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

Comparison of Voice and Swallowing Changes After Thyroidectomy Using the Gasless Transaxillary, Transoral, and Conventional Transcervical Approaches: A Network Meta-analysis

PURPOSE

This study evaluated voice and swallowing outcomes following thyroidectomy by using the gasless transaxillary (GTAA) and transoral (TOA) approaches compared with the conventional transcervical approach (CTA).

METHODS

A comprehensive search of the PubMed, EMBASE, and Cochrane Library databases was conducted through September 2024. Network meta-analyses were performed on 14 comparative studies, encompassing 1723 patients.

RESULTS

Voice handicap index (VHI)-10 scores, highest frequency, and frequency range deteriorated after surgery in all three methods. However, the postoperative voice outcomes of the GTAA and TOA were superior to the conventional approach at all follow-up points up to 3 months after the operation. Specifically, the VHI-10 scores of the GTAA and TOA were significantly lower than those of the CTA at 3 months postoperation. Other acoustic parameters, such as jitter, shimmer, noise-to-harmonic ratio, and intensity range, did not differ among the three methods. The postoperative swallowing impairment score (SIS)-6 of the GTAA and TOA were lower than that of the CTA. Specifically, the SIS-6 of the GTAA was significantly lower than those of the TOA and CTA at 3 months postoperation.

CONCLUSIONS

The postoperative voice and swallowing outcomes, especially VHI-10, highest frequency, frequency range, and SIS-6, following remote-access thyroidectomy using the GTAA and TOA were superior to those observed with the conventional approach. Given the limited number of studies included, further research is needed to confirm these findings as new studies emerge, especially those with larger sample sizes, diverse populations, different approaches, and extended follow-up periods.

A Prospective Comparative Analysis to Study the Impact on Voice Changes Following Endoscopic Thyroidectomy

BACKGROUND

Endoscopic approach has come up as a safe and feasible procedure for thyroidectomy with better cosmetic outcomes. However, concerns over its safety in terms of nerve injury and postoperative voice changes remain. This prospective study evaluated the role of vocal cord function assessment using laryngeal examination and voice analysis in patients who underwent endoscopic hemithyroidectomy either by the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) or the bilateral axillobreast approach (BABA).

METHODS

Thirty-nine consecutive patients were randomly allocated to either of the 2 groups of endoscopic hemithyroidectomy; 19 in TOETVA and 20 in the BABA groups. Vocal cord function was assessed subjectively using the GRBAS scale and objectively by acoustic analysis of parameters such as jitter, shimmer, mean frequency (F 0 ), noise-to-harmonic ratio (NHR), and maximum phonatory time (MPT) at baseline, postoperative day 10, and 3 months after surgery.

RESULTS

There were no significant differences in mean GRBAS scores and values of mean frequency, jitter and shimmer between the 2 groups and on postoperative day 10 and at 3 months compared with baseline. The mean NHR and MPT showed no differences between the 2 procedures. However, there was a significant decrease in their values on day 10 postsurgery, compared with baseline. These values returned to their baseline at 3 months. The other operative parameters were comparable between the 2 groups, except for the shorter mean operative time in the TOETVA group.

CONCLUSIONS

Perioperative quantitative voice parameters were comparable with no statistically significant difference between the 2 techniques of endoscopic thyroidectomy.

A meta-analysis of unilateral axillary approach for robotic surgery compared with open surgery for differentiated thyroid carcinoma

OBJECTIVE

The Da Vinci Robot is the most advanced micro-control system in endoscopic surgical instruments and has gained a lot of valuable experience today. However, the technical feasibility and oncological safety of the robot over open surgery are still uncertain. This work is to systematically evaluate the efficacy of the unilateral axillary approach for robotic surgery compared to open surgery for differentiated thyroid carcinoma.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were utilized to search for relevant literatures of robotic thyroid surgery using unilateral axillary approach compared to open thyroid surgery, and a meta-analysis was performed using RevMan software version 5.3. Statistical analysis was performed through Mantle-Haenszel and inverse variance methods.

RESULTS

Twelve studies with a total of 2660 patients were included in the meta-analysis. The results showed that compared with the open group, the robotic group had a longer total thyroidectomy time, shorter hospital stay, less intraoperative bleeding, more postoperative drainage, fewer retrieved central lymph nodes, and higher cosmetic satisfaction (all P < 0.05). In contrast, temporary and permanent laryngeal recurrent nerve injury, temporary and permanent hypoparathyroidism or hypocalcemia, brachial plexus nerve injury, number of retrieved central lymph nodes, number of retrieved lymph nodes in the lateral cervical region, number of lymph node metastases in the lateral cervical region, hematoma, seroma, lymphatic leak, stimulated thyroglobulin (sTg) and unstimulated thyroglobulin (uTg), and the number and recurrence rate of patients with sTg <1ng/ml were not statistically different between the two groups (P > 0.05).

CONCLUSIONS

The unilateral axillary approach for robotic thyroid surgery may achieve outcomes similar to those of open surgery. Further validation is required in a prospective randomized controlled trial.

Quantitative comparison of three thyroidectomy approaches in neck muscles, voice, and swallowing functions

OBJECTIVE

This study compares endoscopic thyroidectomy by gasless unilateral axillary approach (ETGUA) and sternocleidomastoid leading-edge approach (SLEA) with conventional open thyroidectomy (COT) in hemithyroidectomy. The main focus is on the protection of neck muscles (sternocleidomastoid, omohyoid, sternothyroid) and the postoperative function of voice and swallowing yielded through these common approaches.

METHODS

A total of 302 patients who underwent hemithyroidectomy were enrolled and divided into three groups: ETGUA (n = 101), SLEA (n = 100), and COT (n = 101). Ultrasound was used to measure the thickness of bilateral neck muscles, including the sternocleidomastoid, omohyoid, and sternothyroid. The changes in thickness on the surgical side compared to the non-surgical side. Analyzed factors included muscle thickness changes, Swallowing Impairment Score (SIS), Voice Handicap Index (VHI), Scar Cosmesis Assessment and Rating (SCAR), Neck Injury Index (NII), surgery duration, drainage volume, hospitalization, and number of lymph nodes.

RESULTS

The clinical characteristics among the three groups were consistent except for differences in sex, age, and BMI. Metrics such as sternocleidomastoid muscle, NII, hypocalcemia, postoperative PTH, transient hoarseness, and number of lymph nodes showed no significant differences among the three groups. However, significant differences were found in the duration of surgery, drainage volume, hospitalization period omohyoid muscle, Sternohyoid muscle, VHI, SIS, and SCAR (all p < 0.001).

CONCLUSION

In comparison to COT, ETGUA and SLEA demonstrate superiority in protecting neck muscles and preserving voice and swallowing function without compromising surgical safety or radicality.

A prospective study comparing the gasless endoscopic thyroidectomy trans-axillary approach to conventional open thyroidectomy: health and quality of life outcomes

BACKGROUND

The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL).

METHODS

This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS).

RESULTS

Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation.

CONCLUSIONS

Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.

Patient-reported swallowing outcomes after transoral robotic thyroidectomy: Comparison with conventional transcervical thyroidectomy

BACKGROUND

This study aimed to evaluate the swallowing outcomes after transoral robotic thyroidectomy (TORT) and compare them with those of conventional transcervical thyroidectomy.

METHOD

We enrolled 146 patients who underwent thyroidectomy (73 TORT; 73 conventional approach). We prospectively analyzed swallowing outcomes using the Swallowing Impairment Index-6 (SIS-6) questionnaire, a patient-reported measure, before and 1, 3, and 6 days; 1, 3, and 6 months; and 1 year after surgery. Propensity score-matched analysis was performed using three covariates: age, sex, and extent of thyroidectomy.

RESULTS

SIS-6 scores worsened significantly immediately after surgery and progressively recovered 1 year postoperatively in both groups. Propensity score matching generated two matched groups of 22 patients each. In the propensity score-matched samples, the SIS-6 scores did not differ between the TORT and conventional groups, except at 1 day postoperatively.

CONCLUSION

Patient-reported swallowing outcomes of TORT were comparable to those of the conventional transcervical procedure.

The learning curve for single-port transaxillary robotic thyroidectomy (SP-TART): experience through initial 50 cases of lobectomy

The new da Vinci® single-port (SP) robotic system, which utilizes a smaller incision and work space compared to the previous versions, is suitable for thyroidectomy. This study aimed to evaluate the learning curve for SP transaxillary robotic thyroidectomy (SP-TART) in a single-center. Fifty consecutive patients who underwent SP-TART between October 2021 and April 2022 in Seoul St. Mary's Hospital in Seoul, Korea, were included in this retrospective analysis. We examined the clinicopathological characteristics and short-term surgical outcomes and assessed the learning curve for SP-TART using cumulative summation analysis. The mean operation time was 57.8 ± 14.1 min, and the mean tumor size was 1.0 ± 0.7 (range, 0.3-3.7) cm. The patients were discharged approximately 2 days after surgery, and only two (4%) patients developed postoperative complications, including drainage-site bleeding and surgical site infection. Risk factors for long operation time were thyroiditis, amount of blood loss, and lymph node metastasis. The learning curve for SP-TART was 20 cases for the experienced robotic surgeon. SP-TART is technically feasible and safe with a short incision length and short operation time. It is a valuable alternative operative option with good surgical outcomes and outstanding cosmetic results.

Swallowing disorders after thyroidectomy: a systematic review and meta-analysis

PURPOSE

Swallowing disorders following thyroidectomy are common, even after surgery without confirmed complications. The purpose of the current systematic review is to investigate the prevalence of dysphagia at various time points after thyroidectomy, at the whole spectrum of it (total/partial, open/endoscopic, for benign/malignant disease).

METHODS

The literature available at PubMed, SciELO and Cochrane Library databases was reviewed, according to PRISMA guidelines, using the terms "dysphagia", "swallowing disorder", "deglutition disorder", "thyroidectomy" and "thyroid surgery" in the appropriate combinations. A quantitative synthesis of the results followed.

RESULTS

The systematic review of the literature resulted in 35 articles, which met the inclusion criteria and were analyzed regarding their type, sample, follow-up and results regarding post-thyroidectomy dysphagia in multiple follow-up times. A significant increase of swallowing impairment compared to baseline was recorded shortly after surgery. Dysphagia reverted to pre-operative levels 2-3 months later. Dysphagia continued to be reported in a significantly lower proportion of patients, even 1 year after surgery. No significant difference was noticed between open and endoscopic thyroid surgery at 2-3 months post-surgery.

CONCLUSIONS

The swallowing disorders reported after thyroidectomy should be expected, but are not always detectable through objective methods. This should not lead to underestimation of symptoms, since the patients' quality of life is negatively affected by the symptomatology.

Remote Access Thyroid Surgery: A Review of Literature

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3–3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.

A Single Surgeon's 10-Year Experience in Remote-Access Thyroid and Parathyroid Surgery

BACKGROUND

Remote-access thyroid and parathyroid surgery has gained popularity recently due to its benefit of avoiding visible neck scars. Most of these techniques were described and performed in Asia, on patients with different body habitus compared to American patients. We aim to analyze the learning curve in performing these operations in North America. .

METHODS

This is a retrospective cohort study of a 10-year experience by a single surgeon at a North American institute. Patients who underwent thyroid or parathyroid procedures by a transaxillary, retroauricular, or transoral endoscopic thyroidectomy vestibular approach (TOETVA) were included. Cumulative sum (CUSUM) was used to analyze learning curves based on intraoperative blood loss and total operative times and learning phases were divided accordingly.

RESULTS

Three hundred seventy-two remote-access thyroid and parathyroid procedures were performed during the study period. Total operative time for transaxillary procedures was initially reduced after the 69th procedure and then again after the 134th case. For retroauricular procedures, marked reduction in the operative time was observed after 21 procedures. Most patients (57.02%) were discharged home on the same day during the mastering phase. In the transaxillary procedures, only 1 case of brachial plexus injury occurred prior to the routine use of somatosensory evoked potential (SSEP) monitoring.

DISCUSSION

Remote-access thyroid and parathyroid surgeries can be performed safely with minimal complications in a select group of patients. Analysis of the learning curve in performing these operations aids in structuring a safe and effective learning period for endocrine surgeons seeking to venture into this modality of treatment.

Robotic surgery versus open surgery for thyroid neoplasms: a systematic review and meta-analysis

PURPOSE

Robotic surgical system has been gradually applied in thyroid neoplasms as a novel treatment for years, with presenting some superiorities as well as limitations. To compare the effectiveness and safety of robotic surgery with open surgery for the patients with thyroid neoplasms, this review was conducted METHODS: We performed electronic search in CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray, and Sciencepaper Online databases and manual search in specific online databases and according to the reference list of relevant papers to get all the studies that compared the effectiveness and safety of robotic surgery with that of open surgery for patients with thyroid neoplasms. Last update was conducted in March 2020. Randomized-controlled trials, case-control studies, cohort studies, and cross-sectional surveys were all included.

RESULTS

In this review, 59 studies were included: two RCTs, 15 NRSs, 40 cohort studies, and two cross-sectional studies. Robotic surgery was found to be associated with longer operative duration, less retrieved lymph nodes, higher postoperative thyroglobulin before radioactive iodine ablation, similar complication incidence but less blood loss, better functional recovery, and higher cosmetic satisfaction compared to open surgery.

CONCLUSIONS

Robotic surgery is a safe and feasible approach with remarkable superiority in reducing intraoperative damage and improving patients' quality of life compared to open surgery for thyroid neoplasms. Meanwhile, this procedure is also associated with long operative duration, insufficient removal of neck lymph nodes, which need to be given careful consideration.

Data Collection Methods for the Voice Range Profile: A Systematic Review

Purpose To assess data collection variability in the voice range profile (VRP) across clinicians and researchers, a systematic review was conducted to evaluate the extent of variability of specific data collection points that affect the determination of frequency range and sound level and determine next steps in standardization of a VRP protocol. Method A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist. Full-text journal articles were identified through PubMed, Web of Science, Psych Info, ProQuest Dissertations and Theses Global, Google Scholar, and hand searching of journals. Results A total of 1,134 articles were retrieved from the search; of these, 463 were duplicates. Titles and abstracts of 671 articles were screened, with 202 selected for full-text review. Fifty-four articles were considered eligible for inclusion. The information extracted from these articles revealed the methodology used to derive the VRP was extremely variable across the data points selected. Additionally, there were eight common acoustic measures used for statistical analysis described in included studies that were added as a data point. Conclusions The data collection methods for the VRP varied considerably. Standardization of procedures was recommended for clinicians and researchers.

Patient Perception of Swallowing after Thyroidectomy in the Absence of Laryngeal Nerve Injury

INTRODUCTION

Swallowing and voice alterations may manifest in patients with thyroid disease, especially after thyroidectomy.

OBJECTIVE

To identify the prevalence of patients with complaints of swallowing disorders after thyroidectomy and to evaluate patients' perceptions regarding swallowing before and after the procedure.

METHODS

A prospective longitudinal study was performed with 26 consecutive patients undergoing a private service thyroidectomy, in which the presence of swallowing dysfunction was evaluated using validated questionnaires that addressed the perception of swallowing by patients before (on the day of surgery) and after the surgery (on the first postoperative day).

RESULTS

Of the 26 patients, 18 (69.2%) were subjected to total thyroidectomy and 8 to partial thyroidectomy. Analysis of the domains of the Swallowing Handicap Index questionnaire showed higher scores when evaluated on the first postoperative day, demonstrating a significant worsening in swallowing after the procedure. The same result was demonstrated for the final score of swallowing perception, with 15.3 and 30.8% of patients reporting moderate alterations before and after the thyroidectomy, respectively, and 11.5% reporting the alterations as severe. Swallowing and vocal symptoms on the first postoperative day were more prevalent in the procedure than previously mentioned. Eight patients (30.8%) noted swallowing alterations before the procedure, compared with 80.8% (21 cases) after thyroidectomy.

CONCLUSION

There was a prevalence of 42.3% in swallowing complaints on the first postoperative day, regardless of the lesion in the laryngeal innervation, and this prevalence was significantly higher than that prior to the procedure.

Robotic thyroid surgery

Various remote access robotic thyroidectomy techniques have been developed using the da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA) to hide or avoid neck scarring and overcome the limitations of endoscopic thyroidectomy. Among those used today are the gasless transaxillary approach, the bilateral axillo-breast approach (BABA), the gasless postauricular facelift approach, and the transoral approach. Especially, the recently introduced transoral approach (including robotic and endoscopic procedures) is prominent and now popular worldwide. The most significant advantages of remote access robotic thyroidectomy are excellent postoperative cosmesis and voice outcomes. The important limitations to the adoption of robotic thyroidectomy are the difficult technique, high complication rate during the learning curve, and high cost. In addition, cultural differences, longer operative times, and medicolegal issues are a barrier to the diffusion of robotic thyroidectomy. However, remote access robotic thyroidectomy is feasible, and the outcomes are comparable to those of conventional transcervical thyroidectomy if performed by experienced surgeons in highly selected patients. This article reviews the evolution and recent advances in robotic thyroid surgery.

Thyroidectomy-related Swallowing Difficulties: Review of the Literature

This study aims to provide insight into the etiology and frequency of swallowing complications that arise after thyroidectomy and to outline the available diagnostic procedures by revising the existing literature on this topic. We conducted a bibliographic search using the electronic database MEDLINE/PubMed to identify all relevant articles and 44 studies were included in the review out of a total of 218 published articles. Dysphagia after thyroid surgery is a common postoperative complication which, in the short- or long-term, significantly affects patient life quality. There is no standard diagnostic protocol for thyroidectomy-related swallowing impairment. Among the reviewed studies, 8 questionnaires and 12 instrumental diagnostic tools were used to identify swallowing difficulties related to thyroid surgery. The Swallowing Impairment Index (SIS-6) was the most-used questionnaire. Fiberoptic endoscopy is a standard diagnostic tool performed prior and after thyroid surgery, primarily to identify changes in vocal fold mobility. Although instrumental findings usually reveal non-specific alterations of swallowing; swallowing videofluoroscopy and esophageal manometry can be the most helpful tools in further management of thyroidectomy dysphagia. In patients with thyroidectomy-related swallowing difficulties and suspected laryngopharyngeal reflux, 24-hour MII-pH metry should be performed.

Effectiveness of voice therapy in patients with vocal fold nodules: a systematic search and narrative review

BACKGROUND/OBJECTIVE

An adult with vocal fold nodules can suffer from hoarseness, breathiness and vocal fatigue, which, in turn, significantly affects their vocal participation as well as activities. A well-designed voice therapy program improves the quality of life and vocal functionality. This is a narrative review with a systematic search of the current literature about the effectiveness of voice therapy interventions in adults with vocal fold nodules.

METHODS

Several key terms were used for the database electronic search of articles. Strict inclusion criteria were used and a broad evaluation of the studies was performed. This included the level of evidence based on the National Health and Medical Research Council levels of evidence, assessment, and critical appraisal.

RESULTS

Nine out of 30 reviewed articles met the criteria of inclusion and reported positive effects of voice therapy intervention on adult patients with vocal fold nodules. The vast majority of the reviewed studies reported multidimensional voice measures outcome data, most of them containing visual-perceptual, auditory-perceptual, acoustic and self-assessment results. Regardless of receiving direct or indirect or a combination of both voice therapy contents, nearly all voice quality parameters were found to improve after treatment. Short-term treatment (< 3 weeks) may be as beneficial as longer traditional voice therapy programs, and using telepractice voice therapy may be an achievable and practical way of delivering treatment and enhance adherence to therapy. The study design and the evidence levels of the included studies were low (≤ III-2) and the risk of bias of the comparative studies was moderate.

CONCLUSION

This narrative review cannot conclude the general effectiveness of voice therapy programs. Further research and understanding of what specific parameters (exercise and techniques) of a therapy's content will improve voice outcome measures. More studies are required to investigate whether or not voice therapy benefits are sustainable 6 months after ending the therapy. However, improved evidence is required to suggest that short period treatments are as beneficial as traditional therapy programs. Telepractice voice therapy may be an achievable and practical way of delivering treatment and enhance adherence to therapy.

Clinical Significance of the Preoperative Thyroidectomy-Related Voice Questionnaire Score in Thyroid Surgery

BACKGROUND

The thyroidectomy-related voice questionnaire (TVQ) is an efficient screening tool for detecting postoperative vocal dysfunction. The aim of this study was to confirm the significance of the preoperative TVQ score in thyroid surgery.

METHODS

We examined 180 women who underwent total thyroidectomy with central lymph node dissection from March 2014 to May 2016. Based on the preoperative TVQ score, participants were categorized under "normal" (TVQ score <5) and "abnormal" (TVQ score ≥5) groups. The laryngoscopic examination and acoustic analysis were performed and the TVQ score assessed before and after surgery (2 weeks, 2 months, and 8 months).

RESULTS

In the normal group, the TVQ score increased up to 2 months postoperatively and had decreased at 8 months postoperatively but was significantly higher than the preoperative TVQ score. In the abnormal group, the TVQ score increased up to 2 months postoperatively but had recovered similar to the preoperative TVQ score 8 months postoperatively. The preoperative TVQ score in the abnormal group moderately correlated with the final TVQ score; however, the preoperative TVQ score in the normal group did not correlate with the TVQ score 8 months postoperatively.

CONCLUSION

During preoperative patient counseling, it is important to explain that voice changes without vocal cord palsy may occur postoperatively and that it may take a long time to resolve, particularly in patients with a normal preoperative TVQ score.

Voice outcomes of transoral robotic thyroidectomy: Comparison with conventional trans-cervical thyroidectomy

OBJECTIVES

The purpose of this study was to compare the short-term voice outcomes of transoral robotic thyroidectomy (TORT) and trans-cervical thyroidectomy.

MATERIALS AND METHODS

The acoustic parameters and the voice handicap index (VHI)-10 scores were compared between the two groups preoperatively, and 1 week, 1 month, and 3 months postoperatively.

RESULTS

Forty-two patients in the TORT group and 47 patients in the trans-cervical group completed the VHI-10 questionnaire and acoustic analysis. The highest frequency and pitch range was higher and broader, respectively, in the TORT group than in the trans-cervical group until 3 months after surgery. They were not significantly impaired by surgery in the TORT group. The postoperative VHI-10 score was not significantly different between the two groups at any time point. Surgical approach (TORT vs. trans-cervical) and age were independent factors related to highest frequency and pitch range in multiple regression analysis.

CONCLUSION

TORT has advantages of excellent postoperative voice outcomes compared to trans-cervical thyroidectomy in the short-term period.

Dysphagia following uncomplicated thyroidectomy: a systematic review

OBJECTIVE

Dysphagia after uncomplicated thyroidectomy is commonly reported and it includes a broad spectrum of swallowing complaints. Though various causes have been hypothesized, it remains not completely understood.

METHODS

A systematic review was performed to identify studies concerning dysphagia post uncomplicated thyroid surgery. A qualitative analysis of data extracted was conducted.

RESULTS

We have included 16 studies of which 15 are prospective and one are retrospective. The number of subjects varied from 12 to 254, the mean age from 39 to 54 years with an overall prevalence of females. The duration of the follow-up ranges from 1 month to 4 years. All the included trials documented postoperative dysphagia, 12 of which have detected it in the early postoperative period. Considering long-term follow-up period, 12 studies reported an overall improvement of swallow symptoms. The instrumental findings revealed non-specific alterations of swallowing.

CONCLUSIONS

Dysphagia after uncomplicated thyroidectomy can arise early in the postoperative period resolving spontaneously in the first year. Diagnostic methods failed to identify the physio pathological mechanism of swallow alteration leaving this condition still unclear. Since these symptoms can reduce patient's quality of life, we suggest an appropriate education before thyroid surgery.

A Propensity Score-matched Comparison Study of Surgical Outcomes in Patients with Differentiated Thyroid Cancer After Robotic Versus Open Total Thyroidectomy

INTRODUCTION

The aim of this study, from a surgical, oncological, and functional perspective, was to identify whether bilateral axillo-breast approach robotic total thyroidectomy (RTT) for differentiated thyroid cancer (DTC) has different surgical outcomes compared to open total thyroidectomy (OTT).

METHODS

Initially, 796 patients who underwent total thyroidectomy were primarily reviewed and 178 who were ineligible for analysis were excluded. Propensity score matching analysis adjusted for clinicopathological characteristics (sex, age, body mass index, extent of central node dissection, tumor size, extrathyroidal extension, and thyroiditis) was conducted, with 246 patients in the OTT group matched with 123 patients in the RTT group.

RESULTS

There were no significant differences in surgical outcomes in terms of surgical safety and oncological safety between the OTT and RTT groups, except in mean operation times (123.51 ± 32.63 vs. 198.39 ± 37.93 min, respectively; P < 0.001). However, the median parathyroid and laryngeal function recovery times were shorter in the RTT group than in the OTT group [88 ± 33.09 (95% CI: 23.148-152.852) vs. 100 ± 16.20 (95% CI: 68.242-131.768) days; P = 0.044 and 87 ± 32.40 (95% CI: 23.489-150.511) vs. 118 ± 49.50 (95% CI: 20.985-215.015) days; P = 0.002].

CONCLUSIONS

The recovery times of laryngeal and parathyroid function were significantly shorter in RTT patients than in OTT patients for DTC. To verify a definitive conclusion about the superiority of robotic total thyroidectomy in terms of parathyroid and laryngeal function recovery, further studies may be necessary.

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.

The Impact of Esophageal Compression on Goiter Symptoms before and after Thyroid Surgery

INTRODUCTION

Benign nodular goiter may be associated with swallowing difficulties, but insight into the associated pathophysiology is limited. The aim of this study was to investigate the effect of surgery on the degree of esophageal compression, and its correlation to swallowing difficulties.

METHODS

Esophageal compression and deviation were evaluated blindly on magnetic resonance imaging (MRI) of the neck, prior to and 6 months after thyroid surgery for symptomatic benign goiter. Goiter symptoms and swallowing difficulties were measured by the Goiter Symptom Scale of the Thyroid-Specific Patient-Reported Outcome (ThyPRO) questionnaire. Cohen's d was used for evaluating effect sizes (ES).

RESULTS

Sixty-four patients completed the study. Before surgery, median goiter volume was 57 (range 14-642) mL. The smallest cross-sectional area of the esophagus (SCAE) increased from a median of 95 (47-147) to 137 (72-286) mm² (ES = 1.31, p < 0.001). Median esophagus width increased from 15 (range 10-21) to 17 (range 12-24) mm (ES = 0.94, p < 0.001) after surgery, while no statistically significant change was observed for the sagittal dimension (anterior-to-posterior), thus reflecting an increasingly ellipsoid esophageal shape. Median esophageal deviation decreased moderately after surgery from 4 (0-23) to 3 (0-10) mm (ES = 0.54, p = 0.005). The goiter symptom score improved considerably from (mean ± SD) 40 ± 21 to 10 ± 10 points (ES = 1.5, p < 0.001) after surgery, and the improvements were associated with improvements in SCAE (p = 0.03).

CONCLUSIONS

In patients with goiter, thyroidectomy leads to substantial improvements in esophageal anatomy, as assessed by MRI, and this correlates with improved swallowing symptoms. This information is valuable in qualifying the dialogue with goiter patients, before deciding on the mode of therapy. Clinicaltrials.gov (NCT03072654).

The Impact of Goiter and Thyroid Surgery on Goiter Related Esophageal Dysfunction. A Systematic Review

Background: Patients with goiter referred for thyroidectomy report swallowing difficulties. This might be associated with esophageal compression and deviation as this is present in a significant number of patients. Studies on how goiter and subsequently its treatment affect the esophagus are sparse and point in various directions. Our aim was to investigate, through a systematic review, the impact of goiter and thyroidectomy on esophageal anatomy, esophageal physiology, and subjective swallowing dysfunction. Methods: The search period covered 1 January 1975 to 1 July 2018, using the scientific databases PubMed and EMBASE. Inclusion criteria were adult patients with goiter who were either observed or underwent thyroidectomy. Search terms were variations of the terms for goiter, esophagus, swallowing, and dysphagia. From an initial 3,040 titles, 55 full text evaluations led to the final inclusion of 27 papers. Seventeen papers investigated, prospectively, the impact of thyroidectomy on the esophagus, while five observational and five retrospective studies were also included. Results: Esophageal anatomy impairment: Esophageal deviation occurred in 14% and esophageal compression in 8-27% of goiter patients. The prevalence increased with goiter size and with the extent of substernal extension. The smallest cross-sectional area of the esophagus increased by median 34% after thyroidectomy. Esophageal physiology changes: Goiter patients had increased esophageal transit time, positively correlated with goiter size, but unrelated to esophageal motility disturbances. Decrease in the upper esophageal sphincter pressure occurred early after surgery, and normalized within 6 months. Swallowing related patient-reported outcomes: Evaluated by validated questionnaires, swallowing symptoms worsened in the early period after thyroidectomy, but improved after 6 months, as compared to baseline. Conclusions: Thyroidectomy relieved patients with goiter from dysphagia, within 6 months of surgery probably via increase in the cross-sectional area of the esophagus. Attention to the impact by goiter on the esophagus is needed, and balanced and individualized information about the potential benefits and risks of thyroid surgery is crucial in the management of patients with goiter.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Changes in Swallowing Symptoms and Esophageal Motility After Thyroid Surgery: A Prospective Cohort Study

INTRODUCTION

Swallowing difficulties, the pathophysiology behind which is incompletely understood, have been reported in 47-83% of goiter patients referred for thyroidectomy. We aimed at examining the influence of thyroid surgery on swallowing symptoms and esophageal motility.

METHODS

Thirty-three patients with benign nodular goiter undergoing thyroid surgery were included. All completed high-resolution esophageal manometry examinations and the goiter symptom scale score, assessed by the thyroid-specific patient-reported outcome measure. The evaluations were performed before and 6 months after surgery.

RESULTS

Before surgery, the goiter symptom score was median 39 points (range 2-61), which improved to median five points (range 1-52) after surgery (p < 0.001). The motility parameters were within the limits of normal swallowing physiology, both before and after surgery. Only the upper esophageal sphincter (UES) pressure increased significantly from 70.6 ± 27.7 to 87.7 ± 43.2 mmHg after surgery (p = 0.04). Using regression analyses, there was no significant correlation between change in goiter symptoms and weight of the removed goiter, motility parameters, or motility disturbances. However, patients undergoing total thyroidectomy experienced a larger reduction in pressure in the area of the UES and former thyroid gland after surgery in comparison with patients undergoing less extensive surgery.

CONCLUSIONS

Goiter symptoms improved significantly after thyroidectomy, but without correlation to esophageal motility disturbances. This information is essential when interpreting dysphagia in patients with nodular goiter, and when balancing patients' expectations to surgical goiter therapy.

REGISTRATION NUMBER

NCT03100357 ( www.clinicaltrials.org ).

Postsurgical Outcomes and Surgical Completeness of Robotic Thyroid Surgery: A Single Surgeon's Experience on 700 Cases

BACKGROUND

Advanced technology and understanding of robotic surgical system have rendered robotic thyroid surgery more expanding. The aim of this study was to identify the periodic changes in postsurgical outcomes of robotic thyroid surgery performed by a single surgeon.

METHODS

We conducted a retrospective review of 700 robotic thyroid surgery cases using gasless trans-axillary approach.

RESULTS

All patients underwent successful operations without conversion to open surgery, and were mostly younger than 45 years, female, less-extended thyroid surgery and lymph node dissection, and thyroid cancer. The median follow-up period was 67 months (12-99 months). Regarding technical outcomes, the operation time declined steeply after 100 consecutive cases, and reached 120.0-132.7 minutes for thyroid lobectomy and 162.9-174.1 minutes for total thyroidectomy (TT). The most common complication was transient hypoparathyroidism (43.7%), whose incidence decreased steeply to a range of 9.1% to 25.0% after 300 consecutive cases. Regarding surgical completeness for thyroid cancer, an average of seven lymph nodes was retrieved through central compartment node dissection without fluctuation over time. The proportion of the patients with serum stimulated thyroglobulin levels <10 ng/mL at the time of radioactive iodine remnant ablation after TT and <1 ng/mL 6-12 months after the first remnant ablation ranged between 86.4%-100% and 66.7%-100%, respectively, without significant fluctuation.

CONCLUSION

For properly selected patients, robotic thyroid surgery is useful surgical option with reliable technical outcome and surgical completeness and cosmetic benefit.

Comparison of Postoperative Neck Pain and Discomfort, Swallowing Difficulty, and Voice Change After Conventional Open, Endoscopic, and Robotic Thyroidectomy: A Single-Center Cohort Study

Background: The objective of this study was to compare the postoperative neck pain and discomfort, swallowing difficulty, and voice change after conventional open thyroidectomy (COT), endoscopic thyroidectomy (ET), or robotic thyroidectomy (RT) performed by a single surgeon. Methods: From January 2013 to December 2017, 254 patients underwent COT, ET, or RT performed by a single surgeon and completed a postoperative symptom survey conducted in the outpatient clinic by three nurses. The survey collected information on postoperative neck pain and discomfort, swallowing difficulty, and voice change. Results: Of the 254 patients, 169 underwent COT, 32 underwent ET, and 53 underwent RT. The mean age in the COT, ET, and RT groups was 50.1, 44.5, and 41.6 years, respectively. The mean interval between thyroidectomy and survey in the COT, ET, and RT groups was 42.7, 50.2, and 9.2 months, respectively. Postoperative neck pain was significantly higher in the ET and RT groups than in the COT group (p = 0.026). The average neck impairment index score in the RT group was significantly higher than that in the COT group (p < 0.001). There were no significant differences in pain scale scores, swallowing difficulty, swallowing impairment index, voice change, and voice hand index among the three groups. Conclusions: There were no significant differences in postoperative voice change or swallowing difficulty among the COT, ET, and RT groups, whereas neck pain and discomfort were more common after ET and RT than COT.

Robotic thyroidectomy versus conventional open thyroidectomy for thyroid cancer: a systematic review and meta-analysis

BACKGROUND

Despite the new technical alternative offered by the robotic surgery for minimally invasive thyroid surgery, the role of the robotic thyroidectomy (RT) in thyroid cancer has been highly disputed. This paper gives a systematic review and meta-analysis aiming to compare RT and open thyroidectomy (OT) based on the surgical outcomes and oncologic results.

METHODS

Relevant literature was searched from various databases up to July 2016, including PubMed, MEDLINE, EMBASE, Cochrane Library, Web of science and Clinical Trials. gov. Outcomes of interest included patient characteristics, surgical outcomes, adverse events and complications, recurrence rate, and surgical completeness.

RESULTS

The systematic review and meta-analysis were based on the 5200 cases selected from the twenty-three publications. RT was associated with an equivalent adverse event and complication rate including transient hypocalcemia, permanent hypocalcemia, transient hoarseness, permanent recurrent laryngeal nerve (RLN) palsy, transient hypoparathyroidism, permanent hypoparathyroidism, hematoma, postoperative bleeding, seroma, chyle leakage, the Voice Handicap Index-10 (VHI-10) score, as well as equivalent surgical completeness including postoperative radioactive iodine (RAI) ablation rate, number of RAI ablation sessions, mean total RAI ablation dose, mean stimulated Tg of postoperation RAI, and proportion of stimulated Tg < 1.0 ng/ml on first ablation. Moreover, RT had lesser blood loss (WMD - 1.47, p = 0.04), smaller number of retrieved lymph nodes (WMD - 1.21, p = 0.0002), a low level of swallowing impairment (WMD - 4.17, p < 0.00001), and better cosmetic satisfaction (OR 4.05, p < 0.00001). However, OT was associated with shorter operation time (WMD 69.80, p < 0.00001), less total drain amount (WMD 66.53, p < 0.0001), and lower postoperative serum Tg level (WMD 0.21, p < 0.00001).

CONCLUSIONS

RT is as safe as OT for the treatment of thyroid cancer. Based on the long-time follow-up and surgical completeness, the adverse events and complications, and recurrence rate of RT were comparable with OT. RT was associated with a significantly lesser blood loss, smaller number of retrieved lymph nodes, a lower level of swallowing impairment, and better cosmetic satisfaction. In contrast, OT was associated with shorter operation time, smaller total drain amount, and lower postoperative serum Tg level. Overall, randomized clinical trials and larger patient cohort with long-term follow-up are still essential to further demonstrate the value of the robotic approach.

Revisiting robotic approaches to endocrine neoplasia: do the data support their continued use?

PURPOSE OF REVIEW

Although the advent of the robot has revolutionized the modern treatment of endocrine neoplasia, substantial controversies exist on its applicability, safety and benefits over the conventional laparoscopic operations. The present review aims to review the recent literature on various robotic approaches in treating thyroid, parathyroid, adrenal and pancreatic endocrine neoplasia and see whether its continued use should be supported.

RECENT FINDINGS

In summary, the role of robotic thyroidectomy has been clearly established and should be continued by experienced surgeons on selected patients. Because of the limited availability of evidence, the feasibility of robotic parathyroidectomy has yet to be elucidated. With proven favorable perioperative outcomes, robotic adrenalectomy and pancreatectomy should be continued as potential alternatives to conventional surgery.

SUMMARY

Robotic endocrine procedures still play a pivotal role in minimally invasive endocrine surgery with demonstrable safety and effectiveness. Future research should embark on prospective randomized-controlled trials on robotic endocrine procedures to collect higher level of evidence and long-term survival data.

Long-Term Voice Outcomes After Robotic Thyroidectomy

BACKGROUND

The purpose of this study was to evaluate the long-term voice function after robotic thyroidectomy in comparison with conventional transcervical thyroidectomy.

METHODS

We prospectively evaluated the voice functions of 54 patients with thyroid nodules who underwent robotic thyroidectomy by a gasless unilateral axillary or axillo-breast approach and of 70 patients who underwent conventional thyroidectomy. Subjective voice symptom score (VSS) was evaluated in questionnaires before thyroidectomy and then at 3, 6, 12, and 24 months after surgery. Objective acoustic parameters analyzed during the same period included fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, highest frequency, frequency and intensity range, and maximal phonation time.

RESULTS

At 3 months after surgery, VSS was better in the robotic group than in the conventional group. At 2 years after surgery, VSS had recovered to the pre-operative level in the robotic group, whereas it remained significantly worse at 2 years in the conventional group. The phonatory frequency range and highest frequency were significantly wider and higher, respectively, in the robotic group than the conventional group at 6, 12, and 24 months postoperatively.Within the robotic group, the frequency range and highest frequency recovered to pre-operative levels by 6 months, whereas in the conventional group they remained below the pre-operative levels at 2 years post-operatively. There were no differences in other acoustic parameters between the two groups of patients at any period.

CONCLUSION

Up to 2 years post-operatively, robotic thyroidectomy has advantages in terms of recovery of voice symptoms and acoustic parameters over conventional thyroidectomy.

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.

Comparison of Robotic versus Conventional Selective Neck Dissection and Total Thyroidectomy for Papillary Thyroid Carcinoma

OBJECTIVE

To compare the surgical outcomes of robotic selective neck dissection (SND) with total thyroidectomy and conventional transcervical SND with total thyroidectomy.

STUDY DESIGN

Case series with chart review.

SETTING

University tertiary care facility.

SUBJECT AND METHODS

We retrospectively analyzed 66 patients who underwent total thyroidectomy with SND (≥3 levels of II-V) and bilateral central neck dissection for cN1b papillary thyroid carcinoma, of whom 41 underwent conventional SND and 25 of whom underwent robotic SND. Subjective pain, sensory change, and cosmetic satisfaction were evaluated regularly for 3 months with a questionnaire.

RESULTS

Compared with the conventional group, patients in the robotic group were younger (mean, 36.7 vs 47.5 years; P = .003) and more female dominant (96.0% vs 73.2%; P = .023). Mean total operative time was longer in the robotic group than the conventional group (298 vs 236 minutes; P < .001). Anterior chest pain was higher in the robotic group at postoperative 1 day (pain score, 1.88 vs 0.62; P = .011), 1 week (1.30 vs 0.43; P = .036), and 1 month (0.90 vs 0.18; P = .029). Postoperative cosmetic satisfaction was significantly superior in the robotic group.

CONCLUSION

Compared with conventional transcervical SND with total thyroidectomy, robotic SND with total thyroidectomy yields superior outcomes for cosmetic satisfaction, longer operative time, and higher chest pain in the short term. Further study with a larger number of patients is mandatory.

American Thyroid Association Statement on Remote-Access Thyroid Surgery

BACKGROUND

Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption.

METHODS

A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery.

RESULTS

Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision.

CONCLUSIONS

Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.

Robotic versus Open Thyroidectomy for Differentiated Thyroid Cancer: An Evidence-Based Review

While open thyroidectomy (OT) is advocated as the gold standard treatment for differentiated thyroid cancer, the contemporary use of robotic thyroidectomy (RT) is often controversial. Although RT combines the unique benefits of the surgical robot and remote access thyroidectomy, its applicability on cancer patients is challenged by the questionable oncological benefits and safety. This review aims to analyze the current literature evidence in comparing RT to OT on thyroid cancers for their perioperative and oncological outcomes. To date, no randomized controlled trial is available in comparing RT to OT. All published studies are nonrandomized or retrospective comparisons. Current data suggests that RT compares less favorably than OT for longer operative time, higher cost, and possibly inferior oncological control with lower number of central lymph nodes retrieved. In terms of morbidity, quality of life outcomes, and short-term recurrence rates, RT and OT are comparable. While conventional OT continues to be appropriate for most thyroid cancers, RT should better be continued by expert surgeons on selected patients who have low-risk thyroid cancers and have high expectations on cosmetic outcomes. Future research should embark on prospective randomized studies for unbiased comparisons. Long-term follow-up studies are also needed to evaluate outcomes on recurrence and survival.