Video-assisted surgery for thyroid cancer patients

Definition of learning curve for thyroidectomy: systematic review on the different approaches

Background

Thyroidectomy is one of the most common surgical procedures carried out worldwide and it has evolved in recent years with alternative approaches. With the advent of minimally invasive techniques, the learning curve (LC) concept has become a fundamental "dogma".

Methods

A literature search, according to the PRISMA guidelines, was performed via PubMed (MEDLINE), Scopus, Cochrane Library, EMBASE, and Web of Science. Only studies assessing the learning process to thyroidectomy (including hemi- and total thyroidectomy), reporting a minimum of 30 procedures and describing clearly the minimum number of performances required to achieve proficiency and the main evaluation items used to establish it, were included. Conventional, endoscopic and robotic approaches were separately analyzed. Only English-language studies were considered.

Results

Forty-five relevant studies were selected for the analysis [respectively 16 concerning robotic thyroidectomy (RT), 22 endoscopic thyroidectomy (ET), 6 mini-invasive video assisted thyroidectomy (MIVAT), 1 conventional thyroidectomy (CT)]. The number of procedures required for a single surgeon to achieve competence and the parameters used to define surgical proficiency were fully investigated for each individual technique.

Conclusions

Our research shows how the current literature lacks an objective definition of the LC concept. The heterogeneity of analysis methodologies and parameters evaluated, the various surgical techniques and training background of single surgeons, make it impossible to draw univocal results. Future studies should consider confounding factors and establish criteria that should be consensually recognized in the assessment of surgical performances and skills.

MIVAT: the last 2 years experience, tips and techniques after more than 10 years

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) has been introduced into clinical practice by Miccoli in the late 1990s (Miccoli et al., Am J Surg 181(6):567-570, 2001) and it has become a widespread technique used and welcomed worldwide. In this paper, we present our experience of the last 2 years; we also describe tips and techniques derived from over 460 cases performed in the last 10 years by the same surgical team with the same single operator.

METHODS

In the last 10 years, we did about 460 MIVAT procedures. In the last 2 years, we performed MIVAT on 156 consecutive patients at Sant'Andrea University Hospital of Rome "Sapienza" University. of 156 cases performed, we were able to monitor the follow-up in 110 patients.

RESULTS

On 110 cases, the mean surgical time was 74 ± 7.2 min. In our data, we reported: transitory hypoparathyroidism 11 (10%), definitive hypoparathyroidism 4 (3.60%) (this value is inclusive of patients treated with central neck dissection. The value referred only to MIVAT is 1.05%), 2 (1.81%) transitory monolateral nerve palsy, 16 (14.50%) transitory, and 1 (0.9%) definitive nerve palsy. 4 (3.60%) cases of transitory dysphagia and 0 (0%) cases of definitive dysphagia (Table 4). We also had 1 (0.9%) case of surgical scar infection, 0 (0%) postoperative bleeding, and 2 (1.81%) cases of subcutaneous surgical adhesion. Cosmetic results were: 0 (0%) insufficient, 0 (0%) sufficient, 6 (6.30%) passable, 17 (15.50%) good. and 86 (78.20%) excellent. Conversion rate 0 (0%).

CONCLUSION

MIVAT is a good and safe technique, with similar short-term outcomes and similar costs compared to traditional total thyroidectomy. We hope that the tips and techniques reported in this paper as well as the advices in the use of instruments in MIVAT and open surgery will be useful to improve the skills of young surgeons and make thyroid surgery less invasive.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

Minimally invasive and remote-access thyroid surgery in the era of the 2015 American Thyroid Association guidelines

Thyroid surgery has evolved throughout the years from being one of the most dangerous surgeries to becoming one of the safest surgical procedures performed today. Recent technologic innovations have allowed surgeons to remove the thyroid gland from a remote site while avoiding visible neck scars. There are many endoscopic approaches for thyroidectomy. The most common cervical approach is the minimally invasive video‐assisted technique developed by Miccoli et al. The robotic transaxillary and axillary breast approaches avoid a neck scar and have been demonstrated to be safe and effective in international populations. Novel approaches under investigation include face‐lift robotic thyroidectomy and the transoral approach. This article aims to provide the reader with an overview of the current minimally invasive and alternate‐site approaches used and their capability to assist the surgeons in accomplishing remote‐access thyroid surgery under the scope of the 2015 American Thyroid Association Guidelines.

Minimally invasive thyroidectomy: a ten years experience

BACKGROUND

The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient's quality of life, postoperative morbidity. The mini invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases.

METHODS

We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay.

RESULTS

The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3-4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%).

CONCLUSIONS

The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.