Surgical Excision of Large Multinodular Goiter Using an Endoscopic Transaxillary Approach

Impact of Large Thyroid Nodules (≥4 cm) on Surgical Outcomes Following Endoscopic Thyroidectomy Through the Bilateral Axillo-Breast Approach

OBJECTIVE

Endoscopic thyroidectomy through the bilateral axillo-breast approach (BABA) is predominantly used in cases involving low-risk thyroid malignancies and benign nodules measuring <4 cm. However, the efficacy and safety of this technique in larger goiters remain underexplored.

METHODS

This retrospective study compared perioperative data and pathologic outcomes among patients who underwent endoscopic BABA thyroidectomy categorized on the basis of the size of the dominant nodule (<4 vs ≥4 cm).

RESULTS

Among the 113 included patients, 81 (72%) had a dominant nodule measuring <4 cm (group 1) and 32 (28%) presented with a nodule measuring ≥4 cm (group 2). Group 2 experienced longer operative times, greater blood loss, and higher drainage volumes than group 1. However, pain scores and length of postoperative hospital stay were similar between the groups. None of the patients required conversion to open surgery. The incidence rates of vocal cord palsy and hypoparathyroidism did not differ significantly between groups. In group 2, three patients developed seroma (9%) and one exhibited delayed bleeding (3%). Pathologic examination revealed that 6 patients (19%) in group 2 had malignant neoplasms; 3 were identified in the dominant nodule, whereas the remaining 3 were identified in separate, smaller nodules. Throughout the mean follow-up period of 43 months, no recurrence or metastasis was reported.

CONCLUSIONS

Endoscopic BABA thyroidectomy is a viable option for patients with large thyroid nodules (≥4 cm); however, this technique requires careful execution.

Surgical outcomes of robotic thyroidectomy for thyroid tumors over 4 cm via the bilateral axillo-breast approach

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Endoscopic Thyroidectomy for Large-Sized Goiters: Merits of the Axillo-Breast Approach with Gas Insufflation

Background

Several minimal access approaches to the thyroid gland have been widely applied; nevertheless, such approaches are still challenging when dealing with large-sized thyroid nodules or goiters. We hereby evaluated the outcomes and highlighted the merits of endoscopic axillo-breast hemithyroidectomy (EABH) for large-sized unilateral goiters.

Methods

Patients underwent EABH for unilateral large thyroid nodules ≥6 cm in its greatest dimension or unilateral large goiter (≥60 ml sonographic volume) whatever the size of its contained nodules were identified from a prospectively maintained database. Their demographic data, clinicopathological profiles, and surgical and esthetic outcomes are reported and analyzed.

Results

Over a 2-year period, 33 patients matched the selection criteria. Their mean age was 34.75 ± 11.39 years. There were 30 women and 3 men. The majority of nodules were radiologically TIRADS3 and cytologically Bethesda 3. The mean sonographic dominant nodule greatest dimension was 5.29 ± 1.48 cm (range: 3-9.5 cm). The mean sonographic volume of the pathological lobe was 101.86 ± 54.45 ml (range: 60.11-236.88 ml). All cases were completed endoscopically with no conversion to open. The mean operative time was 110.76 ± 18.75 minutes. No significant postoperative complications were reported except for one case with temporary vocal cord paresis. Most (87.9%) of the patients were extremely satisfied with the procedure.

Conclusion

EABH with our suggested key steps could be considered an effective valid approach for unilateral large goiters in trained hands and in patients desirous for cosmesis.

Endoscopic thyroidectomy via an axillo-breast approach without gas insufflation for benign thyroid nodules and micropapillary carcinomas: preliminary results

PURPOSE

To examine the feasibility of endoscopic thyroidectomy (ET) via an axillo- breast approach without gas insufflation for large thyroid tumors and micropapillary carcinomas.

MATERIALS AND METHODS

The patients in the benign group were separated into groups 1 (n=95, <4 cm in tumor diameter) and 2 (n=37, ≥4 cm in tumor diameter). Also, 57 patients in the micropapillary carcinoma group underwent an endoscopic hemithyroidectomy (HT) (group 3) and were compared with 60 patients who received conventional open HT (group 4). Postoperative functional outcome, local complications, surgical outcomes, and pathological outcomes were compared between the groups.

RESULTS

In the benign group, there was no significant difference in mean operating time, hospital stay, or overall perioperative complications between the two groups. In the micropapillary carcinoma group, mean operating time and hospital stay in group 3 were significantly longer than in group 4 (p=0.015 and p≤0.001). The overall perioperative complications did not differ significantly between the groups. The postoperative cosmetic result was better in groups 1-3 (endo group) than in group 4 (open group).

CONCLUSION

ET via a gasless axillo-breast approach seems to be a safe procedure even for benign thyroid lesions ≥4 cm and micropapillary carcinomas. Although it has the advantage of better cosmetic results over open thyroidectomy, there is room for improvement in terms of lessening its invasiveness and shortening the operative time.