Transient Recurrent Laryngeal Nerve Injury Research Articles

The effectiveness of a novel modified retracting arm for transaxillary endoscopic thyroid surgery to minimize complications: A randomized controlled study

Objective: To evaluate the safety of a novel modified retracting arm for endoscopic thyroidectomy by gasless unilateral axillary approach (ETGUA) and its effectiveness in minimizing complications. Methods: A novel retracting arm, which comprises a suspension part, a retracting arm, and a suction tube, was designed for ETGUA. The thyroid pull hook used in this study is an approved medical device: Su Xu, 20210063 (https://scjgj.xz.gov.cn/). The cohort of this randomized controlled study included 84 patients with unilateral thyroid cancer who underwent ETGUA at Xuzhou Central Hospital from February 2021 to March 2023. The patients (n = 42/group) were randomly assigned to a control group (conventional endoscopic retracting arm) or an experimental group (modified endoscopic thyroid retracting arm). Clinical indicators, complication rates, neck pain scores, and cosmetic scores were compared between the two groups. Results: There were no significant differences in hospitalization time, surgical duration, intraoperative blood loss, postoperative drainage volume, hypoparathyroidism, or postoperative hematoma between the groups. However, there were significant differences in the incidences of transient recurrent laryngeal nerve injury (x2 = 6.65, p = 0.02) and transient superior laryngeal nerve injury (x2 = 4.49, p = 0.03), as well as visual analog scale scores on postoperative day (POD) 1 and 7 (tPOD1 = 12.66; tPOD7 = 10.54; both, p ＜ 0.001), and cosmetic scores (t = -15.27, p ＜ 0.05). Conclusion: The modified retracting arm was safe and effective for ETGUA.

Comparison of learning curves and related postoperative indicators between endoscopic and robotic thyroidectomy: a systematic review and meta-analysis.

Endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) yield similar perioperative outcomes. This study investigated how the learning curve (LC) affects perioperative outcomes between ET and RT, identifying factors that influence the LC. Two researchers individually searched PubMed, EMBASE, Web of Science, and Cochrane Library for relevant studies published until February 2024. The Newcastle-Ottawa Scale assessed study quality. Random effects model was used to compute the odds ratio and weighted mean difference (WMD). Poisson regression comparison of the number of surgeries (NLC) was required for ET and RT to reach the stable stage of the LC. Heterogeneity was measured using Cochran's Q. Publication bias was tested using funnel plots, and sensitivity analysis assessed findings robustness. Subgroup analysis was done by operation type and patient characteristics. This meta-analysis involved 33 studies. The drainage volume of ET was higher than that of RT (WMD=-17.56 [30.22, -4.49]). After reaching the NLC, the operation time of ET and RT was shortened (ET: WMD=28.15[18.04, 38.26]; RT: WMD=38.53[29.20, 47.86]). Other perioperative outcomes also improved to varying degrees. Notably, RT showed more refined central lymph node resection(5.67 vs. 4.71), less intraoperative bleeding (16.56mL vs. 42.30mL), and incidence of transient recurrent laryngeal nerve injury(24.59 vs. 26.77). The NLC of RT was smaller than that of ET(Incidence-rate ratios [IRR]=0.64[0.57, 0.72]). CUSUM analysis (ET: IRR=0.84[0.72, 0.99]; RT: IRR=0.55[0.44, 0.69]) or a smaller number of respondents (ET: IRR=0.26[0.15, 0.46]; RT: IRR=0.51[0.41, 0.63]) was associated with smaller NLC. In RT, transoral approach (IRR=2.73[1.96, 4.50]; IRR=2.48[1.61, 3.84]) and retroauricular approach (RAA) (IRR=2.13[1.26, 3.60]; IRR=1.78[1.04, 3.05]) had smaller NLC compared to bilateral axillo-breast and transaxillary approach (TAA). In ET, the NLC of RAA was smaller than that of TAA (IRR=1.61[1.04, 2.51]), breast approach(IRR=1.67[1.06, 2.64]), and subclavian approach(IRR=1.80[1.03, 3.14]). Rich surgical experience can improve surgical results of ET and RT. After reaching the NLC, the perioperative outcomes of RT are better than those of ET. Study subjects, surgical approaches, and analysis methods can affect NLC.

Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: A prospective cohort study.

Thyroid tumours are a common condition and open surgery is a conventional method for treating benign thyroid tumours when surgery is indicated. In this study, we evaluate the outcomes of benign thyroid tumour treatment using transoral endoscopic thyroidectomy via vestibular approach (TOETVA) and compare the results with those of conventional open thyroidectomy (COT). We conducted a prospective cohort study between 100 patients who underwent TOETVA and 100 who underwent COT surgery for benign diseases from June 2018 to December 2021 in our hospital. Outcomes between the two groups, including post-operative complications, operative time and length of stay, were compared. The surgical time in the TOETVA group was significantly longer than in the COT group. The operative time of lobectomy in the TOETVA and COT groups was 77.5 ± 13.3 and 51.5 ± 4.2 min, respectively, with a P < 0.001. The operative time of total thyroidectomy in the TOETVA and COT groups was 108.1 ± 7.0 and 65.0 ± 4.1 min, respectively, with a P < 0.001. There was no difference in post-operative length of stay between the two groups. In TOETVA group, there were no patients who converted to open surgery. Amongst all 200 patients in the study, there were no cases of post-operative bleeding. The transient hypoparathyroidism rate after surgery in the TOETVA and COT groups was 3% and 2%, respectively, with no statistically significant difference (P = 0.651). Similarly, the transient recurrent laryngeal nerve injury rate showed no difference between the two groups, with rates of 5% and 4% in the TOETVA and COT groups, respectively (P = 0.733). There were no cases of post-operative infection in either group in our study. At 3 months postoperatively, the cosmetic satisfaction were significantly higher in the endoscopic groups than in the conventional group (P < 0.001). TOETVA is a safe and effective method, with a low complication rate and optimal aesthetic results compared to traditional surgery to treat benign thyroid tumours.

Retrospective analysis of 350 cases with dissection of lymph nodes posterior to right recurrent laryngeal nerve in endoscopic thyroidectomy through gasless axillary posterior approach

Objective: To evaluated the safety and feasibility of dissection of lymph nodes posterior to right recurrent laryngeal nerve (ⅥB compartment) in endoscopic thyroidectomy through gasless axillary posterior approach. Methods: A total of 350 cases with right lobe papillary thyroid carcinoma (PTC) who underwent endoscopic lobectomy, isthmusectomy and central compartment neck dissection via gasless axillary posterior approach based at the Department of General Surgery, Nanfang Hospital, Southern Medical University from June 2020 to December 2022 were retrospectively analyzed. Summarize the clinical, pathological characteristics, and postoperative complications of the patients. SPSS 25.0 was used for statistical analysis of the data. Results: All 350 patients underwent endoscopic surgery successfully, with no conversion to open surgery. There were 303 females and 47 males, with an average age of (36.3±9.2) years. Of those, 287 patients were in pT1a stage, 62 in pT1b stage, and one patient in pT2 stage. There was no T3 or T4 stage patient. The mean numbers of yielded lymph nodes in right central compartment and ⅥB compartment were 8.11±4.65 (range, 1-31) and 2.62±1.86 (range, 1-12), respectively. ⅥB compartment metastasis was detected in 52 (14.86%) of 350 patients. The incidence of transient recurrent laryngeal nerve injury was 0.86%(3/350). Postoperative hematoma occurred in three patients (0.86%). Conclusion: The dissection of ⅥB compartment in endoscopic thyroidectomy through gasless axillary posterior approach is safe and feasible in selected PTC patients.

Analysis of Surgical Outcomes in Endoscopic-Assisted Lateral Neck Dissection.

Currently, endoscopic-assisted lateral neck dissection (EALND) is performed to reduce postoperative scarring of the anterior neck. This study aimed to compare surgical outcomes between EALND and conventional open lateral neck dissection (COLND) for papillary thyroid carcinoma (PTC) with lateral lymph node metastases (LNM). The study reviewed 103 PTC patients who were classified on the basis of surgical type and statistically compared using propensity score matching analysis. The mean operation time is longer, and the cost of surgery is higher in the EALND group than COLND group (all p < 0.05). The numbers of retrieved and positive level II LNs, the rate of level II LNs detection between two groups do not differ significantly (all p > 0.05). The incidence of postoperative neck numbness is lower, and patients are more satisfied with postoperative neck scarring in the EALND group than COLND group (all p < 0.05). The common complications of two groups are transient recurrent laryngeal nerve injury and transient hypoparathyroidism. EALND is safe and feasible compared with COLND. The incision is more aesthetically satisfactory, which makes EALND a surgical approach for PTC patients with lateral LNM. 3 Laryngoscope, 134:2221-2227, 2024.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique.

The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO2)-related complications. Herein, we proposed a new technique without CO2 called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA. We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded. Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery. Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.

Recurrent Larnygeal Nerve Injury in Endoscopic Hemithyroidectomy

Objective: To find the frequency of recurrent laryngeal nerve damage in endoscopic thyroidectomy. Study design: Cross sectional descriptive study Place &amp; Duration of study: Ward 25, Jinnah Postgraduate Medical Centre, Karachi, Pakistan from January 2018 to January 2021. Methodology: Eighty patients of solitary thyroid nodules who fulfill inclusion criteria were divided alternatively into endoscopic and open hemi thyroidectomy groups. Patients were assessed for recurrent laryngeal nerve injury in the evening and after 24 hours of surgery by quality of voice. Those patients whose voice is normal discharge on 2nd day while others follow fortnightly until 3 months. Results: There was no recurrent laryngeal nerve injury encountered in group A while in group B 4 (10%) transient recurrent laryngeal nerve injuries were encountered. All injuries were recovered within 3 months post operatively. Out of 4 recurrent laryngeal nerve injuries 3 (75%) on left side (left hemi thyroidectomy) while 1 (25%) on right hemithyroidectomy.2 (50%) recurrent laryngeal nerve injuries in patients when surgery time was approximately 3 hours. Conclusion: Endoscopic thyroidectomy is safe, feasible and emerging minimal invasive technique to remove the thyroid gland without visible scar. Keywords: Recurrent laryngeal nerve, Endoscopic thyroidectomy, Solitary thyroid nodule

A novel anatomy-based five-settlement method for endoscopic thyroid lobectomy and ipsilateral central compartment neck dissection via gasless unilateral axillary approach: a preliminary report.

Endoscopic thyroidectomy (ET) via gasless unilateral axillary (GUA) approach has been widely implemented worldwide. Based on our concept of mesothyroid excision in open surgery, we proposed a novel anatomy-based five-settlement method in ET via the GUA approach. This preliminary report aimed to explore the efficacy and safety of this method in patients with papillary thyroid carcinoma (PTC). PTC patients who underwent endoscopic ET and unilateral central compartment neck dissection (CCND) via GUA approach with the five-settlement method at the Department of General Surgery, Nanfang Hospital, Southern Medical University from March 2020 to December 2021 were retrospectively collected. The data included general clinicopathological characteristics, surgical information (including duration, complication, and clinicopathological features), and hospital stay information, and other medical records were documented. In total, 521 patients underwent lobectomy and CCND under the GUA approach with the five-settlement method. The mean number of lymph nodes yielded (LNY) and positive lymph nodes (PLN) was 5.7 ± 4.3 (range, 1-30) and 1.0 ± 1.8 (range, 0-12), respectively. The incidence of transient recurrent laryngeal nerve injury was 1.1%. Chyle leakage and Horner's syndrome respectively occurred in one patient (0.2%). Five (0.9%) patients developed a hematoma. No severe complications or conversion to open surgery have occurred. The five-settlement method could be implemented safely and efficiently in ET+CCND via the GUA approach in selected PTC patients.

The effectiveness and safety of prophylactic central neck dissection in clinically node-negative papillary thyroid carcinoma patients: A meta-analysis.

This meta-analysis was performed to evaluate the effectiveness and safety of prophylactic central neck dissection (PCND) in patients with clinically node-negative (cN0) papillary thyroid carcinoma. A meta-analysis of the literature was performed using the key words "papillary thyroid carcinomas" and "lymph node ecisions" for searches of electronic databases. Complications such as transient hypocalcemia, permanent hypocalcemia, transient and permanent hypoparathyroidism, transient and permanent vocal cord paralysis, transient recurrent and permanent recurrent laryngeal nerve injury, and local recurrence were pooled by meta-analysis. Stata17.0 was used to carry out the meta-analysis. Data were extracted from 15 studies. In the present review, the group of patients who had total thyroidectomy (TT) with PCND had a lower local recurrence than the group with TT alone (OR 0.22, 95% CI 0.10-0.45, P = 0.000), whereas the incidence of permanent hypocalcemia (OR 4.24, 95% CI 1.05-17.22, P = 0.043) and transient hypoparathyroidism (OR 2.14, 95% CI 1.34-3.42, P =0.001) were higher. No significant differences were recorded in the incidence of other complications: transient hypocalcemia (OR 2.24, 95% CI 0.77-6.51, P = 0.138), permanent hypoparathyroidism (OR 1.70, 95% CI 0.89-3.27, P = 0.111), transient vocal cord paralysis (OR 1.48, 95% CI 0.78-2.83, P = 0.231), permanent vocal cord paralysis (OR 1.44, 95% CI 0.53-3.94, P = 0.477), transient recurrent laryngeal nerve injury (OR 1.47, 95% CI 0.93-2.32, P = 0.102) and permanent recurrent laryngeal nerve injury (OR 1.24, 95% CI 0.56-2.74, P = 0.587) between the two groups. Compared with TT alone, TT with PCND was more effective in reducing local recurrence without increasing the risk of recurrent laryngeal nerve, thyroid and vocal cord, except for hypocalcemia and transient hypoparathyroidism. Therefore, we believe that TT with PCND should be recommended for patients with cN0 PTC. https://www.crd.york.ac.uk/prospero/, identifier CRD4202 2355078.

A novel hybrid approach for "Scarless" (at the neck) lateral neck dissection for papillary thyroid carcinoma: A case series and literature review.

Lateral neck dissection (LND) is a necessary treatment for thyroid cancer with lateral lymph node metastasis. However, the defect created during open surgery leaves a visible scar on the neck. With advancements in surgical technology, many robotic and endoscopic surgical techniques have been reported as alternatives to open surgery. In this study, we present a case series demonstrating the successful application of a novel hybrid approach for endoscopic LND and a review of different surgical approaches for "scarless" (at the neck) LND. We performed endoscopic LND via a combined chest and transoral approach in 24 patients between January 2021 and March 2022. The surgery was completed successfully in all patients with an average operation time of 298.1 ± 72.9min. The numbers of positive/retrieved lymph nodes at levels II, III-IV, and VI were 0.7 ± 0.9/8.4 ± 4.1, 3.6 ± 2.7/19.5 ± 6.8, and 4.9 ± 3.9/10.3 ± 4.5, respectively. Complications included transient hypoparathyroidism in 10 patients, transient recurrent laryngeal nerve injury in 1 patient, internal jugular vein (IJN) injury in 1 patient, IJN sacrifice due to cancer invasion in 1 patient, and chyle leak in 1 patient, and no cases of tumor recurrence were observed during follow-up. The present case series indicates that the combined chest and transoral approach is feasible and effective for performing LND. Our review of different approaches for "scarless" (at the neck) LND identified advantages and disadvantages for all techniques. Our novel approach has unique advantages, and thus, it can provide an ideal surgical procedure for specific papillary thyroid carcinoma patients.

Standardized Intraoperative Neuromonitoring Procedure is Feasible in Transoral Endoscopic Thyroidectomy.

Intraoperative neuromonitoring in thyroid surgeries has become popular, but the standardized manner of intraoperative neuromonitoring during transoral endoscopic thyroidectomy vestibular approach (TOETVA) is not well established. This study evaluated the feasibility of using a standardized intraoperative neuromonitoring method for TOETVA. Medical records of consecutive patients who underwent TOETVA with intraoperative neuromonitoring were retrospectively reviewed. Patients were positioned before intubation to prevent tube migration, then intubated using video laryngoscopy. The electromyography amplitudes of the vagal nerves and the recurrent laryngeal nerves were checked before (V1, R1) and after (V2, R2) thyroid resection. V1 and V2 signals were evaluated using a long ball tip stimulator with a stimulus current of 3mA. R1 and R2 signals were obtained using the stimulus current of 1 to 3mA. Forty-two patients (3 males and 39 females) were included. Lobectomy was performed in 40 patients (95.2%) and total thyroidectomy in 2 (4.8%). Pathologic diagnoses were 30 papillary thyroid carcinomas, 2 follicular thyroid carcinomas, and 9 benign diseases. Conversion to open surgery occurred in 1 patient due to bleeding. Thus, 43 nerves at risk in 41 patients were analyzed. V1 and R1 signals were detected from all nerves. The mean V1 and R1 amplitudes were 738.7±391.4μV and 804.4±347.5μV, respectively, and 38 (88.3%) and 39 (90.7%) nerves had R1 and V1 amplitudes of more than 500μV. There were 2 cases (4.6%) of transient recurrent laryngeal nerve injury. R2 and V2 signals were detected in the 41 remaining nerves. The mean R2 and V2 amplitudes were 917.2±505.2μV and 715.7±356.2μV, respectively, and 36 (87.8%) and 32 (78.0%) nerves had respective R2 and V2 amplitudes of more than 500μV. Intraoperative neuromonitoring could be performed in a standardized manner in TOETVA, and the quality of intraoperative neuromonitoring was excellent. Further studies are needed to verify the feasibility of the current approach.

Transoral Endoscopic Thyroidectomy by Vestibular Approach for Papillary Thyroid Carcinoma with Tumor Size ≥2 cm.

Background: The transoral endoscopic thyroidectomy by vestibular approach (TOETVA) has been developed for papillary thyroid carcinoma (PTC) treatment with satisfactory results. However, there were few malignant thyroid nodules ≥2 cm in previous studies of TOETVA. Therefore, we conducted this study to evaluate the results of treatment by TOETVA for PTC with tumor size ≥2 cm. Materials and Methods: The clinical characteristics and surgical outcomes of 10 PTC patients with tumor size ≥2 cm who underwent TOETVA in our center from June 2018 to August 2021 were, respectively, reviewed. Results: All 10 included PTC patients successfully underwent TOETVA and the mean tumor size was 2.5 ± 0.5 cm. The mean number lymph nodes dissected was 9.6 ± 2.9, and 3.1 ± 3.3 positive lymph nodes were discovered. Postoperatively, transient hypoparathyroidism was recorded in 2 patients (20%), transient recurrent laryngeal nerve injury was noted in 1 patient (10%), transient superior laryngeal nerve injury was noted in 1 patient (10%), and numb chin was identified in 1 patient (10%). The postoperative complications aforementioned recovered within 6 months. During a median follow-up of 23.8 ± 13.1 months, no other complications or tumor recurrence were found. Conclusions: TOETVA is feasible for PTC patients with tumor size ≥2 cm and satisfactory short-term surgical outcomes have achieved in this study. We suggested that experienced surgeons can gradually expand the indications for TOETVA.

Clinical application of transoral and submental thyroidectomy (TOaST): a series of 54 human cases

ObjectiveA new endoscopic thyroidectomy approach—transoral and submental endoscopic thyroidectomy (TOaST)—was applied in clinical practice and considered an improved approach for endoscopic thyroid surgery via the oral approach. This paper discusses the feasibility and effectiveness of this surgical method.MethodsA retrospective analysis was performed on the clinical data of 54 patients who had undergone TOaST in the thyroid disease center of the First Affiliated Hospital of Nanchang University between December 2020 and December 2021. The surgical data and techniques, complications, and cosmetic outcomes of these patients were studied.ResultsAmong the total 54 patients, 23 underwent unilateral subtotal thyroidectomy, 3 patients underwent bilateral subtotal thyroidectomy, 27 with unilateral thyroid cancer underwent affected thyroid + isthmus + central lymph node resection, and only 1 patient underwent total thyroidectomy. The mean operative time was 88.06 ± 12.03 min (range: 65–135 min), the mean intraoperative blood loss was 8.61 ± 4.60 ml (range: 5–20 ml), the mean postoperative drainage volume was 49.96 ± 9.88 ml (range: 30–60 ml), the mean drainage time was 36.61 ± 2.65 h (range: 32–50 h), and the mean length of hospital stay was 46.63 ± 3.28 h (range 45–70 h). One patient experienced transient recurrent laryngeal nerve injury, and another patient experienced transient parathyroid dysfunction; there was no superior laryngeal nerve injury and other complications, such as postoperative subcutaneous hematoma, hypercapnia, mental nerve injury, tracheoesophageal injury, infection, or lymphatic leakage.ConclusionTOaST cannot only achieve a good therapeutic effect but also avoid mental nerve injury, reduce the discomfort of the patient’s jaw, obtain a good cosmetic effect, and facilitate the operation of the operator. It is an endoscopic thyroidectomy technique with a certain clinical value.

Prophylactic Central Neck Dissection to Improve Disease-Free Survival in Pediatric Papillary Thyroid Cancer.

BackgroundPediatric PTC is a rare disease. Although, the prognosis is excellent and the mortality rate is low, the role of prophylactic central neck dissection is still the subject of debate. The aim was to evaluate both the role and safety of prophylactic central neck dissection (CND) in managing pediatric papillary thyroid cancer (PTC), especially in respect of disease-free survival (DFS).Patients and MethodsIn this retrospective study, we collected 54 pediatric cN0 PTC patients (≤ 18 years of age) who were treated from January 2014 to January 2021 at a high-volume thyroid surgery center. Patients were divided into two groups based on the status of prophylactic CND. We analyzed the factors related to the clinicopathological features and recurrence of PTC in children.ResultsOf the 54 cN0 patients, 35 underwent prophylactic CND and 19 patients did not undergo prophylactic CND. The two groups were similar in clinical and pathologic features, such as age, gender, tumor size, multifocal status, and follow-up time. The average DFS was 84.4 ± 2.7 months. Log-rank tests on Kaplan-Meier curves revealed that age, gender, tumor size, multifocality, and extrathyroid extension did not relate to DFS time. Furthermore, DFS time was not affected by the extent of thyroidectomy (p=0.07) or RAI treatment (p=0.21). Prophylactic CND was found to increase DFS time for pediatric patients with cN0 PTC (p = 0.003). There was no statistically significant difference in complications such as transient hypocalcemia (p=0.15) and transient recurrent laryngeal nerve injury (p=0.37) between the prophylactic CND group and the no-prophylactic CND group.ConclusionProphylactic CND was found to be associated with increased DFS and not with increased rates of complications after surgery.

Intraoperative neuromonitoring of the recurrent laryngeal nerve is indispensable during complete endoscopic radical resection of thyroid cancer: A retrospective study.

ObjectiveComplete endoscopic radical resection of thyroid cancer, especially through the areolar approach, can achieve curative and acceptable cosmetic effects in patients with differentiated thyroid carcinoma. However, some inherent characteristics of endoscopic procedures hamper functional protection of the recurrent laryngeal nerve (RLN). Intraoperative neuromonitoring (IONM) is considered the most important accessory to protect the nerves during conventional radical thyroidectomy. This study aimed to evaluate the feasibility and necessity of IONM during complete endoscopic radical resection of thyroid cancer.MethodsA total of 106 patients with differentiated thyroid carcinoma were enrolled in the study between February 2013 and April 2018. Based on the use of the IONM technique, all patients were divided into the IONM (n = 54) and non‐IONM groups (n = 52). Overall, 66 RLNs were involved in the IONM group, and 61 RLNs were involved in the non‐IONM group. The time and ratio of RLN identification and the number of transient and permanent RLN injuries between both groups were compared.ResultsCompared to the non‐IONM group, the IONM group required less time for RLN identification (3.05 ± 1.58 vs. 9.36 ± 4.82 min, p < .01). The ratio of RLN identification in the IONM group was much higher than that in the non‐IONM group (100.00% vs. 88.52%, p = .01). A significant difference was observed in RLN transient injury between the two groups (one case accounting for 1.51% in the IONM group vs. eight cases accounting for 13.11% in the non‐IONM group; p = .03).ConclusionIONM significantly improved RLN identification and reduced transient RLN injuries during complete endoscopic radical resection.Level of Evidence3b.

Thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation: prospective multicentre European study.

BackgroundExtracervical approaches for thyroidectomy are seldom explored in the western population. The objective of this study was to evaluate the outcomes of hemithyroidectomy via endoscopic unilateral axillo-breast approach (UABA) with gas insufflation.MethodConsecutive patients undergoing UABA hemithyroidectomy for symptomatic benign or cytologically indeterminate nodules (Bethesda III lesions) of less than 5 cm from July 2015 to December 2020 at three European institutions were included. Patients were excluded if presenting with a BMI more than 25 kg/m2, had previous neck surgery and/or radiation, had bilateral thyroid lesions, retrosternal goitre, Hashimoto thyroiditis or Graves’ disease. Follow-up was carried out at 2 weeks, 3 months and 1 year. Outcomes of interest were surgical (including operating time, mean duration of hospital stay and complications) and self-assessed cosmetic outcomes.ResultsOut of 984 patients treated with hemithyroidectomy during the study interval, 253 were selected, including 214 women and 39 men. Patients’ mean age was of 46.6 years with a mean BMI of 22.57. Mean operating time was 72.9 minutes. A transient recurrent laryngeal nerve injury was reported in 3.6 per cent of the patients, but none was persistent. Transient pectoral/cervical hypoesthesia was noted in 24.1 per cent of patients, with no permanent hypoesthesia. Skin burns and subcutaneous hematoma developed in 2.4 per cent and 2 per cent of patients but resolved within the third month after surgery. There was no tracheal/oesophageal perforation, conversion to open surgery or reoperation. The final pathology revealed 241 benign nodules, nine underlying papillary thyroid carcinomas, and three cases of follicular carcinoma. Hospital discharge was achieved on the first in 68.8 per cent of the patients and on the second postoperative day in 31.2 per cent of the cases. All patients were satisfied with the cosmetic aspect.ConclusionIn selected patients, UABA with gas insufflation for hemithyroidectomy could be performed for the treatment of unilateral thyroid pathologies.

The Use of Harmonic Focus and Thunderbeat Open Fine Jaw in Thyroid Surgery: Experience of a High-Volume Center.

Background: In thyroid surgery, achieving accurate haemostasis is fundamental in order to avoid the occurrence of complications. Energy-based devices are currently extensively utilized in this field of surgery. This study aims to compare Harmonic Focus and Thunderbeat Open Fine Jaw with regard to surgical outcomes and complications. Methods: Patients submitted to total thyroidectomy in our center, between January 2017 and June 2020, were retrospectively analysed. Based on the energy-based device utilized, two groups were identified: Group A (Harmonic Focus) and Group B (Thunderbeat Open Fine Jaw). Results: A total of 527 patients were included: 409 in Group A and 118 in Group B. About surgical outcomes, the mean operative time was significantly shorter in Group B than in Group A (p < 0.001), while as regards complications, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in Group B than in Group A (p = 0.019). Conclusions. Both Harmonic Focus and Thunderbeat Open Fine Jaw have proven to be effective devices. Operative times were significantly shorter in thyroidectomies performed with Thunderbeat Open Fine Jaw; however, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in patients operated on with this device.

Prevertebral cervical approach to posterior mediastinum parathyroid adenomas.

About 4years ago, we described the pure endoscopic cervical approach to posterior mediastinum parathyroid adenomas, which we called the "prevertebral cervical approach". At that time, we had operated on three patients and did not have enough quality videos to demonstrate this approach. After broadening our experience, we present our results and show this technique through a video. From June 2015 to January 2021, information on patients undergoing the prevertebral cervical approach was obtained from a specific prospective database, including clinical presentation, biochemistry, preoperative imaging, surgical approach and patient outcomes. The step by step technique is described for both right- and left-sided adenomas, by means of a short video clip. Ten patients were operated on using this technique. Seven adenomas were right-sided and three were left-sided. The mean surgical time was 33 ± 7min. There were neither intraoperative nor major postoperative complications. Seven patients presented with a slight subcutaneous emphysema, which did not cause complaints. All patients were discharged the day after surgery, except for one patient with a previous open neck removal of four glands due to secondary hyperparathyroidism, which required calcium replacement. Calcium and parathyroid hormone levels were normalised in the other nine patients after surgery. One patient experienced a transient recurrent laryngeal nerve injury which was spontaneously resolved within 1month. No permanent recurrent laryngeal nerve injury was found. The postoperative cosmetic outcomes were excellent. In our experience, the pure cervical endoscopic approach has shown a high feasibility and short operation time, with excellent postoperative results regarding patient comfort, length of stay and disease cure. This approach also offers a very reasonable procedure cost, and may result in a less aggressive surgical option when compared with thoracic approaches.

Human Amnion/Chorion Membrane May Reduce Transient Recurrent Laryngeal Nerve Injury During Thyroid Surgery

Recurrent laryngeal nerve (RLN) damage is a significant and prevalent complication of thyroid surgery. Based on the beneficial role of a human amnion/chorion membrane (HACM) allograft in wound management and nerve regeneration, we investigated whether placement of a commercially available HACM allograft on dissected RLN could reduce the occurrence and/or duration of RLN injury during thyroidectomy. Among 67 patients undergoing thyroidectomy, 100 at-risk nerves (exposure of at least 3 cm of RLN) received intraoperative placement of HACM; 205 at-risk RLNs without HACM in 134 matched patients served as controls. Patient-reported vocal analysis, physician-assessed vocal analysis, and laryngoscopic assessment of vocal-fold dysfunction were performed before and after surgery. At 24 h after surgery, 17 patients in the control group (12.5%) had documented voice changes; these changes persisted for at least 3 weeks in seven patients (5%). Only one patient (1.5%) in the HACM group had vocal changes at 24 h after surgery, which resolved within 1 week (P < 0.01). Intraoperative placement of the HACM allograft over at-risk RLNs during thyroidectomy may reduce the incidence, severity, and/or duration of intraoperative RLN injury, which could address a significant complication of head and neck surgery. A larger prospectively designed clinical study is warranted to further investigate a possible benefit of the HACM allograft in thyroid surgery and to begin to understand the mechanisms through which a clinical benefit might be mediated.

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Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of “high-volume surgeon” for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes.PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes.Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons.Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes.Systematic Reviews and Meta-Analyses; Level IV