Endoscopic thyroidectomy via bilateral axillo-breast approach (BABA): review of 512 cases in a single institute

Background

Various techniques for endoscopic thyroidectomy have been introduced in the past decade, and the cosmetic superiority of these techniques has been universally acknowledged. We developed the endoscopic thyroidectomy via bilateral axillo-breast approach (BABA) and have performed more than 500 operations. The aims of this study are to analyze the surgical outcomes and to evaluate the effectiveness and safety of BABA endoscopic thyroidectomy.

Patients and methods

Between February 2004 and March 2008, 512 patients with thyroid diseases underwent BABA endoscopic thyroidectomy. The criteria analyzed were clinicopathologic characteristics, types of operation, operation time, tumor–node–metastasis (TNM) stage on the basis of the 7th edition of the American Joint Committee on Cancer (AJCC), results after radioactive ablation therapy, and recurrence of disease in these patients.

Results

Of 512 patients, 397 had a malignant tumor and 115 had benign thyroid disease. Eight patients were diagnosed with Graves’ disease, and nine patients underwent completion thyroidectomy. Three cases were subjected to open thyroidectomy due to uncontrolled bleeding. Mean operation time was 151.2?±?38.1?min for total and near-total thyroidectomy, and 141.7?±?50.1?min for subtotal thyroidectomy and lobectomy. Regarding postoperative complications, transient hypocalcemia occurred in 31.1% of patients and permanent hypoparathyroidism occurred in 4.2% of patients. Transient hoarseness occurred in 20.3% of patients, and permanent vocal cord palsy occurred in 1.7%. Mean hospital stay after operation was 3.34?±?0.8?days (range 3–7?days), and mean follow-up period was 57.1?±?17.6?months (range 38.5–71.7?months). There were eight cases of recurrent thyroid carcinoma, and no mortality has occurred up to the present time.

Conclusions

Endoscopic thyroidectomy via bilateral axillo-breast approach is a safe and effective method that gives good surgical completeness, a low rate of postoperative complications and recurrence, and an excellent cosmetic result. Therefore, this method is a good choice for patients with surgical thyroid diseases.     

Endoscopic Thyroidectomy Using a New Bilateral Axillo-Breast Approach

Introduction Endoscopic techniques have recently been applied in thyroid surgery using cervical, axillary, and breast approaches. We modified the axillo-bilateral breast approach (ABBA) and developed the bilateral axillo-breast approach (BABA) to obtain optimal visualization for total thyroidectomy. Methods We used two 12-mm ports through bilateral circumareolar incisions for flexible videoscopy and Harmonic scalpel and two 5-mm ports through both axillae for graspers and dissectors. Thyroidectomy was performed under full visualization of the superior and inferior thyroidal arteries, parathyroid glands, and recurrent laryngeal nerves. Results After performing 25 ABBA endoscopic thyroid surgeries, we developed BABA and performed 110 operations using this method. The BABA operations included 52 total thyroidectomies, 2 near-total thyroidectomies, 8 subtotal thyroidectomies, 43 lobectomies, and 3 subtotal lobectomies. Pathology revealed 41 benign lesions and 69 cancers. Mean operation time was 165.3 ± 43.5 minutes. There were 2 cases of conversion to open surgery, 1 due to cancer with capsular invasion and the other due to tracheal injury. Nine postoperative complications developed: transient unilateral vocal cord palsy in 4 cases, transient hypocalcemia in 4 cases, and postoperative infection in 1 case. The 2-month postoperative thyroglobulin level was less than 1 ng/ml in all examined cases of total thyroidectomy. Cosmetic results were excellent. Conclusions The BABA technique for endoscopic thyroid surgery is a feasible method of total thyroidectomy with a low rate of postoperative complications and, additionally, excellent cosmetic results. Therefore, in selected cases of thyroid cancer, the BABA endoscopic total thyroidectomy should be considered as a valid surgical option.     

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.     

Hypomagnesemia and Hypocalcemia after Thyroidectomy: Prospective Study

Hypomagnesemia after total thyroidectomy has not been studied extensively. Our anecdotal experience suggests that it may be important in some patients after thyroid excision. The hypomagnesemic hypocalcemic syndrome has been described in other disease states in which a state of functional hypoparathyroidism exists. This study was designed to determine the incidence of hypomagnesemia after total thyroidectomy and relate it to hypocalcemia and symptoms during the postoperative period. A prospective study of all patients undergoing total thyroidectomy between September 1994 and July 1996 was performed. Patient data, thyroid function, retrosternal extension, initial versus reoperative surgery, operative details, parathyroid resection, and pathology were recorded. Calcium, magnesium, electrolytes, blood count, liver function tests, and albumin were measured prior to surgery and twice daily during the postoperative period. Fifty patients underwent total thyroidectomy: 68% were hypocalcemic, 72% were hypomagnesemic, and 36% were symptomatic during the postoperative period. Hypomagnesemia and gender were associated with hypocalcemia. Volume of fluid and neck dissection were associated with low magnesium levels. Hypomagnesemia and parathyroid resection were risk factors for symptoms after thyroidectomy. No patients developed permanent hypoparathyroidism. Transient hypocalcemia and hypomagnesemia occur frequently after total thyroidectomy. The etiology of this phenomenon is probably multifactorial. Patients are more likely to be symptomatic when both cations are low, and attempting to correct only hypocalcemia may prolong symptoms. It is important to monitor both calcium and magnesium levels after total thyroidectomy and to correct deficiencies to facilitate prompt resolution of symptoms.     

Robotic thyroidectomy by bilateral axillo-breast approach: review of 1026 cases and surgical completeness

Background

Good postoperative and excellent cosmetic results have been achieved with bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT). This study was performed to analyze the surgical outcomes and evaluate the surgical completeness and safety of BABA RoT.

Methods

Between February 2008 and February 2012, a total of 1026 cases of BABA RoT were performed. The clinicopathologic characteristics, operation types, and postoperative outcomes of patients were analyzed.

Results

Of the 1026 cases analyzed, 968 cases were a malignant tumor and 58 cases were benign thyroid disease. Mean operating times for BABA total RoT with central lymph node dissection included 38 ± 13 min (range 20–90 min) of working space creation and 75 ± 26 min (range 25–175) of console time. Among the 872 patients who underwent total thyroidectomy with central lymph node dissection, transient hypoparathyroidism occurred in 39.1 %, transient vocal cord palsy occurred in 14.2 %, and permanent hypoparathyroidism and permanent vocal cord palsy occurred in 1.5 % and 0.2 % of patients, respectively. The median stimulated thyroglobulin (Tg) level of patients after their first radioactive iodine therapy was 0.4 ng/mL, with 65.1 % of patients having a stimulated Tg level of <1.0 ng/mL. The median suppressed Tg level at 3 postoperative months of patients without radioactive iodine therapy was <0.1 ng/mL, with 99.4 % of patients showing a suppressed Tg level of< 1.0 ng/mL. There was no recurrence or mortality after a median follow-up of 23 months.

Conclusions

BABA RoT is a safe and effective method that provides good surgical completeness and has low rates of postoperative complications and recurrence.     

Bilateral axillo-breast approach robotic total thyroidectomy in a 5-year-old patient with intractable Graves' disease

Robotic thyroid surgeries in children are gaining popularity due to cosmetic advantages, but most previous studies include patients of school-age or older. We hereby introduce our case of a 5-year-old patient with Graves' disease to show key differences and similarities between pediatric and adult bilateral axillo-breast approach (BABA) robotic thyroidectomies. Despite the small body, no additional working space was needed and the flap creation was performed as similarly done in adults. The anatomy was not much different, except that the parathyroid tissues were easily identified due to low body fat, and the prominent thymus covered most of the level VI area. The patient did not experience postoperative complications such as hypoparathyroidism or vocal cord palsy. Postoperative wounds showed excellent results with minimal scars. BABA robotic thyroidectomy can be performed safely in pediatric patients and may be considered an alternative option for conventional open thyroidectomy in children.     

Early Postoperative Vocal Function Evaluation After Thyroidectomy Using Thyroidectomy Related Voice Questionnaire

Background

The objectives of this study were to evaluate a screening method for detecting postoperative vocal cord palsy and lower-pitched voice and to identify how a pre-thyroidectomy laryngeal disorder affects post-thyroidectomy voice change by using our subjective voice questionnaire.

Methods

We examined 300 consecutive patients scheduled to undergo thyroidectomies between November 2010 and August 2011. Laryngoscopic examination, thyroidectomy-related voice questionnaire (TVQ) administration, and acoustic and perceptual analyses were performed preoperatively and 2?weeks after thyroidectomy.

Results

Ninety-eight (32.6?%) patients had a preoperative laryngeal disorder. Postoperatively, 31 (10.3?%) patients had vocal cord palsy and 54 (18?%) had a lower-pitched voice 2?weeks after thyroidectomy. Postoperative TVQs classified 25 (8.4?%) patients as normal and 275 (91.6?%) patients as abnormal, including 79 (26.3?%) mild, 131 (43.6?%) moderate, and 65 (21.6?%) severe cases. Of the patients with vocal cord palsy, 80.6?% belonged to the severe group, and 92.6?% of patients with lower-pitched voices belonged to the moderate and severe groups. Fundamental frequency and speaking fundamental frequency were decreased significantly in women. The most efficient TVQ cutoff values for detecting post-thyroidectomy vocal cord palsy and postoperative lower-pitched voice were 35 (87.1?% sensitivity, 79.9?% specificity) and 25 (75.9?% sensitivity, 56.5?% specificity), respectively. Total TVQ scores increased more in the nonlaryngeal than in the laryngeal disorder group.

Conclusions

During the early postoperative period, 28.3?% of patients had vocal cord palsy or lower-pitched voices, which could be evaluated using a simple questionnaire. Therefore, early postoperative voice evaluation is important. Patients with nonlaryngeal disorders may be more sensitive than those with laryngeal disorders to laryngeal symptoms.     

Complications associated with different surgical approaches to differentiated thyroid carcinoma

Introduction: With the good prognosis associated with differentiated carcinoma, the morbidity and mortality of different surgical approaches are of crucial importance. Methods: At the Department of Surgery (Virchow Klinikum Berlin), 139 patients who underwent surgery for differentiated thyroid carcinoma between 1979 and 1994 were reviewed, focussing on postoperative complications. In 113 and 18 patients, respectively, primary and completion thyroidectomy was performed. In five patients, less than total thyroidectomy and in three patients only palliative surgery was carried out. We performed thyroidectomy without systematic lymphadenectomy (LAD) in 70 patients (51.1%). In 15 patients (10.8%), lymphadenectomy of the lateral compartment and, in 53 patients (38.1%), central LAD was performed. LAD did not significantly influence survival time in either follicular (n = 42) or papillary carcinoma (n = 97). Results: No patient died because of postoperative complications. Permanent laryngeal nerve palsy occurred in no patients after thyroidectomy without LAD, in one patient after central LAD (1.9%) and in one patient after lateral LAD (6.7%). Transient laryngeal nerve palsy was seen in ten patients [six (8.6%) after thyroidectomy only, two (3.7%) after central LAD and two (13.3%) after lateral LAD] (P = 0.19). Hypocalcemia was distributed equally within the LAD groups: total transient hypocalcemia could be recorded in 54 patients (38.8%), but permanent hypocalcemia occurred only in one patient (0.7%). Postoperative recovery was delayed in patients when a more radical approach was used (P = 0.03). Conclusion: The magnitude of the benefit of LAD in therapy for differentiated thyroid carcinoma is still controversial. This more radical approach is not necessarily accompanied, however, by higher morbidity and mortality. Received: 30 January 1998 Accepted: 18 July 1998     

完全腔镜与中转开放甲状腺癌根治术的比较

目的回顾对比分析完全腔镜和中转开放甲状腺癌根治术的临床效果,评价腔镜甲状腺手术适应证扩展的可行性。方法 2001年6月～2008年5月接受腔镜甲状腺手术且术中确诊为甲状腺癌的患者,根据继续腔镜手术或中转开放手术分为腔镜组(15例)和中转组(10例)。手术范围均为患侧腺叶切除+峡部切除+对侧次全切除+中央区淋巴结清扫。回顾性对比分析两组肿瘤直径、手术时间、出血量、中央区淋巴结清扫数量、术后住院时间、手术并发症发生率以及随访结果的差异。结果腔镜组乳头状微小癌(直径<1 cm)的比例显著高于中转组(9/15 vs.1/10,P=0.018),且肿瘤直径显著小于中转组[(1.1±0.6)cm vs.(1.6±0.5)cm,t=-2.132,P=0.045]。2组手术时间、出血量、淋巴结清扫数量和术后住院时间差异无显著性。腔镜组术后24 h疼痛评分显著低于中转组(3.1±1.2 vs.4.6±1.4,t=-2.945,P=0.007),术后3个月美容评分显著高于中转组(7.7±1.1 vs.3.5±1.2,t=9.009,P=0.000)。腔镜组低钙血症2例、暂时性喉返神经麻痹1例,中转组低钙血症1例,均于出院前缓解。2组分别随访(41.5±22.6)月和(46.8±22.3)月,均未见肿瘤复发和转移。结论 对经验丰富,技术熟练的医师,严格选择的甲状腺癌病例可以作为腔镜手术适应证。     

Paediatric thyroidectomy: When and why? A 25-year institutional experience

ObjectiveThyroidectomy in paediatric patients is relatively uncommon. In this study, we reviewed our experience of thyroidectomy in children and identified risk factors associated with postoperative complications.MethodsWe performed a retrospective analysis of paediatric patients who had thyroidectomy in our institution between April 1995 and January 2021. Demographic data, preoperative cytological findings, indications of surgery, surgical complications and histological results were analysed.ResultsA total of 87 paediatric patients with 92 thyroidectomy were identified. The indications for surgery were Graves’ disease refractory to medical treatments (40.2%), benign thyroid nodules or multinodular goitre (26.4%), thyroid carcinoma (23.0%) and multiple endocrine neoplasm type 2A syndrome (10.3%). Patients presented with thyroid nodules or cervical lymph nodes had a 43.9% risk of malignancy.66 total thyroidectomy were done with median operation time of 134 min(102–170), while 26 hemi-thyroidectomy were performed (Right side 12/92, Left side 14/92) with median operation time of 65 min(49–102). The median postoperative hospital stay was 2 days(1–4). Intraoperative neck dissection (p = 0.003), drain insertion (p = 0.001) and hypocalcaemia requiring medical treatment (p = 0.004) were associated with longer hospital stay.The median follow-up was 11.3 years (3.0–16.8). 32% patients had immediate postoperative hypocalcaemia and 8% patients had permanent hypoparathyroidism. Transient vocal cord palsy was found in 3 patients(3%) and all resolved within 5-month time upon reassessment direct laryngoscopy. The use of intraoperative recurrent laryngeal nerve monitoring was associated with less vocal cord palsy (p = 0.022).The median disease-free survival was 13.7 years(7.4–17.7) for patients operated for well-differentiated thyroid carcinoma(WDTC). amongst the 9 patients who had prophylactic total thyroidectomy for MEN2A syndrome, 44% were found to have medullary thyroid microcarcinomas on pathology.ConclusionsSurgical management of paediatric thyroid disease can be complex. Postoperative hypocalcaemia and vocal cord palsy were usually transient after total thyroidectomy. The use of intraoperative recurrent laryngeal nerve monitoring had resulted in less vocal cord palsy. Long-term disease-free survival of patients with thyroid cancer had been achieved with multi-disciplinary management in our centre.Level of Evidence: Retrospective Comparative Study; Level III     

Surgical complications after thyroid surgery performed in a cancer hospital.

OBJECTIVE: This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy in a cancer hospital with residency training. STUDY DESIGN: A retrospective chart and complications review of 1020 patients (1990-2000) underwent to thyroidectomy. RESULTS: At our cancer hospital, 1020 patients underwent thyroidectomy. The main postoperative complications consisted of transient hypocalcemia in 134 (13.1%) patients, permanent hypocalcemia in 26 (2.5%) patients, transient vocal cord palsy in 14 (1.4%) patients, and permanent vocal cord palsy in 4 (0.4%) patients. The type of thyroidectomy, neck dissection, and paratracheal lymph node dissection were significantly associated with transitory and permanent hypocalcemia. CONCLUSION: Thyroid surgery can be performed safely in a surgical residency training program under direct supervision of an experienced surgeon with little morbidity to the patients. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients who underwent total thyroidectomy.     

Completion thyroidectomy in the management of well-differentiated thyroid carcinoma.

Completion thyroidectomy is the removal of any thyroid tissue that remains after less than total thyroidectomy. At our center, completion thyroidectomy is used when, on permanent sectioning, a frozen section diagnosis is revised from benign to malignant. We reviewed our experience with completion thyroidectomy to examine its indications and complications. We found that the carcinoma was misdiagnosed in 32 of 244 (13%) of cases. Twenty-five of these were initially designated follicular adenomas. The completion proved to be no more technically difficult than a routine hemithyroidectomy. There was one case of permanent hypoparathyroidism (3%). Transient vocal cord palsy occurred in one patient (3%) and transient hypocalcemia occurred in five patients (15%). Complete recovery occurred in all six of these patients. Focal areas of residual carcinoma were found in 8 of 32 (25%) of glands removed at completion. We found completion thyroidectomy to be a safe procedure with minimal morbidity. We recommend its use in those instances of well-differentiated thyroid carcinoma in which the frozen section diagnosis differs from the permanent section.     

Initial experience with a gasless unilateral axillo-breast or axillary approach endoscopic thyroidectomy for papillary thyroid microcarcinoma: comparison with conventional open thyroidectomy

The efficacy of various endoscopic thyroidectomy has not been determined for papillary thyroid microcarcinoma (PTMC). We compared 31 consecutive patients with PTMC who underwent endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach, and the 36 PTMC patients who underwent conventional open thyroid lobectomy from August 2005 to December 2008. There were more female patients (P=0.004) in the endoscopic group, and the mean age of endoscopic group was younger than that of the open thyroidectomy group (P=0.006). The entire endoscopic thyroidectomy was successfully completed in all the patients. The operative time was longer for those undergoing endoscopic thyroidectomy (P<0.001). The complication rate did not differ between the 2 groups. The cosmetic satisfaction, as evaluated by questionnaire, was greater in the endoscopic group (P<0.001). Endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach for selected cases of PTMC is a feasible, safe, and cosmetically superior procedure.     

Sensitivity and Specificity of Intraoperative Recurrent Laryngeal Nerve Stimulation Test for Predicting Vocal Cord Palsy after Thyroid Surgery

INTRODUCTION Recurrent laryngeal nerve (RLN) palsy after thyroidectomy, although infrequently encountered, can decrease quality of life. In addition to the hoarseness that occurs with unilateral RLN palsy, bilateral RLN palsy leads to dyspnea and often to life-threatening glottal obstruction. Therefore, intraoperative awareness of the nerve’s status is of great importance. This study examined the sensitivity and specificity of a palpation technique to detect contraction of the posterior cricoarytenoid muscle (PCA) through the posterior hypopharyngeal wall while the RLN was being stimulated with a disposable nerve stimulator during thyroid surgery (the laryngeal palpation test) to predict postoperative RLN deficits. Methods A total of 2197 RLNs in 1376 patients were identified to be at risk of injury during thyroidectomy performed between July 2003 and August 2004. Postoperative RLN integrity was assessed using direct laryngoscopy or laryngofiberoscopy to visualize vocal fold mobility. Results Altogether, 76 RLNs failed to elicit a PCA contraction in response to nerve stimulation, and 80 cases of temporary vocal cord palsy and 21 cases of permanent vocal cord palsy were recognized on postoperative evaluation. For postoperative vocal cord palsy, the sensitivity and specificity of the laryngeal palpation test were 69.3% and 99.7%, respectively, with a positive predictive value of 92.1% and negative predictive value of 98.5%. For permanent vocal cord palsy, the sensitivity and specificity were 85.7% and 97.3%, respectively, with a positive predictive value of 23.7% and negative predictive value of 99.8%. Conclusions The laryngeal palpation test is not a particularly useful method for predicting the level of RLN function after thyroidectomy. All patients must be examined postoperatively by direct laryngoscopy or laryngofiberoscopy to check vocal cord mobility. Even if there is no contraction of the PCA and we detect vocal cord palsy immediately after surgery, vocal cord palsy often recovers within 1 year when visual preservation of RLN is successful.     

微小乳头状甲状腺癌的内镜手术治疗

目的 探讨微小乳头状甲状腺癌(PTMC)内镜手术治疗的可行性、有效性及安全性.方法 收集2006年3月至2007年9月经胸乳人路内镜下甲状腺手术164例患者的临床资料,对其中经术中冰冻切片检查报告为PTMC的28例患者的临床资料进行回顾性分析.28例患者平均年龄35.2岁,女性27例,男性1例.术前诊断为甲状腺微小癌的12例,结节性甲状腺肿的16例.全部PIMC患者在内镜下行患侧甲状腺腺叶全切除+对侧腺叶次全切除+Ⅵ区淋巴结清扫术.结果 平均手术时间(115±43)min.肿瘤最大径0.2～1.0 cm,平均0.56 cm.5例(17.9%)术后出现一过性声音嘶哑.无术后出血、皮下气肿、饮水呛咳以及低血钙的表现.术后病理报告均为PTMC.Ⅵ区淋巴结清扫数目2～10个,平均4.6个,其中13例(46.4%)淋巴结有癌转移.随访时间1～17个月,B超和ECT提示患侧甲状腺无残留腺体,局部无复发.结论 内镜甲状腺手术治疗PTMC是安全可行的,可作为PTMC手术治疗的一种选择.     

甲状腺全切除术治疗甲状腺良性疾病

目的　探讨甲状腺全切除术治疗甲状腺良性疾病的安全性和临床意义。方法　对 88例甲状腺良性疾病患者进行甲状腺全切除术 ,并对手术并发症进行分析。结果　首次甲状腺全切除术暂时性甲状旁腺功能低下和暂时性喉返神经损伤的发生率分别为 2 .5 %和 1.2 % ,再次手术的并发症明显增高 ,分别为 2 8.6 % (P<0 .0 5 )和2 8.6 % (P<0 .0 1)。术后患者均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。结论　首次甲状腺全切除术安全可行 ,能避免因组织残留所致的病变复发 ,降低再手术率     

达芬奇机器人治疗肿瘤直径大于2 cm甲状腺癌的临床研究

目的与开放手术相比较,评估经腋乳径路达芬奇机器人甲状腺手术治疗肿瘤直径大于2 cm甲状腺癌的手术安全性和肿瘤彻底性。 方法回顾性分析2015年1月至2018年1月在济南军区总医院通过开放手术或机器人手术治疗肿瘤直径2～4 cm的甲状腺乳头状癌患者的临床资料。 结果本研究包括行机器人甲状腺切除手术患者30例,行开放手术患者45例。机器人手术组与开放手术组的肿瘤直径均在2～4 cm,两组患者均行甲状腺全切及颈部淋巴结清扫术,机器人手术组均顺利完成,无中转开放手术。机器人手术组平均年龄为(36.18 ± 3.5)岁,开放组平均年龄为(45.90 ± 2.2)岁。机器人组平均手术时间为(146.2 ± 30.5) min,显著长于开放组手术时间(95.9 ± 26.2) min (P< 0.001)。两组均未发生永久性喉返神经损伤和甲状旁腺功能减退,两组在术后短暂性喉返神经损伤发生率和甲状旁腺功能减退发生率、术后引流量、住院时间、清扫淋巴结数目比较,差异无统计学意义(P> 0.05)。术后美容效果数字评分系统得分,机器人手术组(9.4 ± 0.4)分,显著优于开放组的(5.2 ± 1.2)分(P< 0.05)。 结论与开放手术相比,对肿瘤直径2～4 cm的甲状腺乳头状癌患者行机器人甲状腺手术可以保证手术安全性和肿瘤切除的彻底性,并且具有更好的美容效果,适合于在意颈部瘢痕的患者。     

Influence of the Refinement of Surgical Technique and Surgeon’s Experience on the Rate of Complications after Total Thyroidectomy for Benign Thyroid Disease

Background: In recent years, many surgeons dealing with endocrine surgery have increasingly performed total thyroidectomy for benign thyroid disease. However, total excision of the thyroid in the treatment of benign lesions has been surrounded by even more controversy than its role in cancer treatment. The complication rate appears to be higher when the operation is done by inexperienced surgeons who have no special skills in endocrine surgery using proper techniques. The aim of this study is to determine whether surgeons experience and the refinement of surgical techniques are associated with postoperative recurrent laryngeal nerve (RLN) palsy or hypocalcemia after total thyroidectomy for benign thyroid disease.

Methods: A total of 68 consecutive patients who underwent total thyroidectomy for benign thyroid disease were reviewed. Twenty-six of these were from between January 1998 and June 1999 (first period) and 42 from between June 1999 and September 2000 (second period). Patients were divided into two subgroups according to different periods and different surgical techniques to identify the RLNs and the parathyroid glands. RLNs function was evaluated pre-and post-operatively by an otolaryngologist, and serum calcium levels were measured at the postoperative follow-up. Results: During the first period of the study, transient hypocalcaemia was determined in 8 (31%) patients. Hypocalcaemia was clinically symptomatic in 5 (19%) patients. Transient RLN palsy developed in 4 (15%) patients. Unilateral permanent RLN palsy due to operative injury was observed in 1 (4%) patient. During the second period, we noted transient hypocalcemia in 11 (26%) patients and symptomatic hypocalcemia in 6 (4%) patients. Serum calcium levels returned to normal within 4 weeks after operation in all patients. Neither transient nor permanent RLN palsy was observed during this period.

Conclusions: Complications of total thyroidectomy can be minimized with increasing experience and the refinement of surgical technique.     

腔镜甲状腺手术与开放手术临床对比研究

目的比较腔镜手术和开放手术治疗甲状腺良性疾病的临床效果。方法回顾性分析2009年1月～2010年3月32例行腔镜甲状腺切除术和35例行开放甲状腺切除术患者的临床资料,比较两组手术时间、出血量、术后恢复活动时间、术后并发症、住院费用、患者对手术满意度等。结果腔镜组32例中除1例中转开放手术外,其余31例均获成功。两组手术时间比较无统计学差异(P>0.05);与开放组比较,腔镜组出血少,术后恢复时间短,费用高,患者对手术满意度高(P<0.05)。腔镜组术后有2例患者出现声音嘶哑等神经损伤症状,其中1例为桥本氏甲状腺炎患者,在术后4个月恢复,另1例为结节性甲状腺肿患者,术后1个月恢复正常。1例患者出现皮肤瘀斑,2周后恢复正常。开放组有2例并发症,其中喉返神经损伤1例,术后2个月自行恢复正常,甲状腺功能减退1例,口服甲状腺素片治疗。两组并发症率比较无统计学差异(P>0.05)。结论腔镜甲状腺手术具有美容效果好、出血少、术后恢复快的优点,在治疗甲状腺良性疾病方面,是具有良好发展前景的手术方式。     

Pitfalls of Intraoperative Neuromonitoring for Predicting Postoperative Recurrent Laryngeal Nerve Function during Thyroidectomy

Introduction Intraoperative neuromonitoring has been widely adopted to facilitate the identification and preservation of recurrent laryngeal nerve (RLN) function during thyroid surgery. The present prospective study validated the ability of this technique to predict postoperative RLN outcomes in a single endocrine surgical unit. Methods Neuromonitoring was performed using Neurosign 100 with laryngeal surface electrodes in 171 patients with 271 nerves at risk during thyroidectomy. Vocal cord function was routinely documented perioperatively. Patients were also stratified to low risk (primary surgery for benign disease) and high risk (malignancy and recurrent disease) for subgroup analysis. Results Unilateral vocal cord palsy occurred in 15 patients (5.5%) postoperatively. The incidence of postoperative nerve palsy in the low risk and high risk groups was 4.4% and 7.8%, respectively. All but two patients had recovery of function within a median period of 4 months after the operation. The rates of transient and permanent RLN palsy based on nerves at risk were 4.8% (n = 13) and 0.7% (n = 2), respectively. There were 241 true-negative (positive signal and no cord palsy), 15 false-positive (negative signal but no cord palsy), 8 true-positive (negative signal and cord palsy), and 7 false-negative (positive signal but cord palsy) results, as correlated with the postoperative assessment. The sensitivity, specificity, and positive and negative predictive values were 53%, 94%, 35%, and 97%, respectively. For the high risk group, the sensitivity and positive predictive value increased to 86% and 60%, respectively. Conclusions There are pitfalls associated with the use of intraoperative neuromonitoring during thyroid surgery. Routine application is not recommended except for selected high risk patients. This work was presented as a free paper during International Surgical Week 2005, Durban, South Africa, August, 2005.