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BackgroundTransoral thyroidectomy has superior cosmesis and better postoperative voice outcomes than conventional thyroidectomy. However, it usually requires a steep learning curve and longer operative time. The transoral robotic thyroidectomy (TORT) learning curve has not been well investigated. This study aimed to evaluate the TORT learning curve and factors affecting operative time.MethodsWe retrospectively studied 173 consecutive patients who underwent TORT with or without central neck dissection from July 2017 to August 2021. We assessed the TORT learning curve using operative time, complication rate, and surgical success (procedure conversion) rate. The operative time and surgical success rate learning curves were calculated using the cumulative summation (CUSUM) method. Additionally, we analyzed factors affecting operative time in TORT.ResultsTotal thyroidectomy operative time was significantly longer than those of lobectomy and isthmusectomy (p < 0.001). In correlation analysis, a significantly positive correlation was observed between body mass index (BMI) and operative time (R2 = 0.04, p = 0.025). The TORT learning curve was 52 cases in the CUSUM operative time analysis. In the CUSUM surgical success rate chart, the turning point was the 55th case. Complication and procedure conversion rates were significantly decreased after the learning curve.ConclusionsThe CUSUM learning curve of TORT was about 52–55 cases, and the operative time, total complication rate, and procedure conversion decreased significantly after the learning curve. The operative time was associated with the extent of thyroidectomy and BMI.

BackgroundThis study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce our novel two-step retraction method.MethodsSTART was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed.ResultsAmong the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13–58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m2 (range: 15.9–37.0 kg/m2). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method.ConclusionsSTART is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.

BackgroundThe extent of postoperative pain following transoral thyroidectomy is not well-understood and remains a subject of debate. This study aims to analyze and compare postoperative pain levels between patients undergoing transoral and conventional transcervical thyroidectomy.MethodsA prospective evaluation on postoperative pain was conducted in 310 patients undergoing conventional thyroidectomy and 194 undergoing transoral thyroidectomy. Pain levels were evaluated using the numerical rating scale (NRS, ranging from 0 to 10) through preoperative and postoperative questionnaires at specified time points: 1, 3, and 6 days, and 1 and 3 months following surgery. Propensity score-matched analysis was carried out based on six covariates: sex, age, body mass index, extent of thyroidectomy, tumor size, and central neck dissection.ResultsAfter propensity score matching based on the six covariates, 121 patient pairs were identified from each group. Within this matched cohort, postoperative pain scores significantly worsened 1 day after surgery but showed progressive recovery up to 3 months post-surgery in both groups. The transoral group exhibited higher postoperative pain scores than the conventional group from day 1 (4.43 ± 2.6 vs. 3.11 ± 2.5, p < 0.001) to day 6 (1.76 ± 1.9 vs. 1.13 ± 1.6, p = 0.016) post-surgery, with no significant difference noted at 1 month. Among transoral procedures, pain scores were significantly higher for the endoscopic approach compared to the robotic approach on days 1 (5.52 ± 2.3 vs. 4.29 ± 2.3, p = 0.028) and 3 (3.52 ± 2.5 vs. 2.64 ± 2.0, p = 0.047) post-surgery.ConclusionsPostoperative pain was significantly higher in transoral thyroidectomy compared to conventional thyroidectomy up to 6 days post-surgery. Within the transoral group, the robotic procedure resulted in lower pain levels than the endoscopic approach during the early postoperative period.Graphic abstract

BackgroundTraditional open thyroidectomy is the surgical standard for thyroid cancer; however, it inevitably leaves a visible scar on the neck and affects the patient’s quality of life. Therefore, to avoid making a neck incision, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) have been developed recently, and the surgical outcomes of these techniques are as favorable as open surgery for benign disease. Additionally, positive short-term surgical outcomes have also been achieved in a few patients with thyroid cancer. However, no data on the mid-to-long-term recurrence and survival rates of transoral thyroidectomy in thyroid cancer are available. Therefore, in this study, we analyzed the surgical outcomes and mid-term oncological results of the TOETVA and TORT in patients with thyroid cancer.MethodsWe reviewed patients who had received TOETVA or TORT between July 2017 and November 2021 and followed up on their oncological outcomes until December 2022. Perioperative surgical and mid-term oncological outcomes were analyzed.ResultsThe 115 patients underwent 122 operations (57 TOETVAs and 65 TORTs), including seven complete thyroidectomies for differentiated thyroid cancer (DTC), Stage I–II, including T1–T3, N0–N1a, and initial low- to high-risk groups. There was no conversion from transoral to open surgery. TORT required a longer operating time (median [interquartile range]) than TOETVA (lobectomy: 279 [250, 318] vs. 196 [173, 253] min, p < 0.001; bilateral total thyroidectomy: 375 [309, 433] vs. 279 [238, 312] min, p < 0.001); however, no difference was found between the two groups regarding perioperative complications. Complete thyroidectomy with a second transoral approach was safe. TOETVA and TORT achieved favorable oncological outcomes with 100% survival and 98.2% acceptable response (excellent and indeterminate response) during a mean 37.88 ± 12.42 months mid-term follow-up.ConclusionsTransoral endoscopic and robotic thyroidectomy was safe and achieved favorable mid-term oncological outcomes in a selected cohort of patients with early-stage DTC.

Background The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect. Methods This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English. Result Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group. Conclusion The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy.

Purpose Our study aimed to compare the effectiveness and complications of the transoral endoscopic thyroidectomy submental vestibular approach (TOETSMVA) versus the transoral endoscopic thyroidectomy vestibular approach (TOETVA) or conventional open thyroidectomy (COT) in patients with early-stage papillary thyroid carcinoma (PTC). Methods We searched online databases up to January 2024. The outcomes were analyzed using RevMan 5.4 and inverse variance. Results Seven studies (two RCTs and five retrospective cohort studies) were included. We established higher significance differences for TOETSMVA in comparison with TOETVA in terms of all primary outcomes; operation time, hospital stay, number of resected lymph nodes [MD -21.05, 95% CI= -30.98, -11.12; p  < 0.0001], [MD -1.76, 95% CI= -2.21, -1.32, p  < 0.00001], [MD -2.99, 95% CI= -19.75, 13.76, p  < 0.73], [MD -0.83, 95% CI = -1.19 to -0.47; p  < 0.00001], respectively, except the drainage volume, it showed no difference [MD -2.99, 95% CI= -19.75, 13.76, p  < 0.73]. In secondary outcomes, it was favored only in mandibular numbness and return to normal diet outcomes. Additionally, TOETSMVA compared with COT showed a significant difference in drainage volume, pain, cosmetic effect, and satisfaction score. Conclusions TOETSMVA showed a significant improvement compared to the TOETVA in operation time, hospital stay, number of resected lymph nodes, mandibular numbness, and return to normal diet but did not show a difference in drainage volume. However, TOETSMVA was better in cosmetic effect, drainage volume, satisfaction, and pain scores compared with COT. Further RCTs with larger sample size, multicentral, and longer follow-up are necessary to evaluate the limitations.

BackgroundThyroid surgery has undergone significant transformation with the introduction of minimally invasive techniques, particularly robotic and endoscopic thyroidectomy. These advancements offer improved precision and faster recovery but also present unique challenges. This study aims to compare the learning curves, operational efficiencies, and patient outcomes of robotic versus endoscopic thyroidectomy.MethodsA retrospective cohort study was conducted, analyzing 258 robotic (da Vinci) and 214 endoscopic thyroidectomy cases. Key metrics such as operation duration, drainage volume, lymph node dissection outcomes, and hypoparathyroidism incidence were assessed to understand surgical learning curves and efficiency.ResultsRobotic thyroidectomy showed a longer learning curve with initially longer operation times and higher drainage volumes but superior lymph node dissection outcomes. Both techniques were safe, with no permanent hypoparathyroidism or recurrent laryngeal nerve damage reported. The study delineated four distinct stages in the robotic and endoscopic surgery learning curve, each marked by specific improvements in proficiency. Endoscopic thyroidectomy displayed a shorter learning curve, leading to quicker operational efficiency gains.ConclusionRobotic and endoscopic thyroidectomies are viable minimally invasive approaches, each with its learning curves and efficiency metrics. Despite initial challenges and a longer learning period for robotic surgery, its benefits in complex dissections may justify specialized training. Structured training programs tailored to each technique are crucial for improving outcomes and efficiency. Future research should focus on optimizing training protocols and increasing accessibility to these technologies, enhancing patient care in thyroid surgery.

BackgroundTransoral endoscopic thyroidectomy vestibular approach (TOETVA) has been shown to be safe and has similar outcomes as open thyroidectomy for selected patients. It is not clear if transoral robotic thyroidectomy (TORT) may extend transoral endoscopic thyroidectomy to more complex thyroid operations. The study aimed to compare the safety and outcomes of TORT with those of TOETVA.MethodsWe retrospectively reviewed all patients who had TORT and TOETVA performed by a single surgeon from June 2017 to May 2019. Intrathoracic goiter and combined operations were excluded. Surgical outcomes were compared after propensity score matching. Learning curves, as measured by operating time, were evaluated.ResultsA total of 150 patients underwent 154 transoral (55 TORT and 99 TOETVA) thyroidectomy. Of the 154 operations, 28 (18.2%) were bilateral total thyroidectomy and 126 (81.8%) were unilateral thyroid lobectomy. After propensity score matching, we found a longer operative time (median [interquartile range]) for TORT (n = 53) than for the TOETVA (308 [284–388] vs 228 [201–267] min, P < 0.001). Blood loss and visual analog scale scores for pain were not significantly different between the two groups. Central neck lymph node dissection was performed more frequent in the TORT group (28 of 53 [52.8%] vs 10 of 53 [18.9%], P = 0.001), and when performed, the numbers of total and positive lymph nodes did not differ significantly between the two groups. The rates of hypoparathyroidism and recurrent laryngeal nerve injury did not differ significantly between the two groups. There was no conversion to open thyroidectomy, mental nerve injury, or surgical site infection. The learning curve for TORT was 25 cases, but no obvious learning curve was observed for TOETVA.ConclusionsTORT requires a longer operative time, but is as safe as TOETVA and may be useful for more complex thyroid operations.

IntroductionThe Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA).MethodsBetween February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves’ disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO2 insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices.ResultsTOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1–10 cm). Median operative time was 97 ± 40.5 min (45–300 min). Median blood loss was 30 ± 46.25 mL (6–300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2–7), 1.17 ± 1.4 (0–5), and 0.47 ± 0.83 (0–3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified.ConclusionTOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.

BackgroundThe transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been the subject of increasing interest from several institutions around the world over the last 2 years. Recently, we successfully performed TOETVA in live human patients without CO2 gas using our newly designed retractable blade.MethodsWe reviewed the medical records of 15 consecutive patients who underwent gasless TOETVA using a self-retaining retractor.ResultsWe successfully performed 13 thyroid lobectomies and 2 total thyroidectomies in 15 patients. No patient exhibited serious postoperative complications such as recurrent laryngeal nerve palsy and permanent hypocalcemia. One patient developed transient hypocalcemia but recovered within 2 months. No patient developed a wound infection; furthermore, no visible scar or dimpling was evident on the neck of any patient.ConclusionGasless TOETVA provides enough working space and good visibility to perform thyroid surgery without any risk of CO2 gas-related complications.