Benefits and limits of minimally invasive techniques in thyroid surgery

The present study was designed to investigate the potential benefits and limits of two minimally invasive thyroidectomy procedures, namely minimally invasive video-assisted thyroidectomy (MIVAT) and open minimal-incision thyroidectomy (MIT). From May 2000 to June 2006, a prospective, non-randomised study was performed on 957 consecutive patients undergoing thyroid surgery. Fifty-six (5.8%) underwent MIVAT, 214 (22.4%) MIT and 687 (71.8%) conventional thyroidectomy (CT). Patients were selected for MIVAT when total thyroid volume was < or = 30 mL and for MIT when total thyroid volume was > 30 but < or = 80 mL, as determined by ultrasonography. The length of the central neck skin incision was 1.5-2 cm for MIVAT, 2.5-3.5 cm for MIT and 6-10 cm for CT. The incidence of definitive hypoparathyroidism or recurrent laryngeal palsy after MIVAT or MIT was comparable to that occurring after CT. Patients undergoing MIVAT or MIT experienced significantly less postoperative pain than those undergoing CT. Less pain was also registered in the MIVAT patient cohort as compared to the MIT group. Patients undergoing MIVAT or MIT were more satisfied with the cosmetic result as compared to those undergoing CT, whereas no significant differences were found between the MIVAT and MIT groups. As compared to CT, MIVAT and MIT provided a significant improvement in terms of cosmetic results and postoperative pain. Nevertheless, the main limiting factor for minimally invasive thyroid surgery still remains the size of the thyroid.     

Minimally invasive nonendoscopic thyroidectomy.

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

Video-assisted thyroidectomy: report of a 7-year experience in Rome

Background and aims We report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-year period.Materials and methods VAT is a gasless procedure performed under endoscopic vision through a single 1×5×2.0-cm skin incision. The eligibility criteria are thyroid nodules ≤35 mm, thyroid volume <30 ml, and no previous conventional neck surgery. Small, low-risk papillary thyroid carcinomas (PTC) were considered eligible.Results There were 521 VATs attempted. Conversion was necessary six times (difficult dissection in one case, large nodule size in three, and gross lymph node metastases in two). Thyroid lobectomy was successfully accomplished in 113 cases, total thyroidectomy in 398, and completion thyroidectomy in 14. In 66 patients, the central neck nodes were removed through the same access. Pathology showed benign diseases in 313 cases, PTC in 187, and medullary microcarcinoma in 1. Postoperative complications included 9 transient recurrent nerve palsies, 73 transient hypocalcemias, 3 definitive hypoparathyroidisms, 1 postoperative haematoma, and 2 wound infections. The cosmetic result was excellent. In patients with PTC, no evidence of recurrent disease was shown.Conclusions The indications for VAT are still limited. Nonetheless, in selected patients, it seems a valid option for thyroidectomy and even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result.Presented at the International Symposium “Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany     

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.     

颈前小切口鼻内镜辅助下甲状腺良性肿瘤切除术的临床体会

【摘要】 目的 采用内镜辅助下颈前小切口甲状腺良性肿瘤切除的手术经验并与传统手术比较处理经验。 方法〓回顾性分析62例肿瘤最大直径<4.0 cm的甲状腺良性肿瘤切除术,按手术方式分为内镜组(鼻内镜辅助下甲状腺切除术,n=33)和传统组(传统开放甲状腺切除术,n=29)比较两组的临床治疗效果。 结果〓2组62例患者的肿块均完整切除,切口均I期愈合。术后均无声音嘶哑、呛咳、继发血肿等并发症,无手术死亡病例。鼻内镜辅助下颈前小切口组的手术时间较传统组长,术中出血量较传统组少,且患者术后疼痛程度也较低。 结论〓与传统开放手术相比,鼻内镜辅助下颈前小切口甲状腺手术具有美容、出血少、术后疼痛小等优点,是治疗甲状腺良性肿瘤一种很好的手术选择。     

Minimally invasive open thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize tissue trauma by obviating unnecessary neck exploration. This report describes our technique of performing minimally invasive open thyroidectomy and compares the results with those of conventional thyroidectomy. Minimally invasive open thyroidectomy was performed by making a small skin incision, 3.0–4.5 cm long, and approaching the thyroid directly via a transverse divi-sion of the strap muscles without raising skin flaps. The outcomes of 466 patients who underwent a minimally invasive open thyroidectomy were retrospectively compared with those of 437 patients who underwent conventional thyroidectomy for various types of thyroid nodules. There was no significant difference in the extent of surgery between the group of patients who underwent minimally invasive thyroidectomy and the group of patients who underwent conventional thyroidectomy. However, the length of the skin incision, at 3.7 ± 0.7 vs 9.6 ± 3.3 cm, respectively, operative time, at 57.6 ± 11.7 vs 85.2 ± 32.3 min, respectively, blood loss, at 18.4 ± 15.3 vs 43.1 ± 21.8 ml, respectively, and hospital stay, at 1.6 ± 0.5 vs 4.3 ± 1.6 days, respectively, were significantly reduced in the minimally invasive open thyroidectomy group (P < 0.05). Moreover, the number of patients who required postoperative analgesia was significantly less in the minimally invasive open thyroidectomy group. These results show that minimally invasive open thyroidectomy provides surgeons with a clear operative field, and that it has proven to be simple, safe, and practical for selected patients. Received: September 11, 2000 / Accepted: March 6, 2001     

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.     

Minimally invasive video-assisted thyroidectomy compared with conventional thyroidectomy in a general surgery department

Background

We retrospectively evaluated a series of patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) to define its advantages or disadvantages.

Methods

Between May 2005 and March 2008, 68 patients underwent MIVAT. Sixty-nine patients who underwent conventional thyroidectomy (CT) during the period before the introduction of the MIVAT technique in our department—chosen with the same inclusion criteria used for MIVAT—served as matched controls. The eligibility criteria for both groups was thyroid nodules ≤35 mm, thyroid volume <25 ml, no thyroiditis, and no previous surgery.

Results

Forty-five MIVAT and 43 CT patients underwent hemithyroidectomy. Twenty-three MIVAT and 26 CT patients underwent total thyroidectomy. No differences were found in terms of complications, operative time, and radicality of the procedure. Patients who underwent MIVAT experienced significantly less pain, better cosmetic results, and shorter hospital stay than patients who underwent conventional surgery

Conclusion

The MIVAT technique, in selected patients, seems to be a valid option for thyroidectomy and even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic results, postoperative pain, and postoperative recovery.     

Modified version of minimally invasive open thyroidectomy using an unilateral incision

Background/objectiveOpen thyroidectomy has been the standard approach for patients undergoing thyroidectomy. However, this approach leads to prominent scars, hypesthesia, paresthesia, and uncomfortable sensations. We aimed to describe our modified technique of minimally invasive open thyroidectomy (MIT) and to compare the results with those of conventional thyroidectomy.MethodsThis study included 880 patients who underwent surgery between January 2016 and December 2016. Modified MIT was performed in 249 patients (28.3%), and conventional thyroidectomy was performed in the remaining 631 patients.ResultsLobectomy was performed in the majority of cases (MIT 204 [81.9%] vs. conventional 429 [67.9%]). There were no significant differences in complications between the two approaches (6 [2.4%] vs. 8 [1.3%]). Patients who underwent surgery using the minimally invasive approach had a shorter operative time (77.99 ± 34.5 vs. 91.23 ± 36.58 min) and were discharged earlier (2.4 ± 0.8 vs. 3.2 ± 0.8) than those who underwent conventional thyroidectomy.ConclusionModified MIT is a safe alternative to standard open thyroidectomy and allows the performance of bilateral total thyroidectomy with proper central compartment neck dissection.Level of evidence2b.     

Video-assisted thyroidectomy under local anesthesia

One theoretical limit of video-assisted thyroidectomy (VAT) was the supposed necessity of general anesthesia. Herein we describe a technique for VAT performed under locoregional anesthesia. Eligibility criteria were small thyroid nodules (<2 cm) in small or normal thyroid glands (thyroid volume < or =20 mL), no previous neck surgery or irradiation, and patient motivation for local anesthesia. VAT using locoregional anesthesia was performed under a superficial cervical block. During the procedure, the patients were completely awake and able to speak with members of the surgical team. Intraoperative and postoperative pain, as evaluated by a visual analogue scale, was usually negligible. No complications occurred. Mean postoperative stay was 26 hours. All of the patients were completely satisfied with the cosmetic result, the procedure, and the surgical outcome. VAT is also feasible and safe under local anesthesia. We are optimistic about the future of this approach, which opens a new frontier for minimally invasive procedures in thyroid surgery.     

Video-Assisted Thyroidectomy Significantly Reduces the Risk of Early Postthyroidectomy Voice and Swallowing Symptoms

Background Voice and swallowing symptoms are frequently reported after thyroidectomy even in absence of objective voice alterations. We evaluated the influence of the video-assisted approach on voice and swallowing outcome of thyroidectomy. Methods Sixty-five patients undergoing total thyroidectomy (TT) were recruited. Eligibility criteria were: nodule size ≤30 mm, thyroid volume ≤30 ml, no previous neck surgery. Exclusion criteria were: younger than aged 18 years and older than aged 75 years, vocal fold paralysis, history of voice, laryngeal or pulmonary diseases, malignancy other than papillary thyroid carcinoma. Patients were randomized for video-assisted (VAT) or conventional (CT) thyroidectomy. Videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) evaluation were performed preoperatively and 3 months after TT. Subjective evaluation of voice (voice impairment score = VIS) and swallowing (swallowing impairment score = SIS) were obtained preoperatively, 1 week, 1 month, and 3 months after TT. Results Fifty-three patients completed the postoperative evaluation: 29 in the VAT group, and 24 in the CT group. No laryngeal nerves injury was shown at postoperative VSL. Mean postoperative MPT, F ₀, F _low, F _high, and the number of semitones were significantly reduced in the CT group but not in the VAT group. Mean VIS 3 months after surgery was significantly higher than preoperatively in CT group but not in the VAT group. Mean SIS was significantly decreased 1 and 3 months after VAT but not after CT. Conclusions The incidence and the severity of early voice and swallowing postthyroidectomy symptoms are significantly reduced in patients who undergo VAT compared with conventional surgery. Presented at the ISW2007—IAES free paper session, Montreal, Canada, August 26–30, 2007.     

The minimally invasive open video-assisted approach in surgical thyroid diseases

Background  

The targets of minimally invasive surgery (MIVA) could be summarised by: achievement of the same results as those obtained with traditional surgery, less trauma, better post-operative course, early discharge from hospital and improved cosmetic results. The minimally invasive techniques in thyroid surgery can be described as either endoscopic "pure" approach (completely closed approach with or without CO₂ insufflation), or "open approach" with central neck mini-incision or "open video-assisted approach". Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. The minimally invasive approach wound is much shorter (1.5 cm for small nodules, up to 2–3 cm for the largest ones, in respect of the exclusion criteria) upon the suprasternal notch.     

Safety of video-assisted thyroidectomy versus conventional surgery

BACKGROUND: Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video-assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT. METHODS: Twenty consenting patients were randomly assigned to undergo VAT or conventional thyroidectomy. Serum thyroglobulin levels were monitored as indicators of thyroid manipulation, and C-reactive protein and white blood cell count were monitored to assess surgical stress response. Thyroid capsule integrity and the presence of spilled cells in the thyroid bed were verified. RESULTS: No significant differences were found in the indicators of thyroid gland manipulation and surgical stress response between groups. No thyroid capsules ruptured, and no spilled thyroid cells were found. Patients who had VAT experienced less pain, required fewer analgesics, and were more satisfied with the cosmetic result and the surgical outcome. CONCLUSIONS: VAT is as safe as conventional thyroidectomy and is characterized by a less painful postoperative course and by better cosmetic results and postoperative outcome.     

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.     

Pain after minimally invasive videoassisted and after minimally invasive open thyroidectomy—results of a prospective outcome study

Background Substantial modifications in surgical treatment of thyroid disease have changed the postoperative management of thyroidectomized patients. The reduction of postoperative pain permit a short-stay surgery. Materials and methods We have analyzed the patients treated in our Unit from July 2006 to December 2006, with minimally invasive cervicotomy and mini-invasive video-assisted thyroidectomy. We have registered the postoperative pain applying an evaluation protocol numeric scale. The results were analyzed by t test. Results One hundred thirteen patients were divided in two groups: group A, minimally invasive cervicotomy (15 male and 46 female patients); group B, mini-invasive video-assisted thyroidectomy (9 male and 43 female patients). Upon returning to the ward, the pain scale group A vs B was 2.77 ± 1.16 vs 2.5 ± 0.762 (p = 0.22) .At 24 h after surgery, the pain scale in group A was 1.82 ± 1.258 vs 1.031 ± 0.8608 (p < 0.005). Conclusions Both methods are safe, but mini-invasive video-assisted thyroidectomy gives not only a better cosmetic result but a reduction of postoperative pain especially at 24 h.     

Video-assisted thyroidectomy

OBJECTIVE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained. METHODS: Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules 相似文献   

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 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.     

Comparison of video-assisted thyroidectomy and traditional thyroidectomy for the treatment of papillary thyroid carcinoma

Background  

There is concern regarding the oncological effectiveness of minimally invasive video-assisted thyroidectomy (VAT) for thyroid carcinoma. This study compared the surgical results of VAT and traditional thyroidectomy in patients with small papillary thyroid carcinomas (PTC).     

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.