Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery

INTRODUCTION

Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy.

METHODS

Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate.

RESULTS

As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported.

CONCLUSIONS

The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.

Optimizing robotic thyroid surgery: lessons learned from an retrospective analysis of 104 cases

Background

Robotic assistance in thyroidectomy is a developing field that promises enhanced surgical precision and improved patient outcomes. This study investigates the impact of the da Vinci Surgical System on operative efficiency, learning curve, and postoperative outcomes in thyroid surgery.

Methods

We conducted a retrospective cohort study of 104 patients who underwent robotic thyroidectomy between March 2018 and January 2022. We evaluated the learning curve using the Cumulative Sum (CUSUM) analysis and analyzed operative times, complication rates, and postoperative recovery metrics.

Results

The cohort had a mean age of 36 years, predominantly female (68.3%). The average body mass index (BMI) was within the normal range. A significant reduction in operative times was observed as the series progressed, with no permanent hypoparathyroidism or recurrent laryngeal nerve injuries reported. The learning curve plateaued after the 37th case. Postoperative recovery was consistent, with no significant difference in hospital stay duration. Complications were minimal, with a noted decrease in transient vocal cord palsy as experience with the robotic system increased.

Conclusion

Robotic thyroidectomy using the da Vinci system has demonstrated a significant improvement in operative efficiency without compromising safety. The learning curve is steep but manageable, and once overcome, it leads to improved surgical outcomes and high patient satisfaction. Further research with larger datasets and longer follow-up is necessary to establish the long-term benefits of robotic thyroidectomy.

The Impact of Calcium and Vitamin D Supplementation Prior to Thyroidectomy on Mitigating Postoperative Hypocalcemia

Background Hypocalcemia remains the most frequent complication after thyroidectomy. It can either be transient or permanent, and patients often find it unpleasant due to its association with prolonged hospitalization. The objective of this study was to determine the role of preoperative calcium and vitamin D supplementation in preventing hypocalcemia after subtotal/total thyroidectomy. Material and methods This quasi-experimental study was conducted at the Department of General Surgery, Ayub Teaching Hospital, Abbottabad, Pakistan, from January 2023 to July 2023. We utilized non-probability purposive sampling. Patients undergoing total thyroidectomy were recruited and followed until discharge to ascertain outcomes. They were divided into two groups: Group A received vitamin D (200,000 IU) one week preoperatively as single intramuscular dose and calcium (1 gm) orally two times daily for one week preoperatively, while Group B served as the control. Venous blood samples were taken post-surgery, on the second and seventh day and at day 30 to assess hypocalcemia. Chi-square test was employed, comparing hypocalcemia in both groups with a p-value ≤0.05 considered significant. Results One hundred thirty-two patients underwent subtotal/total thyroidectomy, with 46.2% (n = 61) being male and 53.8% (n = 71) female. The mean age of these patients was 37.12 ± 6.22 years, ranging from 20 to 50 years, and 57.6% (n = 76) were aged over 35 years. More than half (55.3%, n = 73) hailed from rural areas, while 4.7% (n = 59) resided in urban locales. Among the patients, 15.9% (n = 21) had a history of diabetes, and 24.2% (n = 32) were hypertensive. The mean body mass index (BMI) was 23.32 ± 2.41 kg/m2, with 7.6% (n = 10) classified as obese. The mean preoperative serum calcium level was 9.87 ± 1.07 mg/dL. Postoperatively, the mean serum calcium level was 8.74 ± 0.83 mg/dL. Both Group A (preoperative vitamin D and calcium supplementation) and Group B (control) demonstrated comparable baseline characteristics before undergoing thyroidectomy. The incidence of postoperative hypocalcemia was notably lower in Group A, with only 4.5% (n = 3) experiencing this complication. By contrast, 24.2% (n = 16) of patients in Group B, the control group, developed hypocalcemia (P = 0.001). Conclusion Our study supports the use of preoperative calcium and vitamin D supplementation in patients undergoing thyroidectomy to combat hypocalcemia. The treated group showed significantly lower hypocalcemia compared to the untreated group B. We recommend preoperative calcium and vitamin D supplementation for all thyroidectomy patients to reduce related morbidities and hospitalization duration.

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.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.