Advances in the assessment of cosmetic outcomes, sensory alteration in surgical areas, and health-related quality of life of endoscopic thyroidectomy.

BACKGROUND: Endoscopic thyroidectomy has been preliminarily proven effective and safe for thyroid diseases. The cosmetic outcomes and life quality are critical contents of postoperative assessment. This review will primarily focus on the assessment methods and results related to cosmetic outcomes, sensory alteration of surgical area, and quality of life following endoscopic thyroidectomy. METHODS: A comprehensive search of published articles within the last decade was conducted using the terms "endoscopic/robotic thyroidectomy," "patient satisfaction scores," "questionnaire," "quality of life," and "cosmetic" in PubMed. RESULTS: Assessment methods for postoperative cosmetic satisfaction and sensory alterations encompassed verbal/visual analog scales, scar evaluations, Semmes-Weinstein monofilament tests, and more. The evaluation of postoperative quality of life in endoscopic thyroidectomy involved tools such as SF-36, SF-12, thyroid-specific questionnaires, thyroid cancer-specific quality of life questionnaires (THYCA-QOL), as well as assessments related to voice and swallow function. The cosmetic results of endoscopic thyroidectomy generally surpassed those of open thyroidectomy, while the quality of life in endoscopic procedures was either superior or equivalent to that in open thyroidectomy, especially with respect to general health, role emotion, and vitality. CONCLUSIONS: Assessments of cosmetic outcomes and sensory alterations following endoscopic thyroidectomy predominantly relied on patients' subjective feelings. The objective and subjective perspectives of scar assessments remain underutilized. In addition, postoperative laryngoscopy and voice function assessments in endoscopic thyroidectomy procedures require more attention.

Oncologic safety and surgical outcomes of the different surgical approaches of endoscopic thyroidectomy for papillary thyroid carcinoma.

PURPOSE: To evaluate the oncologic safety and surgical outcomes of endoscopic thyroidectomy (ET) performed via different surgical approaches for papillary thyroid carcinoma (PTC). METHODS: We reviewed the medical records of PTC patients who underwent ET between May 2015 and May 2021, at the Department of General Surgery, Beijing Friendship Hospital (affiliated with Capital Medical University). The patients were divided into three groups: the ET via breast approach (ETBA) group, the transoral ET vestibular approach (TOETVA) group, and the ET via transaxillary approach (ETTA) group. We evaluated the safety and surgical outcomes of each of these ET approaches. RESULTS: A total of 490 patients were included in the analysis: 416 in the ETBA group, 57 in the TOETVA group, and 17 in the ETTA group. There were no significant differences among the groups in clinicopathologic characteristics or surgical procedures, or in the incidences of complications such as hematoma, subcutaneous emphysema, infection, and chyle. The incidences of transient and permanent recurrent laryngeal nerve (RLN) injury were 1.4% and 4.3%, respectively, with no significant difference among the three groups. The incidences of transient and permanent postoperative hypoparathyroidism were 13.7% and 1.4%, respectively. The incidence of transient hypoparathyroidism in the TOETVA group was 1.7%, which was significantly lower than that in the ETBA group. The postoperative 1-, 3- and 5-year rates of disease-free survival were 99.5%, 96.8%, and 95.9%, respectively. Univariate and multivariate analyses showed that ET was not a significant risk factor for recurrence or metastasis (p = 0.83 and p = 0.49, respectively), regardless of the surgical approach. CONCLUSIONS: TOETVA may be associated with a lower incidence of temporary hypoparathyroidism than ETBA. Apart from this difference, ETBA, ETTA and TOETVA showed comparable oncologic safety and surgical outcomes.

Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy.

INTRODUCTION: The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated. METHODS: Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100µV with a stimulation level intensity of 1-2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT). RESULTS: The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope. CONCLUSIONS: A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.

Comparison between 3-dimensional and 2-dimensional endoscopic thyroidectomy for benign and malignant lesions: a meta-analysis.

BACKGROUND: The use of 3-dimensional (3D) endoscopic thyroidectomy (ET) has been increasing, but its feasibility and safety have not been well documented for thyroidectomy. Hence, to systematically investigate the comparative outcomes during 3D-ET and 2-dimensional (2D) ET for benign and malignant lesions, we conducted this meta-analysis. METHODS: Based on the PRISMA guidelines, a systematic database search of the PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Chinese Wanfang databases was performed. The eligible studies were published in English and Chinese up to October 2020. The major endpoints evaluated were procedure time, blood loss, postoperative drainage, postoperative hospitalization, postoperative complications, total number of lymph node dissections (LNDs), and total cost. RESULTS: A total of 15 relevant studies including 1190 patients (583 for 3D-ET and 607 for 2D-ET) compared the application of 3D and 2D laparoscopic systems in thyroid surgery, of which 8 were endoscopic benign thyroidectomy (EBT) and 7 were endoscopic malignant thyroidectomy (EMT). Our meta-analysis indicated that 3D-ET generally had advantages over 2D-ET in terms of procedure time (P = 0.000), blood loss (P = 0.000), postoperative drainage (P = 0.000), postoperative complications (P = 0.000), and LNDs (P = 0.006). However, there were no significant differences between the two systems in terms of total cost (P = 0.245) or postoperative hospitalization (P = 0.068). Subgroup analysis showed consistency of the overall outcomes in each subset, but a shorter postoperative hospitalization in 3D-EBT was revealed. CONCLUSIONS: Compared to 2D-ET, 3D endoscopic thyroidectomy is an efficient, safe, and reliable method with better depth perception and stereoscopic vision, and an equally satisfactory outcome. More clinical RCTs with long-term follow-up are required to reproduce these promising results.

Transoral endoscopic thyroidectomy using vestibular approach: A single center experience.

Background: Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique. Materials and Methods: We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel. Results: From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline. Conclusion: Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

Scarless neck endoscopic thyroidectomy via the breast approach: A preliminary report of 45 cases with total or near-total thyroidectomy plus central compartment dissection.

BACKGROUND: There are various endoscopic techniques for thyroid carcinoma dissection but few reports regarding the scarless neck technique and central compartment dissection (CCD) via the breast approach, especially for bilateral CCD are available. In this study, we reported 45 cases with scarless neck endoscopic total or near-total thyroidectomy plus CCD via the breast approach. MATERIALS AND METHODS: Forty-five female patients with papillary thyroid carcinoma (PTC) were enrolled in the study, from January 2011 to March 2013. In brief, 5 mm ultrasonic coagulation device (Harmonic Scalpel, HS; Ethicon Endosurgery, USA) was used to perform thyroid vessel management and thyroidectomy. Twenty patients underwent total thyroidectomy and 25 underwent near-total thyroidectomy. CCD was performed in all 45 patients, including 13 with bilateral CCD and 32 with ipsilateral CCD. RESULTS: The procedure was successful for all 45 patients. Sixteen patients (35.6%) had lymph node metastases in central compartments. Postoperative transient adverse events included voice changes (9 patients) and hypocalcemia (18 patients), including 7 (21.9%) in the unilateral group and 11 (84.6%) in bilateral group. There was no permanent hypocalcemia or recurrent laryngeal nerve (RLN) palsy. None of the case were converted to open surgical procedure. All patients were satisfied with the cosmetic result of the scarless neck endoscopic thyroidectomy (SET). No evidence of residual or recurrent disease was found during a mean follow-up of 22.84 months (range, 12-34 months). CONCLUSIONS: Experienced thyroid surgeons performed the scarless neck endoscopic total or near-total thyroidectomy plus unilateral or bilateral CCD via the breast approach for selected PTC patients. The procedure was safe and feasible with excellent cosmetic results.

Application of transoral continuous intraoperative neuromonitoring in natural orifice transluminal endoscopic surgery for thyroid disease: a preliminary study.

BACKGROUND: The novel concept of continuous intraoperative neuromonitoring (Cont-IONM) through stimulation of the vagal nerve has been used in thyroidectomies to prevent imminent injury of the recurrent laryngeal nerve (RLN). This article reports on this technology and the results of using transoral Cont-IONM in natural orifice transluminal endoscopic surgery for thyroid disease. METHODS: Cont-IONM of the RLN was achieved through automatic cyclical stimulation of the vagal nerve using a C2 monitor and delta stimulating electrode. During the operation, three vestibular incisions were made, and the stimulating electrode was transorally inserted, with its cable line lying outside the trocar. The vagal nerve was gently dissected, looped, and then enveloped by the electrode cuff. Electromyography (EMG) of the vocalis muscle was performed, and the alarm was set to activate when the EMG amplitude reduced by 50% and latency was prolonged by 10%. Demographic data and outcome variables, including incremental time required to achieve Cont-IONM, were obtained. RESULTS: A total of 20 patients (28 nerves at risk) undergoing a transoral endoscopic thyroidectomy vestibular approach were enrolled in this study. All Cont-IONM procedures were successfully completed. In all patients, the stimulation was set at 0.7 milliamps every 1 s, and Cont-IONM use was unassociated with any untoward neural, cardiovascular, or gastrointestinal sequelae. On average, the ipsilateral Cont-IONM procedure required 10.33 ± 2.57 min to complete. Except for one instance, no significant problems occurred with electrode displacement. In one patient, a combined EMG event occurred, which improved after releasing the thyroid retractor, and the patient had no vocal cord paralysis postoperatively. CONCLUSION: Cont-IONM is feasible and safe to use during transoral endoscopic thyroidectomies and may assist in the early detection of adverse EMG changes, thereby preventing paralysis of the RLNs.

Endoscopic thyroidectomy using the EZ-VANS method.

PURPOSE: Several video-assisted and robotic surgery techniques have been reported for resection of the thyroid and parathyroid glands. Our institute has started performing endoscopic thyroidectomy using the Lap-protector and E·Z-access system, referred to as E·Z-access using video-assisted neck surgery (EZ-VANS). In this report, we evaluate the safety and efficacy of this technique. METHODS: From January 2007 to September 2014, 110 patients underwent resection of a primary thyroid tumor, 73 who underwent a cervical collar incision (the Open group) and 37 underwent EZ-VANS (the EZ-VANS group). RESULTS: The average operating time was 159 and 172 min in the Open group and EZ-VANS group, respectively; the amount of blood loss was 46.5 and 54.7 ml, respectively; and the length of hospital stay after surgery was 4.3 and 5.2 days, respectively, with no significant differences observed between the two groups. The learning curve for the EZ-VANS technique was shorter than for open surgery. CONCLUSIONS: We confirmed that the EZ-VANS technique is a safe and useful method for resection of benign and early malignant thyroid tumors.

A systematic review and meta-analysis comparing outcomes between robotic-assisted thyroidectomy and non-robotic endoscopic thyroidectomy.

BACKGROUND: Despite its feasibility, using the da Vinci robot in remote-access thyroidectomy remains controversial. This meta-analysis compared surgical and oncological outcomes between robotic-assisted thyroidectomy (RT) and non-robotic endoscopic thyroidectomy (ET). METHODS: A systematic review was performed to identify studies comparing outcomes between RT and ET. Outcomes included operating time, drain output, complications, number of central lymph nodes retrieved, and preablation stimulated thyroglobulin level. A random-effects model was used. RESULTS: Six studies were eligible. Of the 3510 patients, 2167 (61.7%) underwent RT whereas 1343 (38.3%) underwent ET. Despite a higher drain output (185.8 mLs versus 173.3 mLs, P = 0.019), RT had fewer temporary recurrent laryngeal nerve injury (2.6% versus 3.3%, P = 0.035) and shorter length of hospital stay (3.4 d versus 3.5 d, P = 0.030). In terms of oncological outcomes, despite higher incidence of multicentricity and larger tumors, the number of central lymph nodes retrieved during unilateral central neck dissection in RT was significantly greater than ET (4.5 ± 2.6 and 3.4 ± 2.5, P < 0.001) whereas the preablation stimulated thyroglobulin was comparable (0.8 ng/mL versus 1.1 ng/mL, P = 0.456). However, follow-up data were relatively scarce. CONCLUSIONS: Adding the robot in remote-access thyroidectomy was associated with a significantly lower risk of temporary recurrent laryngeal nerve injury and shorter length of hospital stay. However, despite achieving a comparable level of surgical completeness for low-risk differentiated thyroid carcinoma between RT and ET, this study highlighted the limitations with the current literature and the need for more prospective studies with adequate follow-up.

The CUSUM analysis of the learning curve for endoscopic thyroidectomy by the breast approach.

OBJECTIVES: To evaluate the learning curve for endoscopic thyroidectomy by the breast approach (ETBBA) based on the cumulative summation (CUSUM) technique. METHODS: The study included 110 consecutive patients who underwent ETBBA by a single surgeon between January 2009 and May 2012 at the Xiangya Hospital of Central South University, Changsha, China. The learning curve was evaluated using the CUSUM technique. The patients were chronologically arranged into 3 phases by the CUSUM analysis for operative time. Demographic data and operative parameters were also analyzed. RESULTS: The mean operative time (OT) was 125.3 minutes. The conversion rate for technical difficulties and the definitive complication rate were 6.4% and 10%, respectively. The learning curve was analyzed mainly by OT using the CUSUM technique. There was a significant improvement in the average OT (P < .05) after the first 27 patients and again after the first 67 patients (P < .05). A downward trend in OT was found up to the last patient. There were similarities in gender, tumor size, extent of surgery, blood loss, histology, hospital stay, conversion rate, and complications among the 3 phases. Comparison of 2 neighboring phases also showed no significant differences in age. CONCLUSIONS: ETBBA performed by surgeons has a remarkable learning curve. There were 27 cases in the early stage of the learning curve, whereas mastery level could be achieved with 67 cases.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma.

BACKGROUND: The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease. DATABASE: This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series. CONCLUSION: In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

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

Purpose: 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 via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy. Methods: 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. Results: 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. Conclusions: 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.

Neural Monitoring of the External Branch of the Superior Laryngeal Nerve During Transoral Thyroidectomy.

OBJECTIVES/HYPOTHESIS: There is no study regarding intraoperative neural monitoring (IONM) of the external branch of the superior laryngeal nerve (EBSLN) during transoral thyroidectomy. The objective of this study was to evaluate the feasibility and success rate of electrical identification of the EBSLN during transoral robotic or endoscopic thyroidectomy. STUDY DESIGN: Case series study. METHODS: We studied a cohort of 76 patients (87 nerves at risk, (NARs)) who underwent transoral robotic or endoscopic thyroidectomy and simultaneous intermittent IONM between July 2017 and May 2019. We performed the standard IONM procedure plus routine neural monitoring of the EBSLN. IONM and surgical outcome data were prospectively collected. RESULTS: Sixty-one patients underwent the robotic procedure, and 15 patients underwent the endoscopic procedure. Thirty-seven external branches of the superior laryngeal nerves at risk (42.5%) were electrically identified using electromyography signals (31 NARs, 35.6%) or cricothyroid muscle twitches (6 NARs, 6.9%). The mean pre-(S1) and post-dissection (S2) amplitudes of the EBSLN were 372 ± 147 and 351 ± 159 µV, respectively. The identification rates were not different between the robotic and endoscopic procedures. In comparing the early 20 NARs (18 patients) and the later 67 NARs (58 patients), the identification rate was higher in the later cases, although the difference was not statistically significant (25.0% vs. 47.8%, P = .079). CONCLUSION: IONM of the EBSLN is feasible and useful in identifying and preserving the nerve during transoral thyroidectomy, although the identification rate of the nerve is relatively low. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E671-E676, 2021.

Robotic thyroid surgery.

Various remote access robotic thyroidectomy techniques have been developed using the da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA) to hide or avoid neck scarring and overcome the limitations of endoscopic thyroidectomy. Among those used today are the gasless transaxillary approach, the bilateral axillo-breast approach (BABA), the gasless postauricular facelift approach, and the transoral approach. Especially, the recently introduced transoral approach (including robotic and endoscopic procedures) is prominent and now popular worldwide. The most significant advantages of remote access robotic thyroidectomy are excellent postoperative cosmesis and voice outcomes. The important limitations to the adoption of robotic thyroidectomy are the difficult technique, high complication rate during the learning curve, and high cost. In addition, cultural differences, longer operative times, and medicolegal issues are a barrier to the diffusion of robotic thyroidectomy. However, remote access robotic thyroidectomy is feasible, and the outcomes are comparable to those of conventional transcervical thyroidectomy if performed by experienced surgeons in highly selected patients. This article reviews the evolution and recent advances in robotic thyroid surgery.

Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to carbon dioxide gas insufflation: A comparative analysis of 131 cases.

Although transoral endoscopic thyroid surgery affords several advantages, the use of carbon dioxide (CO2) gas to create and maintain the working space may cause complications such as subcutaneous emphysema and a CO2 embolism. We have used a self-retaining retractor as an alternative to CO2 gas insufflation for some time; we here report its feasibility and safety. We reviewed the medical records of 131 patients who underwent transoral endoscopic thyroid lobectomy; we compared the "CO2 group" and the "retractor" group. All thyroid tumors were completely removed with negative surgical margins. No major complication occurred in the retractor group. Two major events occurred in the CO2 group: one case of permanent vocal cord palsy and one CO2 embolism. Significant subcutaneous emphysema of the neck and chest were noted in 17.7% of CO2 group patients, but in no retractor group patient. Wound infection occurred in one patient in each group but improved after appropriate management. The total operation times from incision to suture did not differ significantly between the two groups (p = 0.514). Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to CO2 gas insufflation is feasible and safe. The superiority of transoral endoscopic thyroidectomy would be emphasized by avoiding CO2 gas insufflation, thus eliminating the risk of CO2 gas-related complications.

Indications, benefits and risks of transoral thyroidectomy.

The advancement of minimally invasive surgery in the field of endocrine surgery over the last 2 decades has fostered the attempt of natural orifice transluminal endoscopic surgery (NOTES) for thyroidectomy and parathyroidectomy via oral incisions. This technically demanding surgery is currently being evaluated in a number of specialised centres. The procedure has gained popularity worldwide and is performed in more than 50 centres. By retrieving information from published or presented articles and direct personal communications, this study reports several issues to enable and optimise correct patient and surgeon candidacy, present the advantages and prevent novel complications under the standards of open thyroid surgery. Not all patients are eligible for the transoral approach. Transoral endoscopic and robotic procedures were described and critically analysed in this study.

Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature. / Tiroidectomía sin incisión cervical por abordaje endoscópico biaxilo-biareolar. Primeras impresiones tras su introducción en una unidad especializada. Revisión de la literatura.

INTRODUCTION: The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature. METHODS: Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4). RESULTS: All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high. CONCLUSION: Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Minimally-invasive endocrine neck surgery. / Cirugía endocrina cervical mínimamente invasiva.

Minimally invasive approaches for endocrine surgery of the neck are the result of efforts by several surgeons to extrapolate to neck surgery the proven benefits of minimally invasive techniques from other regions of the body, including less pain, morbidity and hospital stay. However, the main argument that led to the introduction of these techniques was the improvement of esthetic results. Endoscopic and robotic remote-access endocrine neck approaches through small incisions have been developed over the last 25 years and are constantly being refined. The objective of this review is to determine the current state of the literature through a systematic evaluation of the different techniques available in minimally invasive endocrine surgery of the neck, either with or without remote access, by describing their main characteristics and evaluating their advantages, disadvantages and controversies, while discussing their role and future in neck surgery.

Transoral Endoscopic Thyroidectomy: Review of 81 Cases in a Single Institute.

OBJECTIVE: To evaluate the clinical efficacy and safety of transoral endoscopic thyroidectomy (TOET). MATERIALS AND METHODS: A total of 81 patients with thyroid nodules underwent TOET in our department from November 2011 to September 2015. The surgical outcomes, cosmetic results, and complications were evaluated. RESULTS: Seventy-nine patients were performed TOET successfully, and 2 cases were transferred to open thyroidectomy due to intraoperative CO2 embolism. The average operation time was 89.0 ± 38.6 minutes, and intraoperative blood loss was 29.3 ± 27.6 mL. Two cases experienced transient perioral numbness, and 2 cases experienced transient opening mouth pain. Two cases had transient increased saliva when swallowing. Transient anterior cervical region discomfort was found in 3 cases, and postoperative anterior cervical region infection was found in 4 cases. Other complications were not observed in any case. The average postoperative length of stay was 4.77 ± 2.61 days, and the mean follow-up period was 39.1 ± 22.6 months. During the follow-up period, there were no long-term complications or recurrent patient, and all the patients were satisfied with the cosmetic effect. CONCLUSIONS: TOET is a safe and effective procedure with a low incidence of complications and perfect cosmetic effect for patients with thyroid diseases.

Transoral endoscopic thyroidectomy: preliminary experience in Italy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.