Minimally invasive thyroid surgery for diagnostic excision of solitary thyroid nodules

OBJECTIVE: Various techniques for minimally invasive thyroid surgery (MITS), including endoscopic and video-assisted procedures, have now been described. Based on our units experience with minimally invasive parathyroidectomy via a lateral incision, a similar technique for minimally invasive thyroid lobectomy has been developed and assessed. METHODS: The last 203 consecutive thyroid procedures using the MITS technique, performed between July 2002 and June 2006, comprised the study group. Inclusion criteria for initial surgery were: initial nodule < 3.0 cm; no preoperative evidence of malignancy; absence of clinical multinodular change. A 2.5-cm lateral incision, using a headlight illumination, provided optimal exposure. RESULTS: A total of 202 patients underwent 203 MITS procedures over the 4-year period, with one patient undergoing bilateral MITS. The procedures included 155 thyroid lobectomies and 48 nodule excisions; 31 of the patients underwent a minimally invasive parathyroidectomy (MIP) during which an ipsilateral thyroid nodule was removed. The mean tumour size was 17.3 mm, but the mean size of the thyroid lobe removed was 39.5 mm. Final diagnoses included benign multinodular goitre (26%), follicular adenoma (22%) and carcinoma (20%). The complication rate was low, with one permanent recurrent laryngeal nerve (RLN) palsy (anterior division only) (0.5%), four RLN neuropraxias which recovered (2%), and one haematoma not requiring re-operation (0.5%). The rate of complications was not significantly different from 819 conventional open hemithyroidectomies performed over the same period. CONCLUSION: MITS is a safe and feasible alternative to open thyroid surgery in appropriately selected cases. It offers a valuable option for diagnostic excision biopsy in patients with thyroid nodules demonstrating an atypical fine-needle biopsy whilst avoiding the need for a standard cervical "collar" incision.     

Management of hyperfunctioning single thyroid nodules in the era of minimally invasive thyroid surgery

Both surgical excision and radioiodine ablation are effective modalities in the management of hyperfunctioning thyroid nodules. Minimally invasive thyroid surgery (MITS) using the lateral mini‐incision approach has previously been demonstrated to be a safe and effective technique for thyroid lobectomy. As such MITS may offer advantages as a surgical approach to hyperfunctioning thyroid nodules without the need for a long cervical incision or extensive dissection associated with formal open hemithyroidectomy. The aim of the present study was to assess the safety and efficacy of MITS for the treatment of hyperfunctioning thyroid nodules. This is a retrospective case study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database from 2002 to 2007. There were 86 cases of hyperfunctioning thyroid nodules surgically removed during the study period, of which 10 (12%) were managed using the MITS approach. The ipsilateral recurrent laryngeal nerve was identified and preserved in all cases with no incidence of temporary or permanent nerve palsy. The external branch of the superior laryngeal nerve was visualized and preserved in eight cases (80%). There were no cases of postoperative bleeding. There was one clinically significant follicular thyroid carcinoma in the series (10%). In nine of 10 cases (90%) normalization of thyroid function followed surgery. MITS is a safe and effective procedure, achieving the benefits of a minimally invasive procedure with minimal morbidity. As such it now presents an attractive alternative to radioiodine ablation for the management of small hyperfunctioning thyroid nodules.     

Minimal access thyroid surgery: Is it feasible,is it appropriate?

Background: Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral ‘focused’ or endoscopically assisted approach. Methods: The study group comprised all patients undergoing minimally invasive parathyroidectomy (MIP) during the period May 1998 to April 2002 in whom a concomitant thyroid procedure was undertaken. All procedures were performed either through a 2‐cm lateral cervical incision (n = 19) or endoscopically (n = 7). Results: Twenty‐six patients underwent thyroid surgery, consisting of either local excision of a thyroid nodule (n = 25) or hemi­thyroidectomy (n = 1). In 13 patients the nodule was incidentally discovered, in four patients removal of the parathyroid necessitated partial thyroidectomy, and in nine patients the lesion identified by preoperative parathyroid localization proved to be a thyroid nodule. There were no permanent complications in the study group. Two patients required drainage of a haematoma. The final pathology of all 26 cases revealed benign nodular thyroid disease. Conclusion: Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible option for selected patients. The question remains to be answered as to whether this surgical approach is appropriate treatment for nodular thyroid disease.     

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.     

Minimally invasive thyroidectomy: an emerging standard of care

Virtually all disciplines of surgery now offer some version of minimal access surgical techniques. Because of the challenges related to gas insufflation in the head and neck, endoscopic surgery in this region remains in its infancy. Miccoli and his group at the University of Pisa are responsible for developing a surgical approach that relies on endoscopic and ultrasonic technology, which is easily the most widely practiced technique by minimal access surgeons around the globe. Video-assisted thyroid surgical techniques have emerged as the most feasible compromise between ample exposure and minimal access surgery. In addition to the application of technology, modern thyroid surgery incorporates a number of departures from classical training, including marking of the patient upright in the holding area, no or minimal neck extension, infrequent use of a drain, and outpatient surgery. We have emphasized the concept of customizing the procedure to the patient and disease characteristics, rather than the reverse. Therefore, a spectrum of surgical techniques can be helpful, particularly for the inexperienced minimal access thyroid surgeon. Correspondingly, staging of minimally invasive thyroidectomy has been recommended in order to allow for both uniform reporting of outcome measures across patient populations and a logical basis for determining patient eligibility. With an increasingly sophisticated public, which has virtually unlimited access to medical information, the burden will be on the modern thyroid surgeon to stay abreast of surgical or technical improvements that will yield superior outcomes. Looking forward, it would seem inevitable that continued technologic advances will help surgeons achieve less invasive, safer, and more easily performed procedures.     

Minimally invasive spinal surgery

Minimally invasive surgery offers quicker recovery and less morbidity for our patients through smaller surgical wounds and less tissue trauma. Although minimally invasive surgery has progressed in other fields of surgery for many years, spine surgeons have not previously embraced this philosophy for the various reasons discussed. However, minimally invasive spinal surgery has gained much interest in recent years. With the advent of new instrumentation, technology, and techniques, the promise of minimally invasive surgery in the spinal arena has become a reality. With the use of the microscope, navigational tools, newly developed canula for retraction, and image-guided percutenous pedicle screw systems, we can accomplish the same surgical procedures as currently used through smaller wounds and with greater precision. Nevertheless, all new technology does offer us an initial challenge of steep learning curves. Minimally invasive should not equate to minimal and inadequate treatment for our patients. Furthermore, careful analysis of this new technique is underway to assess its true advantages as compared with our current and proven techniques.     

Minimally invasive living donor nephrectomy – introduction of hand‐assistance

Conventional open living donor nephrectomy (LDN) technique is perceived as a barrier for expanding living donor programmes. Thus, minimal invasive surgery techniques have been advocated to overcome this hurdle. The aim of this study was to evaluate our experience on minimally invasive LDN. During the last decade we have gradually expanded the use of minimally invasive LDN with various techniques; strictly laparoscopic versus hand‐assisted, and laparoscopic versus retroperitoneoscopic. This study is based on 305 consecutive minimally invasive LDN’s, from 1998 to 2009. By multiple regression analysis, minimally invasive hand‐assisted technique was shown to be associated with a significantly lower risk of major complications and intraoperative incidents, as well as reduced warm ischemia and operative time. In our opinion, the introduction of hand‐assisted technique is probably the most significant single factor for improved results, although accumulated experience and developments in equipment will contribute. Our experience indicates that learning curves are facilitated by the use of hand‐assisted technique. Improvements in surgical outcomes following donor nephrectomy may enhance living donor programmes.     

Instrumente f��r die minimalinvasive Unfallchirurgie

For some time now minimally invasive techniques have been implemented in surgical disciplines, including trauma surgery. Indirect reduction techniques, minimal approaches and preservation of soft tissue cover have reduced the incidence of local complications and systemic stress and promoted fracture healing by conserving the biological soft tissue environment. Subtle surgical techniques are required to achieve all this and reduction aids and instruments for minimally invasive surgery are needed. In some cases minimally invasive methods make some otherwise impossible portals and approaches possible. Manual dexterity is of special merit for reduction of soft tissue injury as well as practice and the tips and tricks which should be passed on from one surgeon to another. Minimally invasive trauma surgery is not a black and white image contrasting minimally invasive and conventional surgery but comprises techniques and principles that merge seamlessly into one another. For an experienced surgeon, this is multi-facetted trauma surgery.     

Impact of localization studies on feasibility of minimally invasive parathyroidectomy in an endemic goiter region

BACKGROUND: A localized single-gland disease is the basis for minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (PHPT). (99m)Tc sestamibi scanning (MIBI) and high-resolution Doppler ultrasonography (US) are well-established techniques used to localize enlarged parathyroid glands. Additionally, US enables physicians to diagnose subclinical thyroid abnormalities. The aim of this study was to optimize localization results, applying a combined interpretation of MIBI and US, and to analyze the influence of these results on the feasibility of MIP (endoscopic/video-assisted and open) in an endemic goiter region. STUDY DESIGN: One hundred fifty consecutive patients with sporadic PHPT were prospectively subjected to MIBI and US to localize parathyroid lesions and to review the morphology of the thyroid gland. Bilateral cervical exploration was performed in all patients. The feasibility of MIP was calculated retrospectively on the basis of surgical findings and biochemical outcomes at least 12 months postoperatively (normocalcemia in 148 of 150 patients [99%]). RESULTS: Forty-five percent of patients (67 of 148) would have been suitable for minimally invasive endoscopic or video-assisted parathyroid exploration. These procedures would have succeeded in 38% of patients (56 of 148). Sixty-four percent (94 of 148) would have been suitable for minimally invasive open parathyroidectomy, which would have succeeded in 55% (82 of 148 patients). CONCLUSIONS: Not all patients are suitable for MIP. A combined interpretation of MIBI and US results is helpful in planning targeted exploration. In an endemic goiter region minimally invasive open parathyroidectomy is applicable in significantly more patients than is endoscopic and video-assisted MIP.     

Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.     

Minimally invasive surgery for thyroid and parathyroid diseases

During the past 4 years, some minimally invasive procedures for thyroid and parathyroid surgery have been described. All these techniques have been demonstrated as feasible and safe. Nevertheless, the surgeon should be well trained to obtain the best results with these approaches. Moreover, not all patients are eligible for minimally invasive procedures. At the moment, they can be proposed for most patients with sporadic primary hyperparathyroidism, but only for a minority of patients with thyroid nodules. The results from minimally invasive procedures are almost comparable with those of conventional surgery, but they have additional advantages in terms of cosmetic result and postoperative pain. Therefore, these procedures should be considered a valid option by surgeons dealing with neck endocrine surgery.     

Minimally invasive approaches to vertebral column and spinal cord tumors

Minimally invasive approaches to spinal tumors have evolved rapidly over the past 15 to 20 years as clinicians seek to avoid the morbidity and long-term dysfunction associated with traditional open surgical procedures. We review the noninvasive, percutaneous, and minimally invasive surgical techniques currently available for the treatment of spinal column and intradural spinal tumors, including minimal access thoracic corpectomy and minimal access intradural tumor surgery. The various advantages and limitations of these approaches as well as their appropriate indications and uses are also presented here. A measured understanding of surgical objectives and iatrogenic effects on patients' quality of life allows the surgeon to implement such minimally invasive approaches in the design of individualized treatment plans that range from pure palliation to definitive cure.     

Minimally invasive parathyroid surgery

The standard bilateral neck exploration in primary hyperparathyroidism (HPTH) has been challenged in the recent years by the general trend toward less invasive surgery. The development of more reliable preoperative imaging techniques such as Sestamibi scanning and high definition ultrasonography coupled with improvements in intraoperative rapid assays of intact parathyroid hormone have allowed unilateral explorations in most patients with primary HPTH. This article reviews the currently available preoperative parathyroid localization studies as well as the currently used minimally invasive parathyroidectomy (MIP) techniques, such as open approaches, radioguided surgery and endoscopic procedures. While some techniques are more popular than others, careful selection of patients with primary HPTH has resulted in comparable cure rates to the standard bilateral parathyroid exploration.     

腹腔镜在主髂动脉手术中的应用和进展

传统主髂动脉手术创伤大、并发症多、住院时间长、患者术后恢复慢.经皮血管腔内介入手术属于微创手术,却不适合所有患者,长期疗效也不确定.腹腔镜下主髂动脉手术具有微创、远期手术效果确切的优点,成为主髂动脉疾病的第三种治疗方法.     

Video-assisted endocrine neck surgery: state of the art

During the last two decades, several minimally invasive approaches for endocrine neck surgery have been developed. Minimally invasive video-assisted approaches (minimally invasive video-assisted parathyroidectomy and minimally invasive video-assisted thyroidectomy) gained a quite large worldwide diffusion, maybe because these techniques combine the advantages related to the endoscopic magnification with those due to the close similarity with the conventional surgery that makes these surgical approaches reproducible and feasible in different surgical settings. Several comparative studies have demonstrated the advantages of minimally invasive video-assisted neck surgery in terms of reduced postoperative pain, better cosmetic result, and higher patients’ satisfaction over the conventional endocrine neck surgery. An accurate patients’ selection plays a key role to ensure the success of minimally invasive video-assisted approaches. To date, in selected cases and in experienced Center, minimally invasive video-assisted endocrine neck surgery could be considered the standard treatment or at least a safe and effective surgical option.     

超声引导下射频消融术与腔镜微创手术治疗甲状腺良性结节的应用比较

目的比较超声引导下射频消融术与腔镜微创手术在甲状腺良性结节患者治疗中的应用。 方法收集2015年1月至2019年1月于中国人民解放军联勤保障部队第九二八医院接受手术治疗的甲状腺良性结节患者1 000例,根据手术方式分为超声引导下射频消融术组（594例）和腔镜微创手术组（406例）。比较两组患者手术时间,术中出血量,术后住院时间,手术前后6个月甲状腺功能变化情况,手术前后12 h白细胞介素6（IL-6）、C反应蛋白（CRP）、肿瘤坏死因子α（TNF-α）及术后并发症发生情况。 结果射频消融术组术后IL-6、CRP和TNF-α质量浓度水平显著低于腔镜微创手术组（t=-67.827、-117.340、32.192,均P<0.001）;射频消融术组手术时间、术后住院时间、手术出血量、术后并发症发生率均显著低于腔镜微创手术组（t=85.135、67.418、65.475,χ²=169.568,均P<0.001）。 结论超声引导下射频消融术与腔镜微创手术在甲状腺良性结节患者治疗中均对甲状腺功能损伤较小,且超声引导下射频消融术安全性好、创伤小、术后并发症较少。     

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.     

Clinical experience with devices for facilitated anastomoses in coronary artery bypass surgery

Recent developments in minimally invasive coronary artery surgery have been driven by the introduction of new technologies which should facilitate precise surgical maneuvers on the beating heart within confined spaces. Such technologies include coronary stabilizer systems, cardiac positioning vacuum-assisted devices, and telemanipulative systems. Despite these developments, standard suturing techniques using running polypropylene material remains a limiting factor in the surgeon's ability to perform complete revascularization with high quality anastomoses through minimal approaches to the chest cavity. Clinical validation of proximal and distal anastomotic devices has the potential to substantially improve and perhaps revolutionize minimally invasive coronary surgery. Ideal characteristics of such devices would include applicability to all conduit types, all coronary sizes, interchangeable proximal/distal sequencing of the anastomosis, and safe bail out for device malfunction. However there is an urgent need to define the performance objectives of such systems as well as the general criteria for proper and comparable evaluation and validation of different systems in animal models and subsequently in controlled prospective clinical studies. This review summarizes the most interesting systems available in both experimental and clinical settings.     

Minimally invasive nonendoscopic thyroidectomy.

OBJECTIVES: Minimal-access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach (MIT). STUDY DESIGN: Between October 2002 and December 2004, a prospective nonrandomized study of patients undergoing thyroid surgery was performed to evaluate the variables that might condition the indications to minimally invasive nonendoscopic approach. RESULTS: 296 patients underwent thyroid surgery; 46 of these were eligible for MIT through a 2.5- to 3-cm incision. There was one case of transient inferior laryngeal nerve palsy and no postoperative definitive hypoparathyroidism. MIT was converted to conventional thyroidectomy only in two cases. Cosmetic results were considered excellent by all patients. CONCLUSIONS: Minimal-access thyroid surgery is a safe and feasible alternative to conventional thyroid surgery in selected cases. The advantage that this technique offers, in addition to low morbidity, is an improved cosmetic result.     

Laparoscopic excision of mesenteric cysts: a report of two cases

The authors report two cases of mesenteric cysts that were excised laparoscopically. Resection was accomplished with standard minimally invasive techniques and use of an ultrasonic scalpel. Both patients recovered promptly with minimal morbidity and returned to full activity within a short time. This reveals the suitability of minimally invasive surgery for this particular disease process.