Current and Future of Robotic Surgery in Thyroid Cancer Treatment.

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Transoral endoscopic thyroidectomy submental vestibular approach for early-stage papillary thyroid carcinoma: a systematic review and meta-analysis.

PURPOSE: Our study aimed to compare the effectiveness and complications of the transoral endoscopic thyroidectomy submental vestibular approach (TOETSMVA) versus the transoral endoscopic thyroidectomy vestibular approach (TOETVA) or conventional open thyroidectomy (COT) in patients with early-stage papillary thyroid carcinoma (PTC). METHODS: We searched online databases up to January 2024. The outcomes were analyzed using RevMan 5.4 and inverse variance. RESULTS: Seven studies (two RCTs and five retrospective cohort studies) were included. We established higher significance differences for TOETSMVA in comparison with TOETVA in terms of all primary outcomes; operation time, hospital stay, number of resected lymph nodes [MD -21.05, 95% CI= -30.98, -11.12; p < 0.0001], [MD -1.76, 95% CI= -2.21, -1.32, p < 0.00001], [MD -2.99, 95% CI= -19.75, 13.76, p < 0.73], [MD -0.83, 95% CI = -1.19 to -0.47; p < 0.00001], respectively, except the drainage volume, it showed no difference [MD -2.99, 95% CI= -19.75, 13.76, p < 0.73]. In secondary outcomes, it was favored only in mandibular numbness and return to normal diet outcomes. Additionally, TOETSMVA compared with COT showed a significant difference in drainage volume, pain, cosmetic effect, and satisfaction score. CONCLUSIONS: TOETSMVA showed a significant improvement compared to the TOETVA in operation time, hospital stay, number of resected lymph nodes, mandibular numbness, and return to normal diet but did not show a difference in drainage volume. However, TOETSMVA was better in cosmetic effect, drainage volume, satisfaction, and pain scores compared with COT. Further RCTs with larger sample size, multicentral, and longer follow-up are necessary to evaluate the limitations.

A prospective study to assess cervical scar satisfaction following conventional open thyroidectomy for thyroid cancer.

BACKGROUND: Conventional open thyroidectomy (COT) remains a common method of thyroidectomy in many parts of the world for various reasons. METHODS: In this prospective (cross-sectional) study, we evaluated the scar satisfaction among patients and surgeons following COT using the Patient and Observer Scar Assessment Scale (POSAS) and the Patient Scar Assessment Questionnaire (PSAQ). RESULTS: A total of 116 patients were included. The median age of the patients was 44 years and the majority were women. The median scar length overall was 12.2 cm. On POSAS, the median score for surgeon 1 was 1 (range 1-5), for surgeon 2, it was 2 (range 1-6), and for the patient, it was 1 (range 1-6) suggesting good scar satisfaction. The patient's response in the PSAQ was also echoing similar outcomes with scar satisfaction. CONCLUSIONS: Overall, both the patients and the surgeons seem to be satisfied with the overall scar appearance following COT despite the scar length.

Surgical outcomes of endoscopic thyroidectomy approaches for thyroid cancer: a systematic review and network meta-analysis.

Objectives: This network meta-analysis assesses the outcomes of seven endoscopic approaches, offering valuable insights for researchers and practitioners in choosing the best method for thyroid cancer patients. Methods: A systematic literature search was conducted in the PubMed, Embase and Web of Science databases up to March 2023. The analysis included seven endoscopic approaches, with a focus on their respective outcomes through network meta-analysis. Results: This meta-analysis included 44 studies involving 8,672 patients. The axillo-bilateral breast approach (ABBA) and unilateral axillo-breast approach (UABA) showed advantages in terms of reduced operative time compared to other approaches (MD = 19.66 minutes, 95% CI = -31.66 to 70.98; MD = 30.32 minutes, 95% CI = -1.45 to 62.09, respectively). The UABA and anterior chest approach (ACA) exhibited superiority in controlling intraoperative bleeding (MD = -3.37 mL, 95% CI = -22.58 to 15.85; MD = -13.77 mL, 95% CI = -28.85 1.31, respectively). UABA and ACA also showed advantages in reducing hospital stays (MD = -0.39 days, 95% CI = -1.48 to 0.71; MD = -0.26 days, 95% CI = -1.33 to 0.81, respectively). The transoral approach (OA) yielded results comparable to those of conventional open thyroidectomy (COT) and outperformed other endoscopic surgeries with regards to lymph node retrieval and metastatic lymph node assessment. For the stimulated serum thyroglobulin (TG) levels, no significant difference was observed between bilateral axillo-breast approach (BABA) and OA compared to COT. However, chest-breast approach (CBA) showed significantly lower levels than COT (MD=-0.40 ng/ml, 95% CI =-0.72 to -0.09). Patients in the gasless unilateral transaxillary approach (GUA) group experienced a significant improvement in cosmetic satisfaction (MD=-2.08, 95% CI =-3.35 to -0.82). Importantly, no significant difference was observed in the incidence of surgical complications between endoscopic thyroidectomy and COT. Conclusion: Endoscopic thyroid surgery is a safe and effective choice for thyroid cancer patients. Different approaches have their advantages, allowing personalized selection based on the patient's needs. ABBA and UABA have shorter operative times, while UABA and ACA excel at controlling bleeding and shortening hospital stays. OA shows promise for lymph node assessment. These findings contribute to the growing evidence supporting endoscopic methods, expanding treatment options for thyroid cancer patients.

A propensity score matching analysis of gasless endoscopic transaxillary thyroidectomy with five-settlement technique versus conventional open thyroidectomy in patients with papillary thyroid microcarcinoma.

BACKGROUND: In a previous study, we proposed a novel anatomy-based five-settlement method for transaxillary endoscopic thyroidectomy (fs-TAT) for patients with papillary thyroid carcinoma. The safety of this new method has been reported in a retrospective study of a single cohort. The safety and short-term oncological outcome of this method was confirmed by comparing it with conventional open surgery (COT) in patients with papillary thyroid microcarcinoma. METHODS: The medical records of patients who underwent fs-TAT or COT by a single surgeon from February 2019 to December 2021 were reviewed retrospectively. All patients were diagnosed with papillary thyroid microcarcinoma and underwent lobectomy and ipsilateral central compartment neck dissection. Propensity score matching was used to compare the technical safety and short-term oncologic outcomes of fs-TAT and COT for the purpose of reducing potential selection bias. Reporting was consistent with the STROCSS 2021 guidelines. RESULT: After propensity score matching, 460 (fs-TAT: 230; COT: 230) patients remained in the study population. There were no significant differences in sex, age, tumor size, Hashimoto's thyroiditis, or tumor multifocality between the groups. The operative time was longer [104.5 (90.3, 120.0) vs. 62.0 (52.0, 76.0), P < 0.001] and the total postoperative drainage volume [135(90, 210) vs. 75 (55, 115), P < 0.001] was greater in the fs-TAT group than in the COT group. However, intraoperative bleeding [3.0 (2.0, 5.0) vs. 5.0 (5.0, 7.5), P < 0.001] was greater, and the median number of lymph nodes yielded [5.0 (2.3, 8.0) vs. 7.0 (5.0, 11.0), P < 0.001] was greater in the COT group than in the fs-TAT group. The groups exhibited no significant difference in the rate of complications (fs-TAT: 2.2% vs. COT: 2.6%, P = 0.856), rate of positive lymph nodes (fs-TAT: 32.2% vs. COT: 36.5%, P = 0.377), length of postoperative hospital stay (3 days vs. 3 days, P = 0.305) or total medical costs (26,936 vs. 26,549, P = 0.144). CONCLUSION: Compared to conventional open surgery, fs-TAT offered excellent safety and acceptable short-term oncological outcomes in a selected cohort of patients with papillary thyroid microcarcinoma.

Robotic thyroidectomy. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire).

Transaxillary robotic thyroidectomy is hardly the approach of reference. It is occasionally proposed for carefully selected patients with a small-sized (2cm maximum), exclusively cervical unilateral nodule without lymph node involvement, in a small thyroid lobe (6cm maximum) in a thin individual wishing to avoid a cervical scar. Potential candidates must be informed on the risks specific to this technique and about the scarceness of evidence of its equivalence to cervicotomy in terms of quality of life and patient satisfaction. Shall be excluded from robotic surgery: malignant nodules (or nodules suspected of malignancy>2cm), cancers with microscopic nodal metastases, plunging goiter, patients with previous cervical surgery or overactive thyroid. Robotic thyroidectomy must be performed in centers with expertise in both thyroid surgery and robotic surgery.

Elastic Silicone Occlusive Sheeting Versus Silicone Occlusive Sheeting in the Treatment of Scars: A Randomized Controlled Trial.

INTRODUCTION: Hypertrophic scarring caused by conventional open thyroidectomy is prevalent among Asians and published trials have proved that silicone occlusive sheeting is a useful treatment for hypertrophic scarring. However, silicone occlusive sheeting does not effectively prevent scar widening. Here, we report elastic silicone occlusive sheeting as a new type of silicone application. In this study, we compared the effects of elastic silicone occlusive sheeting on scar width and appearance after conventional open thyroidectomy with those of silicone occlusive sheeting. METHODS: In this prospective, randomized, assessor-blinded study, a total of 74 patients who underwent conventional open thyroidectomy were recruited to undergo elastic silicone occlusive sheeting and silicone occlusive sheeting on the healed wound. Split scar study and scar quality were assessed on the basis of scar width, Vancouver scar scale, pain/itching visual analogue scale, and patients' subjective degree of satisfaction with the scar, during the patients' 6-month review. RESULTS: A total of 61 patients completed the study. Scar width, Vancouver scar scale score, and patients' subjective degree of satisfaction indicated that elastic silicone occlusive sheeting was associated with narrower scars and significant improvement in scar appearance. The two methods did not differ significantly with regard to pain/itching visual analogue scale. CONCLUSIONS: Our findings highlight elastic silicone occlusive sheeting as an effective treatment for scarring, resulting in narrower and better scars after conventional open thyroidectomy. The use of elastic silicone occlusive sheeting after conventional open thyroidectomy may minimize the formation of hypertrophic scars in the early postoperative period. TRIAL REGISTRATION: ChiCTR2100049740.

Comparison of efficacy, safety, and patient satisfaction between thermal ablation, conventional/open thyroidectomy, and endoscopic thyroidectomy for symptomatic benign thyroid nodules.

PURPOSE: Thermal ablation (TA) is a minimally invasive treatment method for symptomatic benign thyroid nodules (BTNs). This study aimed to evaluate the value of TA by comparing the efficacy, safety, and patient satisfaction with conventional/open thyroidectomy (ConT) and endoscopic thyroidectomy (ET) for symptomatic BTNs. METHODS: Patients with symptomatic BTNs who underwent ConT, ET, or TA therapy between January 2018 and January 2020 were included. Pre-operation data of the two comparisons (TA vs. ConT and TA vs. ET) was balanced using propensity score matching. The technique efficacy (volume reduction ratio ≥50%), nodule disappearance, and regrowth rate were calculated after ablation. The operation and hospitalization time, medical cost, complications, post-operative symptoms, and cosmetic scores were recorded and compared. Patient satisfaction was evaluated using a telephone survey. RESULTS: After a median 19-month follow-up (range, 12-36 months), the technique efficacy rate, nodule disappearance, and regrowth rate were 93.2% (119/129), 6.8% (10/129), and 0.8% (1/129), respectively. Operation time, hospitalization time, and medical costs were less for patients in the TA group than for patients in the ConT and ET groups (all p < 0.001). The incidence of complications, post-operative symptoms, cosmetic scores, and overall satisfaction were not significantly different among groups (all p > 0.05). Post-operative hypothyroidism was less frequent in the TA group than in the ConT and ET groups (all p < 0.05). CONCLUSIONS: Compared to ConT and ET, TA has comparable efficacy, safety, and patient satisfaction and exhibits greater protection of thyroid function for the treatment of symptomatic BTNs.

Comparison of endoscopic thyroidectomy by complete areola approach and conventional open surgery in the treatment of differentiated thyroid carcinoma: A retrospective study and meta-analysis.

Background: The feasibility of endoscopic thyroidectomy by complete areola approach (ETCA) remains controversial. This study was conducted by combining our clinical data with the data obtained from a systematic review literature search to examine the effectiveness and safety of ETCA compared with conventional open thyroidectomy (COT) in differentiated thyroid carcinoma (DTC). Methods: A total of 136 patients with a diagnosis of DTC who underwent unilateral thyroidectomy with central neck dissection from August 2020 to June 2021 were enrolled. The enrolled patients were divided into the ETCA group (n = 73) and the COT group (n = 63). The operative time, intraoperative bleeding volume, number of removed lymph nodes, number of metastatic lymph nodes, postoperative drainage volume, length of postoperative hospital stay, postoperative parathyroid hormone (PTH) levels, and complications were analyzed. Then, a systemic review and comprehensive literature search were conducted by using PubMed, Google Scholar, Embase, Web of Science, CNKI, Wanfang, and VIP database up to June 2022. Review Manager software version 5.3 was used for the meta-analysis. Results: The results of clinical data showed that there were significant differences between the two groups in the operative time, intraoperative bleeding volume, removed lymph nodes, and postoperative drainage volume. There were no statistical differences in the length of postoperative hospital stay, number of metastatic lymph nodes, postoperative PTH level, and complications. In the systematic review and meta-analysis, 2,153 patients from fourteen studies (including our data) were ultimately included. The results of the meta-analysis found that ETCA had a longer operative time, larger postoperative drainage volume, and lower intraoperative bleeding volume. In terms of the length of postoperative hospital stay, the number of removed lymph nodes, and surgical complications, there was no significant difference between the two groups. Conclusion: ETCA poses lower surgical bleeding and better cosmetic appearance compared with COT, while the length of operation and postoperative drainage in ETCA is less favorable compared with COT. In addition, ETCA is not inferior to COT in terms of the postoperative hospitalization stay, the number of removed lymph nodes, and surgical complications. Given its overall advantages and risks, ETCA is an effective and safe alternative for patients with cosmetic concerns.

Comparing endoscopic thyroidectomy using the breast approach and conventional open thyroidectomy: A retrospective analysis.

AIMS: Endoscopic thyroidectomy (ET) using the breast approach and conventional open thyroidectomy (OT) are effective approaches to treating thyroid tumors. This study evaluates the effectiveness of ET and OT regarding safety, cosmetic effects, and feasibility. SUBJECTS AND METHODS: Four hundred and fifty-six patients who underwent thyroidectomy in our department from January 2019 to August 2020 were included in this study. Based on the intraoperative rapid pathology, all patients with papillary thyroid carcinoma underwent unilateral thyroid lobectomy and central neck lymph node dissection. Whereas all benign patients underwent unilateral thyroid lobectomy. Differences in various factors such as clinical characteristics, operation time, postoperative drainage volume, parathyroid hormone (PTH) levels, calcium (Ca) levels, total number of central lymph nodes resected, the number of metastatic central lymph nodes resected, hospital duration, hospitalization costs, and cosmetic effects were compared in each group. RESULTS: Baseline characteristics among the four groups were similar, except for patient age and tumor size. Patients in the malignant ET group were younger than those in the malignant OT group with smaller tumors (P < 0.05). There were no significant differences between the OT and ET groups in postoperative Ca levels, PTH levels, the total number of lymph nodes resected, and the number of metastatic central lymph nodes resected. CONCLUSIONS: Compared with conventional OT, ET is a feasible, practical, and safe procedure with excellent cosmetic benefits.

Comparison of Surgical Outcomes between Robotic Transaxillary and Conventional Open Thyroidectomy in Pediatric Thyroid Cancer.

Thyroid cancer in children is very uncommon. For pediatric thyroid cancer, robotic surgery has served as a minimally invasive surgical alternative to conventional open surgery. Our study aimed to evaluate the results of robotic versus open surgical treatment for patients with thyroid cancer younger than 20 years of age at the time of diagnosis. This retrospective review included 161 pediatric patients who underwent robotic transaxillary or conventional open thyroidectomy at our institution from 2008 to 2019. Of these patients, 99 comprised the robotic group and 62 the open group. Patient demographics, surgical outcomes, and disease-free survival rates were compared between the two groups. Patients in the open group were more likely to have advanced stage diseases with a larger tumor size and higher tumor-node-metastasis stage than those in the robotic group. Operation time and follow-up period were similar in both groups. Patients in the robotic group had a lower rate of postoperative complications and a shorter length of hospital stay, but they also had a lower average number of retrieved central lymph nodes. However, there were no significant between group differences in recurrence rates and disease-free survival. In the hands of an experienced surgeon, robotic thyroidectomy is a feasible and safe option for pediatric patients.

Comparison of long-term surgical outcome between transaxillary endoscopic and conventional open thyroidectomy in patients with differentiated thyroid carcinoma: a propensity score matching study.

BACKGROUND: There is an increased use of endoscopic thyroidectomy (ET), including robotic-assisted thyroidectomy (RT), to avoid postoperative scars on the anterior neck. The objective of this study was to compare the surgical and oncologic outcomes between ET and conventional open thyroidectomy (COT) for differentiated thyroid carcinoma (DTC). METHODS: We reviewed 4129 patients with DTC who underwent thyroid lobectomy at Seoul St. Mary's Hospital (Seoul, Korea) from January 2009 to December 2014. Patients were categorized according to the type of surgery and statistically compared using propensity score matching analysis. RESULTS: The mean operation time was significantly longer in the ET group than in the OT group (101.2 ± 26.2 min vs. 86.4 ± 27.0 min, p < 0.001). The number of harvested lymph nodes was significantly lower in the ET group than in the OT group (5.5 ± 4.2 vs. 8.3 ± 6.2, p < 0.001). There was no significant difference in the recurrence rate between the two groups (p = 0.879). Kaplan-Meier analysis revealed no significant difference in the disease-free survival after propensity score matching (p = 0.811). The mean follow-up duration was 90.4 ± 21.0 months. CONCLUSIONS: Transaxillary ET including RT for DTC is a safe and feasible alternative to COT with a cosmetically desirable outcome. Further studies are required to confirm our results.

Comparison of safety and efficacy between total endoscopic resection and conventional open surgery for malignant thyroid tumors: a meta-analysis.

BACKGROUND: Endoscopic thyroidectomy (ET) has been widely accepted as a surgical option for benign thyroid lesions, yet remains controversial in the treatment of malignant thyroid because of concerns with the safety and efficacies. This paper aims at systematically evaluating the advantages and disadvantages of ET in malignant thyroid tumors through meta-analyses. METHODS: Meta-analysis was conducted by retrieving all studies on the treatment of malignant thyroid carcinomas released in database, including PubMed, Web of Science, Cochrane and Google scholar, from January 2005 to January 2019. Then the safety and efficacies were compared between the two surgical modalities based on current reports. RESULTS: Totally, 3,482 cases were included in 11 related studies. Most adverse outcomes by ET were involved in transient or permanent recurrent laryngeal nerve paralysis (RLN) and hypocalcemia, postoperative total complications, hemorrhage, hematoma at the incision, and total relapse rate following surgery. Besides, ET led to higher incidence of transient RLN palsy, yet significantly lower transient hypocalcemia than conventional open thyroidectomy (COT). The difference was insignificant regarding transient or permanent RLN and hypocalcemia, total postoperative complications, postoperative hemorrhage, incisional hematoma and total recurrent rate between the two procedures. Secondary outcomes consisted of operative time, hospital stay and cosmetic results, by which COT was superior to ET, yet cosmetic incision was better by ET than by COT. There was no significant difference in hospital stay. CONCLUSIONS: ET can be feasible and safe surgical option for malignant thyroid lesions, with better cosmetic effect.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis.

BACKGROUND: Despite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC. METHODS: A systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis. RESULTS: Twelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group. CONCLUSION: ET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

Transaxillary Endoscopic Thyroidectomy versus Conventional Open Thyroidectomy for Papillary Thyroid Cancer: 5-year Surgical Outcomes / 대한내분비외과학회지

PURPOSE: The early surgical outcomes of endoscopic thyroidectomy in papillary thyroid cancer (PTC) are comparable to those of conventional open thyroidectomy; however, there is little evidence about long-term outcomes. The aim of this study was to compare the 5-year surgical outcomes of endoscopic versus open thyroidectomy. METHODS: We reviewed 804 patients with PTC who underwent thyroidectomy between October 2008 and October 2010. Of these, 703 patients received conventional open thyroidectomy (OT group) and 101patients underwent endoscopic thyroidectomy (ET group). The clinicopathologic characteristics and surgical outcomes were compared between those treatments. RESULTS: ET was applied significantly more often in young patients and females. The lobectomy and unilateral CCND were performed more frequently in ET, and the mean tumor size was smaller. The prevalence of extrathyroidal extension, multiplicity, and lymphatic invasion was more frequent in OT. The T and TNM stage were more advanced in OT, whereas the N status was similar between treatments. The mean surgical time was significantly longer for ET, while the number of retrieved lymph nodes was greater in OT. However, the stimulated thyroglobulin levels at first RAI ablation, total amount of RAI administration and 5-year recurrence rate did not significantly differ between groups. The incidence of transient hypocalcemia was significantly higher in OT, but the incidence of permanent hypocalcemia and transient/permanent recurrent laryngeal nerve injury were similar in both groups. CONCLUSION: Endoscopic thyroidectomy might be a safe and effective procedure in well-selected PTC patients