New technologies in thyroid surgery. Endoscopic thyroid surgery

The onset of cervicoscopy dates back to the first endoscopic parathyroidectomy in 1996. This operation, along with its several variants, has become a valid option widespread in many important centres. Later on, endoscopic or video assisted thyroidectomy was introduced in spite of the limits imposed by the mass of the gland to remove. It is indicated for a minority of patients for this reason but both parathyroidectomy and thyroidectomy showed some important advantages with respect to conventional surgery, advantages demonstrated also in prospective studies. They are mainly represented by a better cosmetic outcome and a less distressful postoperative course. These approaches proved to be safe and feasible in any surgical background: their complication rate is the same as traditional open surgery in the neck. Very promising seems to be the videoscopic access to neck lymph nodes (central and lateral compartments) whereas other fields of application such as carotid artery surgery and spine surgery still remain object of experimental studies. As far as the lateral neck dissection is concerned the technique is going to be standardized in our centre as a variant of the well known video assisted approach adding a 5 mm trocar placed in the supraclavicular space. By consequence, cervicoscopy has to be considered an important surgical tool which can be further improved but which also has an excellent potentiality.     

Update on endoscopic cervical surgery

The onset of cervicoscopy dates back to the first laparoscopic parathyroidectomy in 1996. This operation, with its several variants, has today become a valid option that is widespread in many centers. Endoscopic or video-assisted thyroidectomy was introduced later, despite the limits imposed by the mass of the gland to be removed. Even though it was indicated for a minority of patients for this reason, both parathyroidectomy and thyroidectomy showed some important advantages with respect to conventional surgery, advantages that were also demonstrated in prospective studies that include a better cosmetic outcome and a less distressful postoperative course. These approaches proved to be safe and feasible in any surgical background, and their complication rate is the same as traditional open neck surgery. The videoscopic access to neck lymph nodes (central and lateral compartments) seems to be very promising, whereas other fields of application such as carotid artery surgery and spine surgery are still being studied experimentally. Cervicoscopy by consequence has to be considered an important surgical tool that can be further improved but which also has an excellent potential.     

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.     

Primary hyperparathyroidism: diagnostic and therapeutic trends

The most interesting aspects of parathyroid disease are the increased incidence of primary hyperparathyroidism, which nowadays is diagnosed more and more frequently through the casual discovery of hypercalcaemia, the various diagnostic methodologies used, the ongoing debate as to the function of parathyroidectomy in asymptomatic patients and the new video-assisted surgical techniques which have recently been developed. The authors retrospectively review 31 consecutive cases of primary hyperparathyroidism. The clinical onset was characterised in 26 cases by an osteoarthralgic syndrome associated with renal and biliary pathology. Five cases were asymptomatic. Prior to surgery, all patients underwent both biochemical and instrumental tests. MIB scintigraphy was found to yield the most reliable diagnosis, leading to identification of 83.6% of diseased parathyroids. As regards surgical treatment, 29 cases were treated with a simple parathyroidectomy, 1 with a bilateral inferior parathyroidectomy and 1 with a thyroid lobectomy. Associated thyroid surgery was performed in 8 cases for concomitant thyroid disease: 1 total thyroidectomy, 2 subtotal thyroidectomies and 5 lobectomies. In 3 cases radioimmunoguided surgery was used. There were no cases of mortality, and 9.6% of patients presented specific morbidity characterised by some degree of paraesthesia. As stated by other researchers, the authors argue that MIBI scintigraphy is the most reliable test for the diagnosis of hyperparathyroidism and that surgical treatment is the first choice for symptomatic primary hyperparathyroidism. The surgical strategy depends on the abnormality underlying the hyperparathyroidism: in the event off an adenoma, a bilateral exploration of the neck and removal of the diseased parathyroid are required; in the case of hyperplasia, a subtotal parathyroidectomy is necessary with marking of the residual parathyroid which will simplify any possible reoperation; in the event of carcinoma, a thyroid loboisthmectomy and ipsilateral parathyroidectomy are performed with removal of the fatty tissue of the antero-superior mediastinum and ipsilateral cervical functional lymphadenectomy.     

Minimally invasive thyroid and parathyroid surgery is not a question of length of the incision

INTRODUCTION: Postoperative cosmesis in the neck is often a major concern of patients, particularly women, undergoing thyroid or parathyroid surgery. Therefore, a reduction in the length of the cervical incision, and even more so, having no scar in the neck, is particularly appealing to these patients. Over the last years, many different so-called minimally invasive procedures have been proposed for the treatment of thyroid and parathyroid diseases, the primary aim being to improve the cosmetic results. Nevertheless, the concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, minimally invasive thyroidectomy or minimally invasive parathyroidectomy should properly be defined as operations through a short, less than 3 cm, and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection. In addition, type of anesthesia, duration of the operation, postoperative pain, complication and success rates, and long-term outcome should also be taken into account to assess surgical invasiveness. CONCLUSION: Thyroid and parathyroid operations that minimize the incision but keep it in the neck may be considered minimally invasive not only in respect of the size of the skin incision but also, and above all, in respect of the accessibility of the operative field and extent of dissection. These operations have some advantages over conventional cervicotomy in terms of postoperative pain and cosmetic results. Until now, there is no evidence to state that morbidity of these new approaches is at least equal to the conventional equivalent. Operations that employ an extracervical approach, which have the advantage of leaving no scar in the neck, cannot reasonably be described as minimally invasive, as they require more dissection than conventional open surgery.     

Postauricular and Axillary Approach Endoscopic Neck Surgery: A New Technique

Background  While the bilateral axillo-breast approach (BABA) to endoscopic neck surgery resolves various benign and malignant thyroid and parathyroid diseases with minimal adverse effects and excellent cosmetic outcomes, it involves circumareolar incisions. Many patients, especially young female patients, are reluctant to have their breast involved. Consequently, we developed the postauricular and axillary approach (PAA) that uses postauricular incisions. Methods  From June 2006 to December 2007, we treated 10 patients with PAA endoscopic neck surgery. After subcutaneous infiltration with diluted epinephrine solution, the subplatysmal and subcutaneous spaces were dissected. Two axillary ports and two postauricular ports were used and low-pressure CO₂ insufflation generated operative space. After dividing the midline between the strap muscles, the isthmus was divided and the thyroid lobe was dissected with ultrasonic shears and excised after careful identification of the recurrent laryngeal nerve and parathyroid glands. Malignant lesions were treated with contralateral thyroid lobectomy. For parathyroid adenomas, we performed parathyroidectomy after dividing the strap muscles in the midline. Results  Two thyroid lobectomies, one parathyroidectomy, one subtotal thyroidectomy, and six total thyroidectomies were performed by PAA endoscopic neck surgery. The mean operation time was 210.0 ± 43.7 min. There were no cases of conversion to open surgery, permanent vocal cord palsy, or facial nerve palsy. None of the thyroidectomy patients exhibited hypocalcemia. The cosmetic outcomes were excellent and all patients were satisfied. Conclusions  PAA endoscopic neck surgery is a feasible method for thyroid and parathyroid surgery that permits good operative visualization and has minimal adverse effects and excellent cosmetic outcomes.     

内镜下甲状腺、甲状旁腺切除手术

目的 探讨开展内镜下甲状腺、甲状旁腺切除手术的意义。方法 查阅国外有关内镜下甲状腺、甲状旁腺切除手术的文献并加以综述。结果 甲状腺、甲状旁腺切除手术可以完全在内镜下或者以内镜作为辅助手段来完成。结论 内镜下甲状腺、甲状旁腺切除手术颈部不残留手术瘢痕，提高患者的生活质量。     

Incidental Parathyroidectomy during Thyroid Surgery: An Underappreciated Complication of Thyroidectomy

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.     

Drains for thyroidectomy/parathyroidectomy: fact or fiction?

BACKGROUND: Many authorities advocate draining the neck routinely after thyroid and parathyroid surgery with no scientific evidence to support this practice. We aimed to establish if the routine use of drains following thyroid/parathyroid surgery is of any value. METHOD: Medical records of patients who underwent thyroidectomy or parathyroidectomy under the care of a single endocrine surgeon (GP) over a 14-year period were reviewed. For the first 6 years, the neck was routinely drained (drain group) and for the subsequent 8 years the neck was only drained if the surgeon felt it necessary according to the operative situation (selective group). RESULTS: A total of 606 procedures (425 thyroidectomy and 181 parathyroidectomy) were performed on 582 patients. Drains were routinely used in 134 (22%) procedures (drain group) and were selectively used in 472 (78%) (selective group) of which 191 (40%) were drained. In all patients, there was a significant increase in the rate of postoperative bleeding/haematoma in patients with a drain (8/314 versus 1/282, Fisher's exact, P < 0.05). Wound infection occurred only in the patients with a drain. There was no difference in the incidence of postoperative bleeding and airways obstruction between the drain and selective groups. CONCLUSION: We conclude that the routine use of neck drains is unnecessary and may indeed be harmful, drain insertion being associated with an increased incidence of wound infection. Drains should, therefore, be used selectively after thyroidectomy and parathyroidectomy.     

Life threatening presentation of thoracic duct injury post thyroid surgery; a case report

BackgroundInjury to thoracic duct is a rare potential complication of time-honored conventional thyroidectomy. Nevertheless, it can be a cause of significant morbidity, and sometimes life-threatening.Patient findingsA 78-year-old female patient with a previous surgical history of thyroid lobectomy for nodular disease presented with primary hyperparathyroidism, and a nodule in the remaining thyroid lobe. The patient underwent completion thyroidectomy and parathyroidectomy. Less than 24 h post operatively, the patient developed progressive shortness of breath and neck swelling requiring immediate intubation and re-exploration. A large amount of chyle was drained and an injured thoracic duct was identified and ligated.SummaryIn experienced hands thyroid surgery is safe. Nevertheless, factors such as the type of pathology and its extent, the level of surgery, and re-operative surgery increase the risk of postoperative complications. Immediate surgical exploration is necessary when patients present with neck swelling and respiratory distress. In our case, a high output chyle leak in a confined space was life threatening.ConclusionTimely re-exploration following thyroid surgery and thorough knowledge of the anatomy of neck structures is crucial in sparing patients potential morbidity and/or mortality.     

Difficulties of parathyroidectomy after previous thyroidectomy

Although the risks of reoperative thyroidectomy and parathyroidectomy have been well studied, the problems associated with parathyroidectomy after prior thyroidectomy have not been emphasized. Among a group of 282 patients who were treated for primary hyperparathyroidism in recent years at the University of Chicago Medical Center, 14 (4.8%) had undergone one or more previous thyroidectomies, and 6 others (2.1%) had undergone thyroid ablation with radioactive iodine as therapy for Graves' disease. Numerous difficulties were encountered during surgery in the postthyroidectomy group of patients as a result of scarring and fibrosis, prior recurrent laryngeal nerve injuries in 13%, the inability to known with certainty how many viable, normal parathyroid glands remained after previous operations, and the need for additional thyroid resection, mostly for associated malignant lesions. Preoperative vocal cord assessment, evaluation of prior operative and pathology reports, and localization studies with thallium-technetium scanning and ultrasonographic techniques were especially helpful. A "lateral approach" was used frequently during surgery. Each of these 14 patients was cured of the hyperparathyroidism. The postthyroid ablation group presented fewer intraoperative challenges, although in some patients the thyroid gland was virtually absent, which obscured the normal landmarks of the surgical field. Five of these six patients were cured of hyperparathyroidism. Parathyroidectomy after thyroidectomy presents many operative challenges to the surgeon and should be approached with the same care and concern that one reserves for a reoperative parathyroid operation.     

Robotics and laparoscopic surgery

Laparoscopic surgery has completely revolutionized modern surgery. In addition to its advantages, however, this approach also presents significant limitations. The most important are loss of the sense of depth, tactile sensation and resistance, as well as loss of natural hand-eye coordination and manual dexterity. The main motivation for the development of surgical robots is the possibility of eliminating all these limitations. Robots have acquired great potential to improve the operative possibilities of surgeons. Given the continual increase in the use of surgical robots, in the near future the structure and appearance of current operating rooms will change. The present article analyzes the origin and development of robotic systems, as well as the characteristics of the latest generation of robots. Because of the strong interest in robotic surgery and its future prospects, surgeons should be familiar with these emerging and innovative techniques.     

Video-assisted parathyroidectomy for primary hyperparathyroidism

Background: Recent advances have allowed the performance of parathyroidectomy as an endoscopic procedure. Carbon dioxide (CO2) insufflation can be used to create a working space in the anterior neck, but it has been associated with a number of complications. We have devised a skin-lifting method to overcome these problems. Methods: Eleven consecutive patients underwent video-assisted parathyroidectomy. Preoperative imaging revealed a solitary adenoma in all 11 cases. A 3-cm oblique incision was made below the clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted, video-assisted parathyroidectomy was performed. Results: Surgery required 186 ± 50 min. No conversions to conventional cervicotomy were needed. Levels of serum calcium and intact parathormone decreased significantly in all patients on postoperative day 1. Laryngeal recurrent nerve paresis and seroma were noted in one patient each. Conclusions: Our procedure eliminates any potential CO2 problems and offers the advantages of direct manipulation and improved cosmesis. Endoscopic parathyroidectomy should be considered a viable option for the surgical treatment of a solitary adenoma.     

Incidental parathyroidectomy in thyroidectomy and central neck dissection

BackgroundAlthough higher thyroidectomy volume has been linked with lower complication rates, its association with incidental parathyroidectomy remains less studied. The volume relationship is even less clear for central neck dissection, where individual parathyroid glands are at greater risk.MethodsPatients undergoing thyroidectomy with or without central neck dissection were evaluated for incidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Univariate and multivariable analyses were performed using binary logistic regression.ResultsOverall, 1,114 thyroidectomies and 396 concurrent central neck dissections were performed across 7 surgeons. Incidental parathyroidectomy occurred in 22.4% of surgeries (range, 16.9%–43.6%), affecting 7.1% of parathyroids at risk (range, 5.8%–14.5%). When stratified by surgeon, lower incidental parathyroidectomy rates were associated with higher thyroidectomy volumes (R² = 0.77, P = .008) and higher central neck dissection volumes (R² = 0.93, P < .001). On multivariable analysis, low-volume surgeon (odds ratio 2.94, 95% confidence interval 2.06–4.19, P < .001), extrathyroidal extension (odds ratio 3.13, 95% confidence interval 1.24–7.87, P = .016), prophylactic central neck dissection (odds ratio 2.68, 95% confidence interval 1.65–4.35, P <.001), and therapeutic central neck dissection (odds ratio 4.44, 95% confidence interval 1.98–9.96, P < .001) were the most significant factors associated with incidental parathyroidectomy. In addition, incidental parathyroidectomy was associated with a higher likelihood of temporary hypoparathyroidism (odds ratio 2.79, 95% confidence interval 1.45–5.38, P = .002) and permanent hypoparathyroidism (odds ratio 4.62, 95% confidence interval 1.41–5.96, P = .025), but not permanent hypocalcemia (odds ratio 1.27, 95% confidence interval 0.48–3.35, P = .63). Higher lymph node yield in central neck dissection was not associated with higher incidental parathyroidectomy rates (odds ratio 1.13, 95% confidence interval 0.85–8.81, P = .82).ConclusionHigher surgical volume conferred a lower rate of incidental parathyroidectomy. Nonetheless, greater lymph node yield in central neck dissections did not result in greater parathyroid-related morbidity. Such findings support the value of leveraging surgical volume to both optimize oncologic resection and minimize complication rates.     

Minimally invasive video-assisted thyroidectomy: five years of experience

BACKGROUND: In the last decade, development of videolaparoscopic surgery allowed several operations to be performed with minimally invasive techniques, making them less invasive and painful. Neck surgery was also involved in this effort, in spite of the skepticism shown by some authors. STUDY DESIGN: Minimally invasive video-assisted thyroidectomy was developed in 1998, and since then, about 600 operations have been performed. Access was the same as was previously described for parathyroidectomy; it was based on a small central incision (1.5 cm) and on external retraction without neck insufflation. RESULTS: From July 1998 to October 2003, 579 patients were selected from 5,450 for minimally invasive video-assisted thyroidectomy. The operation consisted of a total thyroidectomy in 312 patients and lobectomy in 267 patients. Mean operative time was 41 +/- 19.5 minutes (range 15 to 120 minutes) for lobectomy and 51.6 +/- 18.8 minutes (range 30 to 140 minutes) for total thyroidectomy. Postoperative hospital stay was 24 hours (overnight discharge) for all patients. Complications were postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). CONCLUSIONS: After 5 years of experience using this approach for various indications, we achieved a good esthetic result with an operative time comparable to that of conventional open surgery. Minimally invasive video-assisted thyroidectomy was found to be a safe operation, with advantages over traditional procedures represented by better cosmetic outcomes and postoperative course, as demonstrated by visual analogue scales and statistically analyzed numeric scales.     

Video-assisted Thyroidectomy: Report on the Experience of a Single Center in More than Four Hundred Cases

Background We report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-year period and discuss the results obtained. Methods Video-assisted thyroidectomy is a gasless procedure performed under endoscopic vision through a single 1.5–2.0-cm skin incision, using a technique very similar to conventional surgery. Eligibility criteria were these: thyroid nodules <35 mm; thyroid volume <30 ml; no previous conventional neck surgery. Small, low-risk, papillary thyroid carcinomas (PTC) were considered eligible. Results A total of 473 VATs were attempted on 459 patients. Locoregional anesthesia was used in 15 patients. Conversion was necessary in 6 (difficult dissection in 1 case, large nodule size in 3, gross lymph node metastases in 2). Thyroid lobectomy was successfully performed in 110 cases, total thyroidectomy in 343, and completion thyroidectomy in 14. In 66 patients with carcinoma, central neck nodes were removed through the same access. Concomitant parathyroidectomy was performed in 14 patients. Pathology showed benign disease in 277 cases, PTC in 175, and medullary microcarcinoma in 1. Postoperative complications included 8 transient recurrent nerve palsies, 64 transient hypocalcemias, 3 definitive hypocalcemias, 1 postoperative hematoma, and 2 wound infections. Postoperative pain was minimal and the cosmetic result excellent. In patients with PTC no evidence of recurrent or residual disease was shown. Conclusions Indications for VAT are still limited (20% of patients who require thyroidectomy). Nonetheless, in selected patients, it seems a valid option for thyroidectomy and it could be considered even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result. This paper is based on work presented at the ISW2005–IAES free paper session, Durban, South Africa, 21–25 August 2005. No competing interest is declared for this paper.     

Autotransplantation of cryopreserved human parathyroid tissue

Replantation of autologous cryopreserved parathyroid tissue is a procedure well established in surgery of hyperparathyroidism. It has proved to be a good approach to successful surgical treatment of hypocalcaemia in the wake of parathyroid operations. Cryopreservation of parathyroid tissue is indicated in cases of subtotal parathyroidectomy, total parathyroidectomy with autotransplantation of fresh tissue, re-operation for persistent or recurrent hyperparathyroidism, and surgery for hyperparathyroidism following thyroidectomy.     

甲状腺手术中甲状旁腺误切和术后低钙血症

目的分析常见甲状腺手术时甲状旁腺误切和术后患者发现低钙血症之间的关系。方法回顾性分析126例甲状腺手术患者的临床资料,其中双侧腺叶大部切除术18例,一侧或双侧腺叶全切术74例和六区清扫术34例。结果 126例患者中,共有25例（19.8%）病理证实存在旁腺误切,有30例（23.8%）术后出现低钙血症,25例（19.8%）出现低钙临床表现,经治疗后症状在2 d内消失。低钙血症的发生（23.8%）和旁腺误切（19.8%）之间是相关的（r=0.87,P=0.0333）。随访6个月,低钙血症消失时间平均为4.25（1-12）周,没有患者出现永久性低钙血症。六区清扫术的总体旁腺误切率为41.2%（14/34）,高于大部切除术的5.6%（1/18）（P〈0.01）,亦高于腺叶全切除术的13.5%（10/74）（P=0.0013）。结论甲状腺腺叶切除及六区清扫术后短暂的低钙血症是比较常见的并发症;旁腺误切可以导致术后低钙血症的发生;六区清扫术有很高的旁腺误切风险。     

Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive?

HYPOTHESIS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision (main proposition), and the length of the incision is influenced by objective factors. DESIGN: Case series. SETTING: University referral center.Patients and INTERVENTION: Retrospective study of the most recent 200 primary consecutive routine thyroid and parathyroid operations (excluding neck dissections). MAIN OUTCOME MEASURES: The length of incision was routinely measured with a ruler before the incision. Univariate and multivariate analysis was performed to distinguish variables affecting length of incision. RESULTS: Mean length of the incision was 5.5 cm for total thyroidectomy, 4.6 cm for lobectomy, and 3.5 cm for parathyroidectomy (P<.001). It was 4.1 cm for bilateral parathyroid exploration, but was reduced to 3.2 and 2.8 cm for unilateral (P<.001) and focal (P<.001) explorations, respectively. By multiple regression analysis, thyroid specimen volume and patient body mass index were independent predictors of incision length in thyroidectomy. Extent of exploration and resident training level were independent predictors of incision length in parathyroidectomy. CONCLUSIONS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision. Thyroid volume, patient body mass index, extent of the planned parathyroid exploration, and the resident clinical training stage are important variables for incision length in open operation and should be taken into account when minimally invasive thyroidectomy and parathyroidectomy are evaluated.     

Divertículos epifrénicos: ¿cuándo y cómo operar?

The majority of epiphrenic diverticula arise due to a peristaltic mechanism caused by an oesophageal motor disturbance that establishes a barrier effect and causes mucosal and submucosal herniation through a weak point in the muscular layer. Intraluminal oesophageal manometry and video-radiology are important in assessing these patients, since they define the characteristics of the functional disorder, as well as the true relationship between the symptoms of the patient and the diverticulum.Surgical treatment is indicated in symptomatic patients, more so if there are respiratory complications. Left posterolateral thoracotomy followed by diverticulotomy, oesophageal cardiomyotomy and anti-reflux have been considered the surgery technique of choice. Oesophageal myotomy must go beyond, in a proximal direction, the neck of the diverticulum, and, in a distal direction, must progress 1-2 cm into the gastric wall. The laparoscopic approach has won many followers since it has been shown to be both safe and effective as open surgery, adding to the advantages of minimally invasive surgery.