Comparative Analysis of Transoral Endoscopic Parathyroidectomy Vestibular Approach and Focused Open Surgery for Primary Hyperparathyroidism Treatment: A Single Center Experience.

BACKGROUND Primary hyperparathyroidism is one of the most common endocrine disorders, for which the definitive treatment is surgical parathyroidectomy. Generally, surgical exploration is performed as open focused neck surgery. The vestibular route is a new approach to minimally invasive endoscopic parathyroidectomy. This retrospective study from a single center in Turkey aimed to compare surgical outcomes from the transoral endoscopic vestibular approach (TOEPVA) vs direct open parathyroidectomy in 57 patients. MATERIAL AND METHODS Our study included data from 57 patients. TOEPVA was performed in 20 of these patients who did not want a cervical scar, and focused surgery was performed in the remaining 37 patients. The variables we analyzed were size, volume, and localization of the adenoma, operative time, presence of bleeding, presence of the recurrent laryngeal nerve damage, preoperative, short-term, and long-term postoperative PTH levels, use of drain, presence of postoperative hypocalcemia, and short-term and long-term calcium levels. RESULTS No laryngeal nerve and mental nerve damage was observed in either group. The mean operative time in focused open surgery was 80.54±33.1 min, while the mean operative time in TOEPVA was 128.21±30.88 (p: 0.794) min. The mean hospitalization period of patients who underwent open surgery was 3.29±1.9 days, while the mean discharge days of patients who underwent endoscopic surgery was 2.40±1.2. (p>0.05). CONCLUSIONS TOEPVA is a safe method in patients who underwent parthyroid surgery to avoid cervical scarring.

Posterior retroperitoneal versus transperitoneal laparoscopic adrenalectomy in adults: results from the EUROCRINE® surgical registry.

PURPOSE: This study aims to compare posterior retroperitoneal laparoscopic adrenalectomy (PRLA) and laparoscopic transperitoneal adrenalectomy (LTA) in adults using pan-European data as conflicting results have been published regarding length of hospital stay, institutional volume, and morbidity. METHODS: This retrospective cohort study analyzed data from the surgical registry EUROCRINE®. All patients undergoing PRLA and TLA for adrenal tumours and registered between 2015 and 2020 were included and compared for morbidity, length of hospital stay, and conversion to open surgery. RESULTS: A total of 2660 patients from 11 different countries and 69 different hospitals were analyzed and 1696 LTA were compared to 964 PRLA. Length of hospital stay was shorter after RPLA, with less patients (N = 434, 45.5%, vs N = 1094, 65.0%, p < 0.001) staying more than 2 days. In total, 96 patients (3.6%) developed a complication Clavien-Dindo grade 2 or higher. No statistical difference was found between both study groups. After propensity score matching, length of hospital stay was shorter after PRLA (> 2 days 45.2% vs 63.0%, p < 0.001). After multivariable logistic regression, factors associated with morbidity were age (OR 1.03), male sex (OR 1.52), and conversion to open surgery (OR 5.73). CONCLUSION: This study presents the largest retrospective observational analysis comparing LTA and PRLA. Our findings confirm the shorter length of hospital stay after PRLA. Both techniques are safe leading to comparable morbidity and conversion rates.

3D Transoral Endoscopic Thyroid.

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a feasible new surgical procedure that does not require visible incisions. We describe our experience with three-dimensional (3D) TOETVA. We recruited 98 patients who were willing to undergo 3D TOETVA. Inclusion criteria were: (a) patients with a neck ultrasound (US) with an estimated thyroid diameter of 10cm or less; (b) estimated US gland volume ≤45ml; (c) nodule size ≤50mm; (d) benign tumor, such as thyroid cyst, goiter with one nodule, or goiter with multiple nodules; (e) follicular neoplasia; and (f) papillary microcarcinoma without evidence of metastases. The procedure is performed using a three-port technique at the oral vestibule, a 10mm port for the 30° endoscope, and two additional 5mm ports for dissecting and coagulation instruments. The CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule to the sternal notch and laterally to the sternocleidomastoid muscle. Thyroidectomy is performed entirely 3D endoscopically with conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. Ninety-eight 3D TOETVA procedures were successfully performed without any conversions. The mean operative time was 87.6 minutes (59-118 minutes) for lobectomy and 107.6 minutes (99-135 minutes) for bilateral surgery. We observed one case of transient postoperative hypocalcemia. Paralysis of the recurrent laryngeal nerve did not occur. The cosmetic outcome was excellent in all patients. This is the first case series of 3D TOETVA.

Modified Larssen solution (MLS)-fixed cadaver model for transoral endoscopic thyroidectomy vestibular approach (TOETVA) education: a feasibility study.

BACKGROUND: Training formats for transoral endoscopic thyroidectomy vestibular approach (TOETVA) are limited. Our aim was to create and investigate a TOETVA training model for general and ENT surgeons. METHODS: A total of 15 modified Larssen solution (MLS) human cadavers were used in the study. A day duration TOETVA human cadaver workshops were offered in two years consecutive. Post-training verbal and online questionnaires were applied to all trainers to evaluate course structure and program, organoleptic characteristics of MLS-fixed human cadavers, and TOETVA training effectiveness. Cost assessment is included in the study. RESULTS: Ninety-eight participants, i.e., 14 trainers and 84 hands-on (HO) and observer (OB) trainees, attended the workshops, completed the tasks assigned, and fulfilled the questionnaires. Implementation of all steps of TOETVA was approved positively by 89.8% of all participants, 94.4% of HO, and 83.3% of OB trainees. Regarding human cadaver and teaching quality, 10.8 ± 0.8 (10-12) human cadavers were "practical" by 13.2 (94.5%) of the trainers, and by 33.3 (92.5%) of the trainees for all steps of TOETVA. The cadavers were stored for 4.53 years and used 6.27 times repeatedly for endoscopic workshops and research studies. TOETVA workshop cost with repeatable use of MLS-fixed human cadaver is half of other performed TOETVA workshops. CONCLUSIONS: A TOETVA human cadaver workshop model has not been reported yet. Our findings suggest the feasibility of MLS-fixed human cadaver model for training of TOETVA, preserve the organoleptic properties necessary for the implementation of surgical steps, and reduce the cost.

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience.

AIM: Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey. MATERIALS AND METHODS: Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020. RESULTS: Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up. CONCLUSION: TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

Edward D. Churchill (1895-1972): An Innovative Surgeon, His Work, and His Contribution to Parathyroid Surgery.

Edward Delos Churchill, one of the most notorious American surgeons of the 20th century, influenced countless surgeons and set medical practices that were used for decades. His scope of interests included surgery of the lungs, heart, thyroid, parathyroid glands, and military surgery among others. Churchill was one of the first to expand the field of the newly found parathyroid bodies by performing several experimental excisions of the glands and publishing numerous guidelines based on his innovative work. Additionally, he aspired to address many of the literature gaps that led him to conclusions that would benefit both the surgeons and patients throughout the country. Most importantly, his deep interest in endocrinology and his aggregate approach of medicine led him to discoveries that paved the way to the modern endocrine surgery practices.

Status of Alternative Approaches for Thyroidectomy: Is There Any Evidence to Substitute in Place of Conventional Surgery?

Over the past 20 years, various alternative cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed. All of these alternative access methods aim at optimizing the cosmetic results. In principle, the indication for the use of alternative access procedures does not differ from that for conventional surgery. Nonetheless, appropriate experience in traditional thyroid surgery and suitable patient selection, taking into account thyroid volumes and the underlying pathology, are important prerequisites. General contraindications for an alternative approach are large goiter with symptoms of compression, advanced thyroid carcinoma, recurrent interventions or previous radiotherapy in the operating area. The alternative surgical approaches to the thyroid can be divided into cervical minimally invasive, extracervical endoscopic (robot-assisted) and transoral procedures. This article gives an overview of the clinically used alternative approaches in thyroid surgery. The desire for an optimal cosmetic result should not be prioritized over patient safety. Only a few alternative procedures (minimally invasive video-assisted thyroidectomy, transaxillary robot-assisted thyroidectomy) can currently be viewed as a useful addition to conventional thyroid surgery, even when in responsible, experienced hands for a selected group of patients.

An Improved Recurrent Laryngeal Nerve-Monitoring Device: Technical Note for Nim Vital™.

A new device for monitoring the laryngeal nerves during thyroid surgery has been developed. NIM Vital™ (Medtronic Xomed, Inc., Jacksonville, FL, USA) incorporates (a) a new wireless design, (b) NIM NerveTrendTM (Medtronic Xomed) EMG reporting, (c) intelligent noise-reduction technology that suppresses artifacts, (d) smart troubleshooting pop-up alerts, and (e) NIM Nervassure ™ (Medtronic Xomed) for continuous monitoring. This device offers enhanced stability and flexibility for both intermittent and continuous laryngeal nerve monitoring. The new NIM NerveTrend ™ EMG reporting makes it possible to track the recurrent laryngeal nerve condition throughout a procedure, even when using intermittent nerve monitoring. During both continuous and intermittent monitoring, green, yellow and red status bars provide visual information and associated tones provide audible cues, making it easy to monitor nerve function and interpret EMG trends. This new tool for laryngeal nerve monitoring has the potential to augment nerve dissection during surgery. Measurements of long-term outcome are needed to establish their efficacy.

Transoral endoscopic thyroidectomy using the vestibular approach with an endoscopic retractor in thyroid cancer: experience with the first 132 patients.

BACKGROUND: Transoral endoscopic thyroidectomy using the vestibular approach (TOETVA) is a novel technique for thyroid cancer surgery. We aimed to review our initial experiences with TOETVA for the management of thyroid carcinoma, using retrospective analyses of a larger single-center case series. METHODS: From September 2016 to April 2018, 132 patients with thyroid cancer underwent TOETVA. A three-port technique through the oral vestibule was used to perform endoscopic thyroidectomy with ipsilateral central compartment dissection using conventional laparoscopic instruments, and an endoscopic retractor that we developed. RESULTS: All patients had papillary thyroid carcinoma. Less-than total or total thyroidectomy with ipsilateral central compartment node dissection was performed (124 vs. 8). The mean operation time was 87.6 min (range 56-213 min). The average number of lymph nodes resected was 2.6 (range 1-12). Six patients experienced transient hoarseness, which was resolved within 3 months. Most of the patients were discharged within 3 days after surgery. CONCLUSIONS: In this large series from a single center, we found that TOETVA with the endoscopic retractor can be performed safely and radically in selected patients with thyroid cancer.

A surgical and anatomo-histological study on Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA).

BACKGROUND: The number of TOETVA surgeries has increased worldwide but the anatomical passage of trocars is not clearly defined. We aimed to define detailed surgical anatomical passage of the trocars in cadavers. The incisions in oral vestibule, anatomical pathways of trocars, affected mimetic muscles, neurovascular relations of trocars and histological correlation of surgical anatomy were investigated. METHODS: Four cadavers and 6 six patient oral vestibules were used. The locations of optimised vestibular incisions were measured photogrammetrically. Initial steps of TOETVA surgery were performed on cadavers according to those optimal incisions. TOETVA preformed cadavers dissected to determine anatomical passages of the trocars. Afterwards, flap of lower lip and chin were zoned by software appropriate to the trocars routes. Histological analyses of the zones were made in correlation with dissections. RESULTS: Mimetic muscles associated with median (MT) and lateral trocars (LT) are orbicularis oris, mentalis, depressor anguli oris, depressor labii inferioris and platysma muscles. Trocars affect mimetic muscles in the perioral, chin and submental regions in different ways. The risk of mental nerve injury by MT is low. LT pass through the DLI muscle. The transmission of LT to the subplatysmal plane in the submental regions can be in two different ways. The arterial injury risk is higher with LT than the MT. CONCLUSIONS: The surgical anatomy of the perioral, chin and submental regions for the initial TOETVA steps has been defined. Detailed surgical anatomical passages of the MT and LT were determined. Anatomical pattern to reach subplatysmal plane are presented. Mimetic muscles effected by trocars were determined. Endocrine surgeons should know the anatomical passage of TOETVA trocars.

Development of an ontology for laparoscopic transabdominal adrenalectomy via a comprehensive modified Delphi survey and its validation on a multicentric pilot data set for surgical training and future video analysis with machine learning algorithms.

Surgical technique is essential to ensure safe minimally invasive adrenalectomy. Due to the relative rarity of adrenal surgery, it is challenging to ensure adequate exposure in surgical training. Surgical video analysis supports auto-evaluation, expert assessment and could be a target for automatization. The developed ontology was validated by a European expert consensus and is applicable across the surgical techniques encountered in all participating centres, with an exemplary demonstration in bi-centric recordings. Standardization of adrenalectomy video analysis may foster surgical training and enable machine learning training for automated safety alerts.

The Impact of Body Mass Index on Perioperative Outcomes of Robotic Adrenalectomy: An Update.

Background. Robotic surgery has gained increasing popularity over the past 2 decades. However, factors including patient comorbidities and tumor characteristics are still crucial factors for outcomes of surgery. In this study, we evaluated the impact of body mass index (BMI) on perioperative outcomes in patients who underwent robotic adrenal surgery. Methods. Between May 2012 and November 2017, 66 consecutive patients who underwent robotic adrenalectomy were included in this study. Patients were divided into 2 groups based on their BMI: nonobese (<30 kg/m2) and obese (≥30 kg/m2). Additionally, patient demographics, tumor size, total operative time, docking time, console time, estimated blood loss, conversion to open, complications, additional analgesia requirement, length of hospital stay, and rough costs were evaluated. Results. Of the 66 patients, a total of 26 patients were obese (30%). Between study groups, the median BMI was calculated as 26 (18-29) and 33 (30-57). The groups were similar in terms of age, gender, American Society of Anesthesiologists scores, and previous history of abdominal surgery. Likewise, there were no significant differences between groups regarding total operative time (P = .085), docking time (P = .196), console time (P = .211), estimated blood loss (P = .180), complications (P = .991), length of hospital stay (P = .598), and rough costs (P = .468). Five cases were converted to open surgery. Nonobese cases required additional analgesia (P = .007). We had no unexpected hospitalizations in either group. Conclusion. Guidelines express the advantages of robotic surgery in obese patients. No statistically significant differences were detected between the 2 groups except for the additional analgesia required in nonobese patients.

New Paradigms for Neural Monitoring in Thyroid Surgery.

Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.

Efficacy of simvastatin in reducing postoperative adhesions after thyroidectomy: an experimental study.

BACKGROUND: We aimed to investigate whether simvastatin had any impact on the prevention of adhesion formation after thyroidectomy in a rat model. METHODS: This study was performed in 66 Wistar albino rats randomized into three experimental groups. A right hemithyroidectomy was carried out in all the rats. Simvastatin was administered locally at a dose of 0.5 mg/kg and 0.8 mg/kg. Control rats received a saline solution only. Changes during the 1st week, 1st month and 3rd month were evaluated. Efficacy of the treatment was assessed by using a scoring system. RESULTS: The severity of adhesions in low-dose simvastatin group was significantly less than the control and high-dose groups during the 1st and 3rd month (p < .05). In addition, adhesions were less in the high dose group during the 3rd month, when compared to the control group (p < .05). Moreover, fibrosis and fibroblast scores, which represent adhesions, were significantly lower in low-dose and high-dose groups at 3rd month, compared to controls (p < .05). CONCLUSIONS: We investigated the influence of simvastatin application on post-thyroidectomy adhesion formation in rats. Whether adhesions, causing technical difficulties during neck redo surgery, can be reduced by the use of simvastatin in human, needs to be studied.

Turkish endocrine surgery publications in international scientific journals.

OBJECTIVE: In recent years, major progress has been made in the field of endocrine surgery in Turkey, similar to that in the rest of the world. Parallel to these developments, there has been a significant increase in the number of publications in the related field. Our study aimed to evaluate Turkey's publications related to endocrine surgery in the international arena. MATERIAL AND METHODS: Members of the general surgery departments from academic centers in Turkey were determined. Using these member names, a PubMed search was performed for English papers related to "endocrine surgery." For searching papers from non-academic centers, the same engine was used. To reach manuscripts possibly missed by the PubMed search, 3 national calls were made through the website of the Turkish Society of Endocrine Surgery. The obtained papers were divided into "thyroid," "parathyroid," "adrenal," and "neuroendocrine tumors" and were listed according to the publication year. In addition, all manuscripts were listed according to the publishing journal and the 2012 impact factor of that journal. This study did not require ethical approval, because it did not involve evaluation of experimental or patient data. RESULTS: A search of Turkish general surgery clinics revealed 497 international publications, between 1976 and 2012. When listed according to the year of publication, most publications were found to be in the year 2009. Papers appeared mostly in "Surgery Today." The mean impact factor of the journals where the papers have been published was 1.9 (0.1-13.8). The rates of thyroid, parathyroid, adrenal tissue and neuroendocrine tumors related publications were 69%, 10%, 15% and 6%, respectively. Since this study is not an experimental study or a study related to patient data, we did not apply for ethical approval. CONCLUSION: The contribution of Turkish general surgeons' to world science is apparent when evaluated in terms of publications related to endocrine surgery until recently. Particularly, since 2002, with the increase in the number of publications in the field of endocrine surgery, there has been an increase in Turkey's importance on the international platform.

Outcomes of adrenal-sparing surgery or total adrenalectomy in phaeochromocytoma associated with multiple endocrine neoplasia type 2: an international retrospective population-based study.

BACKGROUND: The prevention of medullary thyroid cancer in patients with multiple endocrine neoplasia type 2 syndrome has demonstrated the ability of molecular diagnosis and prophylactic surgery to improve patient outcomes. However, the other major neoplasia associated with multiple endocrine neoplasia type 2, phaeochromocytoma, is not as well characterised in terms of occurrence and treatment outcomes. In this study, we aimed to systematically characterise the outcomes of management of phaeochromocytoma associated with multiple endocrine neoplasia type 2. METHODS: This multinational observational retrospective population-based study compiled data on patients with multiple endocrine neoplasia type 2 from 30 academic medical centres across Europe, the Americas, and Asia. Patients were included if they were carriers of germline pathogenic mutations of the RET gene, or were first-degree relatives with histologically proven medullary thyroid cancer and phaeochromocytoma. We gathered clinical information about patients'RET genotype, type of treatment for phaeochromocytoma (ie, unilateral or bilateral operations as adrenalectomy or adrenal-sparing surgery, and as open or endoscopic operations), and postoperative outcomes (adrenal function, malignancy, and death). The type of surgery was decided by each investigator and the timing of surgery was patient driven. The primary aim of our analysis was to compare disease-free survival after either adrenal-sparing surgery or adrenalectomy. FINDINGS: 1210 patients with multiple endocrine neoplasia type 2 were included in our database, 563 of whom had phaeochromocytoma. Treatment was adrenalectomy in 438 (79%) of 552 operated patients, and adrenal-sparing surgery in 114 (21%). Phaeochromocytoma recurrence occurred in four (3%) of 153 of the operated glands after adrenal-sparing surgery after 6-13 years, compared with 11 (2%) of 717 glands operated by adrenalectomy (p=0.57). Postoperative adrenal insufficiency or steroid dependency developed in 292 (86%) of 339 patients with bilateral phaeochromocytoma who underwent surgery. However, 47 (57%) of 82 patients with bilateral phaeochromocytoma who underwent adrenal-sparing surgery did not become steroid dependent. INTERPRETATION: The treatment of multiple endocrine neoplasia type 2-related phaeochromocytoma continues to rely on adrenalectomies with their associated Addisonian-like complications and consequent lifelong dependency on steroids. Adrenal-sparing surgery, a highly successful treatment option in experienced centres, should be the surgical approach of choice to reduce these complications.

Image-guided thyroid nodule ablation: technical notes and critical appraisal.

Image-guided thyroid nodule ablation is a relatively new technique for the management of thyroid disease. Notably, if there has been the correct patient selection and if they are performed in high volume centers and via a standardized technique, image-guided thyroid nodule ablation seems to be safe and effective and it can be used to treat thyroid goiters. However, there is still paucity of level 1 evidences and recommendation comparing ablation to surgical or to other non-surgical treatment modalities. Herein, some technical notes for the thyroid nodule ablation to achieve the critical view of safety are presented. Moreover, an additional remark and appraisal from a surgical point of view is described.

How informed are endocrine surgery patients about the risks of surgery after approving an informed consent?

OBJECTIVE: The aim is to evaluate if patients reach the level of competence that enables them to make the best decision for themselves with oral and written informed consent process that is legally valid. MATERIAL AND METHODS: This study included 62 patients who applied to Ege University Hospital Department of General Surgery Endocrine Surgery Clinics and in whom oral and written informed consent was obtained by a surgeon. Patients who were willing to participate in the study were asked to fill in a questionnaire containing questions regarding the concept of consent. RESULTS: Seventy-one percent of patients were female and 29% were male, with a mean age of 50.4±17.9 years. Six percent of patients were illiterate, 51.6% had primary education and 16.1% were college graduates. One in every two patients stated that they have never heard of informed consent concept before, 16% stated that they signed the consent without reading it. Among these patients, 88% reported that they trusted the physician and did not bother reading because they have already been verbally informed. Verbal briefing by the doctor was detected as 92%. Similarly, 91% of the patients reported that the time allocated to read and fill-in the form was enough. CONCLUSION: Informing is not composed simply of conveying information, but also to elevate patients to a proficiency level where they could decide with their best interest. It is thought that the results obtained in this study might guide studies to improve the quality of information in patients undergoing surgery.