Tumor border pattern and size help predict lymph node status in papillary microcarcinoma: A clinicopathologic study.

OBJECTIVE: Lymph node metastasis occurs in a subset of papillary microcarcinoma patients. We aimed to analyze the differences between metastatic and non-metastatic papillary microcarcinomas in order to identify a high-risk subgroup that is likely to require more aggressive treatment. MATERIALS AND METHODS: 126 thyroidectomies with lymph node dissections (central ±â€¯lateral), diagnosed as papillary microcarcinoma, were reviewed. RESULTS: Mean age of 126 patients (F/M = 3.3) was 42 years. Mean size of the largest tumor was 7 mm. Classical was the most frequently (89%) encountered subtype. Multiple histologic subtypes co-occurred in 19%. Lymphovascular invasion was present in 16% (n = 20). 55 (44%) and 71 (56%) cases were unifocal and multifocal, respectively. 90 cases (71%) were non-encapsulated with overall infiltrative tumor borders, whereas in 36 cases (29%), the tumor had a well-defined capsule. Among those, 23 (64%) had tumor capsule invasion. 47 (37%) cases had metastasis in lymph nodes. In univariate analysis, metastasis was associated with tumor size of >5 mm (p = 0.02), tumor burden of >5 mm (p = 0.03), lymphovascular invasion (p = 0.02) and non-encapsulation (p = 0.01). No associations were found regarding sex, age, histologic subtype, lymphocytic thyroiditis, tumor capsule invasion (in capsulated tumors), laterality and multifocality (p > 0.05). In multivariate analysis, lymphovascular invasion (p = 0.01, OR = 3.97, 95% CI 1.35-11.67), tumor size >0.5 cm (p = 0.031, OR = 2.92, 95% CI 1.10-7.71) and non-encapsulation (p = 0.033, OR = 2.85, 95% CI 1.08-7.51) were independent risk factors. CONCLUSION: Size (largest tumor or sum of all foci) of >5 mm, non-encapsulation and lymphovascular invasion were independent predictors of LNM in PMs. Unifocal tumors metastasize the same as multifocal tumors, suggestive of the contribution of other factors. Patients with sporadically resected microcarcinomas should be carefully followed-up, especially those that harbor risk factors in histology.

The use of focused, radioguided parathyroidectomy in geriatric patients with a history of thyroid surgery.

OBJECTIVE: Geriatric patients are often reluctant to undergo parathyroid surgery under general anesthesia because of the major comorbidities. The use of minimally invasive techniques for parathyroid lesions under local anesthesia have been published. Radioguided lesion localization has been known to decrease operative time and reduce the occurrence of positive margins in breast cancer surgery. We hypothesize that it could also be effectively used in focused parathyroid surgery in geriatric patients with in history of thyroid surgery. MATERIALS AND METHODS: Our study group consists of geriatric patients with a history of thyroid surgery who underwent focused parathyroid surgery between February 2017 and October 2019. Group-1 included 18 patients who had parathyroidectomy under radioguidance. Group-2, 22 patients who had surgery without it. Patient demographics, operative time, number of frozen sections and length of hospital stay were analyzed. RESULTS: Analyzed data were similar between groups. The mean age of the patients was 72.56±12.65 years (range: 65-88). The operative times for group-1 and group-2, were 65.42±7.78 and 74.63±15.98 minutes, respectively (P=0.002). All patients were discharged uneventfully on postoperative day-2. CONCLUSION: Radioguidance parathyroidectomy positively affected the operative time and also decreased the need for additional frozen section.

Techniques for Thyroidectomy and Functional Neck Dissection.

Thyroidectomy is a commonly performed surgery for thyroid cancer, Graves' disease, and thyroid nodules. With the increasing incidence of thyroid cancer, understanding the anatomy and surgical techniques is crucial to ensure successful outcomes and minimize complications. This review discusses the anatomical considerations of the thyroid and neck, including lymphatic drainage and the structures at risk during thyroidectomy. Emphasis is placed on the significance of cautious dissection to preserve critical structures, such as the parathyroid glands and recurrent laryngeal nerve. Neck dissection is also explored, particularly in cases of lymph node metastasis, in which its proper execution is essential for better survival rates. Additionally, this review evaluates various thyroidectomy techniques, including minimally invasive approaches, highlighting their potential benefits and limitations. Continuous surgical knowledge and expertise updates are necessary to ensure the best results for patients undergoing thyroidectomy.

Impact of Indocyanine Green Angiography on Postoperative Parathyroid Function: A Propensity Score Matching Study.

Background: Thyroidectomy constitutes an important portion of endocrine surgery procedures and is associated with various complications such as bleeding, recurrent laryngeal nerve injury, and postoperative hypoparathyroidsm. Effective parathyroid preservation during thyroid surgery is crucial for patient well-being, with current strategies heavily reliant on surgeon experience. Among various methods, Indocyanine Green Angiography (ICGA) offers a promising method for intraoperative assessment of parathyroid gland perfusion. Methods: In a retrospective study, patients undergoing bilateral thyroidectomy from January 2021 to January 2023 were analyzed, excluding those with previous thyroidectomy, parathyroid disease, or chronic kidney disease. The study compared a control group (n = 175) with an ICGA group (n = 120), using propensity score matching for statistical analysis. Matched cohorts included 120 patients in each group. The primary outcome of this study was identified as temporary postoperative hypoparathyroidism, with secondary outcomes including the rate of parathyroid reimplantation and the incidence of permanent postoperative hypoparathyroidism. Results: The ICGA group showed significantly more parathyroid autotransplantations (p < 0.01). While not statistically significant, the control group had a higher incidence of temporary postoperative hypoparathyroidism (p < 0.09). Rates of hypocalcemia on postoperative day 1 and permanent hypocalcemia were similar. Subgroup analysis indicated more postoperative day 1 hypoparathyroidism in the control group during central neck dissections (p < 0.049). Conclusions: Intraoperative ICGA use correlated with higher parathyroid autotransplantation and suggested reduced postoperative hypoparathyroidism. Changes in fluorescence intensity following a second ICG injection may provide an objective method to assess parathyroid perfusion. Further large-scale studies are needed to fully understand ICGA's impact on parathyroid preservation.

Early Post-operative Stimulated Serum Thyroglobulin: Role in Preventing Unnecessary Radioactive Iodine Treatment in Low to Intermediate Risk Papillary Thyroid Cancer.

AIM: The aims of the study are to evaluate the predictive value of early post-operative stimulated thyroglobulin (sTg) analysis on the recurrence risk, and to define a cut-off value that is related to recurrence risk in low to intermediate risk papillary thyroid cancer (PTC). METHODS: This retrospective cohort study included individuals who were diagnosed with PTC aged 18 years or older and had been operated by experienced surgeons of a tertiary university hospital between the years 2011 and 2021. The American Thyroid Association thyroid cancer guidelines version 2015 was used as the risk stratification system. Early sTg measurement obtained at 3-4 weeks after surgery when TSH >30 µIU/mL. Data was collected from the hospital database. A total of 328 patients who had post-operative early sTg values with negative anti-Tg antibodies were included. RESULTS: The median age was 44 years. Of the 328 patients, 223 (68%) were women. The median tumor diameter was 11 mm. One hundred ninety-one patients (58.2%) had low risk and 137 (41.8%) had intermediate risk for recurrent disease. Of the 328 patients, 4.0% had recurrent disease. In multivariate Cox regression, post-operative early sTg value [OR: 1.070 (1.038-1.116), P = .000], and the pre-operative malign cytology [OR: 1.483 (1.080-2.245), P = .042] were independent risk factors for recurrence. On the ROC curve analysis, the cut-off value of early sTg was 4.1 ng/mL for those with recurrent disease. CONCLUSION: This study demonstrated that early sTg could predict recurrent disease in patients with low to intermediate risk PTC. A cut-off of 4.1 ng/mL was identified with a high negative predictive value.

Single-incision laparoscopic adrenalectomy.

BACKGROUND: The aim of this study was to compare outcome measures between conventional transabdominal laparoscopic adrenalectomy and single-incision laparoscopic adrenalectomy (SILA). METHODS: Between January 2006 and April 2010, a total of 96 patients underwent laparoscopic adrenalectomy. Of these, 74 (77.1%) underwent conventional transabdominal laparoscopic adrenalectomy (group 1) and 22 (32.9%) underwent SILA (group 2). Age, sex ratio, tumor size, operating time, blood loss, postoperative visual analog pain scale (VAS) scores, and duration of hospitalization were compared between the two groups. RESULTS: The mean ages of the patients in groups 1 and 2 were 43.4 ± 12.3 and 43.3 ± 10 years, respectively (P = 0.7). The female:male ratios in groups 1 and 2 were 1.6:1 and 4.5:1, respectively (P < 0.0001). The mean tumor size was significantly larger in group 1 than in group 2 (4.7 ± 1.5 vs. 3.34 ± 1.06 cm, respectively; P = 0.093). No significant difference was found between group 1 and group 2 with respect to the mean operating time (68.4 ± 20.8 vs. 63.9 ± 16.9 min, respectively; P = 0.36) or the level of intraoperative blood loss (38 ± 26.5 vs. 48.4 ± 62.4 ml, respectively; P = 0.26). The postoperative VAS score was significantly lower in group 2 than in group 1 (2.05 ± 0.57 and 3.28 ± 0.63, respectively; P < 0.0001). The length of hospital stay was significantly higher in group 1 than in group 2 (3.04 ± 1.2 and 2.45 ± 0.96 days, respectively; P = 0.04). CONCLUSION: The findings of the present study suggest that SILA is as safe as conventional transabdominal laparoscopic adrenalectomy. Furthermore, SILA is associated with less pain and better cosmesis than the conventional laparoscopic procedure.

Concomittant occurence of well-differentiated thyroid carcinoma metastasis and chronic lymphocytic leukemia in the same lymph node along with internal jugular vein thrombus: a case report.

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is the most common adult leukemia. The coexistence of CLL and papillary thyroid carcinoma (PTC) is extremely rare. PTC sometimes shows microscopic vascular invasion but rarely cause a tumor thrombus in the internal jugular vein (IJV). It is also rare to find both differentiated and poorly differentiated types of thyroid cancer in the same metastatic location. We report a case of 63-year-old Turkish man with history of CLL who had CLL/SLL involvement and PTC metastasis in the same lymph node. Additionally, there was macroscopic metastasis to the IJV with poorly differentiated areas in the removed tumor thrombus. Patient was treated with total thyroidectomy, left radical neck dissection, resection of the left IJV segment that contained the tumor thrombus and radioactive iodine (RAI) therapy. Furthermore, metastatic lesions were found in the brain, lung and bone. Radiotherapy and chemotherapy were performed. However, our patient died approximately 12 months after thyroidectomy. To our knowledge, our present report is the first description with its current features.

Single-incision robotic adrenalectomy (SIRA): the future of adrenal surgery?

In compliance with the trend toward less invasive techniques, single incision robotic surgeries have become more common and they have been increasingly used for several surgeries including adrenalectomy. Single incision robotic adrenalectomy (SIRA) aims to combine the merits of robotic surgery with previously defined single incision laparoscopic techniques. It has been shown to be safe and feasible, however, there are only few studies on this new technique. Due to scant data on SIRA in the current literature, it remains to be a current challenge in adrenal surgery. In this review, our goal is to present current literature on SIRA and discuss the data regarding perioperative outcomes, patient selection, learning curve, and its limitations.

Comparison of Technical Details and Short-term Outcomes of Single-incision Versus Multiport Laparoscopic Adrenalectomy.

To date, the single-incision laparoscopic surgery (SILS) technique has been applied to a wide range of general surgical procedures; however, there are still scant data and debates on adrenal procedures. The aim of this study was to compare surgical outcomes of single-incision versus laparoscopic multiport adrenalectomy. The patients were divided into 2 study groups on the basis of the surgical approach: SILS (group 1) and multiport laparoscopic surgery (group 2). Patient demographics and their perioperative and postoperative results were evaluated retrospectively from the medical records. A total of 80 patients were included in the study. There were 44 patients in group 1 and 36 patients in group 2. The average operative time, estimated blood loss, and tumor size were similar between the study groups. There were no mortalities in both groups and the mean duration of hospital stay was 3 days for both groups. Without using any single-incision access trocars and articulated instrumentation, we achieved the same surgical outcomes in our SILS adrenalectomy series compared with conventional multiport laparoscopy series in terms of postoperative short-term outcomes and cost-effectivity.

Should we perform routine prophylactic central neck dissection in patients with thyroid papillary microcarcinoma?

PURPOSE: Cervical lymph node (LN) metastases in papillary thyroid cancer (PTC) are common in tumors especially that are larger than 1cm. Ipsilateral central neck dissection (CND) is usually preferred even in the absence of a palpable LN. This study aims to clarify the incidence and predictive factors for occult ipsilateral central LN metastasis in these patients, and the management of patients without clinical evidence of metastasis. METHODS: 204 PTC patients were studied. The patients were divided into two according to the tumor size of ≤5mm or larger. Patient demographics, tumor properties, LN metastasis, preoperative neck ultrasonography findings and surgical outcomes were analyzed. RESULTS: There were 152 patients in study group-1 (nodule > 5 mm) and 52 patients in group-2 (nodule ≤ 5 mm). The mean tumor size was 11.9 mm. Overall, preoperative neck ultrasonography showed central neck LN in 25 (12.3%) patients, however, final pathology revealed metastatic LN at central compartment in 59 (28.9%) patients. There were 56 (27.5%) patients with metastasis in group-1 compared to 3 (1.4%) patients in group-2. CONCLUSIONS: Prophylactic CND is advised in PTC for the reduction of recurrence in central compartment. According to our results, in patients with tumors smaller than 5 mm and without evidence of nodal metastasis in preoperative neck ultrasonography, we do not recommend prophylactic CND.

Surgical approaches for papillary microcarcinomas: Turkey's perspective.

OBJECTIVES: The incidence of papillary microcarcinomas, which are defined as thyroid cancers of <10mm in size, has been increasing in the last decade. Herein, we present internet-based questionnaire results performed by the Turkish Association of Endocrine Surgery with the aim to evaluate the perspective of the management of papillary microcarcinomas in Turkey. MATERIAL AND METHODS: The user-friendly questionnaire consisted of 13 questions in total. These questions mainly addressed the surgical management of nodules and cancer of <1 cm in size. Patient management before, during, and after surgical intervention was also included; additionally, the "active surveillance approach" was questioned. RESULTS: There were 420 responders in total who were of multidisciplinary origin (endocrinologists, surgeons, nuclear medicine specialists, pathologists, and oncologists). Total thyroidectomy was the predominant treatment approach (65%) for the classical type of microcarcinoma limited in one lobe, whereas in cases of microcarcinomas incidentally diagnosed during hemithyroidectomy, complementary surgery approach was advised by 40% of the responders. The responders found capsule invasion (86%) and patient based management (94%) of high importance. The percentage of the responders who recommended radioactive iodine ablation in incidental cancers having no aggressive criteria was 51%. The survey participants that were against routine central dissection in these cases accounted for 73% of the responders. The recommendation of active surveillance (follow-up without any interventional therapy) was limited with 9% responders. CONCLUSION: The results of the questionnaire demonstrated that there have been various choices in Turkey for the surgical treatment of the papillary microcarcinomas.

Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves' disease.

CONTEXT: Although some endocrine surgeons administer Lugol solution to decrease thyroid gland vascularity, there is still not an agreement on its effectiveness. OBJECTIVE: The aims of this clinical trial are to evaluate thyroid blood flow and microvessel density in patients with Graves' disease who received Lugol solution treatment preoperatively. DESIGN: This was a prospective clinical trial. SETTING: This clinical trial took place at a tertiary referral center. METHOD: Thirty-six patients were randomly assigned to receive either preoperative treatment with Lugol solution (group 1, n = 17) or no preoperative treatment with Lugol solution (group 2, n = 19). MAIN OUTCOME MEASURES: Blood flow through the thyroid arteries of patients with Graves' disease was measured by color flow Doppler ultrasonography. The microvessel density (MVD) was assessed by immunohistochemical and Western blot analysis of the level of expression of CD-34 in thyroid tissue. The weight and blood loss of the thyroid gland were measured in all patients. RESULTS: The mean blood flow, MVD, CD-34 expression, and blood loss in group 1 patients were significantly lower than those in group 2 patients. There was a negative correlation between Lugol solution treatment and blood flow (r(s) = -0.629; P = 0.0001), blood loss (r(s) = -0.621; P = 0.0001), MVD (r(s) = -0.865; P = 0.0001), and CD-34 expression (r(s) = -0.865; P = 0.0001). According to logistic regression analysis, Lugol solution treatment resulted in a 9.33-fold decreased rate of intraoperative blood loss. CONCLUSION: Preoperative Lugol solution treatment decreased the rate of blood flow, thyroid vascularity, and intraoperative blood loss during thyroidectomy.

Impact of surgical treatment on respiratory muscle dysfunction in symptomatic hyperparathyroidism.

HYPOTHESIS: We hypothesized that surgical treatment would improve respiratory muscle strength in symptomatic hyperparathyroidism (HPT). DESIGN: Prospective clinical trial. SETTING: A tertiary referral center. PATIENTS: Fifteen consecutive patients with symptomatic HPT and 10 with euthyroid multinodular goiter (control group) without a history of obstructive or restrictive lung disease. INTERVENTIONS: Forced vital capacity and forced expiratory volume in 1 second were measured before and 6 months after surgery to estimate respiratory muscle involvement. These measurements were compared with the reference values estimated individually in each patient. Mann-Whitney and Wilcoxon signed rank tests were used for statistical analysis, and P<.05 was considered statistically significant. MAIN OUTCOME MEASURES: Respiratory dysfunction in patients with symptomatic HPT, pulmonary function after parathyroidectomy, and the correlation between the preoperative serum parathyroid hormone and total serum calcium values and the impairment in pulmonary function. RESULTS: Preoperative forced vital capacity and forced expiratory volume in 1 second measurements were below the reference values in 11 (73%) and 9 (60%) patients, respectively. All the patients were normocalcemic, and forced vital capacity and forced expiratory volume in 1 second measurements significantly improved at postoperative month 6 (P = .001). No significant difference was detected in the control group. Improvement in pulmonary function correlated with preoperative serum calcium and parathyroid hormone values in patients with HPT (P<.05 and P<.001, respectively). CONCLUSIONS: Symptomatic HPT impairs inspiratory and expiratory components of respiratory function, and normalization of serum calcium levels after surgical treatment is associated with a significant improvement in lung function.

The advantage of total thyroidectomy to avoid reoperation for incidental thyroid cancer in multinodular goiter.

HYPOTHESIS: To investigate the impact of total thyroidectomy on the rate of completion thyroidectomy for incidentally found thyroid cancer in euthyroid multinodular goiter. DESIGN: A randomized, prospective clinical trial. SETTING: A tertiary referral center. PATIENTS: Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total or near-total thyroidectomy leaving no remnant tissue or less than 1 g (group 1; n = 109) or bilateral subtotal thyroidectomy leaving 5 g or more of remnant tissue (group 2; n = 109). Patients with preoperative or perioperative suspicion of malignancy were excluded. MAIN OUTCOME MEASURES: We compared the complication rates and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. RESULTS: There were no permanent complications. The rates of temporary unilateral vocal cord dysfunction and hypoparathyroidism showed no significant difference between groups 1 and 2 (0.9% vs 0.9% and 1.8% vs 0.9%, respectively; P>.05). Papillary cancer was found in 10 group 1 patients (9.2%) and 8 group 2 patients (7.3%) (P =.80). Of the 9 patients requiring radioactive iodine ablation, reoperation was avoided in 5 group 1 patients; the remaining 4 group 2 patients underwent completion thyroidectomy (P =.007). CONCLUSION: We recommend total or near-total thyroidectomy in multinodular goiter to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid cancer.

Clinical impact of SPECT-CT in the diagnosis and surgical management of hyper-parathyroidism.

UNLABELLED: Hyper-functioning parathyroid glands with autonomous overproduction of PTH is the most frequent cause of hypercalcemia in outpatient populations with primary hyper-parathyroidism. It is generally caused by a solitary adenoma in 80%-90% of patients. Despite the various methodologies that are available for preoperative localization of parathyroid lesions, there is still no certain preoperative imaging algorithm to guide a surgical approach prior to the management of primary hyper-parathyroidism (P-HPT). Minimally invasive surgery has replaced the traditional bilateral neck exploration (BNE) as the initial approach in parathyroidectomy at many referral hospitals worldwide. In our study, we investigated diagnostic contributions of SPECT-CT combined with conventional planar scintigraphy in the detection of hyper-functioning parathyroid gland localization, since planar imaging has limitations. We also evaluated the efficacy of preoperative USG in adding to initial diagnostic imaging algorithms to localize a parathyroid adenoma. METHODS: A total of 256 consecutive surgically naive patients with hyper-parathyroidism diagnosis were included in the following preoperative localization study. The study consisted of 256 consecutive patients with HPT, with a selected 154 patients who had neck surgery with definitive histology reports. All patients had 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) double-phase scintigraphy. The SPECT-CT procedure, combined with standard 99mTc-MIBI planar parathyroid scintigraphy with a pinhole and parallel-hole collimator to evaluate whether the SPECT-CT procedure was able to provide additional information in the localization of the pathology, caused hyper-parathyroidism in both P-HPT and S-HPT. RESULTS: In the 154 P-HPT patients, 168 lesions (142 adenomas including 2 intrathyroidal and 2 double adenoma, 2 carcinoma, and 22 hyperplastic glands (four patients had MEN I, each with four hyperplastic glands)), were found at surgery. SPECT-CT detected more lesions than planar imaging in P-HPT (97.8% vs. 87.6%). SPECT-CT detected all adenomas and increased sensitivity, particularly in small lesions. Regardless of their size, the number of detected hyperplastic glands by SPECT-CT was remarkably higher than planar imaging.

The rate of operative success achieved with radioguided occult lesion localization and intraoperative ultrasonography in patients with recurrent papillary thyroid cancer.

BACKGROUND: To investigate the rate of operative success in excision of nonpalpable lymph nodes with metastatic disease achieved with radioguided occult lesion localization (ROLL) and intraoperative ultrasonography (IOUS) in patients with papillary thyroid cancer (PTC). METHODS: Twenty consecutive PTC patients with nonpalpable lymph nodes with metastatic disease localized in previously operated fields were randomized to receive ROLL (n = 11) or IOUS (n = 9). Nodes were excised along with adjacent soft tissue to accomplish a compartment-oriented dissection. The duration of operation, rate of postoperative complications, pre- and postoperative serum thyroglobulin (Tg) levels, and the findings of postoperative neck ultrasonography and postablation scan were recorded in all patients. Measures of operative success included a postoperative Tg level <50% of preoperative Tg level and no abnormal lesions on postoperative imaging. RESULTS: Histopathologic examination confirmed the excision of all preoperatively identified metastatic nodes. Additional nodes also were excised (2.3 ± 3.3 per specimen in the ROLL group and 1.6 ± 1.8 per specimen in the IOUS group), 23% of which were metastatic. No postoperative complications occurred in either group. The duration of operation was similar in the 2 groups (P = .4). Postoperative imaging confirmed the clearance of suspicious nodes in all patients. The rate of operative success in ROLL and IOUS group were 100% and 89%, respectively. CONCLUSION: In patients with recurrent PTC, a high rate of operative success in excision of nonpalpable metastatic lymph nodes was achieved by both ROLL and IOUS. We recommend compartment-oriented dissection; this approach may maximize the removal of metastatic nodes not identified by preoperative imaging.

Thoracoscopic enucleation of a giant leiomyoma of the esophagus.

Minimally invasive surgery has gained a rapid development and popularity in the recent years. With these developments in minimally invasive surgery, video-thoracoscopic approaches has become more frequently preferred interventions for benign esophageal lesions. Herein, we report a case of a giant esophageal leiomyoma which was successfully enucleated by video-thoracoscopic approach without any peroperative or postoperative complications.

Single-incision laparoscopic left adrenalectomy.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has gained an interest and popularity in the recent years. Although minimally invasive adrenal surgery replaced the open adrenalectomy, SILS adrenalectomy is a step forward technique that improves the cosmesis, decreases acsess related morbidity, and increases the postoperative recovery. We report our first experience with single-incision transperitoneal left adrenalectomy in a patient with Conns' syndrome. CASE: A 46-year-old female patient with a diagnosis of Conns' syndrome underwent single-incision transperitoneal laparoscopic left adrenalectomy. SILS port (Covidien, Norwalk, CT) was used through a 2-cm incision and additional one 5-mm trocar used through one of the holes of SILS port to solve the smoke problem. The operative time was ended in 50 minutes, and no peroperative complication was encountered. The patient was discharged at the second postoperative day. CONCLUSION: SILS adrenalectomy is a safe procedure for a benign adrenal lesion in experienced hands. Further studies are needed to evaluate the special benefits of this technique.

Excision efficiency of radioguided occult lesion localization in reoperative thyroid and parathyroid surgery.

BACKGROUND: The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease. METHODS: Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted. RESULTS: Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated. CONCLUSIONS: The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.