American Thyroid Association Statement on Remote-Access Thyroid Surgery.

BACKGROUND: Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption. METHODS: A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery. RESULTS: Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision. CONCLUSIONS: Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.

Calcium management after thyroidectomy: a simple and cost-effective method.

OBJECTIVE: Hypocalcemia is one of the principal complications of total or completion thyroidectomy. A number of different protocols for managing this potential complication have been published. Our simple postoperative regimen is described and the safety and cost-effectiveness assessed. STUDY DESIGN: Case series with planned data collection. SETTING: Academic medical center. SUBJECTS AND METHODS: All patients undergoing total or completion thyroidectomy from January 2008 through June 2010 were evaluated. Data collected included age; gender; procedure performed; levels of ionized calcium, parathyroid hormone, and vitamin D; complications; and need for readmission. Standard descriptive statistics were used to summarize these data. RESULTS: In total, 526 patients had thyroid surgery during the 30-month study period. Of these, 307 underwent completion or total thyroidectomy and were prescribed a 3-week tapering course of calcium carbonate postoperatively. Twenty-three patients (7.5%) experienced symptoms of hypocalcemia that were managed on an outpatient basis with additional doses of oral calcium. Two patients (0.7%) required readmission. The cost of a 3-week regimen of calcium carbonate is approximately $15. This is considerably less expensive than either the cost of overnight admission or published laboratory protocols that are designed to predict the risk of hypocalcemia. CONCLUSIONS: Prophylactic calcium supplementation without routine laboratory assessment proved to be a safe and cost-effective method of preventing and managing postoperative hypocalcemia following total or completion thyroidectomy.

Thyroidectomy-related malpractice claims.

OBJECTIVE: Little information is available regarding the frequency of thyroidectomy-related malpractice claims. Previous studies have not assessed claims that were settled or dropped before trial, providing only a limited view of the medical-legal environment. We sought to determine the frequency of thyroid surgery-related malpractice claims, their causes, and outcomes. STUDY DESIGN: Database assessment. SETTING: Academic medical center. SUBJECTS AND METHODS: The database of the Physician Insurers Association of America was reviewed. These data are estimated to represent 25% of medical malpractice claims in the United States. Claims from 1985 to 2008 with thyroid-related procedure codes were evaluated for claimant information, insured's specialty, loss description, causation, and claim outcomes. RESULTS: During the 24-year period reviewed, 380 claims related to thyroid surgery were reported. 128 claims (33.7% of total claims) resulted in an indemnity payment either due to settlement or a finding against the defendant. The average indemnity payment was $185,366 (range, $363 to $2,000,000). Among cases in which a specific outcome was reported, 55 were related to laryngeal nerve injury or voice disturbance. No substantial change occurred in the incidence of claims across the study period. During this time, approximately 2,585,000 thyroidectomies were performed. Extrapolating from the Physician Insurers Association of America data, this represents an estimated 5.9 claims per 10,000 cases. CONCLUSION: Malpractice claims related to thyroid surgery are surprisingly infrequent. While the rates of thyroid surgery have risen steadily, there has not been a corresponding increase in the rate of related malpractice claims.

Robotic facelift thyroidectomy: I. Preclinical simulation and morphometric assessment.

OBJECTIVES: Robotic thyroidectomy was introduced in the United States despite scant preclinical data. We pursued a systematic preclinical investigation of a new remote access, robotic thyroidectomy technique via a facelift incision, and sought to define differences in extent of dissection associated with this approach and a second, popular robotic thyroidectomy technique. DESIGN: Surgical simulation and morphometric analysis in fresh human cadavers. METHODS: Eleven specimens were obtained to complete four experiments designed to address two specific aims: to develop a reproducible surgical protocol for robotic removal of the thyroid through a facelift incision, and to quantify the extent of dissection required with two robotic thyroidectomy techniques. RESULTS: The feasibility of the facelift approach was determined using an endoscopic technique, and two lobectomies were accomplished. Inanimate study of the optimal robotic positioning to facilitate resection was then completed. Three additional cadavers were used to develop a reproducible surgical protocol and define a stepwise algorithm of dissection. Seven specimens were used to simulate 28 robotic thyroidectomy dissection pockets. The mean area of dissection required for robotic facelift thyroidectomy was 39.2 ± 6.6 cm(2) compared with 63.5 ± 9.6 cm(2) for robotic axillary thyroidectomy, representing a difference of 38.3% (P < .0001). CONCLUSIONS: We have described and refined a reproducible surgical protocol for accomplishing a new robotic facelift thyroidectomy, and then quantified the reduced dissection required when comparing it with a transaxillary technique. Cautious clinical implementation to explore safety and feasibility appears to be justified.