Feasibility and safety of transaxillary robotic thyroidectomy in Japan - Comparison with video-assisted neck surgery in initial cases.

New approaches to endoscopic thyroid surgery have been developed to improve cosmetic results, one of which is video-assisted neck surgery (VANS). The present study investigates the safety and effectiveness of thyroidectomy by VANS as oncologic surgery for papillary thyroid carcinoma (PTC). The subjects of this retrospective study were 121 patients with PTC, who underwent hemi-thyroid lobectomy and central lymph node dissection via open surgery (n = 102) or VANS (n = 19) at Tokushima University Hospital between 2011 and 2023. We performed 1:1 propensity score matching and then compared the surgical outcomes between the two matched groups. Propensity score matching generated 18 distinct examination pairs. The VANS group had significantly less blood loss (P = 0.003), but a longer operative time (P < 0.001) than the open thyroidectomy group. There were two cases of transient recurrent laryngeal nerve paralysis and one case of recurrence in the lateral regional lymph nodes in the VANS group. However, no significant differences were observed in the incidence of complications (P = 0.243) or recurrence (P = 0.500) between the two groups. VANS is a safe and effective surgical procedure for PTC, but longer follow-up is needed to assess tumor recurrence.

Despite the increase in experience and understanding of robotic thyroidectomy, its application for Graves' disease (GD) remains controversial. This study aimed to assess the safety and feasibility of robotic transaxillary thyroidectomy (RTT) for GD in comparison with the conventional open thyroidectomy (open group: OG) approach. A total of 192 patients who underwent surgical resection for GD were retrospectively reviewed. Among them, 51 patients underwent RTT and the remaining 141 patients were in the conventional OG. All robotic operations were performed successfully without open conversion. Patients who underwent RTT were significantly younger (P < 0.001) and predominantly of the female sex. Operative time was longer for RTT than for the OG (182.5 ± 58.1 vs. 112.0 ± 29.5; P < 0.001). The mean intraoperative blood loss was not statistically different between RTT and the OG (113.3 ± 161.6 vs. 95.3 ± 209.1, P = 0.223). The mean weight of the resected thyroid was reduced in those who underwent RTT compared with open thyroidectomy (P = 0.033). The overall complication rate for RTT and open thyroidectomy was not significantly different (33.3% vs. 22.7%, P = 0.135). In RTT, the most common complication was transient hypocalcemia (21%). Permanent hypocalcemia and recurrent laryngeal nerve injury occurred in only one patient in each group. The weight of the resected thyroid was not related to the incidence of complications in patients receiving RTT. Considering excellent cosmesis, findings of this study support the safety and feasibility of RTT. Nevertheless, it should be performed by expert surgeons with extensive robotic surgery experience.

PurposeTo describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases.MethodsWe describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves’ disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available.ResultsThe working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected.ConclusionsThe VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

Minimal access thyroid surgery – a new dawn?

From July 2006 to October 2007, we performed video-assisted neck surgery (VANS) via a subclavicular approach in 10 patients with thyroid tumor. Seven had benign follicular tumor, and three had papillary carcinoma. All cases underwent hemithyroidectomy. One case of papillary carcinoma underwent additional central neck dissection (D1). The mean operating time was 207 min, and the mean blood loss was 70 ml. Transient recurrent laryngeal nerve palsy was noted. However, postoperative bleeding was not observed. To improve the esthetic outcome, we applied a new method: a skin lifting axillary approach. We applied this method to a 27-year-old female patient with benign follicular tumor showing no postoperative complications. The axillary scar was not visible when the ipsilateral arm was in its natural position. This new method is a feasible procedure with esthetic benefits, and may offer a practical alternative for patients requiring sugical removal of the thyroid gland.

Few studies exist regarding the state of robotic transaxillary thyroidectomy (RT) and its outcomes at high-volume institutions. Eighty-nine patients underwent RT between January 2009 and September 2015 at two tertiary centers. Data were collected from prospectively-maintained IRB-approved databases. Patient demographic and clinical data, and trends were evaluated. Indications for RT included biopsy-proven or suspicion for malignancy in 20.2%, atypical cells or follicular neoplasm in 27.7%, multinodular goiter in 26.6%, thyrotoxicosis in 8.5%, need for completion thyroidectomy in 5.3%, and non-diagnostic FNA in 3.2%. 56% underwent total thyroidectomy and 44% lobectomy. Operative time (OT) was 153.5 minutes for lobectomies and 192.6 minutes for total thyroidectomy. The complication rate was 11.7%: temporary RLN neuropraxia in 2 patients, permanent hypoparathyroidism in 1 patient, temporary hypoparathyroidism in 6 patients, flap seroma in 1 patient, and flap hematoma in 1 patient. Pathology showed malignancy in 43 patients. At a mean follow-up of 31.9 months, there were no recurrences. Since 2013, the number of RTs performed has risen. The number of out-of-state patients increased from 18% to 37% after 2011. RT was performed without compromising outcomes in selected patients. There remains interest among patients seeking this procedure in expert centers.

Endoscopic thyroidectomy offers excellent cosmetic outcomes but requires some time for surgeons to become proficient. We examined the learning curve for the first 100 patients treated by a single surgeon using a subclavian approach for video-assisted neck surgery (VANS). We retrospectively studied the records of 100 patients (99 women, 1 man; mean age, 36.2 years) with either benign or malignant thyroid disease treated between 2016 and 2020. Preoperative diagnosis was papillary thyroid carcinoma (PTC) in 36 cases and other (non-PTC) in 64 cases. All patients underwent lobectomy, with additional unilateral central node dissection for patients with PTC. Mean operative time was 125 min for non-PTC cases and 129 min for PTC cases (p = 0.43); blood loss was 33.8 mL and 7.6 mL, respectively (p = 0.01). Recurrent laryngeal nerve paralysis (RNP) was observed in 12 patients (12%) and hemorrhage in 2 patients (2%). In a comparison of the first 30 cases and subsequent 70 cases, no significant differences in operative time or blood loss were evident, although tumor size was significantly greater among later non-PTC cases (32.4 mm vs. 39.5 mm, p = 0.039). RNP was significantly lower in later cases (26.7% vs. 5.7%, p = 0.003). Multivariate analysis revealed that tumor size was a significant risk factor for increased blood loss, and increased experience significantly correlated with a decrease in RNP. In VANS, satisfactory surgical proficiency was reached after treating 30 patients.

Section 2. Thyroid: Video-assisted neck surgery for thyroid and parathyroid diseases

Background: The introduction of Video assisted neck surgery (VANS) technique for treatment of thyroid diseases was established by K.Shimizu in 1998.Since that time, the indications of this procedure are expanding as regarding the size of the thyroid tumors and the type of thyroid pathology. Results: Twelve patients with small diffuse primary thyrotoxicosis underwent video-assisted thyroidectomy. The estimated thyroid weight of the study patients ranged from 18.2 to 57 with a mean of32.5 grams. Three ofthefirst seven patients had recurrent hyperthyroidism. This was due to poor visualization and subsequently inadequate excision of the thyroid lobe away from the camera. A modification was made thereafter that corrected this defect. Conclusion: Video-assisted near total thyroidectomy for Graves' disease is considered to be safe, effective. It gives excellent cosmetic results.

Lateral approach contributes to shortened surgical time in video-assisted neck surgery (VANS) for thyroid nodule

Aim The purpose of this study was to test the hypothesis that video-assisted thyroidectomy (VAT) affords comparable safety and efficacy compared to open conventional thyroidectomy (CT). Patients and Methods Randomized, controlled trials comparing VAT with CT were ascertained by a methodical search using the MEDLINE, Pubmed, Ovid, Embase and Cochrane Library electronic databases. Primary meta-analysis outcomes were operative time, intraoperative blood loss and complications, including transient recurrent laryngeal nerve palsy (TRP), transient hypoparathyroidism (TH), permanent recurrent laryngeal nerve palsy (PRP), permanent hypoparathyroidism (PH) and wound infection (WI). The secondary outcomes were postoperative pain within 12, 24 and 48 h after the operation, length of hospital stay and cosmetic result. Results Operative time was significantly less with CT than with VAT, while VAT was associated with better cosmetic result and less pain at 24 h, postoperatively. Blood loss, TRP, TH, PRP, PH, WI and postoperative pain at 48 h did not reach significance between procedures. Comparisons between two procedures concerning postoperative pain within 12 h and length of hospital stay depicted statistically-significant differences in favour of VAT, but only in the fixed-effects model. Conclusions VAT is a safe procedure that produces outcomes; in view of short-term adverse events, similar to CT, it needs a longer operative time and produces better cosmetic results and less postoperative pain in the early phase.

For the purpose of minimization of operative scar on the neck from a cosmetic viewpoint, we performed an endoscopic resection for 21 thyroid tumors and a parathyroid tumor out of 20 cases using an anterior neck-lift method which we exploited and named Video-Assisted Neck Surgery (VANS). The approach to the thyroid is made mainly through the chest wall 1.5cm below the clavicle where is completely covered by neck-opened cloths. A prophylactic lymph node dissection of the pre- and paratracheal lymph nodes was added to the patients whose preoperative cytology revealed class 3b. The resected tumors were 17-53mm (mean: 34.7mm) in size and. 2.5-32.6g (mean: 14.3g) in weight. The amount of operative bleeding ranged from 5 to 360ml (mean: 111.3ml), the operating time from 1 hours and 2 minutes to 3 hours and 54 minutes (mean: 2 hours 14 minutes), and postoperative hospital stay from 3 to 8 days (mean: 5.1 days). The operating time and amount of bleeding in VANS varied from case to case depending upon location, size of tumor and operative procedure. Those disadvantages, however, are considered to be improved in accordance with further experience. We are convinced that VANS will become a surgical procedure which is preferably selected by patient in terms of both cosmetic advantages and excellent result.

Cosmetic outcome and incidence of infection with the mammosite breast brachytherapy applicator

Endoscopic endocrine neck surgery is desirable from a cosmetic viewpoint. We compared the effectiveness of our new technique with that of conventional surgery in a clinical study. We performed our original endoscopic method of video-assisted neck surgery (VANS) on 130 patients: 126 with thyroid tumors and 4 with parathyroid tumors. The percentage of patients who underwent VANS among all those who underwent neck surgery and the procedure involved were analyzed. Operating time and blood loss were compared between the first 40 patients and last 39, and all factors were statistically analyzed in the most recent 20 patients who underwent the VANS method and the most recent 20 who underwent conventional surgery. More than 60% of benign thyroid tumors and 5.3% of malignant thyroid tumors were operated on by the VANS method. Nearly total lobectomy was the most common procedure (57.7%), followed by total lobectomy (26.1%), for benign tumors. Malignancy was defined as papillary carcinoma less than 1 cm in diameter. Total lobectomy with lymph node clearance was performed for all malignant tumors. There was less bleeding when the VANS method (P < 0.001) was used than when conventional surgery was performed, and the operating time has been reduced with experience. The VANS method is feasible, practical, and safe, and has great cosmetic benefits.

We developed video-assisted neck surgery (VANS) - a feasible, simple, and safe endoscopic thyroid procedure with cosmetic benefits - in 1998. To date, we have performed this procedure 633 times. We have also introduced the VANS method in Belarus, a country that was left contaminated by the Chernobyl nuclear disaster. From a mass screening, nine Belarusian patients, including two with papillary carcinoma of the thyroid, were selected to undergo an operation using the VANS method, performed by a single surgeon (author Shimizu). We compared indicating factors for minimally invasive surgery, specifically the operating time and blood loss, between the Belarusian cases and the 33 most recent cases performed at our institute in Tokyo. The procedures in Belarus were performed under very different working conditions than in Japan. However, operating time and blood loss improved for the Belarusian cases as the surgeon gained experience in this environment; all the cosmetic outcomes were excellent. Subsequently, over a 2-year period, surgeons in Belarus performed the VANS method, with modification, for 29 cases of thyroid tumor. The VANS method is easily learned by inexperienced surgeons without major technical problems.