Intraoperative neuromonitoring during thyroidectomy does not decrease vocal cord palsy risk, but the cumulative experience of the surgeon may.

PURPOSE: To evaluate the influence of intraoperative neuromonitoring (IONM) on vocal cord palsy (VCP) rates and assess the temporal trends in VCP rates. METHODS: The subjects of this retrospective study were patients who underwent thyroidectomy for thyroid cancer between March, 2014 and June, 2022, at a university hospital in Korea. We compared VCP rates between the non-IONM and IONM groups and analyzed the risk factors for VCP and VCP rates over time. RESULTS: A total of 712 patients were included in the analysis. The rates of transient and permanent VCP did not differ significantly between the non-IONM and IONM groups. Transient VCP occurred in 4.6% and 4.3% patients (p = 0.878) and VCP was permanent in 0.7% and 0.4% patients (p = 0.607) in the non-IONM and IONM groups, respectively. Among the nerves at risk, transient damage occurred in 2.8% and 3.0% patients (p = 0.901), and permanent damage occurred in 0.4% and 0.3% (p = 0.688), respectively. Multivariate analysis revealed no significant risk factors for VCP. There was a significant decreasing trend in VCP rates over time as the cumulative number of cases increased (p = 0.017). CONCLUSIONS: IONM did not reduce the risk of VCP significantly. However, the declining trend of VCP rates suggests that the surgeon's experience may mitigate VCP risk.

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution.

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy.

INTRODUCTION: Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA). MATERIALS AND METHODS: Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab. RESULTS: The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34). CONCLUSIONS: TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Surgical outcomes of robotic thyroidectomy for thyroid tumors over 4 cm via the bilateral axillo-breast approach.

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Outcomes of bilateral axillo-breast approach robotic parathyroidectomy versus open parathyroidectomy for primary hyperparathyroidism: a single-institution retrospective study.

Purpose: Bilateral axillo-breast approach robotic parathyroidectomy (BABA-RP) aims to remove overactive or enlarged parathyroid glands with no visible neck collar incision. In this study, we compared the safety and surgical outcomes of BABA-RP vs. those of an open surgery group to ascertain whether BABA-RP is a safe and feasible surgical approach for patients with primary hyperparathyroidism (pHPT). Methods: This single-institution retrospective cohort study included 74 patients with primary HPT who underwent open parathyroidectomy (n = 37) or BABA-RP (n = 37) at our institution between November 2014 and March 2023. Patient demographics, biochemical cure rates, operative time, blood loss rates, and complication rates were examined and compared. Results: The patients in the BABA-RP group were younger and had a longer mean operative time. Regarding complication events, 2 patients in the open surgery group and 1 patient in the BABA-RP group had transient hypoparathyroidism. All 74 patients achieved biochemical cure at <6 months, regardless of the approach used. Two patients in the BABA-RP group and 1 patient in the open surgery group had carcinoma on surgical pathology. All 3 patients with parathyroid carcinoma remained recurrence-free at 1-year follow-up. Conclusion: Compared with the open procedure, BABA-RP is a safe and feasible procedure that provides an excellent biochemical cure rate for patients with pHPT and has superior cosmetic benefits with equivalent surgical outcomes.

The anterior neck scar outcomes of conventional thyroidectomy using a wound protector: a multicenter double-blinded randomized controlled trial.

PURPOSE: This study aimed to investigate the effectiveness of a novel wound protector in enhancing the cosmetic outcomes of thyroidectomy. MATERIAL AND METHODS: This multicenter, double-blinded randomized controlled trial enrolled 129 patients undergoing open thyroidectomy. The patients were divided into a wound protector group and a control group. Subjective patient assessments were conducted, measuring wound satisfaction, pain, and itchiness. Additionally, blinded observers evaluated scars using the Vancouver Scar Scale. RESULTS: The Vancouver Scar Scale revealed significant advantages for the wound protector group, demonstrating improvements in pigmentation (P=0.002), vascularity (P=0.014), pliability (P=0.001), and height (P=0.001). CONCLUSION: The thyroid wound protector offers a potential to improve post-operative cosmetic outcomes. Further research is warranted to explore patient experiences and optimize the application of this innovative wound protector across diverse surgical contexts.

TSH receptor antibody as a predictor of difficult robotic thyroidectomy in patients with Graves' disease.

Thyroidectomy in Graves' disease can be challenging due to greater thyroid size and vascularity. While thyroid stimulating hormone receptor antibody (TRAb) level is associated with disease severity and thyroid vascularity, its impact on operative outcomes remains unclear. This study aimed to compare challenging factors for robotic thyroidectomy (RT) and open thyroidectomy (OT) in Graves' disease patients, including TRAb as a predictive factor for difficult thyroidectomy. This retrospective study included Graves' disease patients who underwent total thyroidectomy between September 2013 and January 2023. The clinical characteristics and operative outcomes were compared between patients who received OT and bilateral axillo-breast approach RT. Factors affecting operation time and estimated blood loss (EBL) were evaluated in both groups using regression analyses. A total of 85 patients received either OT (n = 48) or RT (n = 37). Median thyroid volumes in the OT and RT groups were 72.4 g and 57.6 g, respectively. Operation time was affected by thyroid volume in both groups. Additionally, higher thyroid hormone levels and bilateral central neck node dissection prolonged operation time in the RT group. EBL was marginally associated with thyroid volume in the OT group. However, in the RT group, TRAb level was independently associated with greater EBL (p = 0.04), while no significant association was found with thyroid volume. Predictive factors for difficult thyroidectomy differed by operation approaches. TRAb significantly predicted intraoperative bleeding in RT, while this association was absent in OT. Caution is warranted when performing RT on Graves' disease patients with high TRAb levels.

Seeding recurrence of follicular thyroid carcinoma after transoral endoscopic thyroidectomy vestibular approach: a case report.

Background: While track recurrence of thyroid cancer following endoscopic and robotic transaxillary surgeries has been reported previously, no such cases have been reported for transoral endoscopic thyroidectomy vestibular approach (TOETVA). This case report describes the first documented case of recurrence of thyroid cancer along the surgical track after TOETVA. Case Description: The patient underwent right lobectomy via TOETVA for a 4 cm follicular thyroid carcinoma (FTC) initially diagnosed as benign follicular nodule on preoperative gun biopsy. The thyroid capsule partially ruptured within the surgical field during surgery. Ultrasonography and computed tomography conducted 27 months after surgery revealed seeding recurrence in the postsurgical thyroid bed, and subcutaneous layers of the right lower lip, submental area, and mid to right upper neck levels I, IIA, and VI. Two-stage re-operation was done to perform completion thyroidectomy, lymph node dissection, and excision of recurrent nodules, which were pathologically confirmed as metastatic FTC. The patient underwent two treatments of radioactive iodine therapy, and post-therapeutic whole-body scintigraphy and computed tomography showed no residual disease. Conclusions: Careful monitoring after TOETVA is essential due to the rare but potential risk of seeding recurrence, especially when the thyroid gland ruptures during surgery. Surgeons should be aware of this atypical complication and be prepared to recommend surgical and/or medical strategies to manage any local seeding of thyroid tissue that may occur.

Usefulness of video laryngoscopy in tracheal intubation at thyroid surgical position for intraoperative neuromonitoring.

This observational study aimed to compare the glottic view between video and direct laryngoscopy for tracheal intubation in the surgical position for thyroid surgery with intraoperative neuromonitoring. Patients scheduled for elective thyroid surgery with intraoperative neuromonitoring were enrolled. After the induction of anesthesia, patients were positioned in the thyroid surgical posture with a standard inclined pillow under their head and back. An investigator assessed the glottic view using the percentage of glottic opening (POGO) scale and the modified Cormack-Lehane grade in direct laryngoscopy and then video laryngoscopy sequentially while using the same McGRATH™ MAC video laryngoscope at once, with or without external laryngeal manipulation, at the surgical position. A total of thirty-nine patients were participated in this study. Without external laryngeal manipulation, the POGO scale significantly improved during video laryngoscopy compared to direct laryngoscopy in the thyroid surgical position (60.0 ± 38.2% vs. 22.4 ± 23.8%; mean difference (MD) 37.6%, 95% confidence interval (CI) = [29.1, 46.0], P < 0.001). Additionally, with external laryngeal manipulation, the POGO scale showed a significant improvement during video laryngoscopy compared to direct laryngoscopy (84.6 ± 22.9% vs. 58.0 ± 36.3%; MD 26.7%, 95% CI = [18.4, 35.0] (P < 0.001). The superiority of video laryngoscopy was also observed for the modified Cormack-Lehane grade. In conclusion, video laryngoscopy with the McGRATH™ MAC video laryngoscope, when compared to direct laryngoscopy with it, improved the glottic view during tracheal intubation in the thyroid surgical position. This enhancement may potentially facilitate the proper placement of the electromyography tracheal tube and prevent tube displacement due to positional change for thyroid surgery.

Re-do transoral robotic thyroidectomy is feasible: preliminary results of the surgical feasibility and efficacy of completion transoral robotic thyroidectomy: cohort study.

BACKGROUND: Transoral robotic thyroidectomy (TORT) has proven to be a safe and effective procedure with favourable surgical and cosmetic outcomes, but its application in completion thyroidectomy procedures remains to be established. In this study, the authors present our experience with completion TORT, assessing its surgical feasibility and efficacy. between February 2017 and August 2023. METHODS: The authors conducted a retrospective analysis of consecutive patients who underwent completion TORT after an initial TORT procedure between February 2017 and August 2023. RESULTS: A total of 10 patients (three males and seven females) were included in the study, with a mean age of 42.2±13.5 years. The indications for completion thyroidectomy included five cases of aggressive initial lesions and five cases of metachronous papillary thyroid carcinoma detected in the remnant lobe. The median interval between the initial and completion TORT procedures was 6.5 months. Flap dissection time showed no significant difference between the initial TORT and completion TORT operations (43.3±7.5 vs. 36.2±11.2, P =0.125). However, the mean console time (127.9±42.6 vs. 86.4±26.3 min, P =0.019) and mean total operation time (206.7±65.9 vs. 146.0±34.9 min, P =0.021) were significantly longer during the initial TORT procedure than during the completion TORT procedure. Two patients experienced transient hypoparathyroidism, which resolved within four weeks postoperatively. No other complications, such as vocal cord palsy, mental nerve injury, or bleeding, were observed. The median follow-up period was 21.5 months, and no recurrences were detected in any of the patients. CONCLUSIONS: Our study demonstrates that re-do TORT is feasible, showing excellent cosmetic results and minimal adverse effects. Completion TORT may be considered a viable option for selected patients who require completion thyroidectomy after an initial TORT procedure.

Observation of changes in quality of life for 5 years after thyroid surgery: an observational cross-sectional study in Korean population.

Purpose: As thyroid cancer patients are experiencing longer disease-free survival periods, evaluating their quality of life after surgery has become crucial. However, studies on this topic have primarily focused on Western populations, leaving a gap in understanding the Korean patient population's experiences and needs. This study aims to address this gap and provide insights into the quality of life of thyroid cancer patients in Korea. Methods: This cross-sectional study evaluated the quality of life of Korean thyroid cancer patients who underwent thyroid lobectomy or total thyroidectomy. Patients were surveyed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30, ver. 3.0) during outpatient clinic visits from January to September 2015. The results were analyzed by comparing them to scores of the general population and based on the time elapsed since surgery. This approach allowed for a comprehensive evaluation of the quality-of-life outcomes in this patient population. Results: The study found that thyroidectomy had a notable impact on patients' role and cognitive functions. Patients also experienced worsened symptoms such as fatigue, dyspnea, and constipation, which improved over time and returned to normal levels. However, there were no significant changes in other functions and symptoms after surgery. Conclusion: The study's findings showed that thyroidectomy had a relatively minor impact on the functional and symptomatic well-being of patients. Therefore, the results suggest that thyroid surgery may be a safe and effective treatment option for thyroid cancer patients seeking to maintain a good quality of life.

Transoral endoscopic thyroidectomy vestibular approach vs. transoral robotic thyroidectomy: systematic review and meta-analysis.

This study aimed to conduct a systematic review and meta-analysis to compare the surgical outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT). We carried out a systematic literature search of PubMed, Web of Science, Cochrane Library, and Google Scholar on studies comparing TOETVA and TORT until January 2023. A total of five articles published between 2018 and 2023 that matched the inclusion criteria were included in the systematic review and meta-analysis. The studies included 641 patients (394 TOETVA patients and 247 TORT patients). TOETVA group was associated with a significantly shorter operative time with a mean difference of 60.08 min [95% confidence interval (CI) - 83.95 to - 36.20; P < 0.001). Transient recurrent laryngeal nerve palsy was more common in the TOETVA group than the TORT group (OR 3.00; 95% CI 1.14-7.88; P = 0.03). There were no significant differences in the other outcomes, including the length of hospital stay, postoperative pain scores, number of central lymph nodes retrieved, permanent recurrent laryngeal nerve injuries, and transient and permanent hypoparathyroidism. The TOETVA group was associated with shorter operative time and more transient recurrent laryngeal nerve palsy than the TORT group. Each procedure has its benefits and limitations. The surgical approach should be determined by considering the patient's characteristics and preferences, as well as the surgeon's preference and area of expertise.

Bilateral axillo-breast approach robotic thyroidectomy in pediatric patients with thyroid disease and cancer.

PURPOSE: Robotic thyroid surgeries have cosmetic advantages over open surgeries, which are especially important in pediatric patients due to social stigmas from neck scars. The present study describes outcomes in a series of children who underwent bilateral axillo-breast approach (BABA) robotic thyroidectomy. METHODS: Pediatric patients aged ≤18 years who underwent BABA robotic thyroidectomy between 2014 and 2022 were retrospectively reviewed. Their clinical characteristics and surgical outcomes were evaluated. Surgical completeness was determined by comparing the number of retrieved lymph nodes per compartment to previously reported lymph node quantification. RESULTS: This study included 26 pediatric patients of mean age 15.5 years (range, 5-18 years). Of these 26 patients, 21 (80.8%) had thyroid cancer, with 9 (42.9%) having aggressive tumor pathology. The mean operation time was 157.3 min. No patient needed open conversion. Five patients (19.2%) experienced complications including transient hypoparathyroidism (n = 5), permanent hypoparathyroidism (n = 2), and chyle leakage (n = 1), but none experienced vocal cord palsy. The mean numbers of retrieved lymph nodes at levels IIa, III, IV, Vb, and VI were 3.2, 4.1, 5.6, 1.0, and 9.7, respectively, numbers comparable with the known quantification except for level II, as IIb dissection was omitted in our series. CONCLUSION: BABA robotic thyroidectomy is safe and effective in pediatric patients with thyroid diseases. Most complications were minor and transient, with the operation time similar to robotic thyroidectomy in adults. Surgical completeness was also satisfactory. Robotic thyroidectomy can be considered a surgical option, regardless of patient age or diagnosis.

Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless alternative to open thyroidectomy (OT). This systematic review and meta-analysis aimed to synthesize evidence comparing the intraoperative and postoperative outcomes of TOETVA and OT. METHODS: A systematic literature search of PubMed, Web of Science, the Cochrane Library, and Google Scholar was performed to identify studies comparing the outcomes of TOETVA and OT published before February 2023. The outcomes of interest were operative time, intraoperative blood loss, hospital stay, postoperative pain, number of central lymph nodes retrieved, number of metastatic central lymph nodes, and incidences of transient and permanent recurrent laryngeal nerve injury, transient and permanent hypocalcemia, hematoma, and infection. RESULTS: Thirteen studies published between 2016 and 2022, involving a total of 2889 patients (TOETVA, n =1085; OT, n =1804) were included in this systematic review and meta-analysis. Meta-analysis showed that the TOETVA group had a significantly longer overall operative time (weighted mean difference [WMD] 55.19; 95% CI, 39.15, 71.23; P <0.001), longer hospital stay (WMD, 0.27; 95% CI, 0.14, 0.39; P <0.001), and lower pain scores on postoperative day 1 (WMD, -1.41; 95% CI, -2.79, -0.03; P =0.04) than the OT group. Other intraoperative and postoperative outcomes were not significantly different between the groups. CONCLUSION: TOETVA has a similar safety profile to OT with less postoperative pain, making it an appropriate and more cosmetically appealing alternative to OT for select patients.

Effect of body habitus on surgical outcomes following bilateral axillo-breast approach robotic thyroidectomy: a retrospective cohort study.

INTRODUCTION: BMI has been shown to predict perioperative outcomes in patients undergoing surgery. Most studies assessing the role of body habitus in thyroid surgery have focused on open surgery, with few studies assessing patients undergoing robotic surgery. The present study evaluated the effects of BMI on surgical outcomes in patients undergoing bilateral axillo-breast approach (BABA) robotic thyroidectomy. MATERIALS AND METHODS: This study included patients who underwent BABA robotic thyroidectomy between January 2013 and September 2021 at Seoul National University Bundang Hospital. Patients were categorized into six groups based on the WHO classification of overweight and obesity. Clinicopathological characteristics, postoperative complications, and surgical outcomes were evaluated. RESULTS: A total of 1921 patients were included. Comparisons of the six BMI groups showed no statistically significant differences in postoperative stay, resection margin involvement, postoperative complications, and recurrence. Subgroup analysis showed that hypocalcemia rates differed among BMI groups in patients who underwent lobectomy, with underweight and class II obese patients being at the highest risk ( P =0.006). However, the actual number of complications was relatively small and similar among the groups. In patients who underwent total thyroidectomy and isthmectomy, BMI was not correlated with postoperative complications, including hypocalcemia, recurrent laryngeal nerve palsy, postoperative bleeding, and chyle leakage. CONCLUSION: Body habitus was not significantly associated with operative time and postoperative complications in patients undergoing BABA robotic thyroidectomy, indicating that this approach is safe and feasible in obese patients.

Investigation of optimal convolutional neural network conditions for thyroid ultrasound image analysis.

Neural network models have been used to analyze thyroid ultrasound (US) images and stratify malignancy risk of the thyroid nodules. We investigated the optimal neural network condition for thyroid US image analysis. We compared scratch and transfer learning models, performed stress tests in 10% increments, and compared the performance of three threshold values. All validation results indicated superiority of the transfer learning model over the scratch model. Stress test indicated that training the algorithm using 3902 images (70%) resulted in a performance which was similar to the full dataset (5575). Threshold 0.3 yielded high sensitivity (1% false negative) and low specificity (72% false positive), while 0.7 gave low sensitivity (22% false negative) and high specificity (23% false positive). Here we showed that transfer learning was more effective than scratch learning in terms of area under curve, sensitivity, specificity and negative/positive predictive value, that about 3900 images were minimally required to demonstrate an acceptable performance, and that algorithm performance can be customized according to the population characteristics by adjusting threshold value.

Bilateral axillo-breast approach robotic total thyroidectomy in a 5-year-old patient with intractable Graves' disease.

Robotic thyroid surgeries in children are gaining popularity due to cosmetic advantages, but most previous studies include patients of school-age or older. We hereby introduce our case of a 5-year-old patient with Graves' disease to show key differences and similarities between pediatric and adult bilateral axillo-breast approach (BABA) robotic thyroidectomies. Despite the small body, no additional working space was needed and the flap creation was performed as similarly done in adults. The anatomy was not much different, except that the parathyroid tissues were easily identified due to low body fat, and the prominent thymus covered most of the level VI area. The patient did not experience postoperative complications such as hypoparathyroidism or vocal cord palsy. Postoperative wounds showed excellent results with minimal scars. BABA robotic thyroidectomy can be performed safely in pediatric patients and may be considered an alternative option for conventional open thyroidectomy in children.

A Time Trend Analysis of 5,000 Robotic Thyroidectomies via Bilateral Axillo-Breast Approach.

BACKGROUND: This study aimed to investigate the time trends of surgical outcomes in patients who underwent bilateral axillo-breast approach robotic thyroidectomy (BABA RT) over the last 14 years. METHODS: From February 2008 to September 2021, we conducted a retrospective medical chart review of 5,011 consecutive patients who underwent BABA RT at three Seoul National University-affiliated hospitals. The patients were divided into three groups based on the main model of the da Vinci robotic surgical system to evaluate trends in surgical treatment strategies and outcomes after BABA RT. RESULTS: Of the 5,011 patients (4,706 malignant and 305 benign), the most common histological subtype was papillary thyroid carcinoma (n = 4,584; 97.4%). The mean tumor size significantly increased from 0.8 cm to 1.2 cm (p < 0.05). The mean numbers of metastatic and harvested lymph nodes from the central neck dissection and the lateral neck dissection showed a significant difference and tendency to increase (from 0.9 to 1.6, 4.7 to 6.2, p < 0.05, and from 0.6 to 3.9, 5.3 to 17.9, p < 0.05), respectively, throughout the study period. Permanent hypoparathyroidism decreased from 3.4 to 2.9%. The rate of transient and permanent vocal cord palsy decreased from 15.2 to 2.7% and from 0.7 to 0.2%, respectively. CONCLUSION: With advancements in robotic surgical systems and improvements in the BABA RT technique, surgical indications have expanded to include more advanced thyroid diseases, and surgical outcomes have improved over the last 14 years.