Comparisons of different approaches and incisions of thyroid surgery and selection strategy

Risk Factors for Scar Formation After Thyroidectomy and Advances in its Prevention and Treatment

An open thyroidectomy typically results in a "suicide" wound in the neck measuring approximately 4 to 6 cm in length. In the event that this wound develops into a hypertrophic scar, it can lead to significant psychological and quality-of-life challenges for the patient. The formation of proliferative scarring in surgical incisions is influenced by a multitude of risk factors, which can be broadly classified into intrinsic and extrinsic categories. Contemporary scar prevention and control strategies encompass a range of modalities, including postoperative rehabilitation physiotherapy, topical dressings, drug injections, laser therapy, combined therapy, and emerging therapeutic approaches. Among these, combined therapy has demonstrated superior efficacy in scar prevention and control. The objective of this article is to present a concise overview of the risk factors and interventions associated with proliferative scar formation following thyroid surgery. This is with a view to informing future research on the prevention of incisional scarring in thyroid surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Transaxillary vs. Transsubclavian Gasless endoscopic thyroidectomy approaches for papillary thyroid cancer

The use of transaxillary and transsubclavian approaches for endoscopic thyroidectomy has increased globally. However, studies examining the comparative outcomes of these procedures are scarce. In this study, we aimed to compare the safety and efficacy of thyroidectomy between the gasless endoscopic thyroidectomy transaxillary approach (GETTA) and gasless endoscopic thyroidectomy transsubclavian approach (GETTSA) in patients with papillary thyroid cancer (PTC). Medical records of patients with PTC who underwent GETTA or GETTSA performed by the same surgical team between August 2022 and August 2023 were retrospectively reviewed. Propensity score matching (PSM) was used to mitigate potential selection bias and adjust for baseline clinical characteristic differences. After PSM using 10 covariates, 196 patients (GETTA: 98; GETTSA: 98) were included. In comparison to the GETTSA group, the GETTA group exhibited a longer duration of operation (120.00 [103.75-140.00] vs. 110.00 [90.00-125.00] min, P = 0.001), longer postoperative hospital stays (1.00 [1.00-3.00] vs. 1.00 [1.00-2.00] days, P = 0.008), higher hospitalisation costs (23,973.02 [22,640.80-25,379.80] vs. 23,306.00 [21,968.97-24,070.68] Yuan, P = 0.015), and greater postoperative drainage (60.00 [50.00-70.00] vs. 46.50 [40.00-56.25] mL, P < 0.001). Intraoperative parathyroid autotransplantation and vocal cord paralysis rates were not significantly different between groups. The number of lymph node metastases via central lymph node dissection was not significantly different between groups (0.00 [0.00-1.00] vs. 0.00 [0.00-1.00], P = 0.645). No significant procedural safety or completeness differences were observed between GETTA and GETTSA. GETTA had better cosmetic outcomes. GETTSA had shorter duration of operation durations, shorter hospital stays, lower hospitalisation costs, and lower postoperative drainage, making it a better option for clinical use.

Anatomical recognition artificial intelligence for identifying the recurrent laryngeal nerve during endoscopic thyroid surgery: A single-center feasibility study

Background

We investigate the feasibility of using artificial intelligence (AI) to identify the recurrent laryngeal nerve (RLN) during endoscopic thyroid surgery and evaluated its accuracy.

Methods

In this retrospective study, we develop an AI model using a dataset of endoscopic thyroid surgery videos, including hemithyroidectomy procedures performed between April 2019 and September 2023 at the National Cancer Center Hospital East, Chiba, Japan. Semantic segmentation deep learning methods were applied to analyze the endoscopic thyroid surgery videos.

Results

Forty endoscopic thyroid surgery videos, all in high definition or better quality, were analyzed. The Dice values were 0.351, 0.568, and 0.746 for the inferior thyroid artery, RLN, and trachea, respectively. Data augmentation was performed by cropping, standardizing, and resizing to reduce false positives and improve accuracy.

Conclusions

The AI model showed high recognition accuracy of the RLN and trachea. This method holds potential for assisting in future cervical gasless endoscopic surgeries.

A Systematic Review of Current Practices, Challenges, and Future Directions for the Use of Robotic Surgery in Otolaryngology in Greece

Robotic surgery is increasingly used in otolaryngology (ENT), particularly for complex head and neck procedures. It offers various advantages, including limited postoperative pain, excellent aesthetic results, better visualization in the surgical field, enhanced dexterity due to movement adjustment by the robotic system, and minimal complications and hospital stay. However, robotic systems' higher cost and limited availability are a burden for clinical applications. This systematic review is a detailed assessment that looks at the existing situation, problems, and prospects for robotic ENT surgery in Greece. It is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The included studies were chosen based on specific criteria after a thorough inspection of electronic databases of clinical trials and medical journals (PubMed, Scopus, Web of Science). Despite steady adoption, Greece needs to catch up with other European countries in deploying robotic surgery technology. Various possible reasons may cause the small number of ENT robotic-assisted surgeries, including the high cost and the availability of robotic systems, mainly in large private or public hospitals in the main cities of Greece (Athens and Thessaloniki). Training on robotic systems is also very limited for surgery residents and young surgeons, while the learning curve of robotic-assisted surgeries in ENT is big. Peer-reviewed literature was analyzed to compare it with other European nations and investigate the economic, training, and geographic aspects that may be a burden for the rise of robotic surgery in Greece. Through the review scope, this study also provided recommendations concerning the implementation of robotic surgery in daily practice among surgeons in Greece and the difficulties that may arise regarding robotic surgery training in resource-limited countries.

A prospective study to assess cervical scar satisfaction following conventional open thyroidectomy for thyroid cancer

BACKGROUND

Conventional open thyroidectomy (COT) remains a common method of thyroidectomy in many parts of the world for various reasons.

METHODS

In this prospective (cross-sectional) study, we evaluated the scar satisfaction among patients and surgeons following COT using the Patient and Observer Scar Assessment Scale (POSAS) and the Patient Scar Assessment Questionnaire (PSAQ).

RESULTS

A total of 116 patients were included. The median age of the patients was 44 years and the majority were women. The median scar length overall was 12.2 cm. On POSAS, the median score for surgeon 1 was 1 (range 1-5), for surgeon 2, it was 2 (range 1-6), and for the patient, it was 1 (range 1-6) suggesting good scar satisfaction. The patient's response in the PSAQ was also echoing similar outcomes with scar satisfaction.

CONCLUSIONS

Overall, both the patients and the surgeons seem to be satisfied with the overall scar appearance following COT despite the scar length.

Postoperative Pain Following Transoral Thyroidectomy via Vestibular Approach and Cervical Thyroidectomy: A Systematic Review and Meta-Analysis

Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) represents a minimally invasive alternative to traditional open thyroidectomy (OT). The objective of this systematic review and meta-analysis was to comprehensively analyze and compare postoperative pain outcomes between conventional open thyroidectomy (COT) and TOETVA. We conducted a systematic search across multiple databases, including PubMed, Medline, Elton B. Stephens Company (EBSCO), and Google Scholar, to identify cohorts and randomized trials comparing postoperative pain outcomes between patients undergoing transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) and those undergoing conventional thyroidectomy. The search period spanned from the earliest available article up to January 15, 2022. Keywords such as "scarless thyroidectomy," "endoscopic transoral via vestibular thyroidectomy," "conventional thyroidectomy," "transcervical thyroidectomy," "postoperative pain," and "visual analog pain score" were utilized to retrieve relevant studies. A total of 1,291 patients from 11 studies were included in our analysis, with 10 studies originating from Asia and one from Europe. Among these studies, seven were prospective, while four were retrospective. The primary outcome measure was postoperative pain. Various statistical tests were also performed for data analysis, including the Chi-square and random effects model. The Newcastle Ottawa Scale was used to assess the quality of studies. There was no significant statistical difference observed between the endoscopic transoral vestibular route and the conventional cervical approach in terms of visual analog scale (VAS) score, with an odds ratio of -0.37 and a 95% confidence interval ranging from -0.9 to 0.17. The overall effect had a P-value of 0.18. However, substantial heterogeneity was noted, with an I2 value for heterogeneity of 98% and a P-value for heterogeneity of less than 0.001. The Chi-square value was calculated as 364.02, and the main difference was 9. In comparison, TOETVA exhibited lower pain levels on the first day post-operation compared to conventional thyroidectomy, with an odds ratio of -1.36 and a 95% confidence interval ranging from -2.65 to -0.06. Transoral endoscopic thyroidectomy via the vestibular approach demonstrated superior outcomes compared to conventional thyroidectomy in terms of postoperative pain management on the first day following surgery. However, when considering overall pain management throughout the recovery period, no significant difference was observed between the two approaches. More extensive studies evaluating pain levels on the day of surgery and controlling for analgesic interventions are warranted.

Comparison of the effectiveness and safety between endoscope-assisted and traditional open surgery in the treatment of thyroid micropapillary carcinoma: A meta-analysis

Endoscopic thyroidectomy (ET), a surgical procedure widely accepted by surgeons, has been proven to be feasible. The aim of this systematic review is to evaluate the effectiveness and safety of ET compared to conventional open thyroidectomy (COT) in the treatment of papillary thyroid microcarcinoma (PTMC) through a meta-analysis. Medical literature databases, including PubMed, Embase, Cochrane Library, CBM,CNKI, Wanfang, and VIP, were systematically searched for relevant studies on ET and COT for the treatment of PTMC. The search period was from January 2000 to June 2023. Two researchers independently performed literature screening and data extraction according to the inclusion and exclusion criteria, and the Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Meta-analysis was conducted using Revman 5.3 software. Six studies were eventually included, involving a total of 440 patients with PTMC. The meta-analysis results demonstrated that the ET group had shorter incision length (MD = -2.96, 95 % CI: -4.27 to -1.65, P < 0.05) and less intraoperative blood loss (MD = -18.06, 95 % CI: -32.76 to -3.37, P = 0.02 < 0.05). There was no statistically significant difference between the two groups in terms of operative time (MD = -0.83, 95 % CI: -19.64 to 17.98, P = 0.93 > 0.05), lymph node dissection (MD = 1.03, 95 % CI: -1.47 to 3.54, P = 0.42 > 0.05), postoperative hospital stay (MD = -0.96, 95 % CI: -2.00 to 0.08, P = 0.07 > 0.05), and transient recurrent laryngeal nerve paralysis (OR = 3.32, 95 % CI: 0.65 to 16.90, P = 0.15 > 0.05). Compared with COT, ET has the advantages of shorter incision length, less intraoperative blood loss, better prognosis and comparable safety, making it a worthy choice for clinical application.