Transient Recurrent Laryngeal Nerve Palsy Research Articles

Clinical utility of needlescopic in hemithyroidectomy and central neck dissection through bilateral breast approach

To study application of needlescopic assisted hemithyroidectomy and central neck dissection using bilateral breast approach. Totally 145 cases of papillary thyroid cancer patients received endoscopic hemithyroidectomy in Fujian Medical University Union Hospital were randomized to needle assisted endoscopic group (NE group, n=81) and conventional endoscopic group (CE group, n=64). The average age of the patients was 35.9 years and 11 patients were male.All patients underwent hemithyroidectomy and central neck dissection through bilateral breast approach, the NE group additional used the MiniLap-assisted intraoperation.The operative time, postoperative complications and cosmetic results were analyzed by t-test and χ(2) test. The operation time of thyroid gland in NE and CE Group was (42±7) min and (31±7) min(t=9.082, P=0.000), respectively. The operation time of central neck dissection was (33±6) min and (26±3) min (t=9.050, P=0.000), respectively.There were 4 cases occurs transient recurrent laryngeal nerve paralysis in CE group and no case occur in NE group(χ(2)=5.206, P=0.036). There was no significant different in other postoperative complications and cosmetic results. Hemithyroidectomy and central neck dissection using bilateral breast approach and needlescopic assisted technique isa safe and reliable approach, with high cosmetic effect. Application needle assistive devices can shorten the operation time while no significant increase trauma in patients, it will makes endoscopic thyroid surgery easier to promote.

Evaluations of Factors Predicting the Need for an Extra-Cervical Approach for Intra-Thoracic Goiter.

Intra-thoracic goiter refers to the extension of enlarged thyroid tissue into the thoracic inlet. This condition can produce symptoms of compression on adjacent organs and can sometimes be accompanied by malignant transformation. Therefore surgical treatment is almost always necessary. In order to remove the pathology with the fewest post-operative complications, selection of the appropriate surgical approach is essential. In this study we aimed to detect the criteria which help us select the best therapeutic approach. In this retrospective study, 82 patients with intra-thoracic goiter were investigated. Their data were extracted from medical records and analyzed using SPSS software. Overall 82 patients, 18 (21%) males and 64 (78%) females with mean age of 56.38 years were studied. The most common clinical symptoms were mass (95%) and dyspnea (73%). In most patients, the surgical approach was cervical (90.2%), while 9.8% of patients required an extra-cervical approach. Post-operation complications were observed in 17.1% of patients; the most common being transient recurrent laryngeal nerve paralysis (4.9%). Malignancy was reported in the histopathology of seven patients (8.5%). The most common malignant histopathology was papillary thyroid carcinoma (7.3%). Extension of the thyroid tissue below the uppermost level of the aortic arch was significantly correlated with the need for an extra-cervical approach to surgery (P<0.001). Because of the compressive effect and risk of malignancy, intra-thoracic goiters require immediate surgical intervention. Commonly, cervical incision is used for removing the extended goiter to the mediastinum. Extension of the goiter below the uppermost level of the aortic arch increases the likelihood of an extra-cervical approach being required.

Treatment Outcome of Total Thyroidectomy for Multinodular Goiter

Background:: In cosmetic problems, compressive symptoms, toxicity and suspicion of malignancy, the best choice of multinodular goiter treatment are surgery. There are several surgical methods. Here we managed to describe the results of total thyroidectomy method for multi nodular goiter surgeries. Patients and Methods:: In this cross sectional study, from January 2009 to January 2011, 101 included patients with multi nodular goiter underwent total thyroidectomy. Outcome assessment was performed for two weeks, 1 month, 2 months, 10 months and 20 months after surgery for each patient. All data were analyzed with using SPSS-19 software. Results:: Of 101 included cases, with mean age of 47.1 ± 12.9 years, 10 cases were male and 91 cases were female. Bilateral gland involvement showed in 88.11%. The fine needle aspiration results were negative for malignancy in 41.6% of patients and were indeterminate and suspicious in 53.5% and 5% of cases. Transient recurrent laryngeal nerve palsy was observed in only one case. Transient hypocalcaemia showed up in 25 patients. Incidental malignancy was determined in 15.84% of patients: one patient with medullary carcinoma, two cases with folicullar carcinoma and 13 patients with papillary carcinoma. All these cases were female and had been presented bilateral involvement of multi nodular goiter. No recurrence appeared. Conclusions:: We believe that, despite the higher rate of post-operative complications, total thyroidectomy will be more beneficial in the surgical treatment of benign thyroid disorders.

Endoscopic thyroid lobectomy using bilateral axillo-breast approach: Surgical techniques and outcomes

Aim The aim of the present study was to report our surgical technique and perioperative outcomes of endoscopic thyroid lobectomy using the bilateral axillo-breast approach (BABA). Patients and Methods We conducted a retrospective cohort analysis of prospectively-collected data on consecutive female patients who underwent BABA endoscopic unilateral thyroid lobectomy for indeterminate thyroid nodules. Results Between July 2012 and July 2014, 18 patients with a mean age of 37.9 ± 14.4 years received BABA endoscopic right (n = 12) and left (n = 6) thyroid lobectomy for nodules with atypia of undetermined significance (n = 7), follicular lesion of undetermined significance (n = 6) and follicular neoplasm (n = 5) in our unit. The mean nodule size was 23.6 ± 9.7 mm. All operations were successfully accomplished with no conversion to open procedures. The mean operating time was 155.9 ± 34.9 min. Intraoperative blood loss was negligible in all patients (below 10 mL). There was no postoperative haemorrhage, wound hematoma or iatrogenic parathyroid injury. Transient recurrent laryngeal nerve palsy occurred in one patient (5.6 per cent), whose condition completely recovered after 6 months. The mean hospital stay was 2.5 ± 0.7 days. At 6 months after surgery, the mean cosmetic satisfaction score was 94.4 ± 12.4 out of 100. Chronic anterior chest wall pain and chest wall paresthesia was only reported in one respective patient (5.6 per cent). Conclusion BABA is a feasible and cosmetically-excellent technique in performing endoscopic thyroid lobectomy. It should be recommended for eligible patients who have strong desire on cosmetic outcomes.

Rationale for near total thyroidectomy in patients with nodular goitre

Aims: To find out the results of near-total thyroidectomy in patients with nodular goitre with benign lesions. Material and Methods: A prospective study was carried out on 42 cases with nodular goitre at NKP Salve Institute of Medical Science & Research Centre and Lata Mangeshkar Hospital, Nagpur from October 2010 to October 2012. Results: In this prospective study of 42 cases with nodular goiter, clinically 29 patients had solitary thyroid nodule and 13 patients had multinodular goiter. Out of these 42 patients 35 (83.33%) were female and 7 (16.67%) were male with ratio of 5:1. The age of the patients ranged from 18 years to 65 years.In this study out of 42 patients, 3 patients had papillary carcinoma on FNAC and were treated by total thyroidectomy. 2 patients had colloid cyst and 7 patient had follicular neoplasm in which hemithyroidectomy was done. 30 patients were treated with near total thyroidectomy. After near total thyroidectomy transient hypoparathyroidism was present in 7(23.33%) patients and transient recurrent laryngeal nerve palsy in 2(6.67%) patients. No patient had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Conclusion: Near-total thyroidectomy achieves a lower complication rate of hypoparathyroidism and a similar complication rate of recurrent laryngeal nerve palsy when compared with the rates reported in the literature for total thyroidectomy. It is an effective and safe surgical treatment option for various benign thyroid diseases.

Total endoscopic versus conventional open thyroidectomy for papillary thyroid microcarcinoma.

The objective of this study was to conduct a meta-analysis to assess the safety and efficacy of total endoscopic thyroidectomy (TET) versus conventional open thyroidectomy (COT) for papillary thyroid microcarcinoma with regard to short-term clinical outcomes. MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials in the Cochrane Library between January 1996 and July 2014 were searched to identify relevant comparative studies. Pooled weighted mean differences (WMD) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using either fixed or random-effects models. The perioperative outcomes were evaluated. Five eligible nonrandomized studies were included, involving 1004 patients: 475 were TET and 529 were COT. Meta-analysis results revealed that TET group had a significantly longer operative time (WMD, 48.15; 95% CI, 27.54-68.75; P < 0.00001), compared with the COT group. While analyzing the number of removed lymph nodes, 4 studies were included. The TET group had a less number of removed lymph nodes (WMD, -0.68; 95% CI, -1.20 to -0.15; P = 0.01). There were no significant differences in terms of hospital stay, transient recurrent laryngeal nerve palsy, permanent recurrent laryngeal nerve palsy, transient hypocalcemia, and permanent hypocalcemia. Total endoscopic thyroidectomy appears to be a much feasible safe surgical procedure for papillary thyroid microcarcinoma in selected patients.

Is it Time to Shift to Total Thyroidectomy for Benign Thyroid Disease: An Analysis of 77 Redo Thyroidectomies

ABSTRACT Aims and objectives To analyze redo thyroidectomies so as to get a possible answer to the controversy surrounding thyroidectomy for benign disease. Materials and methods This is a retrospective observational cohort. From 1996 to 2010, a total 77 cases of redo thyroidectomies were performed. The data of all patients in the department were maintained on a self developed MS access-based software. The data of redo thyroidectomies were reviewed. These patients were from five districts of Andhra Pradesh, 42 were women and 35 men, 51 underwent subtotal thyroidectomy, 21 had hemithyroidectomy and 5 patients had excision procedure; all were benign. The condition varied from multinodular goiter (MNG) and solitary nodule to follicular neoplasm. There were 44 right-sided, and 43 left-sided surgeries. Recurrence occurred in seven in less than 1 year, in 49 in less than 5 years, in 11 of them in less than 10 years and 10 had recurrence after 10 years. A total thyroidectomy was performed in all. Seventy-five had benign disease. Two had suspected neoplasm; one papillary and one Hurthle cell. One patient had transient recurrent laryngeal nerve palsy. Results Seventy-seven redo surgeries for benign thyroid disease were performed. The high rate of referrals for recurrence probably suggests inadequacy of subtotal and hemithyroidectomies for benign thyroid diseases. Conclusion The present series of 77 redo thyroidectomies clearly suggests inadequacy of initial subtotal thyroidectomy. Evidence-based analysis of complication rates and surgical feasibility supports total thyroidectomy as the complete safe, scientifically acceptable choice of primary surgical treatment for benign thyroid disease. How to cite this article Prasad RG. Is it Time to Shift to Total Thyroidectomy for Benign Thyroid Disease: An Analysis of 77 Redo Thyroidectomies. Int J Phonosurg Laryngol 2015;5(1):4-6.

Preliminary report on meticulous operation of thyroid lobectomy

Thyroid lobectomy can be programmed to operate as "step by step". Each step must be performed meticulously with quality control, so as to minimize the complications of surgery. From May 2013 to Auguest 2014, the meticulous thyroid operation was conducted in 72 cases (144 lobectomies). Pre- and post-operative evaluations by strobe laryngoscopy, parathyroid hormone (PTH), and blood calcium examinations were conducted in all cases. Four cases (5.6%) had transient recurrent laryngeal nerve paralysis after surgery, but no permanent recurrent laryngeal nerve paralysis. There was no transient or permanent superior laryngeal nerve paralysis. Transient hypoparathyroidism occurred in 10 cases, with no permanent hypoparathyroidism. No case presented with postoperative bleeding or infection. "Meticulous operation of thyroid lobectomy" may minimize effectively the complication of surgery.

Reprint of: The role of intra-operative nerve monitoring in reducing the risk of recurrent laryngeal nerve injury during thyroid surgery: A systematic review and meta-analysis

Background: Recurrent laryngeal nerve (RLN) palsy is an important complication following thyroid and parathyroid surgery. It can have a significant impact on patients' quality of life and is the most common cause of litigation after these procedures. The aim of this study was to assess the role of intra-operative nerve monitoring (IONM) during thyroid and parathyroid surgery in reducing the incidence rate of laryngeal nerve injury. Methods: Comprehensive searches of PubMed, EMBASE, and Cochrane databases were performed and quality of included papers was assessed using the Cochrane risk of bias tool and a modified Newcastle-Ottawa Scale (NOS). The results of included studies were summarised and meta-analyses were performed where appropriate. Results: Five randomised controlled trials (RCTs) and thirteen interventional cohort studies were included. Thirteen studies assessed the role of IONM in primary thyroid surgery, three in re-do procedures and two in minimally-invasive video-assisted thyroidectomy (MIVAT). Meta-analysis demonstrated: marginally significant lower rates of transient RLN palsy associated with the use of IONM in primary thyroid surgery (OR 0.71; 95% CI 0.50 - 1.00; p = 0.05); significant lower rates of transient RLN palsy associated with the use of IONM in revision thyroid surgery (OR 0.59; 95% CI 0.36 - 0.97; p = 0.04); no significant effect on permanent RLN injury in primary thyroid surgery (OR 0.84; 95% CI 0.47 - 1.50; p = 0.55); and no significant effect on transient RLN injury in MIVAT (OR 0.55; 95% CI 0.17 - 1.74; p = 0.31). Conclusion: This systematic review has shown that IONM can aid the surgeon to reduce the rates of transient RLN injury in primary and revision thyroid surgery. The wide variability in study design, definitions of RLN palsy and methods of assessing nerve injury were the main limitations encountered in this study.

Robotic Lateral Neck Dissection by a Gasless Unilateral Axillobreast Approach for Differentiated Thyroid Carcinoma

The aim of this study was to determine the technical feasibility and intraoperative safety of robotic lateral neck dissection in differentiated thyroid carcinoma (DTC). We analyzed 12 patients with DTC who underwent robotic total thyroidectomy and lateral selective neck dissection by a gasless unilateral axillobreast approach. The procedure was completed successfully in all patients. The mean console time for robotic lateral neck dissection was 54.2 ± 21.5 minutes. Transient hypoparathyroidism occurred in 5 patients, and transient recurrent laryngeal nerve palsy and chyle leak occurred in 1 patient each. Cosmetic satisfaction was excellent in all patients. Robotic lateral neck dissection by a gasless unilateral axillobreast approach for DTC is feasible and safe and allows for excellent postoperative cosmesis in preliminary results. Further studies are needed to establish oncologic safety and surgical completeness compared with conventional neck dissection.

Minimally invasive video-assisted thyroidectomy: experience of 200 cases in a single center.

IntroductionMinimally invasive techniques in thyroid surgery including video-assisted technique originally described by Miccoli have been accepted in several continents for more than 10 years.AimTo analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and to evaluate the feasibility and effects of this method in a general department over a 4-year period.Material and methodsInitial experience was presented based on a series of 200 patients selected for MIVAT at the General Surgery Department of Yantai Yuhuangding Hospital affiliated with Qingdao University during the period from May 2008 to June 2012. The enrolling criteria were rigorously observed. An above sternal incision with average length of 2.5 cm (1.5–3.0 cm) was made. Clinicopathologic characteristics, postoperative pain, length of hospital stay, cosmetic results and complications were retrospectively analyzed.ResultsAll patients received general anesthesia. Thyroid unilateral lobectomy was successfully accomplished in 108 cases, total thyroidectomy in 84, and partial lobectomy in 8. Conversion to standard conventional thyroidectomy was required in 6 patients (3%) because of thyroiditis and bleeding. The mean lymph node yield of the cancer specimens was 3.6 per patient. Permanent unilateral recurrent laryngeal nerve (RLN) palsy occurred in 1 case (0.5%), transient unilateral RLN palsy in 6 patients (3.0%, complete recovery after 1–6 months), and transient hypocalcemia in 7 patients (3.5%). No definitive hypocalcemia was observed. No postoperative hematomas occurred. Postoperative pain was endurable. The cosmetic result was excellent in most cases.ConclusionsThe MIVAT is feasible and safe in selected patients, with better results comparable to conventional thyroidectomy. The MIVAT can also be performed in a general surgery department.

Re-operative thyroid surgery: a 20-year prospective cohort study at a tertiary referral centre.

Re-operative thyroid surgery is a relatively uncommon procedure complicated by distorted anatomy and post-operative tissue changes. Surgery may follow initial benign or malignant pathology. Published outcomes vary widely in the literature. This study aims to report our outcomes from re-operative thyroid surgery. Patient demographics and complication rates for consecutive thyroidectomies performed by a single surgeon at a tertiary centre were collected between 1993 and 2013. Outcomes in re-operative surgery are analysed and compared with local and national data. Cases of re-operative surgery following benign disease are further analysed for histology, re-presenting symptoms and time between procedures. Our cohort comprised 1,657 cases including 164 re-operative procedures (101 malignant, 63 benign). Within our cohort re-operative cases were on average 4 years older (mean 49.9 vs 45.9 years, p = 0.001) and had a higher incidence of haematoma formation (4.3 vs 1.7 %, p = 0.033) and transient recurrent laryngeal nerve palsy (5.5 vs 2.5 %, p = 0.044) compared to primary surgery. Rates of permanent hypocalcaemia (2.4 vs 1.8 %, p = 0.540) and permanent RLN palsy (1.8 vs 0.4 %, p = 0.051) were higher in the re-operative group but did not reach significance. Comparison of complications following re-operation for benign and malignant disease revealed no significant differences. Mean interval to re-operation for benign cases was 17.4 years with 74.6 % found to have multinodular goitre at repeat procedure. Re-operative procedures comprised around 10 % of thyroid surgery at our centre. Re-operative cases experienced more complications than primary surgery but permanent rates were low. Re-operative surgery may therefore be safely considered in experienced hands.

Transoral parathyroid surgery--a new alternative or nonsense?

In recent years, several endoscopic techniques have been explored in thyroid and parathyroid surgery, but only few gained acceptance among patients and surgeons. Based on extensive human cadaver and animal studies, we developed a technique for transoral partial parathyroidectomy (TOPP), which was performed for the first time in a patient with primary hyperparathyroidism (pHPT). We now report on results and the acceptance of this new technique 2 years after its implementation. A pilot study was initiated to recruit a total of 10 patients with benign sporadic pHPT and a preoperatively localized parathyroid adenoma eligible for initial parathyroidectomy. The study protocol was approved by the ethics committee, and an insurance for unforeseen complications and risks was procured. Data of all patients evaluated and operated were prospectively collected, and follow-up examinations were carried out for 19 months on average, which included clinical examinations; ultrasonography; Ear, Nose, and Throat (ENT) investigations; and blood testing. Between January 2010 and May 2012, 75 patients with pHPT and a preoperative localized parathyroid adenoma were eligible for TOPP. After detailed information about the transoral procedure, only five (7 %) female patients consent to undergo TOPP. In three patients, a parathyroid adenoma could be removed via the transoral access, In two patients, the procedure had to be converted to the conventional technique. Median time until resection of a parathyroid adenoma was 122 min (range, 45-175). One patient had a transient recurrent laryngeal nerve palsy, while one patient suffered from a transient palsy of the right hypoglossal nerve and a slight but persisting dysgeusia. Three patients developed a hematoma of the mouth floor and swallowing problems. In four patients, the visual analog scale (VAS) pain score was high (>7) within the first 2 postoperative days. Although TOPP is feasible, it is poorly accepted by patients and its complication rate is high. Thus, TOPP is nonsense with currently available devices.

Complications in thyroid resurgery: a single institutional experience on 233 patients from a whole series of 4,752 homogeneously treated patients

The aim of this study was to examine a homogeneous, consecutive recent series of patients who underwent reoperation on the thyroid bed to assess the incidence of the complications commonly correlated with resurgery. We reviewed clinical charts of 233 patients who underwent resurgery taken from a total of 4,752 patients previously operated on for benign and malignant thyroid diseases from 2006 to 2010 by the same surgical team. We evaluated the incidence of postoperative hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve (RLN) palsy. Analyses were done separately in relation to the type of the type of resurgery adopted: (A) monolateral completion; (B) bilateral completion, after monolateral (B1) or bilateral prior surgery (B2); and (C) lymph node dissection. We also separately analyzed patients according to their final histological diagnosis of benign or malignant disease. Regarding hemorrhage, 6/233 patients (2.5 %) underwent surgical revision of the thyroid within 12 h for postoperative hemorrhage. They included 2 (1.5 %) of the 129 monolateral reoperations (A), 3 (4 %) of the 74 bilateral reoperations (B), and 1 (3.3 %) of the 30 central dissections for nodal relapse (C). Transient and definitive postoperative hypoparathyroidism was recorded in 78 (36.4 %) and 7 (3.3 %) of the 214 eligible patients. Transient RLN palsy occurred in 21 RLNs at risk (7 %) and definitive RLN palsy in 5 (1.7 %). Elective total thyroidectomy cannot always be supported as an effective policy for preventing recurrences in patients with a single, benign node: lobectomy, preferably with extemporaneous histological examination, unquestionably represents the best minimal approach to thyroid resection.

Completion thyroidectomy in differentiated thyroid cancer: When to perform?

Completion thyroidectomy is recommended in patients who have been diagnosed with differentiated thyroid cancer on histopathological evaluation, if their first operation was a conservative approach. The critical issue is when to do the second operation. The medical records of 66 patients who underwent completion thyroidectomy for the treatment of differentiated thyroid cancer in our clinic between 2006-2013 were retrospectively analyzed. All data were compared after patients were divided into two groups according to the interval between the first surgery and completion thyroidectomy. Fifty-two patients (78.8%) were women and 14 patients (21.2%) were male. Completion thyroidectomy was performed 10-90 days after the initial surgery (group 1) in 26 patients, whereas it was performed later than 90 days in 40 patients (group 2). Temporary hypoparathyroidism occurred in two patients (7.7%) in group 1, and in 3 patients (7.5%) in group 2. Transient recurrent laryngeal nerve palsy was observed in 1 patient (3.9%) in group 1, and in 1 patient (2.5%) in group 2. There were no permanent morbidities in both groups. Residual tumor rate after completion thyroidectomy was 45.5%. There was no statistically significant difference between the two groups in terms of complications after completion thyroidectomy. Although in some studies it is recommended that completion thyroidectomy should be performed either before scar tissue development or after clinical remission of scar tissue, edema and inflammation, we believe that timing of surgery has no effect on morbidity.

Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy

BackgroundThe role of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery is still debatable. The aim of this meta-analysis was to evaluate the potential improvement of IONM versus RLN visualization alone (VA) in reducing the incidence of vocal cord palsy. MethodsA literature search for studies comparing IONM versus VA during thyroidectomy was performed. Studies were reviewed for primary outcome measures: overall, transient, and permanent RLN palsy per nerve and per patients at risk; and for secondary outcome measures: operative time; overall, transient and permanent RLN palsy per nerve at low and high risk; and the results regarding assistance in RLN identification before visualization. ResultsTwenty studies comparing thyroidectomy with and without IONM were reviewed: three prospective, randomized trials, seven prospective trials, and ten retrospective, observational studies. Overall, 23,512 patients were included, with thyroidectomy performed using IONM compared with thyroidectomy by VA. The total number of nerves at risk was 35,513, with 24,038 nerves (67.7%) in the IONM group, compared with 11,475 nerves (32.3%) in the VA group. The rates of overall RLN palsy per nerve at risk were 3.47% in the IONM group and 3.67% in the VA group. The rates of transient RLN palsy per nerve at risk were 2.62% in the IONM group and 2.72% in the VA group. The rates of permanent RLN palsy per nerve at risk were 0.79% in the IONM group and 0.92% and in the VA group. None of these differences were statistically significant, and no other differences were found. ConclusionsThe current review with meta-analysis showed no statistically significant difference in the incidence of RLN palsy when using IONM versus VA during thyroidectomy. However, these results must be approached with caution, as they were mainly based on data coming from non–randomized observational studies. Further studies including high-quality multicenter, prospective, randomized trials based on strict criteria of standardization and subsequent clustered meta-analysis are required to verify the outcomes of interest.

Meta-analysis of video-assisted thyroidectomy versus conventional thyroidectomy

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

Selim tiroid hastalıklarının cerrahi tedavisinde subtotal ve total tiroidektominin erken ve geç dönem sonuçlarının karşılaştırılması

Comparison of early and late results of total and subtotal thyroidectomy for benign thyroid disease Background: Recently, total thyroidectomy (TT) has been performed and suggested in benign thyroid disease. But it was reported that the complications of total thyroidectomy was more than bilateral subtotal thyroidectomy (BST) this is still a topic of debate. Purpose of the present study is comparison of complications of BST and TT operations in treatment of benign thyroid disease. Materials and Methods: Early and late complications of TT and BST operations were retrospectively evaluated, which were performed in General Surgery Clinic of Konya Training and Research Hospital inbetween 2004-2008. Results:The study involved 96 patients in BST group and 110 patients in TT group. Follow-up period was 69.4±8.3 months in BST group, 52.7±5.3 months in TT group.Transient hypocalcemia were detected in 10 patients (9.1%) in BST group and 7 patients (7.3%) in TT group. Transient recurrent laryngeal nerve paralysis developed in 12 patients (7.2%); 5 patients (5.2%) in BST group and 7 patients (6.4%) in TT group. Hematoma in 4 patients (4.2%), seroma in 3 patients (3.1%), flap edema in 5 patients (5.2%) occured in BST group. In TT group, there had been; hematoma in 1 patients (1.0%), seroma in 5 patients (4.5%), flap edema in 4 patients (4.5%). Permanent hypocalcemia occured in 2 patients (2.1%) in BST group and 3 patients (2.7%) in TT group. Permanent recurrent laryngeal nerve paralysis developed in 1 patient (1.0%) in BST group and 2 patients (1.5%) in TT group. There was no statistically significant difference inbetween the groups about complications and demographic characteristics. Recurrence was seen in 6 patients (6.3%) in BST group. Discussion and Conclusion: TT not increase early and late complications in bengn thyroid diease requiring sugery. BSThas arisk of recurrenceaftersurgeryand thereforemust be carried outagain.Complications in secondary thyroidectomy in patients with prior thyroid surgery are very high.Therefore, if surgery is necessary in benign thyroid diseases should be TT.

Prophylactic neck dissection in papillary thyroid cancer: When is it necessary?

BACKGROUND The American Cancer Society estimates that there will be approximately 56,460 new diagnoses of thyroid cancer in the United States during 2012, and more than 90% will be papillary thyroid cancer (PTC). Despite the large, ever-increasing number of thyroid cancer cases, the ideal initial management of well-differentiated PTC remains controversial. The role of the prophylactic central neck dissection (pCND) has emerged as the most highly debated topic, with conflicting reports regarding indications, recurrence prevention, and reduction of cause-specific mortality. Currently, there is no argument that a formal, compartmental CND should be performed if preoperative or palpable nodal disease is encountered. However, the 2009 American Thyroid Association (ATA) guidelines state that, “Prophylactic central compartment neck dissection may be performed in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors (T3 or T4; Grade C recommendation; expert opinion).” With the advent of personalized therapy based on molecular testing, the BRAF gene has shown the most promise in predicting lymph node metastases and may be used to direct clinicians on whether to perform a pCND. The focus of the review will seek to answer the question of best practice with regards to pCND in PTC. LITERATURE REVIEW Due to the excellent outcomes seen with PTC, the importance of lymph node metastases has been difficult to interpret. Recent, large, population-based studies have demonstrated a decrease in cause-specific survival in lymph-node positive PTC patients. Zaydfudim et al. used the Surveillance, Epidemiology, and End Results database to analyze outcomes of 30,054 patients with PTC. They concluded through multivariate analysis that metastatic LNs conveyed a 46% increased risk of death (HR, 1.46; P<.001) in patients 45 years, even with the majority of patients with excellent long-term survival. However, in patients< 45, lymph node status did not influence survival. While the presence of metastatic positive lymph nodes in PTC may dictate a decrease in cause-specific survival, does performing a prophylactic central neck dissection actually improve the patient’s outcome? A meta-analysis of five studies with a total of 1,264 patients demonstrated a decrease in lymph node recurrence (2% vs. 3.9%) in the thyroidectomy1pCND group, but this did not achieve statistical significance. The rate of transient recurrent laryngeal nerve paralysis (1.8%–5.4% thyroidectomy1pCND, 1%–1.3% thyroidectomy alone) and transient hypoparathyroidism (18%– 44% thyroidectomy1pCND, 8%–14% thyroidectomy alone (P< 0.02)) was higher in the group receiving pCND. Permanent recurrent nerve paralysis and hypocalcemia were not different between the two arms. The authors concluded that the balance between the risks and benefits favored thyroidectomy alone. However, they recognized several limitations to the study: inclusion of retrospective data, inconsistencies in the use of RAI and thyroid suppression postoperatively, limited data on timing of recurrence, and a lack of standardized reporting with regard to the extent of central neck dissection (ipsilateral vs. bilateral, etc.). The authors conclude with the call for a large, prospective trial to fully resolve the controversy. However, the feasibility of such a randomized trial was investigated by the ATA, which concluded that prohibitively large sample sizes (5,840 patients) and approximately $20 million would be required to demonstrate significant differences in outcomes. From the Louisiana State University Health Sciences Center– Shreveport, Department of Otolaryngology/Head and Neck Surgery, Shreveport, Louisiana, U.S.A.

New Technique Using the Snake Retractor for Complete Lymph Node Dissection in Robotic Thyroid Surgery

We introduce a new technique using a snake retractor to allow for a complete central lymph node dissection (CND) under a more optimal view for robotic thyroid surgery using bilateral axillo-breast approaches. Fifty-eight patients diagnosed with papillary thyroid cancer who underwent robotic thyroidectomy from April to December 2010 were analyzed. A total of 20 patients underwent a robotic surgery without use of snake retractor initially, and 38 patients underwent surgery using snake retractor. Ipsilateral CNDs were performed in all cases. The number of harvested lymph nodes was 5.3 without use of the snake retractor and 7.9 with use (P = 0.04). Serum thyroglobulins off thyroid hormone in total cases were 0.6 and 0.2, respectively (P = 0.42). The rate of postoperative complications including transient hypocalcemia (n = 8) and transient recurrent laryngeal nerve palsy (n = 2) were low between the 2 groups without a significance. Utilization of the snake retractor facilitated safely effective CND with using of 2 arms simultaneously, while providing a superior view to that obtained with robotic thyroid surgery using bilateral axillo-breast approach.