Minimally Invasive Open Bilateral Total Thyroidectomy Using Unilateral Neck Incision in Thyroid Cancer: Preliminary Surgical and Quality of Life Outcomes.

PURPOSE: Thyroid cancer incidence has increased in recent decades, and thyroid surgery is continuously evolving in response to demands for postoperative comfort and cosmesis. This study aimed to introduce a new surgical method for minimally invasive open bilateral total thyroidectomy (MI-BTT) using a unilateral 2.5-3.0 cm neck incision. Furthermore, we reported the surgical outcomes and postoperative quality of life (QoL) using a validated Korean translated Dermatology Life Quality Index (DLQI) questionnaire. MATERIALS AND METHODS: We retrospectively evaluated 41 Asian patients who underwent MI-BTT for low-risk papillary thyroid cancer by a single surgeon from March 2019 to December 2021. RESULTS: A total of 4 male and 37 female patients were included. The mean age and body mass index were 46.2±10.1 years and 23.3±3.3 kg/m², respectively. The average tumor size was 1.1±0.6 cm, and 36 patients (87.8%) had bilateral cancer. Twenty-three (56.1%) patients had occult central lymph node (CLN) metastasis in the final pathologic report, with the mean number of dissected CLNs being 7.2±6.5. Gross capsular extension was found in 6 patients (14.6%). Moreover, 28 patients (68.3%) received additional treatment after surgery with low or high doses of radioactive iodine. The average serum-stimulated thyroglobulin value identified during treatment was 1.57±2.30 ng/mL. The mean operation time was 78.0±13.9 minutes, and postoperative complications included transient hypocalcemia (36.6%), transient hoarseness (24.4%), and seroma (2.4%). The mean total DLQI score was 2.73±0.78, indicating a small effect on QoL. CONCLUSION: MI-BTT is a novel, safe, and feasible technique to improve patient satisfaction for surgical scars and QoL.

Perioperative outcomes of bilateral axillo-breast approach robotic thyroidectomy (BABART) versus minimally invasive thyroidectomy (MIT): a systematic review and meta-analysis.

Minimally invasive thyroidectomy (MIT) is increasingly being used for the thyroid tumors. The comparison of bilateral axillo-breast approach robotic thyroidectomy (BABART) with other MIT has not yet led to a unified conclusion with regard to surgical outcomes. To conduct a systematic review and meta-analysis of the literature on the surgical outcomes of BABART compared with MIT. We performed a systematic search in PubMed, Web of Science, Embase and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare BABART to MIT. The primary outcomes included perioperative, postoperative complications. The odds ratio (OR) and mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Nine studies, comprising 3645 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in hospital stay, number of retrieved lymph nodes, recurrent laryngeal nerve (RLN) injury, and vocal cord dysfunction between BABRT and MIT. However, BABART was associated with a shorter operation time (MD = - 21.45 min, 95% CI [- 47.27, 4.38], p = 0.1) and lower rate of permanent hypoparathyroidism (OR = 0.42, 95% CI [0.20, 0.88], p = 0.02). Additionally, the MIT group had reduced postoperative pain score (MD = 0.45, 95% CI [0.02, 0.88], p = 0.04) and lower rate of hypocalcemia (OR = 2.31, 95% CI [1.04, 5.13], p = 0.04) than the BABART group. In comparison with MIT, BABART exhibits better results in terms of operative time and the rate of permanent hypoparathyroidism, with no significant difference in hospital stay, number of retrieved lymph nodes, RLN injury, and vocal cord dysfunction. However, the postoperative pain score and the rate of hypocalcemia of MIT are slightly better that of BABART.

The Usefulness of AirSeal™ Intelligent Flow System in Gas Insufflation Total Endoscopic Thyroidectomy.

Total endoscopic thyroidectomy (TET) using low CO2 insufflation provides cosmetic advantage, excellent working space and visibility. On the contrary, suctioning blood or mist/smoke produced by energy device application causes narrowing of working space especially in neck surgery. In this regard, AirSeal intelligent flow system would be particularly suitable in TET. However, the benefit of AirSeal is unknown in TET unlike abdominal surgery. Therefore, the impact of AirSeal was evaluated in TET in this study. Twenty patients who underwent total endoscopic hemithyroidectomy were retrospectively analyzed. Insufflation was conducted by either conventional or AirSeal system according to the surgeon's preference. Short-term surgical outcomes including operation time, bleeding, frequency of scope cleaning, and disappearance of subcutaneous emphysema were compared as well as actual visibility. AirSeal application dramatically reduced obstacle smoke/mist and prevented narrowing working space by suctioning. Frequency of scope cleaning was significantly less in AirSeal group than that in conventional group (p = 0.016). In patients with nodule < 5 cm, intraoperative hemorrhage was less in AirSeal group than that in the counterpart (p = 0.077) regardless of larger nodule size in AirSeal group (p = 0.058). Notably, subcutaneous emphysema around surgical cavity disappeared significantly earlier in AirSeal group than in the counter parts (p = 0.019). On the contrary, AirSeal application did not shorten operation time in the current study. AirSeal provided excellent visibility and seamless operation. AirSeal has great potential to decrease not only surgeon's stress but surgical invasion on patients. The results in this study give rational to AirSeal application to TET. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03257-0.

Hemitiroidectomía vía abordaje axilo-mamario unilateral (UABA) con insuflación de gas vs. convencional abierta: estudio prospectivo comparativo / Unilateral axilo-breast approach (UABA) with gas insufflation versus open conventional hemithyroidectomy: A prospective comparative study

Antecedentes: El objetivo de este estudio fue comparar con el abordaje abierto convencional, los resultados quirúrgicos y estéticos de la tiroidectomía endoscópica por abordaje axilo-mamario unilateral (UABA) con insuflación de gas en pacientes con nódulo tiroideo unilateral. Métodos: Entre agosto de 2017 y agosto de 2020, se llevó a cabo un estudio prospectivo comparativo de cohortes en pacientes propuestos para hemitiroidectomía. Los pacientes se asignaron a un tipo de abordaje (abierto o endoscópico) de manera sucesiva. Los resultados quirúrgicos y la satisfacción estética al alta hospitalaria y durante el seguimiento a 12 meses fueron evaluados y comparados entre ambos grupos. Resultados: Un total de 200 pacientes fueron incluidos en el estudio: 100 se asignaron al abordaje abierto y 100 al endoscópico. Las características demográficas de los pacientes fueron similares entre ambos grupos. El tiempo operatorio total fue mayor en el abordaje endoscópico, debido al tiempo necesario para la disección subcutánea (el tiempo de hemitiroidectomía fue similar en ambos grupos). No hubo diferencia significativa en la frecuencia de complicaciones mayores. El tiempo de estancia hospitalaria fue mayor (por un día) en el grupo endoscópico. La satisfacción estética de los pacientes fue significativamente mayor en el grupo endoscópico que en el abierto (p<0,001), al alta hospitalaria y al seguimiento a 12 meses. Conclusión: El UABA con insuflación de gas para la hemitiroidectomía representa una opción terapéutica segura y eficaz para el tratamiento de patologías benignas tiroideas unilaterales. (AU)

Background: The objective of this study was to compare with the conventional open approach, the surgical and aesthetic results of endoscopic thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation in patients with a unilateral thyroid nodule. Methods: Between August 2017 and August 2020, a prospective comparative cohort study was carried out in patients proposed for hemithyroidectomy. The patients were assigned to one type of approach (Open or Endoscopic) in a successive manner. Surgical results and aesthetic satisfaction at hospital discharge and during the 12-month follow-up were evaluated and compared between both groups. Results: A total of 200 patients were included in the study: 100 for the Open approach and 100 for the Endoscopic. The baseline patient characteristics were similar between both groups. Total operative time was longer in the Endoscopic approach, due to the time required for subcutaneous dissection (the hemithyroidectomy time was similar in both groups). There was no significant difference in the frequency of major complications. The length of hospital stay was longer (for 1 day) in the Endoscopic group. The aesthetic satisfaction of the patients was significantly higher in the Endoscopic than in the Open group (p<0.001), at hospital discharge and at 12-month follow-up. Conclusion: UABA with gas insufflation for hemithyroidectomy represents a safe and effective therapeutic option for the treatment of unilateral benign thyroid pathologies. (AU)

Unilateral axilo-breast approach (UABA) with gas insufflation versus open conventional hemithyroidectomy: A prospective comparative study.

BACKGROUND: The objective of this study was to compare with the conventional open approach, the surgical and aesthetic results of endoscopic thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation in patients with a unilateral thyroid nodule. METHODS: Between August 2017 and August 2020, a prospective comparative cohort study was carried out in patients proposed for hemithyroidectomy. The patients were assigned to one type of approach (Open or Endoscopic) in a successive manner. Surgical results and aesthetic satisfaction at hospital discharge and during the 12-month follow-up were evaluated and compared between both groups. RESULTS: A total of 200 patients were included in the study: 100 for the Open approach and 100 for the Endoscopic. The baseline patient characteristics were similar between both groups. Total operative time was longer in the Endoscopic approach, due to the time required for subcutaneous dissection (the hemithyroidectomy time was similar in both groups). There was no significant difference in the frequency of major complications. The length of hospital stay was longer (for 1 day) in the Endoscopic group. The aesthetic satisfaction of the patients was significantly higher in the Endoscopic than in the Open group (p < 0.001), at hospital discharge and at 12-month follow-up. CONCLUSION: UABA with gas insufflation for hemithyroidectomy represents a safe and effective therapeutic option for the treatment of unilateral benign thyroid pathologies.

Comparison of the Postoperative Outcomes of the Mini-Flap Bilateral Axillo-Breast Approach (BABA) and Conventional BABA Robot-Assisted Thyroidectomy.

The bilateral axillo-breast approach (BABA) for robot-assisted thyroidectomy has some advantages over other minimally invasive thyroidectomies. However, some people do not consider this as a minimally invasive thyroidectomy because of the wider surgical skin flap. Thus, we devised mini-flap BABA robot-assisted thyroidectomy and analyzed the postoperative outcomes. The clinical records of 44 patients undergoing BABA robot-assisted thyroidectomy using a conventional flap or mini-flap were evaluated retrospectively. There were no significant group differences in clinicopathological characteristics. The operating and flap making times were shorter in the mini-flap group (206.18 ± 31.09 vs. 178.90 ± 34.43 min, p = 0.009; 38.85 ± 2.73 vs. 32.21 ± 8.62 min, p = 0.003, respectively). The total drainage amount was smaller in the mini-flap group (196.57 ± 81.40 vs. 150.74 ± 40.80 mL, p = 0.027). The numeric rating scale score and number of analgesics were lower at 2 h postoperatively in the mini-flap group (5.52 ± 0.87 vs. 4.57 ± 1.31, p = 0.006; 0.95 ± 0.22 vs. 0.65 ± 0.49, p = 0.012, respectively). There was no significant group difference in immediate oncological outcomes (p = 1.000). Mini-flap BABA robot-assisted thyroidectomy minimized the surgical flap and improved surgical outcomes. Therefore, it is a form of minimally invasive thyroidectomy. However, long-term follow-up of oncological outcomes is needed.

Long-term cosmetic results of video-assisted thyroidectomy: a comparison with conventional surgery.

PURPOSE: We present the long-term cosmetic results of the video-assisted thyroidectomy (MIVAT) in comparison to the conventional operation. METHODS: Forty-eight patients (four males, 44 females; mean age 47.4 ± 12.5 years) constituted the video-assisted group (VA-Group). These were compared with 48 patients (10 males, 38 females; mean age 47.4 ± 12.5 years) operated by conventional surgery (C-Group). The patients were selected from all thyroid operations performed between January 2016 and June 2017. Patient Scar Assessment Scale (PSAS) and Observer Scar Assessment Scale (OSAS) were used for the evaluation performed by an independent surgeon. Both scales contained six items scored numerically on a ten-step scale ranging from 1 (normal skin) to 10 (worst result). Moreover, photos of all scars were taken and analyzed by six team surgeons using modified OSAS. RESULTS: The mean follow-up time was 31.7 ± 6.4 months for the MIVAT group and 32.9 ± 4.6 months for the conventional group (p = 0.39). The mean scar length in the VA-Group was 2.6 cm vs. 3.8 cm in the C-Group (p < 0.0001). The total score of PSAS was 9.93 (6-35) for MIVAT and 9.72 (6-29) for conventional thyroidectomy (p = 0.22). The total OSAS score by the independent surgeon showed a better cosmetic outcome for conventional surgery (13.19 vs. 12.33; p = 0.01). The total OSAS score by the six team surgeons did not differ between both groups in five of six ratings; one surgeon favored MIVAT (12.2 vs. 13.6; p = 0.04). CONCLUSIONS: This study does not find cosmetic advantages of minimally invasive video-assisted thyroidectomy compared to conventional thyroidectomy.

Modified version of minimally invasive open thyroidectomy using an unilateral incision.

BACKGROUND/OBJECTIVE: Open thyroidectomy has been the standard approach for patients undergoing thyroidectomy. However, this approach leads to prominent scars, hypesthesia, paresthesia, and uncomfortable sensations. We aimed to describe our modified technique of minimally invasive open thyroidectomy (MIT) and to compare the results with those of conventional thyroidectomy. METHODS: This study included 880 patients who underwent surgery between January 2016 and December 2016. Modified MIT was performed in 249 patients (28.3%), and conventional thyroidectomy was performed in the remaining 631 patients. RESULTS: Lobectomy was performed in the majority of cases (MIT 204 [81.9%] vs. conventional 429 [67.9%]). There were no significant differences in complications between the two approaches (6 [2.4%] vs. 8 [1.3%]). Patients who underwent surgery using the minimally invasive approach had a shorter operative time (77.99 ± 34.5 vs. 91.23 ± 36.58 min) and were discharged earlier (2.4 ± 0.8 vs. 3.2 ± 0.8) than those who underwent conventional thyroidectomy. CONCLUSION: Modified MIT is a safe alternative to standard open thyroidectomy and allows the performance of bilateral total thyroidectomy with proper central compartment neck dissection. LEVEL OF EVIDENCE: 2b.

The variable direct cost and cost drivers of transoral endoscopic thyroidectomy vestibular approach.

BACKGROUND: As transoral endoscopic thyroidectomy vestibular approach grows in popularity, there is a need for data on cost in order to better characterize its value to patients. To this end, we compared the variable direct cost of transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy and determined which factors drive the increased cost for the transoral approach. METHODS: Patients undergoing thyroid lobectomy and total thyroidectomy that met inclusion criteria for transoral endoscopic thyroidectomy vestibular approach, including those patients that opted for management via the transcervical approach, between 8/2016 and 4/2019 were reviewed. The variable direct cost for the surgical encounter was collected and means were compared between the transoral and transcervical cohorts for lobectomy and total thyroidectomy respectively. The operative time independent variable direct cost was similarly compared between cohorts. RESULTS: Out of 238 patients, 118 (50%) were managed via transoral endoscopic thyroidectomy vestibular approach and 120 (50%) were managed via transcervical approach thyroidectomy. Mean variable direct cost, our primary outcome, was $4,455 (SD 1,129, 95% CI: 4,204-4,706) for transoral lobectomy and $3,179 (SD 687, 95% CI: 2,990-3,369) for transcervical lobectomy [t(132.05)=8.09, P<0.001] representing a difference in cost of $1,276 (SD 158, 95% CI: 964-1,587). Mean variable direct cost was $4,681 (SD 829, 95% CI: 4,405-4,957) for transoral total thyroidectomy and $3,645 (SD 876, 95% CI: 3,431-3,858) for transcervical total thyroidectomy [t(79.92)=5.98, P<0.001], representing a difference in cost of $1,036 (SD 173, 95% CI: 691-1,381). Differences in energy devices alone account for $487.53 and $447.96 of the cost differences, respectively. CONCLUSIONS: The differences in mean variable direct cost between transoral endoscopic vestibular approach and transcervical approach for lobectomy and total thyroidectomy were $1276 and $1036 respectively, amounts far less than some believe them to be. This data will be invaluable as we ultimately aim to define the value of transoral endoscopic thyroidectomy vestibular approach.

Endoscopic thyroidectomy: Which one is the better technique for the beginners?

INTRODUCTION: Endoscopic thyroidectomy is an advanced procedure and has a long learning curve. Most commonly employed approach is combined axillary-breast approach (ABA). Recently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) is being popularised as a scarless procedure. However, it is not established whether TOETVA or ABA approach is better to begin with. PURPOSE: The purpose of the study was to compare the initial experience of TOETVA and ABA with respect to difficulties and outcomes. METHODOLOGY: A prospective non-randomised interventional study was conducted including the initial ten patients in each group who underwent hemithyroidectomy for benign solitary thyroid nodule. Sigma plot version 12.3 was used for the statistical analysis. RESULTS: All the patients were female and comparable with respect to age (33.2 vs. 28.2 years) and size of nodule (2.7 vs. 3 cm) (TOETVA vs. ABA). The operative time (121 vs. 138.5 min, P = 0.34) and blood loss (50 vs. 60 ml, P = 0.9) were similar in both the groups. Even though the flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001), it was associated with more difficulty in approaching upper pole (P = 0.02) and lower pole (P < 0.001), more intra-operative events (30% vs. 10%, P = 0.58) and conversions to open (20% vs. 10%, P = 1). Similarly, post-operative pain scoring was more with TOETVA (3 vs. 2, P = 0.04). Hospital stay was similar in both the groups (2.5 vs. 3 days, P = 1). Patients in both the groups had both overall and cosmetic satisfaction. CONCLUSIONS: Axillary-breast approach should be preferred to start learning the endoscopic thyroidectomy, as it is easier and safer than transoral endoscopic vestibular approach.

Application of minimal invasive technique for thyroidectomy without remote access in locally advanced thyroid carcinoma with gross extra-thyroidal extension.

INTRODUCTION: Minimally invasive thyroidectomy (MIT) is technically less damaging tissue and is better cosmetic results with small neck scar, decreasing postoperative pain and neck discomfort. We present the experience of MIT without remote access with case of grossly extra-thyroidal extension positive papillary thyroid carcinoma. PRESENTATION OF CASE: A 44-year-old, female presented 1.6 cm irregular hypoechoic nodule at upper pole in Right thyroid gland and diagnosed to papillary thyroid carcinoma. The tumor was suspicious to have extra-thyroidal extension. We performed MIT without remote access for this patient with 2 cm cervical incision. Postoperative course was uneventful and patient was discharged on the 3th postoperative day. At present, she is taking 100mcg levothyroxine and is free of disease 3 years post-surgery. CONCLUSION: If experienced surgeons can get sufficient resection margin and control bleeding of superior thyroid artery, MIT without remote access can be feasible method for thyroid carcinoma with gross extra-thyroidal extension, especially, upper pole carcinoma.

Minimally Invasive Approaches for Thyroid Surgery-Pitfalls and Promises.

PURPOSE OF REVIEW: To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies. RECENT FINDINGS: Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

Minimally-invasive endocrine neck surgery. / Cirugía endocrina cervical mínimamente invasiva.

Minimally invasive approaches for endocrine surgery of the neck are the result of efforts by several surgeons to extrapolate to neck surgery the proven benefits of minimally invasive techniques from other regions of the body, including less pain, morbidity and hospital stay. However, the main argument that led to the introduction of these techniques was the improvement of esthetic results. Endoscopic and robotic remote-access endocrine neck approaches through small incisions have been developed over the last 25 years and are constantly being refined. The objective of this review is to determine the current state of the literature through a systematic evaluation of the different techniques available in minimally invasive endocrine surgery of the neck, either with or without remote access, by describing their main characteristics and evaluating their advantages, disadvantages and controversies, while discussing their role and future in neck surgery.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances.

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Transoral Thyroidectomy Using A Flexible Robotic System: A Preclinical Cadaver Feasibility Study.

OBJECTIVES/HYPOTHESIS: Traditionally, most thyroid surgery utilizes a curvilinear cervical incision with a resulting permanent scar. Minimally invasive and remote access thyroid surgery techniques continue to evolve. Transoral approaches through a vestibular incision have been developed at several centers throughout the world, obviating the need for a cutaneous incision and optimizing aesthetics. To date this technique has been performed using rigid endoscopes or a linear robotic platform. The goal of this study was to test the feasibility of a novel flexible robotic system to perform a transvestibular thyroidectomy in a preclinical cadaver model. STUDY DESIGN: Preclinical feasibility study. METHODS: Right and left thyroid lobectomies were successfully performed via a transvestibular approach in four cadavers. RESULTS: A single vestibular incision between bilateral mental nerves allowed entrance of the flexible robot in a subplatysmal plane in both male and female cadavers. The recurrent laryngeal nerves and parathyroids were identified and preserved. The flexible three-dimensional camera allowed excellent visualization and could be easily repositioned for optimal visualization of right and left structures. The flexible and wristed instruments enabled an atraumatic approach and allowed for precise surgical technique. CONCLUSIONS: The transoral vestibular approach to the central neck is a promising technique for thyroidectomy with optimal cosmesis and can be successfully accomplished using this novel flexible robotic system. Improvements in visualization and access offered by this system may improve application of this technique. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1482-1487, 2019.

Transoral endoscopic thyroidectomy: preliminary experience in Italy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

Minimally invasive thyroidectomy: a ten years experience.

BACKGROUND: The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient's quality of life, postoperative morbidity. The mini invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases. METHODS: We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay. RESULTS: The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3-4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%). CONCLUSIONS: The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.

Horner's syndrome subsequent to minimally invasive video-assisted thyroidectomy in two patients.

Horner's syndrome (HS), characterized by a combination of ptosis and miosis, is an uncommon complication of thyroid surgery, particularly in minimally invasive thyroid surgery. Two cases of HS were observed secondary to minimally invasive video-assisted thyroidectomy in the Department of Thyroid Breast Surgery of Zhejiang Provincial People's Hospital between August 2012 and July 2014. The two patients developed miosis and ptosis following total thyroidectomy; all symptoms had resolved at 1 and 11 months subsequent to surgery, respectively. HS has currently been reported secondary to numerous types of minimally invasive thyroid procedures. The literature was reviewed to identify cases of this iatrogenic complication secondary to each type of thyroidectomy and the possible injury mechanisms underlying the syndrome were summarized in the present study. In addition, factors that were associated with minimally invasive thyroidectomy, such as the limited endoscopic vision during the procedure, the retraction effect and the occurrence of thermal damage from the use of the harmonic scalpel, were emphasized. The present study concluded that close attention is required during minimally invasive thyroid surgery in order to avoid HS as a complication of the procedure.

Minimally invasive video-assisted thyroidectomy: Ascending the learning curve.

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. The aim of this report is to point out some aspects of the learning curve of the video-assisted thyroid surgery, through the analysis of our preliminary series of procedures. PATIENTS AND METHODS: Over a period of 8 months, we selected 36 patients for minimally invasive video-assisted surgery of the thyroid. The patients were considered eligible if they presented with a nodule not exceeding 35 mm and total thyroid volume <20 ml; presence of biochemical and ultrasound signs of thyroiditis and pre-operative diagnosis of cancer were exclusion criteria. We analysed surgical results, conversion rate, operating time, post-operative complications, hospital stay and cosmetic outcomes of the series. RESULTS: We performed 36 total thyroidectomy and in one case we performed a consensual parathyroidectomy. The procedure was successfully carried out in 33 out of 36 cases (conversion rate 8.3%). The mean operating time was 109 min (range: 80-241 min) and reached a plateau after 29 MIVAT. Post-operative complications included three transient recurrent nerve palsies and two transient hypocalcemias; no definitive hypoparathyroidism was registered. The cosmetic result was considered excellent by most patients. CONCLUSIONS: Advances in skills and technology allow surgeons to easily reproduce the standard open total thyroidectomy with video-assistance. Although the learning curve represents a time-consuming step, training remains a crucial point in gaining a reasonable confidence with video-assisted surgical technique.