Bilateral Areola Approach Research Articles

Feasibility and safety of modified en-bloc resection in endoscopic thyroid surgery via bilateral areolar approach - long-term institutional analysis ten years after surgery.

This study aimed to introduce a new modified en-bloc resection method and evaluate its feasibility and safety in endoscopic thyroid surgery via bilateral areolar approach (BAA). Papillary thyroid carcinoma (PTC) patients who underwent lobectomy and ipsilateral central node dissection (CND) via the BAA approach were retrospectively reviewed. Their clinical characteristics and outcomes were evaluated, including operative duration, lymph node yield (LNY), surgical complications, recurrence rate, and metastasis rate, over a ten-year follow-up period. Simultaneous lobectomy and CND were performed in the modified en-bloc group, whereas lobectomy was performed first, followed by CND in the conventional group. The study included 108 patients in the modified en-bloc group and 213 in the conventional group. There were no significant differences in gender, age, tumor locations, tumor dominant nodule size, or the incidence of concomitant Hashimoto thyroiditis when comparing clinicopathologic characteristics. The comparison of operative duration (P = 0.14), blood loss (P = 0.13), postoperative hospital stay (P = 0.58), incidence of transient vocal cord paralysis (P = 0.90) and hypocalcemia (P = 0.60) did not show any differences. The mean LNY achieved in the central compartment of the modified en-bloc group (7.5 ± 4.5) was significantly higher than that in the conventional group (5.6 ± 3.6). Two patients in the modified en-bloc group and two in the conventional group experienced metastasis after surgery during the ten-year follow-up (1.8% vs. 0.9%, P = 0.60). The learning curve analysis showed a significant decrease in operative duration after the 25-35th cases for modified en-bloc resection. The modified en-bloc resection method in endoscopic thyroid surgery via BAA is a technically feasible and safe procedure with excellent cosmetic outcomes for selective PTC patients.

Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study

BackgroundRobot-assisted and endoscopic thyroidectomy are superior to conventional open thyroidectomy in improving cosmetic outcomes and postoperative quality of life. The procedure of these thyroidectomies was similar in terms of surgical view, feasibility, and invasiveness. However, it remains uncertain whether the robotic-assisted bilateral axilla-breast approach (BABA) was superior to the endoscopic bilateral areolar approach (BAA) thyroidectomy. This study aimed to investigate the clinical benefit of these two surgical procedures to evaluate the difference between these two surgical procedures by comparing the pathological and surgical outcomes of endoscopic BAA and robotic-assisted BABA thyroidectomy in differentiated thyroid carcinoma.MethodsFrom November 2018 to September 2021, 278 patients with differentiated thyroid carcinoma underwent BABA robot-assisted, and 49 underwent BAA approach endoscopic thyroidectomy. Of these patients, we analyzed 42 and 135 patients of endoscopic and robotic matched pairs using 1:4 propensity score matching and retrospective cohort study methods. These two groups were retrospectively compared by surgical outcomes, clinicopathological characteristics, and postoperative complications.ResultsThe mean operation time was significantly longer in the EG than in the RG (p < 0.001), The number of retrieved lymph nodes was significantly lower in the ET group than in the RT group (p < 0.001). The mean maximum diameter of the thyroid was more expansive in the EG than in the RG (p = 0.04). There were no significant differences in the total drainage amount and drain insertion days between the two groups (p = 0.241, p = 0.316, respectively). Both groups showed that cosmetic satisfaction (p = 0.837) and pain score (p = 0.077) were similar. There were no significant differences in complication frequencies.ConclusionRobotic and endoscopic thyroidectomy are similar minimally invasive thyroid surgeries, each with its advantages, both of which can achieve the expected surgical outcomes.Trial registrationRetrospectively registered.

Retrospective comparison of endoscopic transoral and bilateral areolar approaches for thyroglossal cyst resection: a single-centre experience.

Our study aimed to compare the efficacy, safety, and clinical effect of the transoral approach and the bilateral areolar approach (BAA) for endoscopic thyroglossal duct cyst (TGDC) resection. In total, 42 patients who received an endoscopic TGDC resection between January 2019 and May 2022 via a transoral (n = 22) or bilateral areolar (n = 20) approach by a single surgeon were retrospectively enrolled. We collected and compared the following data: patients' demographic data, complication events, operative time, bleeding volume, drainage volume, 6-h postoperative pain scores, length of hospitalisation, resected TGDC size, and cosmetic satisfaction. There were no cases of conversion to a transcervical approach in the two groups. No significant differences were found between the two groups in terms of age, sex, body mass index, complication, bleeding volume, 6-h postoperative pain scores, and TGDC size (all p > 0.05). However, the operative time and patients' cosmetic satisfaction were higher in the transoral group than in the BAA group (all p < 0.05). In addition, the drainage volume and length of hospitalisation in the transoral group were less than those in the BAA group (all p < 0.05). Both the transoral approach and BAA are safe and reliable; however, the transoral approach is more complex than the BAA and offers better cosmetic satisfaction. Doctors should choose the appropriate surgical procedure based on the patient's condition and preferences.

Robotic bilateral axillo-breast versus endoscopic bilateral areola thyroidectomy outcomes of 757 patients.

Remote endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) seem to be beneficial in selected situations to avoid anterior neck scars. There are limited data in the literature to determine whether RT via a bilateral axillo-breast approach (RT-BABA) is superior to ET via a bilateral areolar approach (ET-BAA). Therefore, the aim of this study was to evaluate the surgical outcomes of RT-BABA versus ET-BAA. Between May 2013 and May 2022, 757 patients who underwent RT-BABA or ET-BAA at a high-volume Chinese thyroid center were included. Intraoperative and postoperative outcome parameters were collected and retrospectively analyzed. The moving average method was used to evaluate the learning curve. The proportion of patients older than 45 years was greater in the RT group than in the ET group (14.8% vs. 7.4%, p < 0.001). The percentage of overweight patients was greater in the RT group (28.8% vs. 9.5%, p < 0.001). The number of patients treated for malignant lesions was higher in the RT group (86.8% vs. 75%, p < 0.001). The rate of thyroiditis was higher in the RT group (10.9% vs. 6.6%, p < 0.001). Surgical time was significantly shorter in the RT group (140 vs. 165min, p < 0.001). Drainage volume was higher in the RT group (100 vs. 85ml, p < 0.001). Postoperative hospital stay was shorter in the RT group (3.04 ± 0.44 vs. 3.67 ± 0.89 days, p < 0.001). The cost in the RT group was higher (49627 ± 2795 vs. 25094 ± 3368 yuan, p < 0.001). Transient vocal cord dysfunction was lower in the RT group (2.9% vs. 8.0%, p = 0.003). There was no significant difference between the two groups in the number of central lymph nodes sampled, positive lymph nodes, neural monitoring (EMG) results, and rate of transient hypoparathyroidism. The learning curve for RT was 26 cases, and the operative time for ET was constant throughout the study. RT-BABA is as safe and feasible as ET-BAA. RT-BABA performed better in some surgical outcomes. Further prospective studies are needed to confirm the safety of RT-BABA.

Drainage Tube Placement May Not Be Necessary During Endoscopic Thyroidectomy Bilateral Areola Approach: A Preliminary Report.

BackgroundThe endoscopic thyroidectomy bilateral areola approach (ETBAA) improved cosmetic outcomes significantly and is now widely applied. The usage of drainage tubes is controversial in conventional open thyroidectomy (COT), but studies about drainage placement decisions during ETBAA are still limited. This study aimed to determine the feasibility of having no drainage tube applied during ETBAA on patients with papillary thyroid carcinoma.MethodsThe clinical data of patients undergoing ETBAA from July 2018 to May 2021 was retrospectively collected. The patients were divided into two groups based on drain placement: no-drain and drain. The two groups were matched at a ratio of 1:1. Fifty-five patients from each group were finally included. Postoperative complications and follow-up data were compared between the two groups.ResultsNo significant difference was observed between the two groups in the incidence of postoperative complications, including hemorrhage, surgical site infection, and subcutaneous seroma. Compared with the drain group, the operation time of the no-drain group was significantly shorter [(107.75 ± 24.59) min vs. (119.91 ± 34.05) min, P < 0.05]. The total and postoperative hospital stay was significantly shorter in the no-drain group [(2.40 ± 0.71) days vs. (4.78 ± 1.33) days, P < 0.001, (2.04 ± 0.19) days vs. (2.15 ± 0.36) days, P < 0.05], and the costs of surgical consumables were also significantly lower [(6,820.83 ± 164.29) CNY vs. (7,494.13 ± 216.7) CNY, P < 0.05]. The postoperative pain score of the no-drain group was significantly lower than the drain group [(1.58 ± 0.63) vs. (1.89 ± 0.76), P < 0.05].ConclusionsNo drainage applied during ETBAA on papillary thyroid carcinoma is safe and feasible. This practice does not increase the risk of postoperative complications, but it does shorten the operation time and hospital stay, as well as reduce medical costs. Furthermore, it alleviates the suffering of patients.

Pros and Cons of Transoral Endoscopic Thyroidectomy Via Vestibular Approach: A Comparative Study.

The objective of this study was to explore the feasibility and safety of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) compared with endoscopic thyroidectomy via bilateral areola approach (ETBAA) in the treatment of patients with benign thyroid nodules. From January 2017 to December 2018, 60 patients who received TOETVA were enrolled as the research group; 65 patients who underwent ETBAA were included as the control group. A retrospective study was performed using the clinical data for these cases. All patients were diagnosed with benign nodules by preoperative examinations. Parameters including surgical trauma, complications, cosmetic satisfaction, and postoperative discomfort were compared between the 2 groups. All operations were completed without incident. There were significant differences in operation time (137.8±18.7 vs. 95.7±17.2 min), intraoperative blood loss (16.8±9.1 vs. 24.6±16.6 mL), drainage volume (123.1±20.9 vs. 153.6±40.2 mL), C-reactive protein level (7.2±5.2 vs. 9.0±4.7 mg/L), drainage time (3.2±0.6 vs. 3.9±1.3 d), postoperative hospital stay (3.3±0.8 vs. 4.1±1.5 d), and sense of skin tension on the neck (0% vs. 10.8%) between the TOETVA and ETBAA groups (P<0.05). There were no significant differences in pain score, incidence of recurrent laryngeal nerve injury, transient hypoparathyroidism, infection, inadvertent parathyroidectomy, or swallow discomfort between the 2 groups. The cosmetic satisfaction score in the TOETVA group was significantly higher than that in the ETBAA group at 1 month after surgery (9.8±0.5 vs. 9.4±0.9, P<0.05), but at 3 months after the operation, the difference was not statistically significant. TOETVA was accompanied by less surgical trauma and skin tension on the neck than ETBAA, and the cosmetic effect of this approach was better than that of ETBAA in the early postoperative period. TOETVA for benign thyroid nodules is safe and feasible. However, there are disadvantages with TOETVA, such as a long surgical period. More cases and further research are needed to delve further into this approach.

A comparative study on the efficacy of transoral vestibular approach, via bilateral areola approach endoscopic and open thyroidectomy on stage T1b papillary thyroid carcinoma

Objective: To compare the surgical efficacy and cosmetic satisfaction of the transoral endoscopic thyroidectomy by vestibular approach (TOETVA), endoscopic thyroidectomy via bilateral areola approach (BAA), and open thyroidectomy (OT) in the treatment of papillary thyroid carcinoma (PTC) in stage T1b. Methods: A total of 178 patients with PTC in stages pT1bN0M0 and pT1bN1aM0 treated from January 2017 to December 2018 were divided into TOETVA group (n=59), BAA group (n=43), and OT group (n=76). The baseline characteristics, relevant indexes of surgical efficacy and follow-up data were compared between the three groups, and also the surgical efficacy indexes were compared between unilateral lobectomy + central lymph node dissection (unilateral lobectomy subgroup) and bilateral lobectomy + central lymph nodes dissection (total resection subgroup). SPSS 19.0 statistical software was used for data analysis. Results: The mean ages of patients in TOETVA group and BAA group were significantly younger than those in OT group, and the proportion of women in TOETVA group and BAA group was significantly higher than that in OT group, all P<0.05. None of patients in TOETVA and BAA groups were converted to open surgery. Among TOETVA, BAA and OT groups, there were significant differences in the mean operation time [unilateral lobectomy subgroup: (198.0±45.2) min, (162.0±36.9) min and (79.4±28.6) min, P<0.05; total resection subgroup: (230.0±36.0) min, (219.8±68.1) min and (102.8±40.0) min, P<0.05], in total drainage volume [unilateral lobectomy subgroup: (195.0±55.6) ml, (178.1±50.4) ml and (127.0±30.1) ml, P<0.05; total resection subgroup: (221.1±46.7) ml, (245.3±71.2) ml and (137.7±41.6) ml, P<0.05], and the incidence of subcutaneous ecchymosis in TOETVA group or BAA group was higher than that in the OT group [5.1% (3/59), 11.6% (5/43) vs. 0, χ(2)=3.952 and 9.225 respectively, both P<0.05]. The mean level of C-reactive protein in TOETVA group was higher than that in OT group [(16.8±10.7) vs. (9.5±6.9), P<0.05]. Following-up in the third month after surgery between three groups in cosmetic satisfaction scores [(2.7±0.5) vs. (2.6±0.7) vs. (1.7±0.8)], scar self-consciousness scores (0[0,1] vs. 1[0,2] vs. 2[1,2]), and quality of life scores [(9.1±1.1) vs. (8.9±1.1) vs. (7.5±0.8)], cosmetic satisfaction and quality of life in TOETVA and BAA group were better than that in OT group, in terms of scar self-consciousness: TOETVA<BAA<OT (all P<0.05). But there were no significant differences in the levels of Tg or TgAb between three groups for total resection subgroup (all P>0.05). The median follow-up time of the three groups was 25 months (TOETVA group), 28 months (BAA group), and 32 months (OT group) respectively, without disease progression. Conclusion: TOETVA and BAA are optional surgical methods for PTC in stages pT1bN0M0 and pT1bN1aM0, with good safety and patient's cosmetic satisfaction.

Risk factors and outcomes of conversion to open surgery in endoscopic thyroidectomy via bilateral areola approach: a retrospective Chinese population study.

Although endoscopic thyroidectomy via the bilateral areola approach (ETBAA) has shown cosmetic advantage over open surgery, the risk factors of conversion to open surgery and its impact on patients remain unknown. The objective of this study is to analyze the predictors for conversion to open procedure in patients who underwent ETBAA and its related outcomes. The clinical data of patients who underwent ETBAA from May 2010 to May 2019 were analyzed retrospectively. The patients were divided into two groups according to operation notes: the conversion group and the non-conversion group. Univariate and multivariate logistic regression analyses were performed to investigate the risk factors for conversion to open surgery. Altogether, 140 patients were included in this study. Sixteen (11.4%) patients underwent conversion during ETBAA. Four factors demonstrated significant difference between the two groups: sex (P = 0.001), body mass index (BMI) (P = 0.021), thyroid peroxidase antibody (TPOAb) level (P = 0), and antithyroglobulin antibody (ATG) level (P = 0). Further univariate and multivariate logistic regression analysis revealed that male sex (P = 0.006), TPOAb level>7.8IU/ml (P = 0.005), and ATG level>79IU/ml (P = 0.003) had a significant correlation with conversion to open surgery in ETBAA. Prolonged operative time, increased surgical cost, and less patient cosmetic satisfaction were demonstrated in the conversion group (P < 0.05). Male sex, high TPOAb level, and high ATG level were independent risk factors for conversion. Conversion to open surgery in ETBAA is associated with prolonged operative time, increased surgical cost and less patient cosmetic satisfaction.

Comparison of parathyroid hormone kinetics in endoscopic thyroidectomy via bilateral areola with open thyroidectomy

BackgroundIn this study, we aimed to compare the kinetics of intact parathyroid hormone (iPTH) during the perioperative period of endoscopic thyroidectomy via bilateral areola approach (ETBAA) in the same period, following a traditional open thyroidectomy approach (OTA).MethodsWe conducted a prospective observational study of patients who were undergoing thyroidectomy and level VI clearance. Patients who had been affected by papillary thyroid cancer (PTC) were stratified into three groups: those eligible for endoscopic treatment (ETBAA); patients who were eligible for ETBAA but had opted for OTA (OTA-L); and patients who were not suitable for endoscopic intervention (OTA-H). A process for locating parathyroid glands was utilized to stratify gland dissection laboriousness. In Type A, the gland is firmly fixed to thyroid gland. This type can be sub-classified into three subtypes. A1: the parathyroid gland is attached to the inherent thyroid capsule. A2: the gland is partially embedded in the thyroid gland. A3: the gland is located in the thyroid tissue. Type B is defined as a gland which is separated from the thyroid gland. The iPTH was sampled at wound closure.ResultsThere were 100 patients in each group. We found a significant difference between the ETBAA and OTA-H groups for type A2, as well as a loss of parathyroid glands and a number of parathyroid transplantation procedures. The endoscopic group was treated during an earlier stage of thyroid cancer. The iPTH profile of each group decreased, although this was the most consistent in the OTA-H group. A comparison of ETBAA with OTA-L demonstrates that the iPTH level change is similar.ConclusionThere is no advantage of endoscopic treatment for preserving parathyroid function.

Application of Carbon Nanoparticles in Endoscopic Thyroidectomy via Bilateral Areola Approach: Total Thyroidectomy Plus Central Lymph Node Dissection.

Background: The aim of this report was dual: (a) to describe the step-by-step standardized intraoperative percutaneous injection of carbon nanoparticles (CNPs) procedure for CNP-stained central compartment lymph nodes (CLNs) and passive display of parathyroid gland by CNP-stained thyroid in endoscopic thyroidectomy via bilateral areola approach (ETBAA) and (b) evaluation and outcomes of percutaneous injection of CNPs in total thyroidectomy plus CLN dissection through ETBAA. Materials and Methods: Video describes the technique of intraoperative percutaneous injection of CNPs for central compartment LNs identification, dissection, and parathyroid glands preservation in ETBAA for papillary thyroid cancer. Results: Supplementary video shows that after intrathyroid injection of CNPs, black carbon can be seen rapidly along the lymphatic vessels to the surrounding LNs. Parathyroid gland can be passive display when the thyroid is black and the parathyroid gland is normal in color. Intraoperative neuromonitoring (Medtronic® NIM-Response 3.0) was applied to identify recurrent laryngeal nerve and external branch of superior laryngeal nerve. No patient had any side effects of CNPs from 152 patients followed up for an average of 19.6 months (6-34 months). LNs were easily found under ETBAA. The accuracy of black-dyed LN in thyroid cancers was 95.9% (1016/1059). The number of parathyroid glands passive display was 69.9% (267/382). Conclusions: It is feasible to use CNPs to show CLNs in thyroid cancer during ETBAA. CNP suspension is safe for thyroidal injection.

Needle-Assisted Endoscopic Lateral Neck Dissection Through Bilateral Areola Approach for Papillary Thyroid Carcinoma Patients

Introduction: Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach is a technique of selective neck dissection for levels IIA, IIB, III, IV, VB, and VI lymph nodes. This technique has a cosmetic effect on patients with N1b papillary thyroid carcinoma (PTC). Methods/Case Presentation: In January 2016, a 26-year-old female patient was found to have PTC with right lateral cervical lymph node metastasis by fine-needle aspiration. It was found to be clinical stage I cT1bN1bM0. After CT scan and ultrasonography inspection, we decided to perform total thyroidectomy and right lateral neck dissection through the bilateral areola approach. Incisions were made at the bilateral areola with a 5-mm trocar and a 10-mm trocar was inserted into the right breast margin at the 4 o'clock position. Needle-assisted instruments directly approached the surgery region through the neck skin. We built up an operating space by the liquid–gas method with 6 mmHg CO2 and suture suspension to maintain the spaces. Using needle-assisted instruments, the external jugular vein was separated primarily and was protected well. Then we anatomized the anterior border of the sternocleidomastoid to show the carotid triangle, including the posterior belly of the digastric muscles, hypoglossal nerve (XII), and accessory nerve (XI), and dissected the levels IIA, IIB, and III lymph nodes at the same time. Furthermore, the level IV lymph node was dissected after exposing the venous angle and ligating the lymphatic duct at the intermuscular approach. For identifying the transverse cervical artery and cervical nerves, we returned to level V to remove the specimen and complete the lateral neck dissection. Finally, the recurrent laryngeal nerves, parathyroids, and other important structures mentioned previously were taken on completely. Three drainage tubes were placed in the neck. This surgery left minimal scars on the neck, and the cervical sensory nerves were properly preserved. Results/Discussion: The patient received treatment after surgery in the hospital for 5 days without postoperative complications. Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach for PTC patients can obtain significant cosmetic results and also minimal invasion for young PTC patients with lateral lymph node metastasis. Conclusions: Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach is considered for N1b papillary thyroid carcinoma without mediastinal metastasis. It is an excellent option for young patients that gives better cosmetic effect and minimal invasion. No competing financial interests exist. Runtime of video: 8 mins 30 secs

Minilaparoscopy-Assisted Modified Neck Dissection Through Bilateral Breast Approach.

Introduction: Minilaparoscopy-assisted modified neck dissection through bilateral breast approach is a technique for thyroidectomy in patients with thyroid disease. This technique can promote the effect of cosmetology in thyroid surgery and neck dissection. In this video, we present a modified neck dissection and demonstrate important structures in the operation.Materials and Methods: In January 2015, we operated a 28-year-old female patient. The patient underwent fine-needle aspiration cytology and was found to have papillary thyroid carcinoma with lateral lymph node metastasis in the right side of the neck. After CT scanning and ultrasonic inspection preoperatively, the clinical staging was cT1bN1bM0 staging I. According to the Chinese thyroid nodule and thyroid cancer guideline,1 we decided to perform total thyroidectomy and right modified neck dissection through the bilateral areolar approach. The operation room setup and the steps to create the operation space are described in the video Minilaparoscopy-assisted hemithyroidectomy and central neck dissection (level VI) using bilateral breast approach.2 So the approach started with incision in front of the sternocleidomastoid muscle, then we dissected the carotid triangle, presenting the posterior belly of the digastric muscles, accessory nerve (XI), and hypoglossal nerve (XII). The dissection continued by the intermuscular approach to expose the venous angle and ligature of the right lymphatic duct. While identifying the transverse cervical artery and cervical nerves, we removed the specimen, then completed the modified neck dissection. Finally, we present the recurrent laryngeal nerves, parathyroids, and other important structures mentioned earlier after dissection.Results: The patient operated using this technique was hospitalized for 6 days without any postoperative complication. Minilaparoscopy-assisted modified neck dissection through bilateral breast approach can give more cosmetic results and minimal invasion for young patients with lateral lymph node metastasis.Conclusions: We prefer to operate N1b thyroid cancer without mediastinal lymph node metastasis. This technique can bring better cosmetic results and minimal invasion for young patients.Acknowledgments: This video is funded under the clinical major departments' construction project by the Ministry of Health, the clinical major department's construction project by the Fujian Provincial and Young and middle-aged backbone training project in health system of Fujian province, grant number 2013-ZQN-ZD-13.No competing financial interests exist.Runtime of video: 7 mins 24 secs

Bilateral Areolar Approach Endoscopic Thyroidectomy for Low-risk Papillary Thyroid Carcinoma

Bilateral Areolar Approach Endoscopic Thyroidectomy for Low-risk Papillary Thyroid Carcinoma

New endoscopic thyroidectomy with the transareola single-site approach: a comparison with the bilateral areolar approach.

We developed the transareola single-site approach (TASSA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas. Here, we report our experience with the TASSA technique in treatment of benign thyroid tumors and evaluate its feasibility through comparison with the bilateral areolar approach (BAA). From September 2009 to December 2011, 129 patients with benign thyroid tumors were enrolled in the study. Of these patients, 51 patients underwent endoscopic thyroidectomy by TASSA and 78 patients by BAA. The TASSA technique was performed using one 10 mm trocar and one 5 mm trocar through circumareolar incisions using conventional endoscopic instruments. The BAA procedure was performed using one 10 mm trocar and two 5 mm trocars through bilateral circumareolar incisions. Comparing TASSA with BAA, there were significant differences in the mean operative time (141.96 ± 19.85 vs. 98.14 ± 14.15 min) for lobectomy (P<0.05) and in the subcutaneous dissection area (101.00 ± 6.33 vs. 132.51 ± 5.25 cm, P<0.05). However, there were no significant differences in the duration of hospitalization, amount of drainage, occurrence of postoperative complications, and postoperative pain. All the patients were satisfied with the cosmetic result in the 2 groups. Endoscopic thyroidectomy using the TASSA procedure is feasible and safe, and affords the advantages of minimal invasiveness and excellent cosmesis results compared with other approaches including BAA. The 2 procedures are technically more challenging procedures, which may become alternative procedures for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis.

Minilaparoscopy-Assisted Hemithyroidectomy and Central Neck Dissection (Level VI) Using Bilateral Breast Approach

Introduction: Minilaparoscopy-assisted thyroidectomy using the bilateral breast approach is a technique for thyroidectomy in patients with thyroid disease. This technique can promote the effect of cosmetology in thyroid surgery. In this video, we outline the instrument, operating room setup, and trocar position, present a minilaparoscopy-assisted hemithyroidectomy and central neck dissection (level VI), and demonstrate recurrent laryngeal nerve and two parathyroids in operation. Materials and Methods: In August 2014, we operated on a 35-year-old female patient. The patient underwent fine-needle aspiration cytology, diagnosed as left papillary thyroid carcinoma. After CT scan and ultrasonic inspection preoperation, the clinical staging is cT1aN0M0 staging I. According to the Chinese thyroid nodule and thyroid cancer guideline,1 we decided to perform left hemithyroidectomy and central neck dissection (level VI) using a bilateral areolar approach. 0.2 mL carbon nanoparticle suspension was injected to the thyroid gland with ultrasonic guidance 2 weeks before operation. The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the superior pole vessels are divided. The superior pole is then mobilized laterally and the recurrent laryngeal nerve is searched for at the inferior pole. The dissection continues between the nerve and the posterior part of the thyroid progressively, from bottom to top. After the recurrent nerve dissection, the gland can usually be extracted without difficulty, dividing the last vessels in berry ligament holding the gland. While in central neck dissection, first, we confirmed the lateral boundaries of central compartment and identified the recurrent laryngeal nerve. Then completed the central neck dissection. Finally, we present the superior thyroid artery, recurrent laryngeal nerve, and parathyroids after dissection, cleaning up, and closure. Results: The patient who was operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Carbon nanoparticle suspension is an ideal lymphatic tracer for endoscopic thyroidectomy and central neck dissection, although there is some leakage of carbon nanoparticle suspension in this patient. It does not affect the identification and preservation of recurrent laryngeal nerve and parathyroids. Conclusions: We prefer to operate cN0 thyroid cancer using this technique because it allows us to better identify and preserve the recurrent laryngeal nerve and parathyroids and same boundaries in central neck dissection. Moreover, it brings better cosmetic results for young patients. No competing financial interests exist. Runtime of video: 9 mins 57 secs

A Novel Method for Creating Working Space During Endoscopic Thyroidectomy via Bilateral Areolar Approach

Endoscopic thyroidectomy (ET) can be performed through the bilateral areolar approach (BAA). A working space (WS) is typically created on the surface of the pectoral fascia in the chest wall and in the subplatysmal space in the neck. There are several limitations of using this WS. The aim of this study was to establish a new WS for ET. A retrospective review was performed on 85 patients with benign thyroid nodules who had undergone ET through a BAA. A WS was created between the anterior and poster layers of the superficial pectoral fascia (SPF) in the chest and underneath the deep layer of the investing layer (IL) in the neck. The time for creating the WS was 7.2 ± 2.1 (range, 5-12) minutes. No hemorrhage occurred during the procedure. Fat liquefaction occurred in 2 patients. Edema of the neck skin flap presented as lack of a suprasternal notch. No skin numbness occurred. No patient required postoperative pain medication. All patients were extremely satisfied with the cosmetic results. This new method of establishing a WS between the two layers of the SPF and underneath the IL is simple and fast, provides good exposure, yields less postoperative pain, and has a lower risk of skin burn.

New Endoscopic Thyroidectomy With the Bilateral Areolar Approach

We developed the bilateral areolar approach (BAA) for less invasive endoscopic thyroidectomy to avoid scars on exposed areas. Here, we report our experience with the BAA technique and evaluate its feasibility through comparison with the bilateral axillo-breast approach (BABA). From January 2009 to November 2009, 88 patients with benign tumors of any size or papillary thyroid microcarcinomas were enrolled in the study. Of these patients, 50 patients underwent endoscopic thyroidectomy by BABA and 38 patients by BAA. The BAA technique was performed using one 11-mm port and three 5-mm ports through bilateral circumareolar incisions using flexible endoscopic instruments. Comparing BAA with BABA, there were significant differences in the mean operation times [121.7 ± 24.5 vs. 102.6 ± 25 min for lobectomy (P<0.05) and 162.5 ± 36.1 vs. 131 ± 28 min for total thyroidectomy (P<0.05), respectively]. However, there were no significant differences in the duration of hospitalization, amount of drainage from the surgical sites, and occurrence of postoperative complications. Most of the patients after BAA and BABA were satisfied with the cosmetic result. However, among the patients who underwent the BABA procedure, 1 patient was dissatisfied and 2 patients experienced discomfort due to conspicuous axillary scar when they wore sleeveless clothes. Endoscopic thyroidectomy using the BAA procedure affords the advantages of minimal invasiveness and excellent cosmesis compared with other approaches including BABA. The BAA procedure is an attractive surgical option, particularly for patients with benign thyroid disease or small-sized papillary carcinoma who want an excellent cosmetic outcome.