Impact of Harmonic Scalpel on operative time during video-assisted thyroidectomy

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) has been practiced in our department since 1998. It has some advantages over conventional surgery in terms of postoperative pain and cosmetic result. The aim of this study was to evaluate the use of the Harmonic scalpel (HS) on the performance of this procedure. METHODS: Between October 1998 and January 2001, 116 patients underwent MIVAT. The HS was used for the last 26 operations. We compared this group of patients (HS-G) with a control group (C-G) of 26 patients who had undergone MIVAT before the introduction of the HS. The following parameters were considered: age, gender, preoperative diagnosis, size of the lesion, type of operation (lobectomy or total thyroidectomy), operative time, complication rate, and postoperative hospital stay. RESULTS: The two groups were well matched for age, gender, preoperative diagnosis, lesion size, and type of operation. The mean operative time was significantly reduced in the HS-G for both lobectomy (37.3 +/- 8.4 vs 49.4 +/- 18.0 min) and total thyroidectomy (53.8 +/- 16.3 vs 90.6 +/- 22.1 min). No differences were found for postoperative stay. One patient in the C-G experienced a transient recurrent nerve palsy. There were no other complications. CONCLUSIONS: This study showed that the utilization of the HS for MIVAT is safe and associated with a shorter operative time. A reduction of the rates for such complications such as hypoparathyroidism and recurrent nerve injuries was not possible to demonstrate in the present study. Much larger series are needed for further evaluation of this instrument.     

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study.

BACKGROUND: Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated. METHODS: Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated. RESULTS: MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 +/- 24 minutes for MIVAT and 45 +/- 15 minutes for CT (P = .001). Postoperative course was significantly less painful in the patients who underwent MIVAT (P = .003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT (P = .003 and P = .01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies. CONCLUSIONS: Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages.     

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.     

Video-assisted thyroidectomy

BACKGROUND: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this article we report on the entire series of patients who underwent VAT and discuss the results obtained. STUDY DESIGN: Forty-seven patients were selected for VAT. Eligibility criteria were: thyroid nodules of 35 mm or less in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; neither previous neck surgery nor irradiation; and no thyroiditis. After a learning period, VAT was proposed also for completion thyroidectomy (of previous video-assisted lobectomy) and nodules with maximum diameter up to 45 mm. The procedure is performed by a totally gasless video-assisted technique through a single 1.5- to 2.0-cm skin incision. Dissection is performed under endoscopic vision using a technique very similar to conventional operation. RESULTS: Fifty-three VATs were attempted on 47 patients. Thirty-three lobectomies, 10 total thyroidectomies, and 6 completion thyroidectomies were successfully performed. Six patients with papillary carcinoma underwent central neck lymph node removal by the same access. Mean operative time was 86.8 minutes for lobectomy, 116.0 minutes for total thyroidectomy, and 77.5 minutes for completion thyroidectomy. Conversion rate was 7.5%. Postoperative complications included one transient recurrent nerve palsy, three transient symptomatic postoperative hypocalcemias, and one wound infection. The cosmetic result was considered excellent by most of the patients who successfully underwent VAT. CONCLUSIONS: VAT is feasible and safe and allows for an excellent cosmetic result. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.     

Minimally invasive video-assisted thyroidectomy

BACKGROUND: In this paper we describe the results of our personal technique for minimally invasive video-assisted thyroidectomy (MIVAT). METHODS: Sixty-seven patients were selected for MIVAT. Selection criteria were nodule size less than 30 mm, thyroid volume less than 20 mL, no thyroiditis, no previous neck surgery or irradiation. The procedure, totally gasless, is carried out through a 15-mm central incision above the sternal notch. Dissection is performed under endoscopic vision, using conventional and endoscopic instruments. RESULTS: We performed 51 lobectomies and 15 total thyroidectomies. Mean operative time was 73.6 minutes for lobectomy and 109.6 minutes for total thyroidectomy. Conversion to open procedure was required twice (3%). We observed 2 cases of transient postoperative hypocalcemia and 1 case of transient recurrent laryngeal nerve palsy. The cosmetic result was considered excellent by most patients. CONCLUSIONS: MIVAT is safe and feasible. The indications are limited at present, but the results are encouraging, and we are optimistic about the future expansion of its applicability.     

Minimally invasive video-assisted thyroidectomy in pediatric patients

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign diseases and malignancies. We report our experience in thyroid surgery in pediatric patients.

Methods

From October 1998 to December 2005, 35 patients (27 females and 8 males) underwent MIVAT for thyroid disease. The mean age was 14.0 years (range, 8-18 years); mean ecographically estimated thyroid volume was 11.13 mL (range, 8-25 mL).

Results

A total thyroidectomy was performed in 22 patients, whereas lobectomy was performed in 13. Two patients of the latter group had a second lobectomy for a false-negative result at frozen section during the first operation. One patient underwent also a prophylactic central neck dissection for positive RET oncogene. The histologic examination found a papillary carcinoma in 11 patients, a microfollicular nodule in 7 patients, and multinodular goiter in 17 patients. The mean operative time was 54.1 minutes for thyroidectomy (range, 25-110 minutes) and 38.5 minutes for lobectomy (range, 20-65 minutes). All patients but one was discharged on the first postoperative day. One transient hypoparathyroidism was observed in the patient who underwent total thyroidectomy plus central neck lymphadenectomy.

Conclusions

The MIVAT technique proved to be as safe and effective as conventional thyroidectomy with Kocher approach to treat patients with both benign and malignant diseases of the thyroid gland. The advantages of MIVAT are represented by a better and faster postoperative course and an improved aesthetic result, which is particularly important in this group of patients.     

Video-assisted endoscopic thyroidectomy

BACKGROUND: Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS: In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle's tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS: All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS: VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results.     

Evolution of mitral valve surgery: toward a totally endoscopic approach

BACKGROUND: Our study evaluates a series of video-assisted minimally invasive mitral operations, showing safe progression toward totally endoscopic techniques. METHODS: Consecutive patients with isolated mitral valve disease underwent either manually directed (n = 55) or voice-activated robotically directed (n = 72) video-assisted mitral operations. Cold blood cardioplegia, a transthoracic aortic clamp, a 5-mm endoscope, and a 5-cm minithoracotomy were used. This video-assisted minimally invasive mitral operation cohort was compared with a previous sternotomy-based mitral operation cohort (n = 100). RESULTS: Group demographics, New York Heart Association classification, and cardiac function were similar. Repairs were performed in 61.8% manually directed (n = 34), 75.0% robotically directed (n = 54), and 54% sternotomy-based (N = 54) mitral operations. The robotically directed technique showed a significant decrease in blood loss, ventilator time, and hospitalization compared with the sternotomy-based technique. Manually directed mitral operations compared with robotically directed mitral operations had decreased arrest times (128.0 +/- 4.5 minutes compared with 90.0 +/- 4.6 minutes; p < 0.001) and decreased perfusion times (173.0 +/- 5.7 minutes compared with 144.0 +/- 4.6 minutes; p < 0.001). In the minimally invasive mitral operation cohort, complications included reexploration for bleeding (2.4%; n = 3) and one stroke (0.8%), whereas the 30-day mortality was 2.3% (n = 3). CONCLUSIONS: Video-assisted mitral surgery provides safe and effective results when compared with conventional sternal approaches. These positive results show a safe and stepwise evolution toward a totally endoscopic mitral valve operation.     

微创外科技术在中央型肺癌治疗中的应用

微创手术有助于减少手术创伤和疼痛,帮助患者康复,改善生活质量。包括胸腔镜和机器人在内的微创肺切除术目前主要用于早期周围型肺癌的外科治疗,中央型肺癌由于肿瘤位置、淋巴结转移和治疗模式等原因,手术难度较大、技术要求较高,尤其是袖状切除术和全肺切除术,大多需要开胸手术切除。随着微创手术技术的不断进步,近年来临床上开始尝试将其应用于中央型肺癌的外科治疗,其可行性和安全性已得到初步结果证明,代表了微创胸肺癌外科的发展方向。但仍需要更多研究结果证实其功能优越性和肿瘤学效果,让更多肺癌患者从外科技术的进步中获益。     

Video-assisted thyroidectomy with minimally invasive central cervicotomy: initial experience in an endocrine surgery division

Minimally invasive video-assisted thyroidectomy, a recently developed technique, has been shown to be feasible and safe. Nevertheless, to obtain the best results, the surgeon should be well trained in endoscopic surgery. We attempted to answer the question whether an endocrine surgery division with no previous experience in endoscopic neck surgery could easily import the new technique. The inclusion criteria were nodules < or = 3.5 cm diameter or thyroid lobe volume less than 15 ml, and no thyroiditis or previous neck surgery. Suspect malignant nodules were excluded. The procedure was carried out through a 20 to 30 mm central neck incision, with external retraction and no neck insufflation. The vessels were ligated or closed by means of clips. From March 2004 to March 2005, 127 thyroidectomies were performed, of which 36 were thyroid lobectomies. Of these, 12 lobectomies by minimally invasive video-assisted thyroidectomy were performed for monolateral goiter (4 left, 8 right). There were no intraoperative complications. No recurrent laryngeal nerve palsy or permanent hypoparathyroidism occurred. The mean operative time was 74.4 min (median: 70; range: 45-115). The results, in terms of patient comfort, reduced postoperative pain and cosmetic quality were excellent. The technique allowed careful assessment of the inferior and superior laryngeal nerve. Thorough haemostasis was aided by the magnification of the image and optimal illumination. The learning curve appeared short, owing probably to previous experience in conventional endocrine surgery and the closer similarities of minimally invasive video-assisted thyroidectomy to enhanced-view conventional surgery than to laparoscopic surgery. In our experience the clinical impact was limited as a result of the small percentage of patients fulfilling the strict inclusion criteria.     

Long-term complaints after minimal invasive thoracic surgery operations and thoracotomy]

BACKGROUND: Minimally invasive techniques are now frequently used in general thoracic surgery. More than 30% of all minimally invasive procedures are operations in patients with spontaneous pneumothorax. Recently, it has been shown that the video-assisted approach compared to the standard anterolateral thoracotomy results in a significant reduction of the early postoperative pain. However, little is known about the influence of video-assisted surgery on long-term complaints. METHODS: We analyzed the frequency and characteristics of chronic complaints in 60 patients after video-assisted operations for spontaneous pneumothorax using a standardized questionnaire. For comparison, 27 patients after anterolateral thoracotomy for benign diseases were interviewed 24 months postoperatively using the same questionnaire. RESULTS: After minimally invasive surgery and a median observation time of 59 months, 19 (31.7%) out of 60 patients suffered from chronic complaints. Two of them (3.3%) required daily oral pain medication. On a visual analog pain scale (ranging from 0 to 100), 17 patients described a pain intensity of < 20 and 2 (3.3%) patients > 50. After thoracotomy 14 (51.8%) out of 27 patients suffered from chronic complaints, 5 (18.5%) of them with regular use of oral pain medications. The mean pain intensity (analog scale) was 3.6 points after minimally invasive operations and 14.4 points after thoracotomy (P = 0.01). CONCLUSIONS: In conclusion, even after minimally invasive thoracic operations some patients suffer from chronic complaints. However, they are less frequent and of lower intensity than after thoracotomy.     

Differentiated Operative Strategy in Minimally invasive,Video-assisted Thyroid Surgery Results in 196 Patients

To date, experience in minimally invasive thyroid surgery has been limited to unilateral lobectomy and total thyroidectomy. There are no reports regarding selective operative strategy, guided by morphology and function, which is widely accepted in endemic goiter regions. To analyze the efficiency and outcome of tissue-preserving thyroid surgery using a minimally invasive video-assisted technique (MIVA-T), a total of 196 patients were operated on for thyroid nodules between February 1999 and October 2003. Concurrent primary hyperthyroidism was treated in 22 (11%) cases. Indications for operation were solitary, multiple unilateral, or bilateral nodules with a maximum diameter of 30 mm and a maximum lobe volume of 15 ml. Contraindications for minimally invasive operation were thyroid malignancy diagnosed by fine-needle aspiration (FNA), recurrent goiter, and Hashimotos thyroiditis. Nodule excision was performed in 6% of these cases; subtotal lobectomy, in 6%; selective resection, in 48%; and total lobectomy, in 39%. Histological examination revealed follicular adenoma in 82%, colloid and cystic lesions in 11%, thyroiditis in 1%, and differentiated thyroid carcinoma in 6%. Conversion to open surgery was necessary in 7.7% of the patients (secondary to malignancy demonstrated on frozen section in 3% and to technical difficulties in 4.7%). Transient and permanent laryngeal nerve palsy occurred in 2.0% and 0.5% of patients, respectively. Temporary hypoparathyroidism occurred in 5.6% of patients exclusively after conversion to open total thyroidectomy or in those patients (n = 22) with additional primary hyperparathyroidism. Given a correct indication, MIVA-T technique can be performed with low conversion and complication rates. Selective operative strategy, guided by morphology and thyroid function, with a variety of operative procedures fitting the individual situation may be performed by this minimally invasive technique.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Minimally invasive video-assisted thyreoidectomy (MIVAT) with and without use of harmonic scalpel—a randomized study

BACKGROUND AND AIMS: Minimally invasive video-assisted thyroidectomy (MIVAT) has been used for the removal of small thyroid nodules to improve cosmetic results and diminish pain. The aim of this study was to compare the outcomes of the MIVAT operations with and without the use of an ultrasonic harmonic scalpel (HS). PATIENTS AND METHODS: Seventy-six patients with a solitary thyroid nodule below 30 mm in diameter were randomized to two groups of 38 patients each. Unilateral thyroid lobectomy was performed in each patient. In the clip-ligation group (CL-G), during MIVAT, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic scalpel group (HS-G), HS was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity, scar length, cosmetic satisfaction at 1 and 6 months following surgery, and cost-effectiveness. RESULTS: HS-G vs CL-G operations were shorter (31.4 +/- 7.7 vs 47.5 +/- 13.2 min; p < 0.001), the mean blood loss was smaller (12.9 +/- 5.7 vs 32.8 +/- 13.0 ml; p < 0.001), the mean scar length at 1 month following surgery was shorter (15.6 +/- 1.4 vs 21.5 +/- 1.9 mm; p < 0.001), and greater cosmetic satisfaction was achieved at 1 month after surgery (88.9 +/- 9.7 vs 81.9 +/- 5.4 pts; p < 0.001), but the difference became nonsignificant at 6 months postoperatively. MIVAT with HS was 20-30 euros more expensive. No major complications were observed in both groups. CONCLUSIONS: HS in the MIVAT operations is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits, such as lower blood loss, a scar a few millimeters shorter, or a slightly better early cosmetic result, are offered at slightly increased costs.     

Combination of minimally invasive thyroid surgery and local anesthesia associated to iopanoic acid for patients with amiodarone-induced thyrotoxicosis and severe cardiac disorders: a pilot study

Background and aims Amiodarone-induced thyrotoxicosis is a life-threatening condition. A prompt control of thyrotoxicosis is obtained by thyroidectomy. Preparation with iopanoic acid proved to be very effective in reducing cardiovascular complications. Nevertheless, general anesthesia and extensive surgery may affect negatively patients also after adequate preparation. Safety and efficacy of minimally invasive video-assisted thyroidectomy performed under regional anesthesia (bilateral modified deep cervical block) in patients with amiodarone-induced thyrotoxicosis was evaluated. Patients and methods Eight patients with amiodarone-induced thyrotoxicosis (three with type I and five with type II), mean age 66.2 years, were prepared with iopanoic acid. There were five men and three women. Three patients had dilatative cardiomyopathy, three had heart failure secondary to severe myocardial infarction, and two had refractory unstable rhythm disorders. Results Minimally invasive video-assisted thyroidectomy was performed under regional anesthesia. Mean operative time was 55.5 min. During surgery, lung and heart function remained well and no surgical complications occurred. After surgery, all patients remained on amiodarone therapy and two patients were subsequently removed from the checklist for heart transplantation. Conclusion Minimally invasive video-assisted thyroidectomy under regional anesthesia can be proposed as resolution of amiodarone-induced thyrotoxicosis in high risk patients with severe cardiac disorders, after preparation with iopanoic acid. Presented at the 2nd Biennal Congress of the European Society of Endocrine Surgeons in Krakow, Poland, 18–20 May, 2006.     

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.     

Minimally invasive video-assisted kidney transplantation (MIVAKT)

BACKGROUND: Minimally invasive surgery has been applied to nearly all fields of surgery due to its advantages such as reduced morbidity, a better cosmetic outcome, and early recovery. The recent advances in its technique have allowed us to use modified minimally invasive surgery technique in the field of kidney transplantation. MATERIALS AND METHODS: From January 2004 to March 2006, minimally invasive video-assisted kidney transplantation was carried out in 20 patients. Many clinical variables were compared with the conventional method. The operative procedure began with a 7 to 8 cm skin incision. A laparoscopic balloon dissector was used to create the retroperitoneal space for the placement of the grafted kidney. Vascular anastomosis and ureteroneocystostomy were performed under direct vision and with video-assisted TV monitoring. RESULTS: The average length of the wound was 7.8 cm and it was placed below the belt line. The average operating time was 186 min. Less analgesic was given compared with conventional methods. There was one postoperative complication, a mild lymphocele. All patients showed normalized serum creatinine levels within 4 d. All grafted kidneys showed normal findings on the postoperative ultrasound and renal scans. CONCLUSIONS: Minimally invasive video-assisted kidney transplantation is technically feasible and may offer benefits in terms of better cosmetic outcomes, less pain, and quicker recuperation than conventional kidney transplantation.     

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 video-assisted thyroidectomy: multiinstitutional experience

Minimally invasive video-assisted thyroidectomy (MIVAT) was described in 1998. In this study we collected the experience of four third-level referral centers that adopted this technique. A total of 336 patients (279 females, 57 males) were selected for MIVAT. Selection criteria were thyroid volume <15 ml, nodules not exceeding 3.5 cm of diameter, and an absence of thyroiditis, previous neck surgery, or previous irradiation. The procedure, totally gasless, is carried out through a 15 mm central incision above the sternal notch. Dissection is performed under endoscopic vision using conventional and endoscopic instruments. The mean operating time was 69.4 ± 30.6 minutes for lobectomy (range 20–150 minutes) and 87.4 ± 43.5 minutes for total thyroidectomy (range 30–220 minutes). The mean postoperative stay was 1.9 ± 0.8 days. Postoperative complications were 7 transient and 1 definitive recurrent nerve palsies and 11 cases of hypoparathyroidism (9 transient, 2 definitive). Conversion to open surgery was necessary in 15 patients (4.5%). This study confirms in a large number of cases the safety and feasibility of MIVAT, even in different surgical settings where similar results were achieved. The complication rate was not different from that of standard thyroidectomy. Although the operating time appears longer than with conventional procedures, the learning curve demonstrates a sharp decrease with increasing experience and the introduction of new technologies. The number of patients eligible for this approach remains low, thereby limiting its use, but it should be considered a valid option in selected surgical centers, offering some advantages to patients in terms of cosmetic results and postoperative distress.     

The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery

HYPOTHESIS: The technique of thyroidectomy has undergone little change in several decades. The harmonic scalpel, using ultrasonic frictional heating to ligate vessels, is widely used in laparoscopic surgery, but there is little experience in open thyroidectomy. We hypothesized that the use of the harmonic scalpel could lead to a significant reduction in operative time as compared with knot tying in thyroid surgery. DESIGN: Retrospective case-controlled study. SETTING: Teaching institution. PATIENTS: One hundred seventy-one consecutive patients undergoing lobectomy or total thyroidectomy by one surgeon (A.E.S.). INTERVENTIONS: Eighty-six patients underwent thyroid surgery with the conventional clamp-and-tie technique (lobectomy, n = 49; total thyroidectomy, n = 36) and 85 with the harmonic scalpel (lobectomy, n = 38; total thyroidectomy, n = 47). MAIN OUTCOME MEASURES: Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using a 2-tailed t test, chi(2)test, and Wilcoxon rank sum test. RESULTS: The 2 groups were similar regarding age and sex. There were no intraoperative complications. Mean +/- SD thyroid size tended to be larger in the harmonic scalpel group for both lobectomy (5.1 +/- 2.6 cm vs 4.2 +/- 2.2 cm; P =.06) and total thyroidectomy specimens (6.3 +/- 3.8 cm vs 4.8 +/- 2.9 cm; P =.08) compared with the conventional technique. Mean +/- SD operative time was shorter in the harmonic scalpel group compared with the conventional technique group for both lobectomy (89 +/- 20 minutes vs 115 +/- 25 minutes; P<.01) and total thyroidectomy (132 +/- 39 minutes vs 161 +/- 42 minutes; P<.01) procedures. There was no difference between the 2 techniques regarding the amount of blood loss for different procedures. There was no effect of tumor size on operative time (Pearson correlation factors: 0.14 for total, 0.21 for unilateral thyroidectomy). CONCLUSIONS: The use of the harmonic scalpel for the control of thyroid vessels during thyroid surgery is safe, and it shortens the operative time by almost 30 minutes compared with the conventional technique for both unilateral lobectomy or total thyroidectomy procedures.     

Minimally Invasive Video-Assisted Thyroidectomy for Small Follicular Thyroid Nodules

Minimal access surgery in the thyroid compartment has evolved considerably over the past 10 years and now takes many forms. This study examined the feasibility and reliability of minimally invasive thyroid surgery for the management of small benign thyroid lesions. A total of 68 patients with small thyroid nodules admitted to the Oncology Center of Mansoura University, Egypt, were enrolled in this prospective randomized trial. Patients were allotted to one of two procedures: minimally invasive video-assisted thyroidectomy (MIVAT) or minimally invasive open thyroidectomy using the Sofferman technique of strap muscle transection. Exclusion criteria were nodules > 4 cm, presence of thyroiditis, and thyroid gland volume > 20 ml. Preoperative diagnosis, operating time, blood loss, postoperative pain, complications, and cosmetic outcome were all evaluated. The MIVAT group included 35 patients, and the Sofferman group included 33 patients. The main preoperative pathology was a benign follicular lesion (70.5%), and the main postoperative final pathology was follicular adenoma (54.4%). The two groups were comparable regarding age, sex, and extent of thyroid surgery. Operating time was significantly longer in the MIVAT group (115.4 ± 33.5 minutes) compared to the Sofferman group (65.6 ± 23.7 minutes). The postoperative course was significantly less painful in the MIVAT group (p < 0.05). Although patients in the MIVAT group had smaller incisions (p < 0.05), the cosmetic outcome in the two groups was comparable. No long-term complication was encountered in either group. Two distinct approaches of minimally invasive thyroidectomy are now available and can be performed safely in selected patients. Despite some MIVAT advantages of less postoperative pain and slightly better cosmesis, minimally invasive open thyroidectomy offers an advantage of less operating time with comparable cosmetic results.