Conventional 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
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.
A 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.
Out 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.
This 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.
Background
The aim of this study was to evaluate the safety and efficacy of transoral robotic and endoscopic thyroidectomy.
Methods
We analyzed and compared the first 100 cases of transoral robotic ...(71 cases) and endoscopic (29 cases) thyroidectomy with 207 cases of conventional transcervical thyroidectomy.
Results
Transoral thyroidectomy was completed successfully in all patients, except for three who were converted to the robotic facelift or transcervical approach. The mean operative time of the transoral procedure was significantly longer than that of the conventional procedure. Perioperative complications such as hypoparathyroidism, vocal cord palsy, hematoma, and seroma did not differ between the two groups. However, there were some unusual complications such as CO2 embolism, surgical site infection, skin trauma, burn, and ecchymosis in transoral thyroidectomy. Postoperative cosmesis was significantly better in the transoral group.
Conclusion
Transoral robotic and endoscopic thyroidectomy is feasible and comparable to conventional transcervical thyroidectomy in highly selected patients.
Background
Transoral thyroidectomy has superior cosmesis and better postoperative voice outcomes than conventional thyroidectomy. However, it usually requires a steep learning curve and longer ...operative time. The transoral robotic thyroidectomy (TORT) learning curve has not been well investigated. This study aimed to evaluate the TORT learning curve and factors affecting operative time.
Methods
We retrospectively studied 173 consecutive patients who underwent TORT with or without central neck dissection from July 2017 to August 2021. We assessed the TORT learning curve using operative time, complication rate, and surgical success (procedure conversion) rate. The operative time and surgical success rate learning curves were calculated using the cumulative summation (CUSUM) method. Additionally, we analyzed factors affecting operative time in TORT.
Results
Total thyroidectomy operative time was significantly longer than those of lobectomy and isthmusectomy (
p
< 0.001). In correlation analysis, a significantly positive correlation was observed between body mass index (BMI) and operative time (
R
2
= 0.04,
p
= 0.025). The TORT learning curve was 52 cases in the CUSUM operative time analysis. In the CUSUM surgical success rate chart, the turning point was the 55th case. Complication and procedure conversion rates were significantly decreased after the learning curve.
Conclusions
The CUSUM learning curve of TORT was about 52–55 cases, and the operative time, total complication rate, and procedure conversion decreased significantly after the learning curve. The operative time was associated with the extent of thyroidectomy and BMI.
Graphical abstract
Background
Carbon dioxide (CO2) embolism is a serious, although rare, complication of remote access thyroidectomy using CO2 insufflation. Recently, we encountered a case of CO2 embolism during ...transoral thyroidectomy, and present it here with a review of the literature.
Methods and Results
A 59‐year‐old female patient with papillary thyroid carcinoma underwent transoral robotic thyroidectomy with CO2 insufflation. During skin flap elevation, the anterior jugular vein was lacerated. Simultaneously, an electrocardiogram (ECG) showed bradycardia with premature atrial complexes, followed by asystole. After 2 cycles of cardiopulmonary resuscitation with an injection of 1‐mg epinephrine, spontaneous circulation returned, and sinus tachycardia with ST segment elevation was noted in ECGs. The patient's vital signs returned to normal within 30 minutes, and normal sinus rhythm was observed. She was discharged on postoperative day 7, without neurologic and cardiac deficit.
Conclusion
The possibility of CO2 embolism during transoral thyroidectomy with CO2 insufflation should not be overlooked.
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.
Background
The transoral thyroidectomy vestibular approach has been utilized via both robotic (TORTVA) and endoscopic (TOETVA) techniques to perform thyroidectomy. However, there have been no studies ...evaluating outcomes between these approaches. Here we describe our outcomes for thyroid lobectomy with TORTVA and TOETVA.
Methods
All cases of transoral vestibular approach thyroid lobectomy at Johns Hopkins Hospital were reviewed. Primary outcomes and demographic data were then compared between TORTVA and TOETVA.
Results
Twenty‐seven cases were identified, 7 using the robotic approach and 20 using the endoscopic approach. The procedural success rate for the robotic and endoscopic cohorts was 5 of 7 (71%) and 19 of 20 (95%), respectively (P = .15). There were no persistent nerve injuries, mental, or recurrent in either cohort. Median operative time for TOETVA was 188 minutes versus 322 minutes for TORTVA (P = .001).
Conclusion
Thyroid lobectomy can be safely performed via both techniques, although performed more quickly endoscopically, which is likely due in part to differences in the learning curves.
Background
This study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce ...our novel two-step retraction method.
Methods
START was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed.
Results
Among the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13–58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m
2
(range: 15.9–37.0 kg/m
2
). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method.
Conclusions
START is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.
Background
The aim of this study was to evaluate the feasibility, safety, and early surgical outcomes of transoral thyroidectomy and to compare robotic and endoscopic procedures.
Methods
A total of ...37 patients underwent robotic (23 cases) or endoscopic (14 cases) transoral thyroidectomy. We compared the outcomes of the two procedures.
Results
Of the 37 patients, 2 were converted to the robotic facelift approach as a result of an intraoperative CO2 embolism and inability to remove the tumor. The mean operative time was 172.8 ± 37.5 minutes. Transient recurrent laryngeal nerve palsy occurred in one case, and transient hypoparathyroidism in two cases. Most of patients were satisfied with the postoperative cosmesis. There were no significant differences between the robotic and endoscopic procedures, except for operative time, which was significantly longer in the robotic group.
Conclusion
Robotic and endoscopic transoral thyroidectomies are both feasible and safe in appropriate patients.
To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral ...approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.
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