Prevention of transoral thyroidectomy complications: An analysis of surgical outcomes in 423 consecutive series

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

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

Three-port transoral robotic thyroidectomy without axillary incision: A preliminary report on a case series from Vietnam

BACKGROUND

Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. Here, we present our preliminary data from the initial 5 consecutive patients to explore the feasibility of three-port TORT without axillary incision.

METHODS

From August 2022 to December 2022, we performed TORT using three ports via the da Vinci Xi system with three robotic arms.

RESULTS

All 5 patients had cT1aN0M0 papillary thyroid carcinomas with a mean tumour size of 6 mm. All patients underwent lobectomy with ipsilateral central neck dissection. The mean surgical time was 170 ± 15,8 min; the average length of hospital stay is 4.2 days. The number of retrieved central lymph nodes was 4.2 ± 0.8. All patients were discharged uneventfully without complications and completely satisfied with the cosmetic results.

CONCLUSIONS

TORT is feasible and safe when performed on carefully selected patients by experienced surgeons.

Five-Year Oncologic Outcome and Surgical Completeness of Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Comparison with Conventional Transcervical Thyroidectomy Using Propensity Score Matching

OBJECTIVE

This study aimed to evaluate the oncological outcomes and surgical completeness of transoral robotic thyroidectomy (TORT) for papillary thyroid carcinoma (PTC) compared with conventional transcervical thyroidectomy.

METHODS

We analyzed 489 patients with PTC who underwent thyroidectomy with or without central neck dissection (CND; 311 conventional thyroidectomy and 178 TORT) between January 2017 and December 2021. Patients with gross invasion of the surrounding structures, revision or completion thyroidectomy, and lateral neck dissection were excluded. Propensity score-matched analysis was performed using eight covariates, including age, sex, extent of thyroidectomy, tumor size, extrathyroidal extension (ETE), radioactive iodine (RAI) ablation, lymphovascular invasion (LVI), and CND.

RESULTS

Before propensity score matching (PSM), age, male-to-female ratio, and body mass index were lower in the TORT group. The ratio of total thyroidectomy and CND, tumor size and bilaterality, LVI, and RAI ablation were higher in the conventional group. PSM generated two matched groups of 100 patients each. After PSM, significant differences between the two groups in the baseline analysis disappeared. In the matched samples, the recurrence rate (2% and 0% in the conventional and TORT groups, respectively) and recurrence-free survival curves did not differ between the two groups. The mean thyroid-stimulating hormone (TSH)-stimulated thyroglobulin level in the RAI group and TSH-suppressed thyroglobulin level in the non-RAI group were not different between the two groups.

CONCLUSIONS

The 5-year oncologic outcomes and surgical completeness of TORT were comparable with those of conventional thyroidectomy in patients with small, localized, low-risk PTC when performed by experienced surgeons.

Transoral thyroidectomy implemented by a novice surgeon: Efforts for safe implementation

Background

This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon.

Methods

We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy.

Results

Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome.

Conclusions

Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework.

Level of Evidence

Level 4.

Feasibility and Safety of Ambulatory Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)

Background

In search of an ideal cosmesis, transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has recently been introduced to avoid a visible scar. Although ambulatory thyroid surgery is considered safe in carefully selected patients, this remains unclear for TOETVA.

Methods

All consecutive adult patients who underwent ambulatory TOETVA or open thyroid surgery at a French university hospital were prospectively enrolled from 12/2020 until 11/2021. The primary outcome was postoperative morbidity (recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, wound morbidity, or hospital readmission). The secondary outcome was quality of life (QoL), measured by a survey including a validated questionnaire (SF-12) and a modified thyroid surgery questionnaire six weeks after surgery.

Results

Throughout the study period, 374 patients underwent a unilateral lobectomy or isthmectomy in ambulatory setting, of which 34 (9%) as TOETVA (including 21 (62%) for a possible malignancy). In the TOETVA group, younger age (median 40 (IQR 35–50) vs. 51 (40–60) years, P < 0.001) and lower BMI (median 23.1 (20.9–25.4) vs. 24.9 (22.1–28.9) kg/m², P = 0.001) were noted. No cases were converted to open cervicotomy. TOETVA was at least as good as open cervicotomy with nil versus four (1%) re-interventions for bleeding, one temporary (5%) versus 13 (4%) (temporary) RLN palsies, and one (<1%) wound infection (open cervicotomy group). No hospital readmissions occurred in all ambulatory surgery patients. No differences were found in physical (P = 0.280) and mental (P = 0.569) QoL between TOETVA and open surgery.

Conclusions

In carefully selected patients, the feasibility and safety of ambulatory TOETVA are comparable to open surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06666-y.

The Advantages of Robotic Over Open Thyroidectomy in Thyroid Diseases: A Systematic Review

Over a hundred thousand thyroid surgeries are performed per year in the United States. Although conventional thyroidectomy has successful surgical outcomes, robotic minimally invasive procedures, known for their scar free (regarding the neck, no collar incision) surgical outcomes gained popularity through the years. Furthermore, these techniques are new and still debatable. The purpose is to know the advantages of robotic over open thyroidectomy in thyroid diseases. Note that we didn't aim to compare different robotic techniques due to the lack of data.

We performed a systematic review comparing surgical approaches for thyroidectomy, open vs robotic techniques, from January 2017 to December 2021, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. All papers with no full free article access and not in the English language were excluded. The outcomes of interest were superior cosmetics outcome, cost-effectiveness, limitations, operation time, length of hospital stay and postoperative pain or complications, and future outcomes.

A literature search was carried out in electronic databases (PubMed, Google Scholar) in order to retrieve all papers comparing the effectiveness of robotic vs open thyroidectomy. An initial reference search yielded 433 articles. Finally, we chose nine studies covering different robotic thyroidectomy techniques compared to the open thyroidectomy approach. Promising results were seen in these studies, especially with superior cosmetic results, less post-operative pain, swallowing discomfort, and voice changes. In addition, the risk of recurrent laryngeal nerve injury is almost the same as the open approach. Multiple types of biases were caused by the selection of the population and the limitation of the studies to certain regions associated with the low numbers of robotic thyroidectomy approaches in Europe and the United States of America and the lack of randomized trials and long-term follow-up respectively. All studies discussed the importance of the surgeon's skills and the patient decision in choosing the appropriate approach for the thyroidectomy depending on the risk factors, a larger number of patients, and longer follow-up from multiple hospitals.

Comparison of Different Mandibular Jawlines Classifications on Transoral Endoscopic Thyroidectomy for Papillary Thyroid Carcinoma: Experiences of 690 Cases

BACKGROUND

The influences of patients' different mandibular jawlines on transoral endoscopic thyroidectomy via vestibular approach (TOETVA) have not been described before. The objective of this study was to introduce a new classification to assess different mandibular jawlines, and to evaluate the effects on TOETVA in terms of safety, feasibility, and postoperative feelings in the treatment of papillary thyroid carcinoma (PTC).

METHODS

The crossing angle of esthetic plane and mandibular plane was defined as Wang Angle, used to assess patients' different mandibular jawlines. Mandibular classifications of A (angle: 80° ~ 110°), B (angle > 110°), and C (angle < 80°) types were compared to evaluate the surgical outcomes of TOETVA by a retrospective study. 690 patients of PTC who received TOETVA were included in this study, which were divided into three groups according to mandibular classifications.

RESULTS

Clinicopathological characteristics of the patients including age, gender, body mass index, tumor size, Hashimoto thyroiditis were similar in the three groups. Patients' length of jay in group C was significantly longer than group A and group B (P < 0.01). The ratios of using suspension system in group C were significantly higher than group A and group B (P < 0.01). The scores of postoperative visual analogue scale (VAS) and ratios of mandibular swell in group C were significantly higher than group A and group B (P < 0.01). There was no significant difference in the three groups regarding surgical outcomes, including postoperative vocal cord paralysis, hypocalcemia, serum white blood cells and C-reactive protein levels.

CONCLUSIONS

The Wang angle and mandibular jawline classifications were firstly introduced in TOETVA. All the patients of class A, B, and C mandibular jawline can achieve safe and effective surgical outcomes in the treatment of PTC with TOETVA. Patients of class C need more assistance of suspension system, would experience higher scores of VAS, and higher ratios of mandibular swell compared with class A and B.

Transoral and submental thyroidectomy using intraoperative nerve stimulation and indocyanin green fluorescence imaging

There is a recent proliferation of clinical studies about the minimally invasive scarless thyroid surgery. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) carries a great potential for being scarless surgery via a short dissection flap. However, TOETVA has limitations in extracting larger thyroid tumours via the transoral vestibular incision and due to its potential damage to the branches of the mental nerve. The rapidly evolving surgical innovations have now introduced transoral and submental thyroidectomy (TOaST) approach that allows extraction of large thyroid tumours with less flap dissection and minimal postoperative pain. We present a 39-year-old man with a large multinodular goitre. The patient was euthyroid with moderate to severe compression symptoms of difficulty in breathing and swallowing. We performed a TOaST procedure using intraoperative neuromonitoring and indocyanin green fluorescence imaging with an uneventful recovery. This is a first case report from the middle east region that will pave the way to large clinical trials to determine the efficacy and safety of TOaST.