Endoscopic surgery for lateral cervical cysts. A report of three cases

Endoscopically-Associated Hairline Approach to Excision of Second Branchial Cleft Cysts

To improve the treatment outcome and post-operation rehabilitation of patients with second branchial cleft cysts (SBCC), 46 patients were operated for SBCC. 22 patients were operated by conventional approach, 22 patients were operated by original occipital hairline approach and 2 patients were operated via axillary approach. Assessment of intra-operation and post-operation complications was done and comparative evaluation of the preparations of the morphological structure in the main and reference group I was conducted. Clinical psychological assessment was performed in the post-operation period. Based on the clinical criteria and morphological method, the authors made conclusions on the benefits of the proposed approach to the excision of SBCC and determined indications and contraindications to endoscopically-associated surgery via the proposed approach. Comparative analysis of beneficial outcome clinically significant criteria of the conventional, axillary and proposed original approaches showed differences in the following criteria: "average operation time", "average wound dressing duration", "average duration of hospitalization" and "subjective satisfaction with incision scar". There were no differences revealed in the criteria "average incision length". The proposed approach allowed the authors to shorten the treatment duration and to accelerate the patients port-operation recovery. Due to the proposed approach, the incision opened the fascial layer where the cyst was located. The dissection was performed along the hairline and did not involve upper and lower located layers. Minimal surgery traumatic rate of the proposed approach was proved by the morphological studies.

Robotic-Assisted Parathyroidectomy

Objective. Targeted parathyroidectomy is the gold standard for localized parathyroid disease. A robotic-assisted approach has not been investigated. The aim was to assess the feasibility of a robotic technique that avoids a neck scar.

Study Design. Feasibility study.

Setting. Tertiary referral center.

Subjects and Methods. Eleven patients with primary hyperparathyroidism were prospectively evaluated. Triple modality concordant localization was a prerequisite. All patients underwent robotic-assisted parathyroidectomy (RAP). Outcome variables assessed were operative time, voice change, biochemical cure, and histopathological confirmation. Patient-reported outcome measures (PROMs) included subjective assessment of pain and scar cosmesis, Voice Handicap Index 2, and EQ-5D quality-of-life assessment. Mean follow-up was 6 months (range, 3-12 months).

Results. The parathyroid adenoma was successfully excised in all cases with negligible blood loss (<5 mL). There was 1 conversion. There was no voice change in any case. Robot docking time plateaued to 10 minutes after 8 cases. Mean exposure and console times (31 and 51 minutes, respectively) were affected by body habitus. The mean visual analog scale for scar cosmesis was 75% on the first postoperative day, improving to 92% at 6 months and 95% at 1 year. Pain scores decreased to 8% at 2 weeks. All 5 EQ-5D quality-of-life parameters significantly improved following surgery.

Conclusion. The robotic approach is feasible for performing targeted parathyroidectomy that avoids a neck scar. The clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted parathyroidectomy warrant further evaluation to establish if this represents a viable alternative to the existing targeted techniques.

Videoscopic thyroidectomy: the uncertain path to practicality

Since 1997, successful attempts at endoscopic thyroidectomy have led to controversies. The procedure has, as yet, no alarming operative complication, but its benefits to patients are debatable. By means of very individualized and ingeniously designed approaches, the procedure has proven to be feasible and safe in trained hands. Cautious trials and evaluations of endoscopic thyroid surgery are now in progress internationally at expert centres. The technique itself is undergoing progressive evolution and larger studies are underway. Although endoscopic thyroidectomy has little chance of acquiring the same popularity as open thyroidectomy due to its inherently higher technical demand, it may become a practical and safe alternative option for selected suitable patients.

Total video endoscopic thyroidectomy via the anterior chest approach using the cervical region-lifting method

Endoscopic surgery offers superior cosmetic results compared to open procedures and is strongly preferred by many patients, especially women. We performed total endoscopic thyroidectomy via the anterior chest approach using a neck skin-lifting technique in which the skin is lifted by a large number of hooks to create the working space. This method is quite flexible and can be modified based on the size of the space needed. The fine hooks leave no scar on the anterior neck, the skin incisions are small, and the scars are completely covered by patients' undergarments. Endoscopic thyroidectomy is suitable for benign thyroid nodules, but some malignant foci diagnosed by frozen section usually can be managed without conversion to an open procedure. Women under 45 years of age with nodules <2 cm who have no evidence of lymphatic spread or local invasion are ideal candidates for this procedure.

Total endoscopic thyroidectomy

We have developed endoscopic thyroidectomy procedures using anterior chest and axillary approaches. Both of our procedures differ significantly from the usual thyroidectomy, which involves lifting both the platysma and the sternohyoid muscle. Because only the platysma is lifted during our procedures, a CO(2) insufflation pressure of less than 4 mmHg is sufficient. While the sternohyoid muscle is transected to obtain greater exposure of the thyroid gland in minimally invasive procedures in the neck, we do not divide it so as to prevent adhesions to the platysma, unless the nodule is large. As we accumulated experience with these procedures in 58 patients, typical operation time decreased to less than 120 minutes for the anterior approach and to less than 150 minutes for the axillary approach. Large follicular tumours can be extracted using the axillary approach, with all of its cosmetic advantages, whereas the anterior chest approach is advocated for removal of bilateral multinodular goitres and parathyroid lesions. Both approaches result in minimal postoperative hypoaesthesia, paraesthesia, and discomfort during swallowing. We conclude that endoscopic neck surgery is the procedure of choice in carefully selected patients with thyroid disease.

Endoscopic thyroid surgery today: a diversity of surgical strategies

The advancement of video-assisted minimally invasive surgery in this decade fostered the successful attempt at endoscopic thyroidectomy in 1997. This technically demanding surgery is now being evaluated in a small number of specialized centers. The procedure earned the most attention in Japan and is performed in more than 20 centers; a conference dedicated to the technique was held in Japan in 2001. By retrieving information from published or presented articles and direct personal communications, we report on the multitude of surgical strategies designed by different experts to enable relocalization of the surgical wounds to optimize cosmesis to the patient while complying with the gold standard of thyroid surgery.