Robotic Transaxillary Thyroid Lobectomy of a Follicular Neoplasm

Purpose

Minimally invasive thyroid surgery using various techniques is well described. The purpose of this video is to show a robotic-assisted transaxillary right thyroid lobectomy for a follicular neoplasm with intraoperative nerve monitoring and stimulation of recurrent laryngeal nerve. Herein, we show our experience with the technique and its safety and feasibility.

Methods

We performed a right thyroid lobectomy on a 33-year-old patient using the da Vinci-Si-HD Surgical System. The operation was done via a single axillary incision, 5?cm in length. The flap creation time was approximately 26?min. The robot docking time was 6?min. The recurrent laryngeal nerve was identified and nerve stimulation was used to stimulate with 0.5?milliamps. The operative console time was 21?min. Total operative time was 69?min.

Results

The procedure was successfully completed. Blood loss was minimal. Postoperative laryngoscopy showed intact and mobile bilateral vocal cords. There were no complications. Patient was discharged 4?h after surgery.

Conclusions

Robotic transaxillary endoscopic gasless thyroid surgery with monitoring and stimulation of the RLN is feasible and safe. This technique eliminates a visible neck scar and affords excellent high definition optics of the cervical anatomy. This new technique can be accomplished on an outpatient basis.     

Robot-Assisted Sistrunk’s Operation, Total Thyroidectomy, and Neck Dissection via a Transaxillary and Retroauricular (TARA) Approach in Papillary Carcinoma Arising in Thyroglossal Duct Cyst and Thyroid Gland

Background

Carcinomas arising in the thyroglossal duct cysts are rare, accounting only for about 0.7?C1.5?% of all thyroglossal duct cysts.1 ^?C 3 Synchronous occurrence of thyroglossal duct carcinoma and thyroid carcinoma is reported to be even rarer.4 Traditionally, surgical treatments of such coexisting thyroglossal duct cyst carcinoma (TGDCa) and papillary thyroid carcinoma (PTC) were typically performed through a single transverse or double incisions on the overlying skin. A longer, extended cervical incision might be required if neck dissection is necessary. Though this method provides the operator with the optimal surgical view, the detrimental cosmetic effect on the patient of possessing a scar cannot be avoided, despite the effort of the surgeon to camouflage the scar by placing the incision in natural skin creases. Recently, the authors have previously reported the feasibility of robot-assisted neck dissections via a transaxillary and retroauricular (??TARA??) approach or modified face-lift approach in early head and neck cancers.5 ^, 6 On the basis of the forementioned surgical technique, we demonstrate our novel technique for robot-assisted Sistrunk??s operation via retroauricular approach as well as robot-assisted neck dissection with total thyroidectomy via transaxillary approach.

Methods

This is a case presentation of a 22-year-old woman with synchronous TGDCa and PTC with minimal lymph node metastasis who underwent resection of TGDCa and total thyroidectomy with left neck level III and IV lymph node dissection as well as central compartment lymph node dissection (CCND) via TARA approach with a robotic surgery system after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The incision was just like the TARA approach in head and neck cancer, which has been reported by our institute.6 The operation was proceeded as follows. First, excision of the TGDCa through the retroauricular incision was done followed by total thyroidectomy with CCND via transaxillary approach. Finally, neck dissection of left level III, IV was conducted via transaxillary approach. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via retroauricular or transaxillary port. A 30° dual-channel endoscope was used, and the two instrument arms were equipped with 5?mm Maryland forceps and a 5?mm spatula monopolar cautery for TGDCa excision via retroauricular approach. When conducting total thyroidectomy and neck dissection via transaxillary approach, three instrument arms were utilized, each equipped with 5?mm Maryland forceps, ProGrasp forceps and a 5?mm spatula monopolar cautery or Harmonic curved shears. The rest of the surgery was completed with the robotic system (see Video).

Results

The operative procedure was successfully completed utilizing the robotic surgical system with no conversion to open surgery. The operation time for TGDCa excision was 97?min, including the time for skin flap elevation (15?min), setting up the robotic system (5?min), and console time using the robotic system (77?min). Also, the total operation time for the consecutive total thyroidectomy with CCND and level III, IV dissection was 142?min including the time for skin flap elevation (27?min), setting up the robotic system (3?min), and console time using the robotic system (112?min). There were no intraoperative complications. The retroauricular approach for the removal of the TGDCa allowed for an excellent magnified surgical view revealing important structures of the local anatomy. It also created sufficient space for the cutting of the relevant portion of the hyoid bone. Handling of the robotic instruments through the incision was technically feasible and safe without any mutual collisions throughout the operation. The patient??s postoperative parathyroid hormone (PTH) level was within normal range and functions of her both vocal cords were intact. The histopathologic results of the specimens revealed thyroglossal duct cyst with internal papillary carcinoma measuring 1.1?cm with infiltrative tumor margins and papillary microcarcinoma measuring 0.9?cm within the left thyroid lobe with extrathyroidal soft tissue extension. There was no evidence of tumor in the right lobe and the pyramidal lobe of the thyroid gland. As for the lymph nodes resected, 7 out of 9 paratracheal nodes and 2 out of 7 left level III, IV nodes revealed metastatic carcinomas. The patient was discharged on the 8th?day after the operation with no complications. The patient was extremely satisfied with the cosmetic results. The patient has received high-dose radioiodine ablation (RAI) therapy and is currently doing well with no evidence of recurrence.

Discussion

Although there is still a great deal of controversy regarding the treatment of TGDCa, there is little debate that for the cases of synchronous TGDCa and PTC, total thyroidectomy in addition to the Sistrunk procedure must be performed.5 ^?C 6,12 As for the patient in our case where left level IV lymph node metastasis was detected under preoperative ultrasonography (USG), if the usual method of surgical procedure was to be selected, double incisions or a single extended transverse incision must be adopted for the Sistrunk??s operation and total thyroidectomy with lateral neck dissection. The conventional method to remove neck masses was to do so by placing an incision on the overlying skin. This ??open?? approach to viewing the lesion has an advantage of providing the operator with the best surgical view, but the recognizable surgical scar that results from the surgery can be displeasing for patients. Therefore the surgeon can try to make a small incision and camouflage the scar by placing the incision in natural skin creases, yet the cosmetic results can still be displeasing for the patient due to its visibility and permanence. This can be an even greater problem if the patient is young and an active member of his/her society and if the lesion is benign or low-grade malignancy which can be simply dissected and excised. Therefore it is the surgeon??s best interest to perform an operation successfully with a ??least obvious?? or ??hidden?? scar whenever possible. Accordingly, we have adopted a novel approach, the transaxillary and retroauricular approach, in view of our increasing surgical experience with various indications such as submandibular gland (SMG) resections and neck dissections in head and neck cancer or thyroid papillary carcinoma.5 ^?C 7 Some investigators have demonstrated that robot-assisted neck dissections performed on patients with thyroid cancer and lateral neck node metastasis are feasible and safe.13 We conducted total thyroidectomy with bilateral CCND and level III and IV dissection using the same approach. Although the technical feasibility and safety of neck dissection or SMG resection via retroauricular approach has already been reported previously at our institute, Sistrunk??s operation via retroauricular approach will be challenging. In spite of that, we were able to demonstrate successfully Sistrunk??s operation including the hyoid bone resection through the retroauricular approach. There are however, certain areas of potential difficulties which must be considered with caution during the operation procedure. First, when removing the TGDCa through the retroauricular port, identification of the ipsilateral hyoid bone is primarily important and it is also crucial that dissection along the capsule must be done carefully so as not to rupture the tumor. It is essential that sufficient working space must be created for the comfortable movement of the robotic arms through the retroauricular port and in order to do so, sufficient skin flap elevation in both superior and inferior directions must be performed. It is necessary to elevate the superior skin flap up to the level of the inferior border of the mandible but during this process, the platysma muscle must be identified and meticulous dissection along the subplatysmal plane must be carried out so as not to damage the marginal mandibular branch of the facial nerve. Another area of potential pitfalls concerns the total thyroidectomy with neck dissection through the transaxillary port. Sufficient amount of working space must be secured in order to perform comfortably the contralateral thyroidectomy and neck dissection and in order to do so, skin flap elevation must be done at least 2?cm further based on the ipsilateral omohyoid muscle and the contralateral thyroid gland must be adequately exposed. Using the robotic surgical system in removing the thyroglossal duct cyst, the free movement of wristed instrumentation through the retroauricular incision allowed for efficient dissection and easy handling of the tissue. In this particular case we could not identify the tract beyond the hyoid and up to the foramen cecum, but we anticipate that there would be no technical problems of dissection and excision had it been so. To our knowledge, Sistrunk??s operation and total thyroidectomy with lateral neck dissection via TARA approach utilizing the robotic surgical system has never been attempted before. It has some advantages over the conventional surgery in terms of cosmesis. However, careful consideration in selecting appropriate cases is required and prospective trials should be conducted to recognize long-term outcomes and to overcome potential limitations.     

Operative outcomes of robot-assisted transaxillary thyroid surgery for benign thyroid disease: early experience in 50 patients

Purpose

The main benefits of robot-assisted transaxillary thyroid surgery are to overcome the technical limitations of other endoscopic procedures for this surgical pathology and to avoid any cervical skin incision. This article describes the first experience of a Romanian team with the endoscopic robot-assisted thyroid surgery.

Material and methods

We used the da Vinci SI intuitive surgical system to carry out 50 thyroid operations: 33 unilateral total lobectomies with isthmectomy (TL), 8 unilateral total lobectomies, with contralateral subtotal lobectomy, and 9 total thyroidectomies. Preoperatively, the patients were diagnosed with nodular goiter in 42 cases, nodular autoimmune thyroiditis in 3 cases, Basedow disease in 2 cases, toxic thyroid adenoma in 2 cases, and diffuse goiter in 1 case. We analyzed the clinical characteristics, size and location of the nodules, surgery duration, postoperative complications, pain medication, histopathological findings and postoperative cosmetic results.

Results

All surgical procedures were carried out without major incidents. One case required conversion to open approach. The mean length of surgery was 159?±?38.2 min and the average console time was 68?±?39.9 min; postoperatively, we recorded one case of transient brachial plexus neurapraxia, one transient vocal cord paresis, one transient hypocalcemia, and four postoperative wound complications. The final histopathological examination revealed two cases of well-differentiated carcinoma.

Conclusions

This paper reports the largest series to date in Southeast Europe about robot-assisted transaxillary thyroidectomy. On a group of selected Caucasian patients, postoperative results were similar to open cervicotomy in terms of postoperative complications. The major cosmetic advantage is the absence of scar in the anterior cervical region.     

Impact of incision length on the short-term outcomes of laparoscopic colorectal surgery

Background

The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections.

Methods

Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test.

Results

A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4–6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications.

Conclusions

Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.     

Robot-assisted Supraomohyoid Neck Dissection via a Modified Face-lift or Retroauricular Approach in Early-stage cN0 Squamous Cell Carcinoma of the Oral Cavity: A Comparative Study with Conventional Technique

Background

Supraomohyoid neck dissection (SOND) in clinical N0 (cN0) neck of oral cavity squamous cell carcinoma (SCC) is performed by many head and neck surgeons showing improved regional control and disease-specific survival. However, disfiguring neck scars have been accepted to be unavoidable. In this study, we sought to introduce and evaluate the feasibility of our surgical technique to hide the external scar of neck dissection using the robotic system via a modified face-lift or retroauricular approach.

Methods

Twenty-six patients with cN0 oral cavity SCC were divided into two groups of robot-assisted neck dissection and conventional neck dissection via external cervical incision. The operation time, amount and duration of drainage, length of hospital stay, complications, number of retrieved lymph nodes, and satisfaction scores were compared.

Results

Mean operation time was longer in the robot-assisted group (157?±?22?min) than the conventional group (78?±?16?min) (P?<?0.001). However, the amount and duration of drainage, hospital stay, retrieved lymph nodes, and complications were comparable. Because the postoperative scar was hidden by the auricle and hair, the satisfaction score was significantly higher in the robot-assisted group (P?<?0.001).

Conclusions

Robot-assisted SOND via a modified face-lift or retroauricular approach in cN0 oral cavity SCC was feasible compared to conventional technique and showed a clear cosmetic benefit. Longer operation time remains the drawback of this procedure. However, it could be considered for patients who require SOND and prefer to avoid external neck scar.     

Robotic Total Thyroidectomy with Modified Radical Neck Dissection via Unilateral Retroauricular Approach

Background

Traditionally, total thyroidectomy was performed through an open transcervical incision; in cases where there was evident nodal metastasis, the conventional surgical approach was to extend the incision into a large single transverse incision to complete the required neck dissection. However, recent innovation in the surgical technique of thyroidectomy has offered the opportunity to reduce the patient’s burden from these prominent surgical scars in the neck. Minimally invasive surgical techniques have been developed and applied by many institutions worldwide, and more recently, various techniques of remote access surgery have been suggested and actively applied.1–6 Since the advent of robotic surgical systems, some have adopted the concept of remote access surgery into developing various robotic thyroidectomy techniques. The more former and widely acknowledged robotic thyroidectomy technique uses a transaxillary (TA) approach, which has been developed by Chung et al. in Korea.7,8 This particular technique has some limitations in the sense that accessing the lymph nodes of the central compartment is troublesome. Terris et al. realized some shortcomings of robotic TA thyroidectomy, especially in their patients in the United States, and developed and reported the feasibility of robotic facelift thyroidectomy.9–13 In cases of thyroid carcinomas with lateral neck node metastases, most abandoned the concept of minimally invasive or remote access surgery and safely adopted conventional open surgical methods to remove the tumor burden. However, Chung et al. have attempted to perform concomitant modified radical neck dissection (MRND) after robotic thyroidectomy through the same TA port.14 This type of robot-assisted neck dissection (RAND) had some inherent limitations, due to fact that lymph nodes of the upper neck were difficult to remove. Over the past few years, we have developed a RAND via modified facelift (MFL) or retroauricular (RA) approach and reported the feasibility and safety of this technique.15, 16 Since then, we have actively applied such RAND techniques in various head and neck cancers. In our country, almost all cases of robotic total thyroidectomy utilize the TA approach. According to the reports made by Terris et al., robotic facelift thyroidectomy technique has been solely applied for ipsilateral hemithyroidectomy. For total thyroidectomy, Terris et al. performed the robotic surgery with bilateral RA incisions. Here, we intend to introduce our novel surgical method after successfully attempting simultaneous robotic total thyroidectomy and RAND via a single RA approach without an axillary incision. To our knowledge, this is the first to report in the medical literature.

Methods

We present four cases of our surgical experience since the beginning of 2013. All patients received robotic total thyroidectomy with MRND via single RA port without axillary incision after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The inclusion criteria for this operation were as follows: (1) patients with malignant carcinomas of the thyroid gland with evident cervical lymph node metastasis on preoperative imaging studies which are indicated for surgery; (2) patients with no previous history of treatment for thyroid carcinoma. The exclusion criteria were as follows: (1) patients with recurred thyroid tumors; (2) patients with thyroid carcinomas that showed gross invasion to local structures or extensive extrathyroidal capsular spread; (3) patients with clinically evident neck nodal metastasis with extracapsular spread; (4) patients with past history of neck surgery of any kind. In order to assess the extent of disease, neck ultrasonography with fine needle aspiration, neck CT or MRI and PET-CT were performed as preoperative evaluation. All patients were given full information of the possible treatment options for their thyroid cancer comprising of open transcervical approach and robotic surgery via RA approach, including the advantages and disadvantages of each treatment choice and provided written, informed consents before the surgery. General clinical information of the patients is outlined in Table 1. The skin incision for the operation was designed just like the approach for robotic facelift thyroidectomy by Terris et al. and RAND, which has been first reported by our institution.11 ^, 16 The operation was performed by the following sequence. Initially, the skin-subplatysmal flap was elevated after making the skin incision to create sufficient working space. During this process, the elevated skin flap was retracted and maintained by retractors held by the assistant. After application of the self-retaining retractor (Sangdosa Inc., Seoul), neck dissection of the upper neck levels was performed under gross vision. Next, RAND through the RA incision was conducted followed by ipsilateral thyroidectomy with central compartment neck dissection (CCND) via the same approach. Finally, contralateral thyroidectomy with CCND was performed via the single RA port. During these steps, the operator is aided by the bedside assistant with long-suction tips to manipulate and direct the dissected specimen to maintain optimal surgical view or to suck out the fume created by the thermocoagulation from the Harmonic shears. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via the RA port with a facedown 30° dual-channel endoscopic arm placed in the center, and two instrument arms equipped at either side with 5-mm Maryland forceps and Harmonic curved shears. During the step of robotic contralateral thyroidectomy, a ProGrasp forceps was utilized at times, instead of 5-mm Maryland forceps. The rest of the surgery was completed with the robotic system (see Video for demonstration of operation for patient 2).

BMI body mass index, RA retroauricular approach, PC papillary carcinoma, CCND central compartment neck dissection, MRND modified radical neck dissection     

Is Robotic Surgery Superior to Endoscopic and Open Surgeries in Thyroid Cancer?

Background

Endoscopic thyroidectomies have been performed using various approaches, and indications have expanded with the development of new surgical techniques and instruments. Endoscopic thyroid surgery using bilateral axillo-breast approaches have excellent cosmetic results and a symmetrical, optimal operative view. However, because of the two-dimensional view and the nonflexible instruments, these approaches are not easy to use in performing a central lymph node dissection (CND). Robotic surgery has drawn attention as a potentially safe and effective method for treating thyroid cancer. The aim of the present study was to determine whether robotic surgery is superior to endoscopic and open surgery through comparing technical aspects and surgical outcomes.

Methods

From October 2008 to December 2009, 302 patients had total thyroidectomies and CND with cancer less than 1?cm. Patients were divided into three groups according to operation methods (open group; n?=?138), (endo group; n?=?95), (robot group; n?=?69).

Results

Young patients preferred the robotic and endoscopic surgery. The number of retrieved lymph nodes in the open group (4.8?±?2.8) was not different from the robot group (4.7?±?2.7) and the endo group (4.6?±?3.7). The operative time of the robot group was longer than the open and the endo group. The total drain amount in the robot group was more than the open and endo groups; however, there was no difference in the length of hospitalization and complication rates. There were no differences between the open (0.8?±?2.0) and robot groups (0.8?±?1.4), but the endo group (2.4?±?6.3) showed higher postoperative serum thyroglobulin off thyroid hormone (Off-Tg) when compared to the open and robot groups.

Conclusions

Robotic surgery was equal to open surgery except with respect to operative time and was superior to endoscopic surgery in Off-Tg levels presenting completeness of the operation in thyroid cancer surgery. Because it has excellent cosmetic results and various technical advantages, it should be considered in young, low-risk patients with thyroid carcinoma less than 1?cm.     

Frameless image-guided stereotaxy with real-time visual feedback for brain biopsy

Background

Frame-based stereotaxy remains the “gold standard” for cerebral biopsies and functional neurosurgery though new frameless stereotactic systems are evolving continually. As the technique of frameless stereotaxy gains increasing acceptance among neurosurgeons, this study assesses the feasibility of a system for frameless image-guided stereotaxy.

Methods

All patients biopsied for intracranial lesions between February 2007 and August 2010 using the BrainLAB VarioGuide frameless stereotactic system were evaluated prospectively. Prior to surgery, patients underwent magnetic resonance (MR) imaging; additionally, fluoroethyl-tyrosine (FET)-positron emission tomography (PET) images were acquired and fused to MR images in selected cases. Biopsy trajectory length, lesion volume, procedure duration, and diagnostic yield were assessed.

Results

Ninety-six diagnostic biopsies in 91 patients were evaluated. Lesion volume ranged from 0.17 to 121.8?cm³; trajectory length from 25.3 to 101.9?mm. Diagnostic yield was 93.8%. Mean operation time from skin incision to wound closure was 42?min; in the operating room, it was 99?min.

Conclusions

Clinical experience indicates VarioGuide to be safe and accurate. Reachable range of lesion localisation appears to be comparable to a frame-based stereotaxy system. Operation times are brief. The unique design of this frameless stereotactic system allows real-time visual feedback of needle positioning.     

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction

Purpose

Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM.

Methods

The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision.

Results

Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple–areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions.

Conclusion

The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.     

Minimally Invasive Thyroid Surgery for Single Nodules: An Evidence-based Review of the Lateral Mini-incision Technique

Background

Minimally invasive thyroidectomy techniques are being developed in an effort to minimize pain, shorten the length of hospital stay, and improve cosmesis. Various minimally invasive thyroid surgery (MITS) techniques have been shown to be safe and feasible with some benefits in terms of cosmesis and pain outcomes; however, no single technique has been broadly accepted. This study was designed to review the evidence in relation to MITS and our experience with the direct lateral mini-incision technique.

Methods

A review of literature published until December 2007 on minimally invasive thyroidectomy techniques was undertaken. Three issues were addressed: 1) Does MITS provide any benefit compared with conventional open thyroidectomy? 2) Is there any advantage to the use of endoscopic or video-assisted techniques compared with the direct mini-incision technique? 3) Is the lateral mini-incision technique safe and efficacious? Additional data in relation to the above issues was derived from a retrospective cohort study of patients undergoing mini-incision thyroid surgery within our unit.

Results

Issue 1: Five prospective randomized studies and eight studies at a lower level of evidence have demonstrated consistent advantages of MITS compared with open thyroid surgery in terms of reduced pain and improved cosmesis with equivalent operative safety. Issue 2: In compiling four level III and IV studies that compared open and video-assisted minimally invasive surgery, there do not seem to be significant differences in patient satisfaction with the incision. The video-assisted approaches require significantly longer operative times but also seem to be less painful. Issue 3: Three cohort studies (level IV) have demonstrated that the lateral mini-incision technique is both safe and efficacious compared with open surgery for hemi-thyroidectomy. Data from our cohort study of 1281 patients (open hemi-thyroidectomy 1054 vs. MITS 227) confirmed MITS to be a safe and effective procedure. The rate of postoperative hematoma formation and wound infection was equivalent between groups. The rate of permanent recurrent laryngeal nerve injury was 0.4% for MITS and 0.3% for CHT and not significantly different (p = 0.7).

Conclusions

MITS has demonstrated advantages over conventional open approaches for both hemi- and total thyroidectomy and the benefits do not depend on the open or video-assisted approach. For thyroid lobectomies, the lateral mini-incision approach can be performed with an operative time and postoperative complication profile equivalent to conventional hemi-thyroidectomy while providing excellent cosmesis with a 2–3 cm scar.     

Facelift Approach for Resecting Benign Upper Neck Masses

Background

This study evaluated the feasibility of non-magnified resection of various benign lesions of the upper neck using the facelift incision without endoscopic equipment to establish indications for the procedure.

Methods

This retrospective analysis examined 86 patients who underwent surgery for upper neck masses using the facelift incision or conventional transcervical incision at our institute between January 2012 and December 2015.

Results

We performed 41 operations using facelift incisions (facelift group) and 45 using conventional horizontal incisions (conventional group). All 86 operations were successful. In the facelift group, no patient needed conversion to conventional open resection and no patient required the use of an endoscopic device due to a limited surgical view for safe resection. There were no major surgical complications in either group. Transient sensory changes in the auricle occurred in 26% of the patients in the facelift group, but all patients recovered within 2 months. In all patients in the facelift group, the scars were invisible as they were covered by the auricle and hair, while the surgical scars were noticeable in 91% (41/45) of the patients in the conventional group when they were wearing standard shirts (p < 0.001) at 3–4 weeks after surgery.

Conclusions

The facelift approach provides a short direct route to upper neck masses, and it enables an adequate workspace not only for endoscopic or robotic surgery, but also for open surgery with the naked eye. The surgical indications for the facelift incision include the removal of most benign tumors occurring in the upper neck at levels II and III.

     

Laparoscopic Colorectal Surgery for Obese Patients: Decreased Conversions with the Hand-Assisted Technique

Background

Laparoscopic surgery benefits obese patients but technical difficulties associated with suboptimal exposure and access in these subjects may prompt conversion to open surgery. Hand-assisted laparoscopic surgery (HALS) confers advantages over standard laparoscopy (LAP) by facilitating tactile feedback, assisted dissection, and retraction. These benefits could be particularly valuable in obese patients, allowing completion of difficult laparoscopic procedures in this subgroup. Our aim was to compare intra-operative and post-operative outcomes of HALS and LAP approaches in obese patients undergoing colorectal resection at our institution.

Methods

A retrospective study of a prospectively maintained laparoscopic colorectal surgery database was performed. HALS and LAP cases performed in obese patients (body mass index (BMI)?>30) were identified and compared for the following outcomes: operative time, intra-operative complications, rate of conversion to open, blood loss, length of stay, post-operative morbidity, and mortality. Outcomes for the converted patients were included on an intention-to-treat basis for all primary analyses. A secondary analysis of nonconverted and converted cases was also performed.

Results

Over a 5-year period, 496 obese patients underwent laparoscopic colorectal resection; 86 HALS and 410 LAP cases. The two groups were comparable in terms of age, gender, BMI, and indications for surgery. Conversion to open surgery was less often necessary in HALS compared to LAP cases (3.5 % vs. 12.7 %, p?=?0.014). The LAP group had a significantly smaller incision length for specimen extraction (HALS (7.0?±?1.3 cm) vs. LAP (5.7?±?2.1 cm), p?<?0.001). Length of stay, operative time, morbidity, and mortality rates were comparable between the two groups.

Conclusion

In obese patients who require colectomy, the HALS approach increases the likelihood of a successful minimally invasive operation. At the cost of a clinically negligible increase in incision length, HALS may save a high-risk group conversion to formal laparotomy and the adverse outcomes related to this.     

Single-incision multiport laparoendoscopic (SIMPLE) surgery: early evaluation of SIMPLE cholecystectomy in a community setting

Background

Conventional Laparoscopic Cholecystectomy (LC) is a safe, established procedure for gallbladder disease. This is usually performed through three to four small incisions. Although postoperative pain is minimal, there still exists some discomfort from multiple incisions. In theory, fewer incisions or incisionless surgery may decrease postoperative morbidity more than that already exists. Reports of microport instrumentation as well as normal orifice translumenal endosurgery (NOTES) cholecystectomy transvaginally, transcolonically, or transgastrically have recently surfaced. However, these require a different skill set and new technology, which is still in its developmental infancy. Single incision surgery has recently entered the minimally invasive arena.

Methods

Ten consecutive patients requiring laparoscopic cholecystectomy were performed with a single incision multiport technique as described below.

Results

All ten patients had a successful completion of a single incision multiport laparoendoscopic cholecystectomy without need for conversion to two, three, or four incisions. There were no complications and the recovery was comparable to a conventional LC.

Conclusion

We describe here a single incision multiport laparoendoscopic cholecystectomy (SIMPLE cholecystectomy) technique that is safe for the patient, reproducible, easy to learn, and uses commonly available instruments already in most operating rooms. Conversion, if required, is placement of the remaining two to three ports for a more conventional LC.     

Minimalinvasive,videoassistierte Schilddrüsenresektion

Background

This study retrospectively evaluated a series of patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) during the introduction stage of this surgical technique at the Martha-Maria Hospital in Nuremberg.

Patients and methods

The eligibility criteria for MIVAT were a thyroid volume <?25 ml, nodules <?30 mm, no thyroiditis, no preoperative evidence of carcinoma and no previous neck surgery. A retrospective evaluation was performed together with a control group of patients who underwent conventional thyroid surgery during the same time period and included a follow-up for general patient satisfaction and cosmetic results.

Results

Between August 2008 and July 2009 a total of 55 patients underwent MIVAT including 8 conversions to open surgery and 45 patients who underwent conventional surgery served as matched controls. No significant differences in terms of perioperative complication rates were found (e.g. recurrent laryngeal nerve palsy, hypocalcemia or secondary hemorrhage). The mean operating time was significantly longer in the MIVAT group (96.8?±?3.7 min vs. 69.8?±?2.3 min, p?=?0.001) whereas a significant decrease in the mean operating time for hemithyroidectomy after 5 months was observed (98.1?±?3.77 min vs. 76.0?±?4.98 min, p?=?0.013). Patients in the MIVAT group were more satisfied with the cosmetic outcome (8.5?±?0.3 vs. 8.2?±?0.2, p?=?0.05) as well as with the overall surgical procedure (9.0?±?0.3 vs. 8.6?±?0.2, p?=?0.02).

Conclusion

During introduction of the MIVAT procedure a learning effect can be observed which is hallmarked by a decrease in operating time and conversion rate to open surgery. Moreover, no significant differences in terms of main postoperative complications were found so that MIVAT can be considered a safe and feasible technique under the conditions of correct eligibility criteria.     

Three-dimensional stomach analysis with computed tomography after laparoscopic sleeve gastrectomy: sleeve dilation and thoracic migration

Background

Laparoscopic sleeve gastrectomy (LSG) is frequently performed as a definitive bariatric procedure today. Quantitative data on the detailed anatomy of the stomach after LSG are yet sparse.

Methods

Thirty-two multislice computed tomography (MSCT) data sets acquired in 27 LSG patients (22 female, 5 male) with a dedicated examination protocol and post-processing were evaluated for gastric volume, stomach length, sleeve length, antrum length, staple line length, and maximum cross-sectional sleeve area. Obtained parameters were compared to time after surgery, weight loss, and the occurrence of postsurgical regurgitation.

Results

Mean gastric volume was 186.5?±?88.4?ml. Gastric volume correlated significantly with the time interval after surgery. Sleeve sizes of 105.3?±?30.2?ml during early follow-up confirmed correct primary sizing of the sleeve, whereas marked dilation to 196.8?±?84.3?ml was found in patients with a follow-up of 6?months and longer (p?=?0.038). Sleeve area and staple line length were also positively correlated with time after surgery. No correlation was found between gastric volume and excess weight loss. In ten patients an intrathoracic migration of the staple line could be noted, with four of these patients developing persistent regurgitation after LSG. Regurgitation was present in only 2 of 17 patients without sleeve herniation.

Conclusion

Multislice computed tomography allows for a comprehensive and quantitative evaluation of the anatomy after LSG and thus provides new insights in the process of sleeve dilation. Intrathoracic migration of the staple line could be identified as a possible cause of persistent regurgitation.     

A comparative study of the surgical outcomes of robotic and conventional open modified radical neck dissection for papillary thyroid carcinoma with lateral neck node metastasis

Background

Several endoscopic modified radical neck dissections (MRND) have been conducted since the introduction of the endoscopic technique to thyroid surgery with the aim of avoiding a long cervical scar. Furthermore, the recent introduction of surgical robotic systems has increased the precision of endoscopic techniques. The aim of this study was to evaluate and compare the early surgical outcomes of robotic and conventional open MRND for papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM).

Methods

From January 2009 to May 2010, 165 patients with PTC underwent bilateral total thyroidectomy with central compartment neck dissection and ipsilateral MRND. Of these patients, 56 formed the robotic procedure group (RG) and 109 the conventional open procedure group. These two groups were retrospectively compared with respect to their clinicopathological characteristics, early surgical outcomes, and surgical completeness.

Results

The operative time was longer, mean tumor size was smaller, mean age was lower, and disease stage was earlier in the RG. However, mean numbers of retrieved lymph nodes were similar in the two groups, and mean hospital stay after surgery was shorter in the RG. Furthermore, complication rates were similar in the two groups, and there was no statistical difference in postoperative Tg levels between the groups.

Conclusions

Robotic MRND was found to be similar to conventional open MRND in terms of early surgical outcomes and surgical completeness but leaves no scar on the neck area. Robotic MRND can be viewed as an acceptable alternative method in low-risk PTC with LNM.     

Endoscopic thyroidectomy using the EZ-VANS method

Purpose

Several video-assisted and robotic surgery techniques have been reported for resection of the thyroid and parathyroid glands. Our institute has started performing endoscopic thyroidectomy using the Lap-protector and E·Z-access system, referred to as E·Z-access using video-assisted neck surgery (EZ-VANS). In this report, we evaluate the safety and efficacy of this technique.

Methods

From January 2007 to September 2014, 110 patients underwent resection of a primary thyroid tumor, 73 who underwent a cervical collar incision (the Open group) and 37 underwent EZ-VANS (the EZ-VANS group).

Results

The average operating time was 159 and 172 min in the Open group and EZ-VANS group, respectively; the amount of blood loss was 46.5 and 54.7 ml, respectively; and the length of hospital stay after surgery was 4.3 and 5.2 days, respectively, with no significant differences observed between the two groups. The learning curve for the EZ-VANS technique was shorter than for open surgery.

Conclusions

We confirmed that the EZ-VANS technique is a safe and useful method for resection of benign and early malignant thyroid tumors.

     

Laparoscopic retrosternal bypass for corrosive stricture of the esophagus

Introduction

Surgical management of corrosive stricture of the esophagus entails replacement of the scarred esophagus with a gastric or colonic conduit. This has traditionally been done using the conventional open surgical approach. We herein describe the first ever reported minimally invasive technique for performing retrosternal esophageal bypass using a stomach conduit.

Methods

Patients with corrosive stricture involving the esophagus alone with a normal stomach were selected. The surgery was performed with the patient in supine position using four abdominal ports and a transverse skin crease neck incision. Steps included mobilization of the stomach and division of the gastroesophageal junction, creation of a retrosternal space, transposition of stomach into the neck (via retrosternal space), and a cervical esophagogastric anastomosis.

Results

Four patients with corrosive stricture of the esophagus underwent this procedure. The average duration of surgery was 260 (240–300) min. All patients could be ambulated on the first postoperative day and were allowed oral liquids between the fifth and seventh day. At mean follow-up of 6.5 (3–9) months, all are euphagic to solid diet and have excellent cosmetic results.

Conclusions

Laparoscopic bypass for corrosive stricture of the esophagus using a gastric conduit is technically feasible. It results in early postoperative recovery, effective relief of dysphagia, and excellent cosmesis in these young patients.     

An S-shaped incision for the insertion of deep brain stimulators

Background

The S-shaped incision is a novel technique we have developed to minimise wound complications for the insertion of bilateral deep brain stimulators.

Methods

An S-shaped incision incorporating both burrholes allows better exposure compared to the traditional bilateral incisions. The burrholes are drilled under each limb of the S and the incision does not run across them, decreasing the risk of infection. The electrodes are subsequently tunneled down the right side and connected to the battery.

Conclusion

The use of the S-shaped incision results in less wound and electrode complications compared to the traditional bilateral linear incisions in our experience.