Minimally Invasive Thyroidectomy Research Articles

Controversies in Thyroid Surgery: Debating Transoral Endoscopic Thyroidectomy versus Small Incision Thyroidectomy

In the ever-evolving landscape of thyroid surgery, one cannot ignore the ongoing debate surrounding the optimal approach for thyroidectomy. minimally invasive thyroidectomy techniques have been developed. However, there is currently no single accepted technique in minimally invasive thyroidectomy (MIT) [1]. Proponents of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) advocate for its minimally invasive nature and favorable cosmetic outcomes [2]. Experienced thyroid surgeons performing thyroidectomy with an anterior incision, shortening the classic Kocher incision by 2-3 cm without the need for additional complex instruments with simple preparation and minimal costs, have obtained better cosmetic results compared to open surgery [1]. Supporters of open thyroidectomy with or without endoscopic assistance through a 3 to 4-cm incision (small incision thyroidectomy; SIT) argue that their approach achieves similar minimally invasive results while maintaining the safety and efficacy of traditional open surgery [3,4]. TOETVA has garnered attention for its innovative approach, utilizing a natural orifice—the mouth—as the entry point for thyroidectomy. Advocates of TOETVA highlight its cosmetic advantages, as the incisions are hidden within the oral cavity, resulting in virtually scarless necks. Furthermore, TOETVA offers reduced postoperative pain and faster recovery times than traditional open surgery, enhancing patient satisfaction and quality of life. Proponents argue that the evolution of TOETVA represents a paradigm shift in thyroid surgery, offering patients a less invasive alternative with comparable oncological outcomes [5]. Conversely, proponents of SIT through a 3 to 4-cm incision contend that their approach achieves similar minimally invasive results while preserving the safety and efficacy of traditional open surgery. They argue that the smaller incision size of open thyroidectomy minimizes tissue trauma and postoperative pain, leading to faster recovery times and superior cosmetic outcomes compared to larger incisions (Figure 1,2). Moreover, advocates of SIT emphasize the importance of tactile feedback and direct visualization in ensuring optimal surgical outcomes, which may be compromised in endoscopic approaches such as TOETVA [2,3,5]. Among these contrasting viewpoints, it is essential to recognize that TOETVA and SIT have their respective strengths and limitations. While TOETVA offers the attraction of scarless necks and enhanced cosmetic outcomes, concerns remain regarding its learning curve and technical challenges, particularly in cases of large or multifocal thyroid tumors. Conversely, SIT boasts a long-standing safety and efficacy track record, with established surgical technique and perioperative care principles. However, its neck incision may be perceived as a drawback by patients seeking minimally invasive alternatives. Addressing these controversies requires understanding patient preferences, tumor characteristics, and surgeon expertise. Individualized decision-making is paramount, carefully considering the risks and benefits of each approach. Moreover, ongoing research and innovation are essential to refining surgical techniques and optimizing outcomes in thyroid surgery.

Perioperative outcomes of bilateral axillo-breast approach robotic thyroidectomy (BABART) versus minimally invasive thyroidectomy (MIT): a systematic review and meta-analysis.

Minimally invasive thyroidectomy (MIT) is increasingly being used for the thyroid tumors. The comparison of bilateral axillo-breast approach robotic thyroidectomy (BABART) with other MIT has not yet led to a unified conclusion with regard to surgical outcomes. To conduct a systematic review and meta-analysis of the literature on the surgical outcomes of BABART compared with MIT. We performed a systematic search in PubMed, Web of Science, Embase and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare BABART to MIT. The primary outcomes included perioperative, postoperative complications. The odds ratio (OR) and mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Nine studies, comprising 3645 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in hospital stay, number of retrieved lymph nodes, recurrent laryngeal nerve (RLN) injury, and vocal cord dysfunction between BABRT and MIT. However, BABART was associated with a shorter operation time (MD = - 21.45min, 95% CI [- 47.27, 4.38], p = 0.1) and lower rate of permanent hypoparathyroidism (OR = 0.42, 95% CI [0.20, 0.88], p = 0.02). Additionally, the MIT group had reduced postoperative pain score (MD = 0.45, 95% CI [0.02, 0.88], p = 0.04) and lower rate of hypocalcemia (OR = 2.31, 95% CI [1.04, 5.13], p = 0.04) than the BABART group. In comparison with MIT, BABART exhibits better results in terms of operative time and the rate of permanent hypoparathyroidism, with no significant difference in hospital stay, number of retrieved lymph nodes, RLN injury, and vocal cord dysfunction. However, the postoperative pain score and the rate of hypocalcemia of MIT are slightly better that of BABART.

MT4 Implementation of Minimally Invasive Thyroidectomy for Cancer Care: Conversion Rates Are Associated with Facility Learning Curve but Not Total Volume of Thyroidectomies

Minimally invasive thyroidectomy (MIT), both laparoscopically and robotically, is increasingly being implemented for cancer care in the United States. Rates of conversion to an open procedure and risk factors for conversion at a national level are unknown.

HPR5 Minimally Invasive Thyroidectomy Implementation for Cancer Care: Do Racial, Ethnic and Insurance Characteristics Play a Role?

Racial, ethnic and insurance coverage-related disparities have been documented with regard to traditional thyroid cancer treatment access. Minimally invasive thyroidectomy (MIT) implementation data for those inequalities is yet to be known nationwide.

Surgical outcomes of minimally invasive thyroidectomy in thyroid cancer: comparison with conventional open thyroidectomy.

Minimally invasive thyroidectomy (MIT) is a safe method of performing thyroidectomy with notable benefits, such as improved cosmesis and reduced postoperative pain. The objective of this retrospective study was to report our experience with the technical feasibility of MIT, and compare its early surgical outcomes with those of conventional open thyroidectomy (COT) in patients with differentiated thyroid carcinoma (DTC). A total of 617 patients who underwent MIT and 2,674 patients who underwent COT were reviewed between March 2006 and November 2017 at Yonsei University (Seoul, Korea). The mean follow-up duration was 41.2±19.7 months. The mean age of patients with DTC was 46.1±11.2 years. The mean operation time in the MIT group was significantly shorter than that of the COT group (63.5±26.2 vs. 85.3±36.8 minutes, P<0.001). The mean hospital stay was significantly shorter in the MIT group than it was in the COT group as well (2.7±0.6 vs. 3.1±0.8 days, P<0.001). There were significantly fewer painkillers used after surgery in the MIT group than in the COT group (1.2±0.5 vs. 2.7±1.6, P<0.001). The mean number of harvested LNs in the MIT group was significantly lower than that of the COT group (3.1±2.6 vs. 5.5±4.0, P<0.001). This study demonstrated that MIT is technically feasible in patients with DTC. MIT is a valuable alternative operative technique to COT with good surgical outcomes and outstanding cosmetic results.

Transoral Vestibular Thyroidectomy: Is the New Era Already Here?

Minimally invasive thyroidectomy sounds non-familiar to the general surgeon. Since conventional open approach has been widely adopted, surgeons in their effort to further improve their skills passed to the new era of the Natural Orifice Transluminal Endoscopic Surgery (NOTES). The widespread adoption of robotics has led to the inevitable usage of robotic technology in simple and more complicated procedures. Although cervical area is limited and difficult to handle the necessary instruments, many efforts have been noted and the new era in minimal invasive thyroidectomy is coming. Transoral vestibular thyroidectomy promises excellent cosmetic results, in accordance with the elimination of complications, such as recurrent laryngeal nerve injury. The safety of the procedure has to be the main thought for the surgeon who perform the technique. A comprehensive search of PubMed Database was conducted for English-language studies using a list of key words. All transoral vestibular thyroidectomies that had intraoperative and postoperative complications were included from January 2000 till December 2018. A total of 11 studies, including 428 patients that underwent transoral thyroidectomy via vestibular approach, were analyzed. Postoperative data and complications were gathered among these studies. Recurrent laryngeal nerve injury was more likely to be discovered during the first postoperative days as transient hoarseness. Small hematomas were noticed, and most of them were definitively treated at the hospital where the injury occurred. Transient hypocalcemia was treated with per os supplements. Transoral vestibular thyroidectomy is a safe and adequate alternative to conventional open approach, with excellent cosmetic results. On the other hand, surgeons must be already experienced and familiar with robotic or endoscopic techniques, so as to overcome the problem of the eliminated space in the central neck area.

Minimally invasivethyroidectomy: A cosmetic alternative to standard thyroidectomy

Background: We report on minimally invasive thyroidectomy (MIT) through a 2–4cm incision hypothesize similar clinical results to standard open thyroidectomy. Methods: Between January 2019 and March 2020, 61 MIT were evaluated for clinical outcomes, and patient satisfaction on a 1–10 scale. Results: The 61 study patients underwent MIT procedure. The final diagnoses were benign nodular goitre (63%), and papillary thyroid carcinoma (37%). Five patients had temporary recurrent laryngeal nerve paresis and four patients had temporary hypocalcemia. Conclusion: In selected patients, MIT through a 1,5–3cm incision assistance is a safe alternative to standard open thyroidectomy in the hands of an experienced surgeon. The clinical results are equivalent and patient satisfaction is significantly improved.

Minimally invasive, nonendoscopic thyroidectomy: A cosmetic alternative to robotic-assisted thyroidectomy

The desire to improve cosmesis has driven the introduction of robotic-assisted and video-assisted thyroidectomy techniques. We report on minimally invasive thyroidectomy (MIT) through a2-cm incision without the added need for video assistance and hypothesize similar clinical results to standard open thyroidectomy. Between May 2012 and December 2013, 62 nonendoscopic MIT were evaluated for demographics, clinical outcomes, and patient satisfaction on a 1-10 scale. The results were compared with a case-matched control group who underwent conventional open thyroidectomy by the same surgeon. The 124 study patients demonstrated no differences between groups for demographics or clinical outcomes except a smaller thyroid lobe in the MIT group (9.2 vs 11.7g; P=.05). There were longer operative times in the MIT group (135.4 vs 119.6minutes; P=.07) that were not equivalent by equivalence testing (P=.534). In MIT patients, transient recurrent laryngeal nerve injury occurred per nerves at risk (1.1% vs 3.4%; P=.62) with no permanent injuries in either group. There was no difference in symptomatic hypocalcemia (9.7% vs 11.3%; P=.77) and postoperative hematoma (0%vs 3.2%; P=.50). On follow-up, the measured MIT scar was significantly shorter (2.22 vs 3.98cm; P<.00001), which resulted in significantly improved cosmetic satisfaction ratings (9.56 vs 8.66; P=.03). In selected patients, MIT through a 2-cm incision without endoscopic assistance is a safealternative to standard open thyroidectomy in the hands of an experienced endocrine surgeon. Theoperating time is slightly increased, but clinical results are equivalent and patient satisfaction issignificantly improved.

Recent progress in thyroid surgery

The management of thyroid disease has evolved rapidly within the past decade. The history of thyroid surgery starts in the second half of XIX century with Billroth, Kocher and Halsted, who developed safe technique of thyroid resection. Since then, the objectives for thyroidectomy are: conservation of the parathyroid glands and preserving laryngeal nerves, an accurate hemostasis and recently excellent cosmesis. In the recent decades, the dynamic development of new technologies, applied in thyroid surgery caused major improvements in results of this type of surgery. In particular, a large progress in minimally-invasive thyroidectomy, new dissecting devices and intraoperative neuromonitoring have been observed. Moreover, recent progress in robotic surgery and transoral thyroidectomy indicates new fields of development of thyroid surgery. In addition, radiological advances are changing the way in which we manage thyroid diseases and continue to aid in the diagnosis and treatment of thyroid cancer. New imaging techniques have been implemented to facilitate the diagnosis and management of thyroid cancer by multidisciplinary teams. Apart from surgical techniques, our understanding of the molecular genetics of thyroid diseases continues to progress, and with it new techniques for diagnosis and treatment are expected to develop.

The minimally-invasive thyroidectomy incision: A histological analysis

SummaryBackgroundMinimally invasive thyroidectomy (MIT) has gained popularity in the surgical management of benign and malignant pathology of the thyroid. One of the main benefits of utilizing this technique is the use of smaller incisions resulting in increased cosmetic satisfaction. Unfortunately, the retraction required for adequate exposure during MIT may lead to skin damage, impaired wound healing and poor cosmetic outcomes. Some have proposed that excising incision edges prior to closure may improve cosmesis. A review of the literature does not reveal any histologic evidence to support this technique.Material/MethodsIn this prospective observational study, nine subjects undergoing MIT were identified. Both the superior and inferior skin edges were excised and labeled for orientation. Specimens were sent for hematoxylin and eosin staining and histologic analysis by a staff pathologist.ResultsAll specimens showed no significant findings such as damage to the architecture of the dermis, acute inflammation, edema or evidence of hemorrhage. Focal blood vessel ectasia within the dermis was identified in three of nine subjects.ConclusionsOur findings do not yield a histological basis supporting the routine trimming of incisions during MIT. Although no significant findings were noted histologically, further studies are warranted to investigate the long-term cosmetic outcome of MIT incisions.

Minimally Invasive Thyroidectomy: Basic and Advanced Techniques

Minimal access surgery in the thyroid compartment has evolved considerably over the past 10 years and now takes many forms. We advocate at least two distinct approaches, depending on the disease process and multiple patient factors. The technical aspects are explored in depth with liberal use of videographic demonstration. The authors conducted a comparison of two distinct surgical techniques with photographic and videographic documentation of two distinct minimal access approaches to the thyroid compartment termed minimally invasive thyroidectomy (MITh) and minimally invasive video-assisted thyroidectomy (MIVAT). Both historic and previously unpublished data (age, gender, pathology, incision length, and complications) are systematically analyzed. Patients who underwent minimally invasive thyroidectomy (n = 31) had a mean age of 39.4 +/- 10.7 years; seven were male and 24 were female. The most common diagnosis was follicular or Hürthle cell adenoma (29%), followed by papillary or follicular cancer (26%). The mean incision length was 4.9 +/- 1.0 cm. One patient developed a hypertrophic scar and one patient developed thrombophlebitis of the anterior jugular vein. There were 14 patients in the MIVAT group with a mean age of 43.7 +/- 11.4 years; one was male and 13 were female. The majority of patients had follicular adenoma (42.9%) or papillary carcinoma (21.4%) as their primary diagnosis. The mean incision length was 25 +/- 4.3 mm (range, 20-30 mm), and there were no complications. Two distinct approaches to minimal access thyroid surgery are now available. The choice of approach depends on a number of patient and disease factors. Careful patient selection will result in continued safe and satisfactory performance of minimally invasive thyroid surgery.

Minimally Invasive Thyroidectomy Using the Sofferman Technique

Access to the thyroid compartment has traditionally been achieved by a Kocher incision followed by subplatysmal flap elevation and strap muscle retraction. A combination of novel access techniques was used to allow for minimally invasive thyroidectomy (MITh). A prospective, nonrandomized evaluation of consecutive patients undergoing thyroidectomy was performed. A minimally invasive incision (< or =6 cm) was used in conjunction with the Sofferman technique (transection of the strap muscles) and videoendoscopic assistance to perform hemithyroidectomy or total thyroidectomy in eligible patients. Prospectively collected data include age, sex, pathology, incision length, duration of surgery, and blood loss and complications were considered. Forty-four patients underwent 48 thyroid surgeries between September 2003 and May 2004. There were 13 men and 31 women, with a mean age of 41.9 (range 19-73) years. Thirty-one (64.6%) of these were eligible to be performed by MITh; the remainder (n = 17, 35.4%) underwent conventional thyroidectomy. The mean incision length in the MITh cohort was 4.9 +/- 1.0 cm compared with 9.1 +/- 1.5 cm for conventional thyroidectomy. The mean surgical time for minimally invasive hemithyroidectomy was 115.7 minutes (n = 23), and for total thyroidectomy was 147.4 minutes (n = 8). There were no cases of permanent hypocalcemia or recurrent laryngeal nerve paralysis in either group. No patients in the MITh group had to be converted to a conventional thyroidectomy. The cosmetic results were excellent, although one patient in the MITh group developed a mildly hypertrophic scar that responded to triamcinolone injection. MITh is safe in carefully selected patients and probably results in more rapid wound healing. The cosmetic result is superior to that achieved with conventional thyroidectomy.