Minimally Invasive Video-assisted Thyroidectomy Research Articles

A Miniaturized Endoscopic Device Integrating Raman Spectroscopy and Laser Speckle Technology Via an Image Fusion Algorithm for Intraoperative Identification and Functional Protection of Parathyroid Glands

Abstract The importance of parathyroid glands (PGs) protection is increasingly recognized by thyroid surgeons in the field of minimally invasive video-assisted thyroidectomy (MIVAT). However, current techniques for intra-operative identification and vascularity assessment of the PGs are contentious and complex. This study presents the design and validation of a miniaturized device for fusion near-infrared autofluorescence (NIRAF) based on Raman spectroscopy and laser speckle contrast imaging (LSCI) via an image fusion algorithm for functional protection of PGs in the MIVAT. Our light source components include an integrated light emitting diode (LED) light source fiber, an NIRAF optical fiber, an acquisition optical fiber, and a laser speckle optical fiber in the endoscopic system to achieve identification and vascularity assessment of PGs using a single endoscopic probe. It has been validated in ex vivo tissue experiments that the fluorescence intensity detected by the device was equivalent to that of the marker indocyanine green (ICG) in visual images and superior to that of the thyroid and all other tissues in the neck. Based on clinical studies, MIVAT using functional fluorescence endoscopy, compared with the White light pattern group, the NIRAF combined with LSCI modality group increased the number of intra-operative confirmations of the PGs (P < 0.001), declined the decrease in parathyroid hormone (PTH) (P < 0.05) and calcium levels (P < 0.05) on the first postoperative day, and reduced the incidence of symptomatic hypocalcemia (P < 0.05). Our device may reduce the incidence of postoperative permanent hypoparathyroidism. Application of an miniaturized functional fluorescence endoscope for real-time and label-free PGs identification and vascularity assessment in MIVAT could be realized.

Mini-invasive video-assisted thyroidectomy vs robot-assisted transaxillary thryoidectomy: analisys and comparison of safety and outcomes.

Thyroid surgery is characterized by large volumes and typically affects a young female population. Mini-invasive or remote access surgical techniques are born driven by the desire to improve aesthetic outcomes of the traditional technique, following technological advances that have upset the surgical world in the last 20years. In our multicenter, retrospective observational study, we first compared an endoscopic technique with a robotic one: minimally invasive video-assisted thyroidectomy (MIVAT) and robot-assisted transaxillary thyroidectomy (RATT). We evaluated intraoperative features, complications, and cosmetic outcomes in a cohort of 609 patients. The efficacy and safety of these techniques are proven by a large literature and the comparison made in our study does not show inferiority of one technique compared to the other. Even the aesthetic results tend to be equal in the long term. It is desirable that further prospective and randomized studies are conducted to evaluate the outcomes of these procedures and the cost-benefit ratio.

A Prospective Randomized Clinical Study of Minimally Invasive Video-assisted Thyroidectomy for Papillary Thyroid Microcarcinoma.

The purpose of this study was to observe the effectiveness of minimally invasive video-assisted thyroidectomy (MIVAT) in treating papillary thyroid microcarcinoma (PTMC). A total of 224 patients with PTMC who met the inclusion and exclusion criteria were selected from the Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, between January 2017 and December 2019. They were randomized into the MIVAT group or traditional open operation group. For both groups, we observed the number of lymph node dissections, amount of intraoperative blood loss, duration of the operation, length of the incision, and number of injuries to the recurrent laryngeal nerve. The average operation time (132.8±29.4min) in the MIVAT group was significantly higher than that in the open surgery group (83.8±14.29min) (P=0.026). The length of incision (2.8±0.6cm) in patients in the MIVAT group was significantly shorter than that in patients in the open group (7.4±1.1cm) (P=0.000). No significant differences were observed in the number of lymph node dissections (P=0.712), the amount of intraoperative bleeding (P=0.581), and the number of recurrent laryngeal nerve injuries (P=0.634). The average follow-up was 5 years, and both groups had no recurrence. In the treatment of PTMC, MIVAT had similar outcomes as traditional open operations, although the operation time was longer. However, the length of the incision was significantly shorter and thus provided cosmetic advantages for patients.

Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis.

PurposeConventional thyroidectomy has been standard of care for surgical thyroid nodules. For cosmetic purposes different minimally invasive and remote-access surgical approaches have been developed. At present, the most used robotic and endoscopic thyroidectomy approaches are minimally invasive video assisted thyroidectomy (MIVAT), bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET), bilateral axillo-breast approach robotic thyroidectomy (BABA-RT), transoral endoscopic thyroidectomy via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy.MethodsA systematic search was conducted in Medline, Embase and Web of Science to identify original articles investigating operating time, length of hospital stay and complication rates regarding recurrent laryngeal nerve injury and hypocalcemia, of the different minimally invasive techniques.ResultsOut of 569 identified manuscripts, 98 studies met the inclusion criteria. Most studies were retrospective in nature. The results of the systematic review varied. Thirty-one articles were included in the meta-analysis. Compared to the standard of care, the meta-analysis showed no significant difference in length of hospital stay, except a longer stay after BABA-ET. No significant difference in incidence of recurrent laryngeal nerve injury and hypocalcemia was seen. As expected, operating time was significantly longer for most minimally invasive techniques.ConclusionsThis is the first comprehensive systematic review and meta-analysis comparing the eight most commonly used minimally invasive thyroid surgeries individually with standard of care. It can be concluded that minimally invasive techniques do not lead to more complications or longer hospital stay and are, therefore, not inferior to conventional thyroidectomy.

Postoperative quality of life and cosmetic outcome between minimally invasive video-assisted thyroidectomy and bilateral axillo-breast approach robotic thyroidectomy: a single center retrospective cohort study.

Different approaches to endoscopic thyroidectomy utilize incisions that result in inevitable physical trauma to patients since postoperative tissue fibrosis and scars will influence their quality of life for a lifetime. Over the past few years, most studies have discussed the safety concerns of different kinds of endoscopic thyroidectomy; conversely, there has been less discussion on postoperative quality of life. Because most patients undergoing thyroidectomy for cancer or benign diseases are likely to have long-term survival, it is essential to study the cosmetic outcome of patients' scars from minimally invasive video-assisted thyroidectomy (MIVAT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy on quality of life. From July 2015 to December 2017, 95 patients-60 who underwent MIVAT and 35 who underwent BABA robotic thyroidectomy-were retrospectively studied. Patient demographics, operative indications, pathologic findings, pain scores after surgery, complications, perception of scars, and overall satisfaction were compared between the two groups. The cosmetic outcome and overall satisfaction were evaluated at least 2years after the operation using the patient scar assessment questionnaire and the 36-item short form health survey (SF-36). There was no statistically significant difference in scar perception between the two groups. However, in the SF-36, the MIVAT group had better satisfaction than the BABA robotic group regarding general health, vitality, mental health, and health change. MIVAT and BABA robotic thyroidectomy can be safely performed in selected patients, and patients who underwent MIVAT had better postoperative qualities of life than those who underwent the BABA robotic approach.

Continuous Intraoperative Neuromonitoring (C-IONM) During Minimally Invasive Video-Assisted Thyroidectomy (MIVAT): A Preliminary Study

Castagnola, Giorgio MD; Cossa, Alessandra MD; Lucarini, Alessio MD; Bellotti, Carlo MD Author Information

Minimally invasive video-assisted thyroidectomy in Asian patients: experience from Singapore.

Minimally invasive video-assisted thyroidectomy (MIVAT) although well established in Europe has not yet gained widespread acceptance in Asia. We describe our learning experience in the first reported series of 105 cases from Singapore. A retrospective analysis of outcomes in 105 patients who underwent MIVAT from April 2011 to 2018 was performed. The inclusion criteria were - symptomatic benign thyroid pathologies and follicular lesions or neoplasms needing a hemi-thyroidectomy. A thyroid lobe volume less than 35 mL was used as cut-off. Patients underwent surgeon-performed thyroid ultrasound with biopsy of solid nodules. All cases were operated by one surgeon using standard Miccoli technique with energy device used in all cases. From a total of 424 patients with nodular goitres undergoing thyroidectomy, 105 (24%) symptomatic eligible patients underwent the MIVAT procedure (M:F - 23:82). The mean incision lengths at start and completion were 1.7 cm (range 1.5-2 cm) and 2.4 cm (range 2-2.7 cm), respectively. Mean operating time was 97 min (range 59-160 min). There were four conversions (3.8%) in the first 25 cases and four patients (3.8%) experienced transient hoarseness with full recovery. Visual analogue pain scores at 6 and 24 h post-operatively were 2.7 and 1.1, respectively. Scar satisfaction was reported as excellent (75%), satisfactory (23%) and poor (2%). Although technically more demanding, MIVAT is a safe and useful operation in a thyroid surgeon's armamentarium. The limitation of goitre size, however, allows only a small percentage of symptomatic patients to undergo this procedure.

Minimally invasive video-assisted thyroidectomy (MIVAT).

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain. The authors conducted a retrospective analysis about patients who underwent MIVAT between 1998 and 2019 in the Endocrine Surgery Unit of the University Hospital in Pisa. Indications and contraindications are mentioned and strictly followed. Total thyroidectomy was performed in 1,862 cases (69%) and hemithyroidectomy was performed in 763 cases (28.3%). Conversion occurred in 43 cases (1.6%). In 188 cases (7%) a postoperative transient hypoparathyroidism was reported, whereas definitive hypoparathyroidism was reported in 12 cases (0.4%). Thirty-eight patients (1.4%) suffered from a definitive postoperative recurrent laryngeal nerve palsy. No definitive bilateral recurrent laryngeal nerve palsy occurred. From our multi-years' experience which spreads over 20 years, we can reaffirm the concept that MIVAT is a safe procedure which is not burdened by an increase complications rate or additional costs. Furthermore, this technique offers advantages in terms of cosmetic results and post-operative pain.

Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews.

Background:We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure.Materials and Methods:PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test.Results:The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups.Conclusions:TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.

Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery

BackgroundEarly Hypocalcemia is the most frequent complication after thyroid surgery. Several studies have tried to identify factors (patient caracteristics or surgical technique variations) affecting hypocalcemia following thyroid surgery. This studiy evaluates the role of several factors in postoperative hypocalcemia development.MethodsA retrospective study conducted on 2108 patients that underwent thyroid surgery in a single center (1669 women and 439 men). Postoperative early hypocalcemia was defined as serum calcium levels lower than 8,0 mg/dl measured 24 h after surgery. Following factors were evaluated in the study: sex, age, glandular hyperfunction, preoperative diagnosis, preoperative serum calcium levels, preoperative serum PTH levels, type of surgery performed (total thyroidectomy vs. lobectomy); minimally invasive video assisted thyroidectomy (MIVAT); number of parathyroid preserved in situ, postoperative serum calcium levels, changes in perioperative calcium levels (difference between preoperative values ​​and postoperative calcium levels), presence of carcinoma in the surgical specimen, presence of thyroiditis based on histopatology reports.ResultsAmong evaluated factors only gender and surgical procedure revealed to be significantly correlated to early hypocalcemia development. In fact female patients experienced postoperative hypocalcemia in 42% (701/1669) of cases, which was signicantly higher than the 21.4% (94/439) identified in men. We also noticed a greater hypocalcemia incidence in patient undergoing total thyroidectomy (38.8%) than in patient undergoing lobectomy group (13.8%). Early hypocalcemia development didn’t appear to be related to preoperative serum calcium levels but it showed a statistically significant correlation with perioperative serum calcium level drop.ConclusionThis findings suggest that sex (female gender is a strong risk factor),surgical procedure and perioperative changes in serum calcium are the only factors (among all variables examined) that influence early hypocalcemia development.

Minimally Invasive Video-Assisted Thyroidectomy: Analysis of Complications From a Systematic Review.

Nowadays, minimally invasive video-assisted thyroidectomy (MIVAT) is considered a safe and effective option. However, its complication rate has not been specifically discussed yet. The aim of this systematic review was enrolling a large number of studies to estimate early and late complications (transient and definitive, uni- and bilateral laryngeal nerve palsy; transient and definitive hypocalcemia; cervical hematoma; hypertrophic or keloid scar) of MIVAT compared with conventional technique. The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in PubMed and Embase. Search terms were "minimally invasive," "video-assisted," and "thyroidectomy." We enrolled randomized clinical trials, nonrandomized trials, and noncontrolled trials. Thirty-two articles were considered suitable. Complication rate of MIVAT was quite similar to conventional technique: only one randomized trial found a significant difference concerning overall skin complication, and a single trial highlighted hypocalcemia significantly increased in MIVAT, concerning serologic value only. No difference concerning symptomatic nor definitive hypocalcemia was found. We can confirm that MIVAT is a safe technique. It should be adopted in mean-high-volume surgery centers for thyroidectomy, if a strict compliance with indication was applied.

Factors Affecting Long-Term Cosmetic Results after Minimally Invasive Video-Assisted Thyroidectomy and Conventional Thyroid Surgery

Approximately 90,000 thyroid operations are performed in Germany each year. Minimally invasive video-assisted thyroidectomy (MIVAT) accounts for 5 - 10% of these operations. There are few data that compare long-term cosmetic results after MIVAT to those after conventional surgery. Current systematic reviews show no advantage for MIVAT. The goal of this study was to analyse the long-term postoperative results in both procedures and the evaluation of relevant factors. The analysis of the long-term results is based on follow-up examinations using a validated method for scar appraisal (POSAS). Cohort analysis was performed on MIVAT operations in our hospital between 2004 and 2011 and conventional thyroid operations in 2011. Follow-up examination data were analysed from 117 patients from the MIVAT group and 102 patients from the conventional group. The follow-up examination was performed with a mean of 23.1 vs. 23.6 months postoperatively (MIVAT vs. conventional). The Friedman Test showed that scar pigmentation (mean rank 4.79) and scar surface structure (mean rank 3.62) were the deciding factors influencing the long-term cosmetic results. Both MIVAT and conventional surgery gave very good long-term cosmetic results. From the patient's perspective, there is no significant advantage with conventional surgery. The evaluation of the long-term results largely depends on factors such as scar pigmentation and surface structure that can only be influenced to a limited extent by the surgical procedure.

MIVAT: the last 2 years experience, tips and techniques after more than 10 years.

Minimally invasive video-assisted thyroidectomy (MIVAT) has been introduced into clinical practice by Miccoli in the late 1990s (Miccoli et al., Am J Surg 181(6):567-570, 2001) and it has become a widespread technique used and welcomed worldwide. In this paper, we present our experience of the last 2 years; we also describe tips and techniques derived from over 460 cases performed in the last 10 years by the same surgical team with the same single operator. In the last 10 years, we did about 460 MIVAT procedures. In the last 2 years, we performed MIVAT on 156 consecutive patients at Sant'Andrea University Hospital of Rome "Sapienza" University. of 156 cases performed, we were able to monitor the follow-up in 110 patients. On 110 cases, the mean surgical time was 74 ± 7.2min. In our data, we reported: transitory hypoparathyroidism 11 (10%), definitive hypoparathyroidism 4 (3.60%) (this value is inclusive of patients treated with central neck dissection. The value referred only to MIVAT is 1.05%), 2 (1.81%) transitory monolateral nerve palsy, 16 (14.50%) transitory, and 1 (0.9%) definitive nerve palsy. 4 (3.60%) cases of transitory dysphagia and 0 (0%) cases of definitive dysphagia (Table4). We also had 1 (0.9%) case of surgical scar infection, 0 (0%) postoperative bleeding, and 2 (1.81%) cases of subcutaneous surgical adhesion. Cosmetic results were: 0 (0%) insufficient, 0 (0%) sufficient, 6 (6.30%) passable, 17 (15.50%) good. and 86 (78.20%) excellent. Conversion rate 0 (0%). MIVAT is a good and safe technique, with similar short-term outcomes and similar costs compared to traditional total thyroidectomy. We hope that the tips and techniques reported in this paper as well as the advices in the use of instruments in MIVAT and open surgery will be useful to improve the skills of young surgeons and make thyroid surgery less invasive.

Morbidity from minimally invasive video-assisted thyroidectomy: a general review.

Minimally invasive video-assisted thyroidectomy (MIVAT) is known and used worldwide, it combines the advantages associated with endoscopic magnification with those due with traditional surgery. In selected patients, it should be considered a safe and valid alternative. Indeed, a lot of comparative studies have demonstrated the advantages of MIVAT in terms of low rate of complications, reduced postoperative pain, improved cosmetic results and higher patient satisfaction over traditional surgery. Anyway, for obtaining the best results, with similar or even less complication rate than traditional surgery, surgeons should be well trained, acquired confidence with a smaller surgical incision and with the use of endoscopic instruments.

A Meta-analysis of comparing effectiveness and safety between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy in the treatment of papillary thyroid carcinoma without lymph node metastasis

Objective:To compare the effectiveness and safety between minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT) in the treatment of papillary thyroid carcinoma without lymph node metastasis, providing clinicians using video-assisted way to treat thyroid papillary carcinoma with a more reasonable basis.Method:According to the including and excluding criterion,we searched the published articles which compare the effectiveness of MIVAT and CT curing PTC in randomized controlled clinical trials. The searching time was from January 2011 to December 2016, and the data was analyzed by using revman 5.3 software.Result:Twelve articles involving 1 080 cases were included,and there were 514 cases in the MIVAT group and 566 cases in the CT group. The results of metaanalysis showed that: the operation time of MIVAT group is longer than that of CT group (MD=17.19, 95%CI12.43-21.96, P<0.05); however the VAS point of MIVAT group is less than that of CT group in twentyfour hours after surgery (MD-1.07, 95%CI-1.61--0.53, P<0.05). There is no significant difference in the incidences of transient recurrent laryngeal nerve injury(OR=2.21,95%CI0.9-5.07,P>0.05),transient hypoparathyroidism (OR=0.78, 95%CI0.48-1.28, P>0.05), serum thyroglobulin after five years followed up (MD-0.05, 95%CI -0.25-0.16, P>0.05), number of retrieved central lymph nodes (MD=-0.36, 95%CI -0.72-0.01, P>0.05) and number of retrieved central positive lymph nodes (MD=-0.15, 95%CI -0.45-0.16, P>0.05).Conclusion:Using MIVAT treating papillary thyroid carcinoma (without lymph node metastasis) is safe when its indications are strictly controlled.

Minimally Invasive Video-assisted Thyroidectomy. Experience the same working group

To demonstrate the feasibility, safety and efficacy of minimally invasive video-assisted thyroidectomy (MIVAT). Design: Retrospective Ninety six patients with thyroid nodules were selected for MIVAT if they presented nodules under 35 mm in diameter, thyroid volume below 30 ml and absence of high-risk malignant tumor, lateral cervical lymphadenopathy or prior cervical surgery. Indirect laryngoscopy was performed before and after surgery to all patients. Surgery was performed through a midline incision of 1.5 cm above the sternal notch, without carbon dioxide and with magnification endoscopy. We evaluated postoperative complications, pain after surgery, the cosmetic outcome and length of stay. Ninety patients underwent total thyroidectomy or near-total thyroidectomy. The average operative time was 54 ± 9 minutes. The average diameter of the nodule was 20 ± 6 mm. The average volume was 19 ± 6 ml. We documented six (6.2%) hyperparathyroidism and one recurrent laryngeal nerve palsy (0.96%), both transient and none of them permanent. The postoperative pain was minimal and all patients were discharged within 24 hours. Conclusion: In our experience the MIVAT is a safe and feasible technique for the treatment of thyroid disease, with clear advantages over conventional thyroidectomy in selected patients. In our experience the MIVAT is a safe and feasible technique for the treatment of thyroid disease, with clear advantages over conventional thyroidectomy in selected patients.

Continuous intraoperative neuromonitoring in minimally invasive video assisted thyroid surgery: first experience

Background: Visual identification of the recurrent laryngeal nerve (RLN) is mandatory in thyroid surgery independent of the approach. Intermittent intraoperative neuromonitoring (ioNM) is broadly in open and minimally invasive thyroid surgery. However, the use of continuous intraoperative neuromonitoring (C-ioNM) has yet not been described for minimally invasive video-assisted thyroidectomy (MIVAT). The correct placement of the vagal electrode and the problem of its dislocation represent the limiting factor due to the narrow space. We describe the technique for correct electrode positioning and report on our first experiences with the C-ioNM in MIVAT. Methods: C-ioNM was used in 9 patients eligible for MIVAT. To avoid dislocation of the electrode due to traction or interference with the electrode-wires during dissection both the wires and the electrode were pulled through an additional skin incision. MIVAT was then performed using a 5 mm 30° optical device and special instruments according to the original description from Miccoli. Video assisted hemithyroidectomy was performed in 3 patients, while 6 patients underwent total thyroidectomy. Results: Video-assisted application of the vagal electrode and positioning of the wires via an additional access was feasible in all patients without complications. In 6 cases, the electrode-wires were pulled through an additional skin incision on the dominating side lateral to the sternocleidomastoid muscle. In two patients the wires were pulled through an additional incision in the midline below the surgical approach. In one patient the wires were diverted directly through the primary incision. A significant intermittent decrease of the electromyographic (EMG) amplitude was observed in one patient. However, postoperative RLN palsy rate was zero. Conclusions: C-ioNM in MIVAT is feasible. An additional skin incision is helpful to avoid electrode dislocation. Traction of the thyroid lobe during thyroid lobe mobilization does not seem to affect RLN function. However, more data has to be collected to definitely estimate the significance of C-ioNM in MIVAT.

Continuous intraoperative neuromonitoring in minimally invasive video assisted thyroid surgery: first experience

Background: Visual identification of the recurrent laryngeal nerve (RLN) is mandatory in thyroid surgery independent of the approach. Intermittent intraoperative neuromonitoring (ioNM) is broadly in open and minimally invasive thyroid surgery. However, the use of continuous intraoperative neuromonitoring (C-ioNM) has yet not been described for minimally invasive video-assisted thyroidectomy (MIVAT). The correct placement of the vagal electrode and the problem of its dislocation represent the limiting factor due to the narrow space. We describe the technique for correct electrode positioning and report on our first experiences with the C-ioNM in MIVAT.

Gasless trans-axillary robotic thyroidectomy: the introduction and principle.

A historic review of the main stages of evolution of the minimally-invasive techniques in thyroid surgery. The endoscopic era is divided into direct and indirect approaches. Examples are the minimally invasive video-assisted thyroidectomy (MIVAT) and the minimally invasive lateral approach. The indirect approach is divided into transaxillary and chest/breast incisions. A brief historic review of the advent of robots to the medical and mainly surgical field. And finally, an introduction to transaxillary robotic thyroidectomy.

Minimally Invasive Video-Assisted Thyroidectomy (MIVAT) in the Era of Minimal Access Thyroid Surgery

Background: In the era of minimal access thyroid surgery, the terms minimal access and minimally invasive are often used interchangeably and in most instances this is far from being accurate. The aim of this article is to examine the characteristics and potential of one of the first minimal access thyroid procedures described; minimally invasive video-assisted thyroidectomy (MIVAT). Methods: The purpose of this article was obtained by almost two decades of experiences with the procedure at the authors’ center, and a systemic literature review was undertaken of all available medical literature to evaluate available literature by conducting a PubMed search limited to articles originally written in English language between the years 1997 and 2016. The search was limited by using the terms: minimally invasive thyroid surgery, video-assisted, endoscopic, and robotic thyroidectomy. The procedure’s design, radicality and safety, learning curve, cost, advantages and disadvantages were addressed. MIVAT’s potential as a surgical tool for thyroid pathology was also addressed by evaluating its indications, contraindications, and limitations. Results: MIVAT is a gasless hybrid procedure that is comparable to conventional thyroidectomy (CT) in terms of radicality and safety, with the added advantage of reduced early postoperative voice and swallowing symptoms. MIVAT has a relatively rapid learning curve with an additional advantage over other minimal access procedures; the ability of being adopted by the low-volume surgeon at a cost and time comparable to CT, but with improved patient satisfaction. Furthermore, it is non-inferior to procedures free of a neck scar in terms of patient satisfaction. MIVAT’s main drawback is that it is limited by its strict selection criteria. It is a viable treatment option for all types of thyroid pathologies. However, its role in therapeutic neck dissection remains to be validated. Conclusions: MIVAT is a safe and effective procedure which is obviously described in its name “minimally invasive”. It seems that in the era of innovative technologies and scarless-in-the neck thyroid surgery, MIVAT is here to stay.