and risks of transoral thyroidectomy

The advancement of minimally invasive surgery in the field of endocrine surgery over the last 2 decades has fostered the attempt of natural orifice transluminal endoscopic surgery (NOTES) for thyroidectomy and parathyroidectomy via oral incisions. This technically demanding surgery is currently being evaluated in a number of specialised centres. The procedure has gained popularity worldwide and is performed in more than 50 centres. By retrieving information from published or presented articles and direct personal communications, this study reports several issues to enable and optimise correct patient and surgeon candidacy, present the advantages and prevent novel complications under the standards of open thyroid surgery. Not all patients are eligible for the transoral approach. Transoral endoscopic and robotic procedures were described and critically analysed in this study.

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.

Hybrid techniques and patients' safety in implementing transoral sublingual thyroidectomy

PURPOSE

Cosmetic advantages and minimally invasive aspects become more and more important for patients undergoing thyroidectomy. We report on our personal experience and conceptual design in dealing with approaches to the thyroid gland, which we were the first to describe. We report on ideas and experiences concerning its implementation.

METHODS

Our own experiences and considerations in the process of finding an endoscopic minimally invasive access in thyroidectomy are compared in a systematic review with the available literature on minimally invasive or endoscopic thyroid surgery. We describe our failures and risk assessment.

RESULTS

Our analysis of the literature on minimally invasive thyroidectomy and our own experiences lead us to the conclusion that using different hybrid technologies during the implementation of endoscopic procedures in thyroid surgery can be helpful and could improve patients' safety. A combination of transoral endoscopic and non-transoral techniques might be a useful safer, but more traumatizing alternative for implementation. Several studies show the feasibility of the transoral access in thyroid surgery. We believe that the implementation of these new procedures as routine surgery in specialized centers must be carefully considered and discussed.

CONCLUSIONS

The transoral access seems to be less invasive than other extracollar endoscopic accesses in thyroid surgery. For a sublingual single-access routine surgery, better instruments are needed. The vestibular access is possible with standard instruments. Using hybrid technologies for implementation should not be considered as a failure. The transoral thyroidectomy can be a safe method in the hand of experienced surgeons. We expect this hybrid technique to play a major part in further spreading endoscopic transoral thyroid surgery.

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

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

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.

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.

Minimally invasive video-assisted thyroidectomy: tips and pearls for the surgical technique

BACKGROUND

The objectives of this study were first to show principles of the minimally invasive video-assisted thyroidectomy (MIVAT), based on a video highlighting critical steps, and second to discuss tips and pearls to assist surgical teams that would like to start using this technique.

METHODS

Based on a video, we described tips and pearls of a MIVAT.

RESULTS

MIVAT includes 5 main steps: (1) skin incision and identification of the common carotid artery, (2) dissection and ligation of the upper pedicle, (3) identification of the inferior laryngeal nerve and parathyroid glands, (4) isthmectomy and lobe extraction, and (5) closure.

DISCUSSION

Coordination between the surgeon and the 2 assistants is of paramount importance for the performance of MIVAT. Appropriate material is also required. The magnification and tissue contrast emphasizes the identification of the vessels, the superior and inferior laryngeal nerves, and parathyroid glands, on a large-view screen.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparison of postoperative pain after conventional open thyroidectomy and transaxillary single-incision robotic thyroidectomy: a prospective study

BACKGROUND

The aim of this study was to compare conventional open thyroidectomy with robotic thyroidectomy in terms of postoperative pain.

METHODS

We compared the intensity of postoperative pain experienced by patients who received conventional open thyroidectomy (n = 45) versus those who underwent robotic thyroidectomy (n = 45). During surgery, we carefully controlled the anesthetic conditions. All the patients underwent a total thyroidectomy with ipsilateral central compartment node dissection. Postoperative pain in the 2 groups was compared using a visual analog scale and the amount of rescue analgesic at 30 min, 4 h, 1, 2, 3, and 10 days after surgery.

RESULTS

The postoperative pain at 30 min and 4 h after surgery were 3.0 ± 0.9 and 2.6 ± 0.9 (p = .066) and 4.9 ± 1.3 and 4.4 ± 1.3 (p = .055) in the conventional open group and the robotic group, respectively. The mean pain scores at 1, 2, 3, and 10 days after surgery were 3.8 ± 1.3 and 3.0 ± 1.3 (p = .001), 2.6 ± 1.2 and 2.0 ± 0.9 (p = .005), 1.7 ± 0.9 and 1.3 ± 0.6 (p = .034), and 0.9 ± 0.7 and 1.2 ± 1.1 (p = .093), respectively. No significant differences were observed between the 2 groups in terms of postoperative rescue analgesic use (1.1 ± 1.1 and 0.8 ± 0.9, p = .264).

CONCLUSIONS

Even though robotic thyroidectomy using the transaxillary technique requires a more extensive subcutaneous dissection than conventional open thyroidectomy, robotic thyroidectomy does not result in more postoperative pain or use of analgesic when compared with open thyroidectomy.

Effects of a cost-effective surgical workflow on cosmesis and patient's satisfaction in open thyroid surgery

PURPOSE

In thyroid surgery, minimally invasive procedures are thought to improve cosmesis and patient's satisfaction. However, studies using standardized tools are scarce, and results are controversial. Moreover, minimally invasive techniques raise the question of material costs in a context of health spending cuts. The aim of the present study is to test a cost-effective surgical workflow to improve cosmesis in conventional open thyroid surgery.

METHODS

Our study ran between January 2009 and November 2010, and was based on a prospectively maintained thyroid surgery register. Patients operated for benign thyroid diseases were included. Since January 2010, a standardized surgical workflow was used in addition to the reference open procedure to improve the outcome. Two groups were created: (1) G1 group (patients operated with the reference technique), (2) G2 group (patients operated with our workflow in addition to reference technique). Patients were investigated for postoperative outcomes, self-evaluated body image, cosmetic and self-confidence scores.

RESULTS

820 patients were included in the present study. The overall body image and cosmetic scores were significantly better in the G2 group (P < 0.05). No significant difference was noted in terms of surgical outcomes, scar length, and self-confidence.

CONCLUSIONS

Our surgical workflow in conjunction with the reference technique is safe and shows significant better results in terms of body image and cosmesis than do the reference technique alone. Thus, we recommend its implementation in order to improve outcomes in a cost-effective way. The limitations of the present study should be kept in mind in the elaboration of future studies.

Minimally invasive video-assisted thyroidectomy: Learning curve in terms of mean operative time and conversion and complication rates

BACKGROUND

The purpose of this study was to evaluate the learning curve for minimally invasive video-assisted thyroidectomy (MIVAT).

METHODS

Fifty consecutive patients were prospectively included in groups corresponding to their surgical order (10 patients in each group).

RESULTS

The mean operation times between 2 neighboring groups were 33.9 minutes longer in group 1 than in group 2 (p = .01) and 25.8 minutes longer in group 3 than in group 4 (p = .002). The conversion rate for technical difficulties in group 1 was 6% (3 of 50). The definitive complication rate was 2% (1 of 50).

CONCLUSIONS

In terms of operative time, 10 patients represented the early stage of the learning curve, and 30 patients represented the number of procedures required to reach an advanced level of skill. Considering the low conversion and complication rates, improved aesthetic results and postoperative course, MIVAT should become a tool in the repertoire of high-volume thyroid surgeons.

Functional voice and swallowing outcomes after robotic thyroidectomy by a gasless unilateral axillo-breast approach: comparison with open thyroidectomy

BACKGROUND

Voice and swallowing alterations are common complaints after thyroidectomy, even in the absence of laryngeal nerve impairment. However, voice and swallowing functions after robotic thyroidectomy have not been thoroughly investigated. This study compared the functional outcomes for voice and swallowing after robotic thyroidectomy and conventional open thyroidectomy.

METHODS

The study prospectively analyzed the voice and swallowing functions of patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillo-breast (GUAB) approach (50 cases) or by conventional open thyroidectomy (61 cases) from September 2009 to October 2010. Videolaryngostroboscopy or flexible laryngoscopy was performed pre- and postoperatively. Subjective voice and swallowing alterations were assessed by questionnaire preoperatively and then 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively. In addition, objective acoustic voice analysis was performed using a Multidimensional Voice Program, with Voice Range Profiles and maximum phonation times measured preoperatively and then 1 week, 1 month, 3 months, and 6 months postoperatively.

RESULTS

Subjective postoperative voice function was significantly better in the robotic group at 1 day, 1 month, and 3 months postoperatively than in the open group. The mean values of fundamental frequency, jitter, shimmer and noise-to-harmonic ratio before and after surgery did not differ between the two groups. However, the frequency range and the highest frequency were significantly better in the robotic group than in the open group at 3 months postoperatively. Subjective swallowing function did not differ between the two groups.

CONCLUSION

Postoperative voice function is better with robotic thyroidectomy using the GUAB approach than with conventional open thyroidectomy. This is an advantage of robotic thyroidectomy by the GUAB approach in addition to the excellent 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.