Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide.

BACKGROUND: The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket. METHODS: In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures. RESULTS: Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches. CONCLUSION: Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.

Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Perioperative Outcomes of 100 Consecutive Patients.

BACKGROUND: Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC). METHODS: This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed. RESULTS: There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8 years, and a mean tumor size of 0.8 ± 0.5 cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9 min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery. CONCLUSION: In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z.

We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≥45mL, (3) nodule size ≥5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

Effect of Antiadhesion Barrier Solution and Fibrin on Capsular Formation After Silicone Implant Insertion in a White Rat Model.

INTRODUCTION: One of the most serious complications of breast reconstruction and augmentation using silicone implants is capsular contracture. Several preventive treatments, including vitamin E, steroids, antibiotics, and cysteinyl leukotriene inhibitors, have been studied, and their clinical effects have been reported. However, the problem of capsular contracture has not yet been completely resolved. This study was performed to compare anti-adhesion barrier solution (AABS) and fibrin in their ability to prevent fibrotic capsule formation and simultaneously evaluated their effect when used in combination by capsular thickness analysis and quantitative analysis of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and type I collagen within the fibrous capsule. MATERIALS AND METHODS: This study used female six-week-old Sprague-Dawley rats. Eighty rats were equally subdivided into the four following groups: AABS-treated, fibrin-treated, AABS and fibrin combined-treated, and untreated control groups. Each rat received two silicone chips under the panniculus carnosus muscle layer. The test materials were applied around the silicon chips. Four weeks later, the implantation sites including the skin and muscle were excised to avoid the risk of losing the fibrous capsule around the implants. The capsular thickness was analyzed by Masson's trichrome stain. Quantitative analysis of type I collagen, MMPs, and TIMPs was performed by real-time PCR, Western blot, and zymography. RESULTS: The mean capsular thickness was 668.10 ± 275.12 µm in the control group, 356.97 ± 112.11 µm in the AABS-treated group, 525.96 ± 130.97 µm in the fibrin-treated group, and 389.24 ± 130.51 µm in the AABS and fibrin combined-treated group. Capsular thickness was significantly decreased in all experimental groups (p < 0.05). Capsular thickness was greater in the fibrin-treated group than in the AABS-treated group (p < 0.05). There was no statistically significant difference in capsular thickness between the AABS and fibrin combined-treated group and the AABS- or fibrin-treated group (p > 0.05). Compared to the control group, the experimental groups had significantly lower expressions of type I collagen and MMP-1 (p < 0.05), but there was no statistically significant difference in expressions of type I collagen and MMP-1 between the AABS-, fibrin-, and AABS and fibrin combined-treated groups (p > 0.05). The expressions of MMP-2 and TIMP-2 were not significantly different between the control and the experimental groups (p > 0.05). CONCLUSION: AABS is more effective in reducing capsular thickness compared with fibrin treatment in a white rat model.

Robotic transoral thyroidectomy: Total thyroidectomy and ipsilateral central neck dissection with da Vinci Xi Surgical System.

BACKGROUND: Transoral approach for thyroidectomy draws attention recently among the thyroid surgeons, with the merits of cosmetic outcomes and minimal flap dissection. The aim of this study is to demonstrate the details and the steps of transoral robotic thyroidectomy. METHODS: We made three incisions in the gingival-buccal sulcus for three 8-mm intraoral ports: one inverted U-shaped 1-cm midline incision approximately 2 cm above the frenulum, and two 0.5-cm lateral incisions near the commissure of lips. An additional 8-mm axilla port was inserted for countertraction and later drain insertion. RESULTS: Right thyroid lobectomy, ipsilateral central neck dissection, and left thyroid lobectomy were performed with preserving recurrent laryngeal nerves and parathyroid glands. There was no development of transient or permanent hypoparathyroidism, vocal cord palsy, postoperative bleeding, or surgical site infection. CONCLUSION: Transoral robotic total thyroidectomy and ipsilateral central neck dissection using the da Vinci Xi Surgical System are feasible and safe.

Robotic Transoral Thyroidectomy: Right Thyroidectomy and Ipsilateral Central Neck Dissection with da Vinci Si Surgical System.

Transoral approach for thyroidectomy recently gains a lot of attention among the thyroid surgeons, with the merits of cosmetic outcomes and minimal flap dissection. We've successfully introduced the robotic surgical system to the transoral approach for thyroidectomy. For transoral robotic thyroidectomy, we made 3 incisions in the gingival-buccal sulcus for three intraoral ports. An additional axilla port was inserted for counter-traction and later drain insertion. Herein, our unique procedures of transoral robotic thyroidectomy (TORT) are described in the treatment of a patient with papillary thyroid carcinoma.

Safety of LigaSure in recurrent laryngeal nerve dissection-porcine model using continuous monitoring.

OBJECTIVES/HYPOTHESIS: This study investigated recurrent laryngeal nerve (RLN) real-time electromyography (EMG) data to define optimal safety parameters of the LigaSure Small Jaw (LSJ) instrument during thyroidectomy. STUDY DESIGN: Prospective animal model. METHODS: Dynamic EMG tracings were recorded from 32 RLNs (16 piglets) during various applications of LSJ around using continuous electrophysiologic monitoring. At varying distances from the RLN, the LSJ was activated (activation study). The LSJ was also applied to the RLN at timed intervals after activation and after a cooling maneuver through placement on the sternocleidomastoid muscle (cooling study). RESULTS: In the activation study, there was no adverse EMG event at 2 to 5 mm distance (16 RLNs, 96 tests). In the cooling study, there was no adverse EMG event after 2-second cooling time (16 RLNs, 96 tests) or after the LSJ cooling maneuver on the surrounding muscle before reaching the RLNs (8 RLNs, 24 tests). CONCLUSION: Based on EMG functional assessment, the safe distance for LSJ activation was 2 mm. Further LSJ-RLN contact was safe if the LSJ was cooled for more than 2 seconds or cooled by touch muscle maneuver. The LSJ should be used with these distance and time parameters in mind to avoid RLN injury. LEVEL OF EVIDENCE: N/A. Laryngoscope, 127:1724-1729, 2017.

Robotic transoral periosteal thyroidectomy (TOPOT): experience in two cadavers.

BACKGROUND: Transoral techniques for endoscopic thyroidectomy have recently been reported, including a robotic transoral technique to access the thyroid gland. Herein, we developed a robotic transoral periosteal thyroidectomy technique. MATERIALS AND METHODS: The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA) robot was used in two human cadavers to perform robotic transoral periosteal thyroidectomies. In the first cadaver, the anterior neck was exposed below the platysmal muscle. The anatomical spaces and surgical planes were observed with four ports by a periosteal approach. In the second cadaver, robotic transoral periosteal thyroidectomy was performed using three ports. RESULTS: A total thyroidectomy and central neck dissection were performed in two cadavers using the da Vinci robot with the transoral periosteal approach. Complete thyroidectomy and central neck dissection were possible without injury to the recurrent laryngeal nerve. CONCLUSIONS: Robotic transoral periosteal thyroidectomy provides superior access to the thyroid and central neck compartment. Transoral thyroidectomy using four ports is a feasible and safe method.

The safety of transoral periosteal thyroidectomy: results of Swine models.

BACKGROUND: Endoscopic thyroid surgery is gaining wide acceptance; however, existing endoscopic methods for thyroidectomy have shown several limitations. Recently, a transoral technique using video assistance and endoscopy has been reported for thyroidectomy. The aim of this study was to define a new technique of transoral thyroidectomy using a mandibular periosteal approach to complement other types of natural orifice surgery and minimally invasive surgery. MATERIALS AND METHODS: Transoral periosteal thyroidectomies were performed in seven living pigs to evaluate the feasibility and safety of the new approach. Total thyroidectomies were performed in all animals. Follow-up examinations were carried out for 7 days and followed by autopsy. RESULTS: Through three trocars in the mandibular periosteal area, it was possible to create a working space under the platysma muscle and to reach the pretracheal area. Total thyroidectomies were also performed via the transoral, mandibular periosteal approach without complications in seven orally intubated living pigs. Postoperatively, the white blood cell count remained normal in all cases. On the postoperative sacrifice of the pigs, three locally encapsulated seromas were observed. Both recurrent laryngeal nerves were intact in all cases. CONCLUSIONS: Transoral periosteal thyroidectomy could be feasible and safe.