Background
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been shown to be safe and has similar outcomes as open thyroidectomy for selected patients. It is not clear if transoral ...robotic thyroidectomy (TORT) may extend transoral endoscopic thyroidectomy to more complex thyroid operations. The study aimed to compare the safety and outcomes of TORT with those of TOETVA.
Methods
We retrospectively reviewed all patients who had TORT and TOETVA performed by a single surgeon from June 2017 to May 2019. Intrathoracic goiter and combined operations were excluded. Surgical outcomes were compared after propensity score matching. Learning curves, as measured by operating time, were evaluated.
Results
A total of 150 patients underwent 154 transoral (55 TORT and 99 TOETVA) thyroidectomy. Of the 154 operations, 28 (18.2%) were bilateral total thyroidectomy and 126 (81.8%) were unilateral thyroid lobectomy. After propensity score matching, we found a longer operative time (median interquartile range) for TORT (
n
= 53) than for the TOETVA (308 284–388 vs 228 201–267 min,
P
< 0.001). Blood loss and visual analog scale scores for pain were not significantly different between the two groups. Central neck lymph node dissection was performed more frequent in the TORT group (28 of 53 52.8% vs 10 of 53 18.9%,
P
= 0.001), and when performed, the numbers of total and positive lymph nodes did not differ significantly between the two groups. The rates of hypoparathyroidism and recurrent laryngeal nerve injury did not differ significantly between the two groups. There was no conversion to open thyroidectomy, mental nerve injury, or surgical site infection. The learning curve for TORT was 25 cases, but no obvious learning curve was observed for TOETVA.
Conclusions
TORT requires a longer operative time, but is as safe as TOETVA and may be useful for more complex thyroid operations.
Background
Transoral thyroid surgery is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. Nonetheless, technical ...obstacles have precluded the wide dissemination of this procedure. We present the surgical procedures and outcomes of transoral robotic thyroidectomy (TORT).
Methods
From September 2012 to June 2016, we performed TORT at Korea University Hospital. We used three intraoral ports and a single axillary port for the system’s four robotic arms. The surgical outcomes were retrospectively reviewed.
Results
Twenty-four female patients (mean age 39.6 ± 11.6 years; mean tumor size 1.0 ± 1.3 cm) underwent unilateral thyroid lobectomies with or without ipsilateral central neck dissection. Twenty patients had papillary thyroid carcinomas (PTC), three had benign nodules, and one had a follicular thyroid carcinoma. The mean surgical time was 232 ± 41 min; the mean hospital stay was 3.3 ± 0.8 days. The number of retrieved central lymph nodes in the PTC patients was 4.7 ± 3.2. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the median follow-up period of 16.8 months. Paresthesia of the lower lip and the chin due to mental nerve injury was observed in nine of the first 12 patients (six transient, three permanent), but no further reports of paresthesia were recorded after patient 12, when the locations of the intraoral incisions were modified.
Conclusions
TORT is feasible and safe for selected patients after technical refinements, and can be a potential alternative approach for scarless thyroid surgery.
Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and ...surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.
Background
Few studies in the literature have reported recovery data for different types of recurrent laryngeal nerve injuries (RLNIs). This study is the first attempt to classify RLNIs and rank them ...by severity.
Methods
This prospective clinical study analyzed 281 RLNIs in which a true loss of signal was identified by intraoperative neuromonitoring (IONM), and vocal cord palsy (VCP) was confirmed by a postoperative laryngoscope. For each injury type, the prevalence of VCP, the time of VCP recovery, and physical changes on nerves were analyzed. Additionally, different RLNI types were experimentally induced in a porcine model to compare morphological change.
Results
The overall VCP rate in at-risk patients/nerves was 8.9/4.6 %, respectively. The distribution of RLNI types, in order of frequency, was traction (71 %), thermal (17 %), compression (4.2 %), clamping (3.4 %), ligature entrapment (1.6 %), suction (1.4 %), and nerve transection (1.4 %). Complete recovery from VCP was documented in 91 % of RLNIs. Recovery time was significantly faster in the traction group compared to the other groups (
p
< 0.001). The rates of temporary and permanent VCP were 98.6 and 1.4 % for traction lesion, 72 and 28 % for thermal injury, 100 and 0 % for compression injury, 50 and 50 % for clamping injury, 100 and 0 % for ligature entrapment, 100 and 0 % for suction injury, and 0 and 100 % for nerve transection, respectively. Physical changes were noted in 14 % of RLNIs in which 56 % of VCP was permanent. However, among the remaining 86 % IONM-detectable RLNIs without physical changes, only 1.2 % of VCP was permanent. A porcine model of traction lesion showed only distorted outer nerve structure, whereas the thermal lesion showed severe damage in the inner endoneurium.
Conclusions
Different RNLIs induce different morphological alterations and have different recovery outcomes. Permanent VCP is rare in lesions that are visually undetectable but detectable by IONM. By enabling early detection of RLNI and prediction of outcome, IONM can help clinicians plan intra- and postoperative treatment.
Background Operative traction of the thyroid lobe is a necessary component of thyroid surgery. This surgical maneuver can cause traction injury of the recurrent laryngeal nerve (RLN), and this ...complication has been reported to be the most common mechanism of nerve injury. The goal of this study was to investigate the electromyographic (EMG) signal pattern during an acute RLN traction injury and establish reliable strategies to prevent the injury using intraoperative neuromonitoring (IONM). Methods Fifteen piglets (30 RLNs) underwent IONM via automated periodic vagal nerve stimulation and had their EMG tracings recorded and correlated with various models of nerve injury. Results In the pilot study, a progressive, partial EMG loss was observed under RLN tractions with different tension ( n = 8). The changes in amplitudes were more marked and consistent than were the changes in latency. The EMG gradually gained partial recovery after the traction was relieved. Among the nerves injured with electrothermal ( n = 4), clamping ( n = 1), and transection ( n = 1) models, the EMG showed immediate partial or complete loss, and no gradual EMG recovery was observed. Another 16 RLNs were used to investigate the potential of EMG recovery after different extents of RLN traction. We noted the EMG showed nearly full recovery if the traction stress was relieved before the loss of signal (LOS), but the recovery was worse if prolonged or repeated traction was applied. The mean restored amplitudes after the traction was relieved before, during, and after the LOS were 98 ± 3% ( n = 6), 36 ± 4% ( n = 4), and 15 ± 2% ( n = 6), respectively. Conclusion RLN traction injury showed graded, partial EMG changes; early release of the traction before the EMG has degraded to LOS offers a good chance of EMG recovery. IONM can be used as a tool for the early detection of adverse EMG changes that may alert surgeons to correct certain maneuvers immediately to prevent irreversible nerve injury during the thyroid operation.
Abstract Background Recurrent laryngeal nerve (RLN) palsy is the most common and serious complication of thyroid surgery. The use of energy-based devices (EBDs) has replaced hand-tying methods in ...many institutions. However, EBD use proximal to the RLN presents risks related to lateral thermal spread and associated nerve damage. THUNDERBEAT (TB) is one of the most widely used EBDs. This study aimed to test the safety of TB during thyroidectomy. Methods Four piglets weighing 30–40 kg experienced thyroidectomy while continuous electrophysiologic monitoring (continuous intraoperative neuromonitoring) occurred, using an electromyography endotracheal tube and NIM 3.0 response system. TB was applied at various distances from the RLN, and we assessed the safety of the protocols. Results Adverse electromyography events did not occur at distances >3 mm from the RLN. Amplitude decreased at 2 mm from the RLN after 8 s. However, immediate loss of signal occurred at 1 mm from the RLN, likely due to immediate shrinkage of surrounding tissue after TB application. Conclusions TB can be used safely at 3 mm from the RLN but must be used for <8 s at more proximal locations. This is the first report assessing the safety of TB, and findings indicate that TB should be used at least 1 mm from the RLN to avoid injury.
Abstract
This prospective, randomized controlled trial evaluated the effect of neostigmine for intraoperative neuromonitoring (IONM) during thyroid surgery. Forty subjects undergoing thyroidectomy ...with IONM, randomized into neostigmine administration after tracheal intubation (Group N, n = 20) or control treatment with normal saline (Group C, n = 20), completed the trial. Electromyography amplitudes of the vagus nerve (V1) were recorded before thyroid dissection. The time from the initial V1 signal check to successful V1 stimulation was recorded. In Group N, all the patients had a successful V1 signal at the first check, whereas ten (50%) patients in Group C had a time delay between the initial V1 check and successful V1 (
p
< 0.001). The mean delay time among the delayed patients in Group C was 11.2 ± 1.4 min. The mean time from skin incision to successful V1 stimulation was significantly shorter in Group N than in Group C (15.4 ± 2.4 min vs. 19.9 ± 5.7 min,
p
= 0.003). In Groups N and C, the mean V1 amplitudes were 962.2 ± 434.5 μV vs. 802.3 ± 382.7 μV (
p
= 0.225), respectively, and the mean R1 amplitudes were 1240.0 ± 836.5 μV vs. 1023.4 ± 455.8 μV (
p
= 0.316), respectively. There was one bucking event in Group N. In conclusion, neostigmine administration immediately after tracheal intubation can be useful to reverse neuromuscular blockade for successful IONM in thyroid surgeries.
Remote endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) seem to be beneficial in selected situations to avoid anterior neck scars. There are limited data in the literature to determine ...whether RT
a bilateral axillo-breast approach (RT-BABA) is superior to ET
a bilateral areolar approach (ET-BAA). Therefore, the aim of this study was to evaluate the surgical outcomes of RT-BABA versus ET-BAA.
Between May 2013 and May 2022, 757 patients who underwent RT-BABA or ET-BAA at a high-volume Chinese thyroid center were included. Intraoperative and postoperative outcome parameters were collected and retrospectively analyzed. The moving average method was used to evaluate the learning curve.
The proportion of patients older than 45 years was greater in the RT group than in the ET group (14.8% vs. 7.4%, p < 0.001). The percentage of overweight patients was greater in the RT group (28.8% vs. 9.5%, p < 0.001). The number of patients treated for malignant lesions was higher in the RT group (86.8% vs. 75%, p < 0.001). The rate of thyroiditis was higher in the RT group (10.9% vs. 6.6%, p < 0.001). Surgical time was significantly shorter in the RT group (140 vs. 165min, p < 0.001). Drainage volume was higher in the RT group (100 vs. 85ml, p < 0.001). Postoperative hospital stay was shorter in the RT group (3.04 ± 0.44 vs. 3.67 ± 0.89 days, p < 0.001). The cost in the RT group was higher (49627 ± 2795 vs. 25094 ± 3368 yuan, p < 0.001). Transient vocal cord dysfunction was lower in the RT group (2.9% vs. 8.0%, p = 0.003). There was no significant difference between the two groups in the number of central lymph nodes sampled, positive lymph nodes, neural monitoring (EMG) results, and rate of transient hypoparathyroidism. The learning curve for RT was 26 cases, and the operative time for ET was constant throughout the study.
RT-BABA is as safe and feasible as ET-BAA. RT-BABA performed better in some surgical outcomes. Further prospective studies are needed to confirm the safety of RT-BABA.
Background
Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because ...of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).
Methods
We retrospectively reviewed and compared the medical records of consecutive patients who underwent TORT or OT for thyroid carcinoma from March 2009 to January 2018. Propensity score matching using 10 clinico-pathologic factors was used to generate two matched cohorts, each composed of 186 patients.
Results
The study included 372 patients who underwent TORT (
n
= 186) or OT (
n
= 186). Mean age, tumor size, and gender were not different between both groups. The two groups showed similar surgical outcomes, except for a longer operative time for TORT. There was one patient with immediate postoperative bleeding in the TORT group. The patient underwent re-operation for hemostasis with endoscopic approach. In the OT group, one patient had wound seroma, which was treated by several rounds of needle aspiration without infection. Vocal cord palsy was present in one patient in the TORT group, which was recovered in 3 months.
Conclusions
TORT could be performed safely and had comparable surgical outcomes with OT in the selected patients. TORT may be a suitable operative alternative for patients who do not want to leave scars on the neck.
Highlights • Transoral thyroidectomy via a vestibular approach is an option for patients who are motivated to avoid a neck scar. • This approach does not appear to be limited by increased body mass ...index. • Advantages include limited dissection, midline access to both thyroid lobes and safe same-day discharge.
