Remote-Access Thyroidectomy: A Multi-Institutional North American Experience with Transaxillary, Robotic Facelift, and Transoral Endoscopic Vestibular Approaches (original) (raw)
Related papers
Gland Surgery
Background: Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection. Methods: A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study. Results: Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed. Conclusions: The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.
Transoral Endoscopic Thyroidectomy: A Systematic Review of the Practice So Far
JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2018
Background and Objectives: Thyroid disease largely affects young females, but the incidence is also increasing among males. In an effort to avoid the scarring of the neck that is synonymous with conventional thyroidectomy, endoscopic techniques have been developed over the years. The transoral endoscopic approach is the latest of these innovations that promises a scarless surgical outcome. This review evaluates whether this technique is safe and feasible in live patients and outlines the outcomes in published literature so far. Database: PubMed, Medline, BioMed Central, Cochrane Library, OVID and Web of Science were systematically searched by using a Medical Subject Heading (MeSH)optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting strict inclusion and exclusion criteria. Sixteen studies were included in the final analysis. Discussion: This systematic review presents cases of 785 patients. Surgeons in 15 of the studies used a completely vestibular approach, whereas those in the remaining 2 used the floor of the mouth for primary access. Conversion to open surgery took place in 1.3%. In total, 4.3% of patients experienced transient laryngeal nerve palsy, whereas 0.1% had permanent recurrent incidences of the condition. Transient hypocalcemia occurred in 7.4% of cases, with no recorded permanent cases. Carbon dioxide embolism occurred in 0.6% of cases, and another 0.6% had a deep-seated neck infection. The complication rates within the review were deemed acceptable and the overall technique feasible. A prospective randomized controlled trial was proposed to compare this technique with conventional thyroidectomy.
Robotic Transaxillary Thyroidectomy: An Examination of the First One Hundred Cases
Journal of the American College of Surgeons, 2012
BACKGROUND: The influence of minimally invasive options has led to the application of new evolving techniques in thyroid surgery to eliminate visible neck scars. Here, we describe one author's experience with transaxillary robotic thyroidectomy and examine the effect of experience on determining the learning curve and improvements over time in operative performance. STUDY DESIGN: With IRB approval, a prospective analysis of our surgical experience was performed. All patients underwent robotic transaxillary thyroidectomy by a single surgeon between September 2009 and June 2011. Principal outcomes measures included length of hospital stay, incidence of complications, and effect of obesity on outcomes.
Transoral thyroidectomy: advantages and limitations
Journal of endocrinological investigation, 2017
In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, "transoral thyroidectomy" (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10 cm; (b) US-estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conven...
Anterior cervical incision‐sparing thyroidectomy: Comparing retroauricular and transoral approaches
Laryngoscope Investigative Otolaryngology, 2018
Objectives: The robotic retroauricular approach and transoral endoscopic thyroidectomy vestibular approach (TOETVA) have been employed to avoid anterior neck scarring in thyroidectomy with good success. However, outcomes have yet to be compared between techniques. We compare our initial clinical experience with these approaches for thyroid lobectomy at our institution. Methods: A review of initial consecutive patients who underwent robotic facelift thyroidectomy (RFT) (August 2011-August 2016) at our institution was conducted. This was compared with the same number of initial consecutive patients who underwent TOETVA (September 2016-September 2017) at our institution. Demographics, operative time, pathology, complications, and learning curve were compared between cohorts. Learning curve was defined based on the slope of linear regression models of operative time versus case number. Results: There were 20 patients in each cohort. There was no statistically significant difference in demographic data between cohorts. One hundred percent of RFT cases versus 95% TOETVA cases (P = .999) were completed without conversion to standard open technique with median operative times of 201 (124-293) minutes versus 188 (89-343) minutes with RFT and TOETVA, respectively (P = .36). There was no incidence of permanent recurrent laryngeal nerve injury in either cohort. The slopes of the regression models were 0.29 versus −8.32 (P = .005) for RFT and TOETVA, respectively. Conclusion: RFT and TOETVA are safe and feasible options for patients motivated to avoid an anterior neck scar. However, the quicker learning curve without the need for a costly robotic system may make TOETVA the preferred technique for institutions wishing to perform anterior cervical incision-sparing thyroidectomy.
Transoral thyroidectomy: A reflexive opinion on the technique
Archives of Endocrinology and Metabolism
W hen analyzing the literature published on thyroidectomy using a "timeline" we can observe that we have notoriously progressed from a procedure that was almost prohibited in the mid-nineteenth century due to complications to a point where it is considered safe, resolutive, and highly efficient. This progress is especially due to the advances in surgical techniques. Theodore Kocher (Nobel Prize in 1909 for his contribution to thyroidectomies) flawlessly described the anatomical basis for the success of this surgical technique 130 years ago. Besides this, advances in anesthetic procedures, surgical materials, and medications were fundamental to intraoperative and postoperative advances and patient management. With time, the knowledge on the different thyroid diseases has exponentially increased and serves as indicators for the extension of treatment and surgical procedures, all efforts should be directed to apply them into clinical practice (1). In the past twenty years, the introduction of new technologies such as the application of energy in surgical instruments and neuromonitoring brought advances to the procedure. These technologies helped providers to achieve a shorter surgical time, a shorter length of hospital stay, a reduction in the risk of bilateral laryngeal paralysis, and a reduced risk of intra and post-operative bleeding (2,3). In the last decade, stimulated by the current advances in endoscopic and robotic surgery, new approaches for thyroidectomy procedures were investigated to substitute the classic cervical incision, and are currently a theme for several scientific debates.
Journal of Clinical & Experimental Pathology, 2015
Introduction: The treatment and particularly the extension of surgical therapy of papillary thyroid carcinoma (PTC) remain still controversial in some issues, especially for the lack of preoperative information or variables that allow predicting the level of aggressiveness of the tumor. Aim of the study: The purpose of the study was to assess the impact of the central node neck dissection (CNND) on surgical outcome and disease free-follow up of PTC-patients operated on at our center by evaluation of postoperative complications (parathyroid and recurrent nerve damage, hemorrhage rates) and pts rates presenting detectable serum Thyroglobulin (TG) or TG-Antibodies (TG-AB) values, at the time of 131 Iodine treatment and subsequently at 6-12 months, combined with neck high-resolution ultrasound (HRUS) The results of a prospective study on 149 pts preoperatively diagnosed and HR-US staged N0-PTC who underwent total thyroidectomy and CNND were compared with the results of a retrospective study on 114 similar postoperatively diagnosed PTC-pts who received total thyroidectomy, without nodes dissection. Materials and methods: 149 patients who underwent total thyroidectomy (TT)+CNND from March 2012 to August 2013 (group-A) and 114 patients who underwent TT from January to December 2011 (group-B) were compared on the following variables: gender, age, histological variant of PTC, tumor size, TNM stage, multifocality, vascular invasion, thyroiditis, expression of BRAF mutation, surgical complications (transient postoperative hypocalcemia and hypoparathyroidism, temporary or permanent dysphonia and hemorrhage), values of TG and anti-TG Ab in suspension or under TSH stimulus, in pre-ablation and on the last clinical and instrumental evaluation of the patient. Statistical analysis was performed using the Student t-test and Fisher. A p value less than 0.05 was considered statistically significant. Results: Comparing the patients of group-A with group-B the following variables present with statistically significant differences: transient postoperative hypocalcemia (group-A 50.3% vs group-B 21.9% , p<0.0001) , association with lymphocitary chronic thyroiditis (group-A 63.1% vs group-B 37.7%, p<0.0001), median postoperative serum TG value (group-A 1,05 ng/L vs group-B 2,4 ng/L , p=0.01), median postoperative anti-TG antibodies value (group-A 903 kU/L vs group-B 118.5 kU/L, p=0.006), median value of anti-TG antibodies at the last follow up after radioiodine therapy (group-A 481,5 kU/L vs group-B 35 kU/L, p=0.0001).
Changing trends in thyroidectomy
Irish medical journal, 2012
The objective of this study was to establish the indications, referral trends and demographics for thyroidectomies performed in our institutions over a 13-year period by a single surgeon. We conducted a retrospective chart review of 1003 consecutive thyroidectomies at our institutions during the period 1998 until 2010. The parameters incorporated to this study were age, sex, county, referral source, symptoms, thyroid status, procedure performed, histopathology and post-operative complications. The age range of patients was 4-87 years. There were 777 females and 226 males, with a sex ratio of 3.4:1. The mean age was 51 years. The commonest indications for surgery were a potential or definite neoplastic thyroid mass (781 cases--78%), compressive symptoms (119 cases-- 12%), thyrotoxicosis and endocrine related causes (103 cases--10%). 896 (89.3%) patients were euthyroid, 4 (0.4%) hypothyroid and 103 (10.3%) hyperthyroid. There were 739 partial thyroidectomies and 264 total thyroidectom...
SiSli Etfal Hastanesi Tip Bulteni / The Medical Bulletin of Sisli Hospital, 2021
Objective: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless method that enables thyroidectomyusing natural orifice of the body. The opinion which is even common among TOETVA performing surgeons is that this surgery involves a small percentage of thyroidectomy applied patients. In this study, based on the currently accepted exclusion criteria, we aimed to determine what percentage of patients, who underwent thyroidectomy in an endemic area are actually suitable for TOETVA. Methods: Between January 2017 and December 2019, 1197 consecutive patients who underwent surgery for thyroid pathology in our clinic were analyzed retrospectively. Pre-operative evaluations were made according to the current exclusion criteria and as a result, patients with no previous neck surgery, no history of radiotherapy, no retrosternal thyroid extension, and none lymph node dissection operation been made and whose thyroid gland diameter is <10 cm and gland volume is not more than 45 ml, malignant nodule diameter is <2 cm, and benign nodule diameter is <4 cm are involved to this study by being considered appropriate for TOETVA procedure. Results: According to the criteria, 513 patients (42.8%) were found suitable for TOETVA. A total of 421 (82%) of these patients were female and 92 (18%) were male. The mean age was 46.2±13.2. A total of 192 (37%) of these patients were operated due to the benign reasons, and 321 (63%) of these patients operated due to the malignancy or suspicion of malignancy. Average nodule size was 1.9 cm, and the average thyroid volume was 23.8 ml among benign patients. Whereas among malignant patients, the average nodule size was 1.7 cm and the average thyroid volume was 21.8 ml. A total of 462 (90.1%) of the patients were applied to the total thyroidectomy and 51 (9.9%) of the patients were applied to the hemithyroidectomy. In the same period, 29 patients operated through TOETVA and 4 patients operated through bilateral axillary breast approach thyroidectomy. When the final pathology, results of the patients were examined, papillary thyroid carcinoma was seen in 301 (58.7%) patients, benign pathologies were seen in 192 (37.4%) patients, and 20 (3.9%) patients were diagnosed with other pathologies (follicular thyroid carcinoma, poorly differentiated carcinoma and Hürthle cell neoplasia, etc.). Conclusion: Although "patient willingness" factor could not be included in the study, TOETVA eligible patient repository is wider contrary to popular belief. In our humble opinion, TOETVA method is going to pursue its spread and become a part of the routine surgical training session due to its effectiveness in terms of credibility in today's world where cosmetic concerns gradually gain prominence.