Jonathon O. Russell

Transoral thyroidectomy and parathyroidectomy – A North American series of robotic and endoscopic transoral approaches to the central neck

OBJECTIVE Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma. MATERIALS AND METHODS Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017. RESULTS Fifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life. CONCLUSION The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Central neck dissection via the transoral approach

There has been a strong impetus for the development of remote access approaches to the central neck. The primary motivation for this has been to alleviate the negative impact that some patients may perceive from a central neck scar. Numerous approaches have been described; however the only approach that provides midline access and equivalent visualization of the bilateral thyroid lobes and paratracheal basins is transoral neck surgery (TONS). TONS has been shown to be safe and effective in performing thyroidectomy, parathyroidectomy, and central neck dissection (CND) via both the endoscopic and robotic techniques. In contrast with other remote access techniques, it provides the surgeon with familiar views of the bilateral recurrent laryngeal nerves (RLN) at their insertion site in concert with equivalent access to both paratracheal basins, thus uniquely facilitating safe and comprehensive CND. Though feasible and safe, CND via TONS is not appropriate in all cases. CND via TONS should only be performed with concomitant transoral total thyroidectomy, either prophylactically if the surgeon routinely performs prophylactic CND, or therapeutically if there is newly found evidence of nodal metastasis in the central compartment at the time of surgery. We base these recommendations on both the recent American Head and Neck Society (AHNS) consensus statement for indications for transcervical CND and the baseline indications for TONS.

Minimally invasive and remote-access thyroid surgery in the era of the 2015 American Thyroid Association guidelines

Thyroid surgery has evolved throughout the years from being one of the most dangerous surgeries to becoming one of the safest surgical procedures performed today. Recent technologic innovations have allowed surgeons to remove the thyroid gland from a remote site while avoiding visible neck scars. There are many endoscopic approaches for thyroidectomy. The most common cervical approach is the minimally invasive video‐assisted technique developed by Miccoli et al. The robotic transaxillary and axillary breast approaches avoid a neck scar and have been demonstrated to be safe and effective in international populations. Novel approaches under investigation include face‐lift robotic thyroidectomy and the transoral approach. This article aims to provide the reader with an overview of the current minimally invasive and alternate‐site approaches used and their capability to assist the surgeons in accomplishing remote‐access thyroid surgery under the scope of the 2015 American Thyroid Association Guidelines.

Transoral Thyroid and Parathyroid Surgery Vestibular Approach: A Framework for Assessment and Safe Exploration

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new approach to the central neck that avoids an anterior cervical incision. This approach can be performed with endoscopic or robotic assistance and offers access to the bilateral central neck. It has been completed safely in both North American and, even more extensively, international populations. With any new technology or approach, complications during the learning curve, expense, instrument limitations, and overall safety may affect its ultimate adoption and utility. To ensure patient safety, it is imperative to define steps that should be considered by any surgeon or group before adoption of this new approach.

Characterizing the operative findings and utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with normal baseline IOPTH and normohormonal primary hyperparathyroidism

Background. During parathyroidectomy with intraoperative parathyroid hormone monitoring, the successful removal of a hypersecreting gland(s) resulting in normocalcemia is indicated by a >50% decrease in intraoperative parathyroid hormone level, typically into the normal range. Some patients, however, will have baseline parathyroid hormone levels within the normal range. We sought to determine the utility of intraoperative parathyroid hormone testing in these patients. Methods. We retrospectively studied all patients who underwent parathyroidectomy for primary hyperparathyroidism at our institution over a 10‐year period. Results. Overall, 317 (17%) patients had parathyroid hormone within the normal range at the onset of operation (baseline intraoperative parathyroid hormone), and 1,544 (83%) had classic primary hyperparathyroidism. The intraoperative parathyroid hormone degradation was slower in normal baseline intraoperative parathyroid hormone patients than classic primary hyperparathyroidism patients, though this did not reach statistical significance (P < .254). A >50% intraoperative parathyroid hormone decrease predicted cure in 98.7% of normal baseline patients and 98.8% of classic primary hyperparathyroidism patients (P = .810). Normal baseline patients had a lesser cure rate the longer it took to achieve a 50% decrease intraoperatively; however, the cure rate was constant at any time point the 50% decrease occurred in patients with classic primary hyperparathyroidism (P < .05). Conclusion. The 50% rule delineating operative cure can be applied with equal confidence to patients with normal range, baseline intraoperative parathyroid hormone. Moreover, the time at which the 50% drop is achieved impacts operative success rates in these patients.

Transoral robotic thyroidectomy: a preclinical feasibility study using the da Vinci Xi platform

Transoral thyroid surgery allows the surgeon to conceal incisions within the oral cavity without significantly increasing the amount of required dissection. TORT provides an ideal scarless, midline access to the thyroid gland and bilateral central neck compartments. This approach, however, presents multiple technical challenges. Herein, we present our experience using the latest generation robotic surgical system to accomplish transoral robotic thyroidectomy (TORT). In two human cadavers, the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to complete TORT. Total thyroidectomy and bilateral central neck dissection was successfully completed in both cadavers. The da Vinci Xi platform offered several technologic advantages over previous robotic generations including overhead docking, narrower arms, and improved range of motion allowing for improved execution of previously described TORT techniques.

Indications and contraindications to transoral thyroidectomy

Patient motivation to avoid neck scarring has been a strong impetus in the development of remote access approaches to the thyroid, including transoral robotic or endoscopic thyroidectomy vestibular approach (TOR/ETVA). TOR/ETVA continues to become more prevalent given its early success in North America and the demonstration of its safety and efficacy in Asia. As more surgeons perform this procedure, it is important that specific and uniform indications and contraindications exist to prevent surgical complications due to poor patient selection. In this article, we review the existing English literature regarding TOR/ETVA and compile the inclusion and exclusion criteria of individual authors for both robotic and endoscopic techniques to date. We then resolve differences in the existing literature to provide recommended indications and contraindications to TOR/ETVA based on both our review and our own experience with TOR/ETVA to date. The following are our resultant recommended indications for TOR/ETVA: patient history of hypertrophic scarring or motivation to avoid a cervical neck incision with a maximal thyroid diameter ≤ 10 cm and dominant nodule ≤6 cm, with one of the following pathologic criteria; benign lesion, multinodular goiter, indeterminate nodule, or suspicious lesions/well-differentiated thyroid carcinomas ≤ 2 cm. Recommended contraindications to TOR/ETVA are as follows: history of head & neck surgery, history of head, neck, or upper mediastinal irradiation, inability to tolerate general anesthesia, evidence of clinical hyperthyroidism, preoperative recurrent laryngeal nerve palsy, lymph node metastasis, extrathyroidal extension including tracheal or esophageal invasion, oral abscesses, substernal thyroidal extension, or failure to meet inclusion criteria as above. Relative contraindications include smoking and other oral pathology, and surgeons should be aware that morbid obesity may make it difficult to raise skin flaps.

Early outcomes in transoral vestibular thyroidectomy: Robotic versus endoscopic techniques

The transoral thyroidectomy vestibular approach has been utilized via both robotic (TORTVA) and endoscopic (TOETVA) techniques to perform thyroidectomy. However, there have been no studies evaluating outcomes between these approaches. Here we describe our outcomes for thyroid lobectomy with TORTVA and TOETVA.

Completion thyroidectomy via the transoral endoscopic vestibular approach

The safety and efficacy of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) continues to be verified with the growing literature in regards to the procedure. While early cases were thyroid lobectomies performed for benign disease, the indications for TOETVA have now expanded to include total thyroidectomy for select small well-differentiated thyroid cancers (DTCs). Oncologic efficacy of this procedure remains unproven at this time, as the procedure was described only recently. Furthermore, as many of the cases completed via TOETVA are often diagnostic lobectomies, the appropriate management for patients requiring or opting for further surgical intervention per American Thyroid Association (ATA) guidelines has not been established. Here we present a case of a diagnostic lobectomy via TOETVA followed by interval completion thyroidectomy via the same approach for minimally invasive Hurthle cell carcinoma. Postoperative ultrasound demonstrated no evidence of thyroid remnant and serum thyroglobulin without circulating anti-thyroid antibodies was 0.3 ng/mL (reference range, 1.5-38.5 ng/mL) following the patients completion thyroidectomy.

Surgical Management of Normocalcemic Primary Hyperparathyroidism and the Impact of Intraoperative Parathyroid Hormone Testing on Outcome

Objective To review our surgical experience and the impact of intraoperative parathyroid hormone (IOPTH) testing among patients with normocalcemic primary hyperparathyroidism. Study Design Case series with chart review. Setting Academic referral hospital. Subject and Methods Normocalcemic hyperparathyroidism (NCHPT) patients were identified with normal-range blood ionized calcium and serum elevated parathyroid hormone. Patient demographics, intraoperative findings, IOPTH dynamics, and biochemical outcomes were compared with those of classic primary hyperparathyroidism (PHPT) patients. Results Of the 2120 patients who underwent parathyroidectomy, 616 patients met the inclusion criteria: 119 (19.5%) patients had NCHPT, and 497 (80.5%) had classic PHPT. NCHPT patients had higher rates of multigland hyperplasia as compared with classic PHPT (12% vs 4%, P = .002) and smaller gland size (P < .001). Of 119 NCHPT patients, 114 (97%) achieved >50% drop in IOPTH intraoperatively, as opposed to 492 (99%) among 497 classic PHPT patients (P = .014). IOPTH drop >50% had an equivalent positive predictive value for long-term cure in both groups. Conclusions Surgeons treating NCHPT patients should suspect the presence of multigland disease and have a low threshold for converting to bilateral exploration depending on IOPTH decay dynamics.