Robotic thyroid surgery using bilateral axillo-breast approach: personal initial experience over two years.

AIM: Although endoscopic thyroid surgery is gaining wide acceptance, however, manual endoscopic operation also has shown several limitations. The advent of robotic surgical systems, such as the da Vinci surgical system (Intuitive Surgical, Mountain View, CA, USA), is expected to make it possible to overcome some limitations of manual endoscopic operation. Herein we report a single surgeon (H.Y.K.)'s initial two-year experience of new robotic thyroid operations using the bilateral axillo-breast approach (BABA), the approach which has definite advantages and recently has been widely used for the traditional endoscopic thyroid surgery. METHODS: Between July 2008 and July 2010, 93 patients underwent robotic thyroid surgery using the BABA, with the da Vinci-S surgical system, at the Korea University Anam Hospital, Seoul, Korea. The data on the patients' clinicopathological characteristics, operation types, operation times, surgical results, postoperative hospital stays and complications were collected in a prospective manner, and later evaluated. RESULTS: Seventy-two total thyroidectomies with or without central neck dissections mostly for the papillary carcinomas, twenty lobectomies with or without central neck dissections for the minute ­ smaller than 0.5 cm in their maximal diameter ­ papillary carcinomas, follicular neoplasms and benign tumors, and a bilateral subtotal lobectomy for the multinodular goiter were performed robotically. There was no conversion of robotic procedure to traditional endoscopic or open procedure. The mean total operation time was 288.5±48.0 minutes. The mean number of retrieved lymph nodes by the central neck dissection was 5.1±1.97 (range, 0-12). The mean hospital stay of the patients was 2.8±1.2 days. And the mean postoperative 3rd month serum thyroglobulin level in patients undergone total thyroidectomy was 0.3±0.14 ng/mL (range, 0.08-1.95). Three (3.2%) patients suffered from transient hoarseness postoperatively, but all of them recovered in three months. Transient hypocalcemias were observed in 17 out of 72 (23.6%) patients who had undergone total thyroidectomy, but none of them left permanent. No other complication, such as bleeding, infection, neither fluid collection, was observed. CONCLUSION: Our initial surgical results of robotic thyroid surgery using BABA demonstrate the feasibility and safety of the procedure in the treatment of benign tumors and early differentiated carcinomas.

Invasive ductal carcinoma arising in ectopic breast tissue of the axilla. Case report and review of the literature.

Mammary carcinoma arising in ectopic breast tissue is an uncommon occurrence. Most reported cases have involved ductal carcinoma, but other types, such as medullary, papillary, and lobular carcinomas, have been described. For pathologists, the diagnosis of mammary carcinoma arising in ectopic breast tissue can be difficult, especially in the axilla, where carcinoma of adnexal origin must be excluded. We describe a 51-year-old woman who developed invasive secretory ductal carcinoma in ectopic left axillary breast tissue and micrometastatic carcinoma in an ipsilateral axillary lymph node. The carcinoma arose in a left axillary mass that had been present for several years, from which she had secreted fluid during prior menstrual periods.

Thyroidectomy with ultrasonic dissector: a multicentric experience.

INTRODUCTION: We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery. PATIENT AND METHODS: Between January 2007 and December 2009 a CCT was conducted on 2.736 consecutive patients admitted to our clinical wards, who had undergone thyroidectomy for goitre or thyroid carcinoma. They were divided in two group: 1.021 patients (203 male and 818 female) underwent thyroidectomy with ultrasonic dissector (UAS) and 1.715 patients (369 male and 1.346 female) underwent throidectomy with conventional technique (vessel ligation and tight) (CT). RESULTS: The operative time (UAS 80 minutes mean, 50 to 120 min., vs CT 120 minutes, 70 to 180 minutes) was much lower in the thryoidectomy with UAS group. The incidence of transient laryngeal nerve palsy (UAS 17/1.021 patients. 1.6% vs CT 16/1.715 patients, 0.9%) was higher in the thyroidectomy with UAS group; the incidence of permanent laryngeal nerve palsy was similar in two groups(UAS group; there are no relevant difference in the incidence of permanent hypocalcemia (UAS 26/1.021 patients, 2.5% vs 35/1.715 patients, 2%) which was similar in two groups. Also the average post-operative hospitalization was similar in two groups (2 days). CONCLUSIONS: Actually, the only significant advantage shown from this CCT is represented in terms of cost-effectiveness (reduction of the usage of operating room and hospitalization) for patients treated with UAS, subsequent to the significant reduction of operative duration. Although the analysis showed that the patients who were treated with ultrasonic dissection don't present more favourable results in incidence of post-operative transient complication:transient laryngeal nerve palsy (1.6% in UAS vs 0.9% in CT) and transient hypocalcaemia (9.5% in UAS vs 7.7% in CT). There is no significant difference in the incidence of permanent laryngeal nerve palsy (0.9% in UAS vs in 1% CT). The experience of surgeon is the only important factor which can influence the appearance of these complications; the usage of Ultrasonic dissector can only help surgical action but can't repair the experience of the operator.

Ultrasound scissors versus electrocautery in axillary dissection: our experience.

The ultrasound scissors are recently emerging as an alternative surgical tool for dissection and haemostasis and have been extensively used in the field of minimally invasive surgery. We studied the utility and advantages of this instrument compared with electrocautery to perform axillary dissection. The operative and morbidity details of thirty-five breast cancer patients who underwent axillary dissection using the ultrasound scissors were compared with 35 matched controls operated with electrocautery by the same surgical team. There was no significant difference in the operating time between the ultrasound scissors and electrocautery group (36 and 30 mins, p>0.05). The blood loss (60 +/- 35 ml and 294 +/- 155 ml, p<0.001) and drainage volume (200 +/- 130 ml and 450 +/- 230 ml, p<0.001) were significantly lower in the ultrasound scissors group. There was a significant reduction of draining days in ultrasound scissors group (mean one and four days, respectively p<0.05). There was significant difference in the seroma rate between the two groups (10% and 30%, respectively). Axillary dissection using harmonic scalpel is feasible and the learning curve is short. Ultrasound scissor significantly reduces the blood loss and duration of drainage as compared to electrocautery.

[Complications of thyroid surgery: cervical thoracic duct injuries]. / Complicanze chirurgiche della tiroidectomia: le lesioni del dotto toracico.

Thoracic duct injury is uncommon in surgery of the neck: relatively more common after laryngeal and esophageal surgery, rare in thyroid surgery. From January 1986 to June 2009 were treated 14 patients with lesions of the cervical thoracic duct undergo surgery for thyroid disease: 4 goitre cervico-mediastinal and 10 total thyroidectomy for cancer, 9 of which have laterocervical left lymphadenectomy. In 2 cases, the intraoperative detection has allowed immediate ligature. In 12 patients a cervical chylous fistula without chilothorax was found: 5 low-flow fistulas and 7 high-flow fistulas. Of the 5 cases of low-flow fistula, 4 were recovered after 1 month of conservative treatment, only 1 patient required surgical correction. The 7 patients with high-flow fistula were undergoing surgery: 4 in the first week post-operative and 3 after a period of more than 30 days of medical therapy. In patients with high-flow fistula prolonged medical treatment does not provide benefit and increase the risk of complications during and after surgery.

Recurrences of thyroid well differentiated cancer: ultrasonography-guided surgical treatment.

AIM: Differentiated thyroid carcinomas (DTC) have a favourable outlook overall. Cornerstone of treatment is total thyroidectomy (TT), followed, if needed, by radiometabolic therapy. Such lesions however show a definite tendency to recur (about 35% of cases), generally in the first decade of follow-up: in 70% of patients such recurrence is local. Surgical resection is the only curative treatment option for local recurrence of well-differentiated thyroid cancer. Intraoperative ultrasonography (US) can be of significant help in facilitating localization and complete resection of lesions. The aim of the study was to review the authors' own experience with the use of such diagnostic method in the clinical setting of thyroid neoplasm recurrence. METHODS: Between January 2005 and March 2008 31 patients with DTC recurrences underwent intraoperative US exploration. Recurrences were easily identified and resected in all patients. Postoperative tireoglobuline (TG) was undetectable. RESULTS: In all 31 patients preoperative US confirmed the presence of the lesion. In 26 patients digital exploration of the surgical field did not yield a definitively positive finding, whereas in 5 the lesion was easily palpable. Intraoperative US revealed the presence of pathologic tissue in all cases, with examination time ranging from 4 to 14 minutes (median 8 minutes). In all cases surgical resection was complete, with pathologic confirmation of the sample, and no necessity to extend ablation. CONCLUSION: Intraoperative US can be of significant help in the identification of DTC recurrences, in particular when lesion dimensions are smaller than 10 mm in diameter and can facilitate a more radical excision of the tumor in a surgical field were anatomical landmarks can be altered by previous surgery and/or radiometabolic therapy.

Surgical treatment of sporadic medullary thyroid carcinoma: strategy and outcome.

BACKGROUND: Medullary Thyroid Carcinoma (MTC) originates from the thyroid C cells and accounts for approximately 5-9% of all thyroid cancers. Aim of this study was to retrospectively evaluate the outcomes of 41 patients with MTC who underwent treatment at our institution. PATIENTS AND METHODS. We reviewed the records of 41 patients who underwent surgery between 1995 and 2004. The patients were divided into two groups: A) patients (n 30) without any previous surgery. B) patients (n 11) previously thyroidectomized and high calcitonin levels with or without radiological evidence of local regional or distant metastases. We performed total thyroidectomy with central compartment lymphadenectomy and ipsilateral modified radical neck dissection in group A patients. Group B patients underwent re-excision of the central neck compartment and bilateral modified radical neck dissection if it had not been previously performed. RESULTS: Most patients had major reduction in postoperative calcitonin levels. Compartmental dissection of the cervical node significantly improved the results of primary surgery and calcitonin returned to normal levels in approximately 60% of the patients in group A, but only the 30% of the patients in group B. CONCLUSIONS: The extent of the primary surgical resection and the evidence of local or distant metastases significantly influence the outcome of MTC patients. An extensive lymphadenectomy performed early in the treatment and re-operative cervical lymphadenectomy in patients with persistently high calcitonin levels after thyroidectomy significantly improved the outcome, although re-operation rarely results in normalized calcitonin levels and is associated with a higher incidence of complications.

[Laparoscopic approach versus laparotomy for suspected acute appendicitis]. / Approccio laparoscopico versus laparotomia per sospetta appendicite acuta.

Acute appendicitis is one of the most common surgical disease but, in spite of the progression diagnostic imaging, a definite diagnosis is frequently difficult and often is based in essentially clinical grounds. The Authors retrospectively analyze the results of conventional laparotomic appendectomy (CLA) and videolaparascopic appendectomy (VLA) as performed by two teams of their Department of Surgery. Between January 2000 and November 2001, 156 patients, age ranging from 3 to 67 yrs, underwent surgery because suspected acute appendicitis; 96 patients underwent VLA and 60 patients underwent CLA; a diagnosis of acute appendicitis was confirmed in 142 cases (91%). The patients who had a confirmed diagnosis of acute appendicitis were grouped according to clinical-pathologic criteria into follicular, gangrenous and complicated appendicitisi; operating time, complications and length of hospital stay were compared among the three groups. VLA resulted superior to CLA in terms of diagnostic performance: among the patients with suspected acute appendicitis, VLA allowed to establish a different diagnosis in 41% as compared to 13% with CLA. In two cases (2.08%) VLA was turned into CLA. There were non differences between VLA and CLA in terms of surgical operating time and hospital stay. A significantly higher incidence of surgical complications, such as wound infections and pelvic abscesses, was observed in the CLA group as compared to VLA. The Authors conclude that VLA allows a complete exploration of the abdomen, a better localization of the appendix and an easier diagnosis of unexpected conditions or pathologic processes associated with the clinical appendicitis; further, VLA is gravated by fewer complications.