Marco Raffaelli

Minimally invasive video-assisted thyroidectomy

The first endoscopic procedures proposed to reduce the invasiveness of surgery in the neck were the endoscopic and video-assisted parathyroidectomies because it was quite evident that parathyroid adenomas were ideal candidates for a minimal access surgery, being these tumors mostly benign and characterized by their limited size. Later on, the same accesses proved to be suitable also for removing small thyroid nodules, and new approaches were soon proposed, in some cases, also modifying the old ones. At present, some controversies still exist about what should be considered a real minimally invasive operation for thyroid. Although the concern raised by some about the possible adverse effect of CO2 insufflation in the neck was probably over evaluated, the procedure we set up in 1998, minimally invasive video-assisted thyroidectomy (MIVAT), was characterized by the use of an external retraction avoiding any gas inflation which is not necessary to create an adequate operative space in the neck. This approach to the thyroid has been used in our Department of Surgery for the last 8 years on more than 2,500 patients with results that can successfully rival those of standard open surgery also in terms of operative time. Of course, this is not an operation which might be proposed for any patient: its main limit is represented by the necessity of a severe selection of the patients undergoing surgery. Only 10–30% of the cases, according to different authors, fulfill the inclusion criteria for a MIVAT.

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.

Minimally invasive, totally gasless video-assisted thyroid lobectomy

BACKGROUND Neck surgery is one of the newest fields of application of video-assisted surgery. We developed a technique for minimally invasive, totally gasless video-assisted thyroid lobectomy. METHODS The procedure was accepted by a patient with a follicular nodule of the left lobe of the thyroid. We performed a left thyroid lobectomy through a single 20-mm horizontal skin incision, just above the sternal notch, after inserting a 5-mm 30 degrees laparoscope, by using both endoscopic and conventional instrumentation. RESULTS The recurrent laryngeal nerve and the parathyroid glands were easily identified and preserved. The operating time was 2.5 hours. No complication occurred. The postoperative stay was 2 days. The cosmetic result was excellent CONCLUSIONS We concluded that our technique is feasible and safe. This makes us optimistic about the future of minimally invasive, video-assisted thyroid surgery.

Total thyroidectomy for management of benign thyroid disease: review of 526 cases

Total thyroidectomy is not frequently performed in cases of benign disease because of the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve (RLN) damage. We chose a series of patients who had undergone total thyroidectomy (TT) for benign thyroid tumors to evaluate the safety of this approach and its role in the treatment of nonmalignant lesions of the thyroid. We considered only patients with a minimum follow-up of 24 months. Records of 526 patients who underwent TT were carefully reviewed, assessing for perioperative complications and late sequelae. The mean age was 44 ± 15.7 years; 109 patients (20.7%) were male and 417 (79.3%) were female. Altogether, 65 patients (12.3%) were operated on for toxic goiter, 429 (81.6%) for bilateral nodular goiter, and 32 (6.1%) for thyroiditis. Postoperative hemorrhage requiring reoperation occurred in 8 cases (1.5%). The incidences of permanent RLN palsy (considered as a percentage of the nerves at risk) and permanent hypocalcemia were 0.4% and 3.4%, respectively. A trend toward a decrease in the complication rate was observed during the last 5 years. There were no disease recurrences during a mean follow-up of 44 months. The results of our series show that TT can be performed safely in patients, with a low incidence of lifetime disabilities. TT has the advantage of reducing/avoiding the risk of disease recurrence and reoperation and should therefore be considered a valuable option for treating benign thyroid diseases.Résumé.La thyroïdectomie total mais n’est pas réalisée fréquemment en cas de maladie bénigne en raison du risque d’hypoparathyroïde postopératoire et de lésions du nerf récurrent. Nous avons sélectionné une série de thyroïdeectomies totales (TT) pour maladie bénigne afin d’évaluer la sécurité de cette approche et son rôle dans le traitement des lésions non malignes de la thyroïde. Nous avons pris en compte seulement les patients ayant un suivi minimum de 24 mois. Les dossiers de 526 patients ayant eu une TT ont été revus pour évaluers les complications péri-opératoires et les séquelles tardives. L’âge moyen était de 44 ± 15.7 ans. Cent neuf patients (20.7%) étaient des hommes et 417 (79.3%) des femmes. Soixante=cinq patients (12.3%) ont été opérés pour goitre toxique, 429 (81.6%) pour goitre nodulaire bilatéral et 32 (6.1%) pour thyroïdite. Une hémorragie postopératoire a nécessité une ré-intervention dans 8 cas (1.5%). L’incidence de paralysie permanente du nerf récurrent (pourcentage de nerfs récurrents à risque) et d’hypocalcémie permenente ont été, respectivement, de 0.4% et de 3.4%. On a observé une tendance vers une diminution du taux de complications pendant les cinq dernières années. Aucune récidive n’a été observée avec un suivi moyen de 44 mois. Les résultats de notre série indiquent que la TT peut être réalisée avec sécurité dans cette population avec une incidence d’incapacité permenent réduite. La TT a l’avantage de réduire/éviter le risque de récidive de la maladie et de réopération et devrait être une option valable pour le traitement de maladies bénignes de la thyroïde.ResumenLa tiroidectomia total no es un procedimiento de realización frecuente en la enfermedad benigna por razón del riesgo de hipoparatiroidismo postoperatorio y de lesión del nervio laríngeo recurrente. Tomamos una serie de tiroidectomías totales (TT) practicadas por tumores benignos con el objeto de evaluar la seguridad de esta conducta y su papel en el tratamiento de lea lesiones no malignas de la tiroides. En el presente estudio sólo fueron considerados pacientes con un seguimiento mínomo de 24 meses. Se revisaron las historias de 526 pacientes que habían sido sometidos a TT para determinar las complicaciones postoperatorias y las secuelas tardías. La edad promedio fue 44 ± 15.7 años; 109 (20.7%) eran hombres y 417 (79.3%) mujeres; 65 (12.3%) fueron operados por bocio tóxico, 429 (81.6%) por bocio nodular bilateral y 32 (6.1%) por tiroiditis. Se presentó hemorragia postoperatoria que requirió reoperación en 8 casis 91.5%). La incidencia de parálisis permamente del nervio laríngeo recurrente consierada como porcentaje de los nervios en riesgo y de hipocalcemia fue 0.4% y 3.4% respectivamente. Se observó tendencia hacia la disminución de las complicaciones en el curso de los últimos 5 años. No se registró recurrencia de la enfermedad en el seguimiento de 44 meses. Los resultados del análisis de nuestra serie indican que la TT puede ser practicada con seguridad en pacientes con enfermedad benigna de la tiroides, con una baja tasa de complicaciones permenentes. La TT tiene la ventaja de reducir o abolir tanto el riesgo de recurrencia de la enfermedad como el de una reoperación, y en consecuencia, debe ser considerada Bellantone et al.: Benign Thyroid Disease and Total Thyroidectomy como una opción valiosa en el tratamiento de la enfermedad tiroidea benigna.

Complications of Laparoscopic Adrenalectomy: Results of 169 Consecutive Procedures

Laparoscopic adrenalectomy (LA) has become the gold standard for adrenalectomy. Review of the literature indicates that the rate of intra- and postoperative complications is not negligible. The aim of this study was to evaluate the complications observed in a series of 169 consecutive LAs performed at a same center for a variety of endocrine disorders. Between June 1994 and December 1998 a series of 169 LAs were performed in 159 patients: 149 unilateral LAs and 10 bilateral LAs. There were 98 women and 61 men with a mean age of 49.7 years (range 22–76 years). There were patients with 61 Conn syndrome, 41 with Cushing syndrome, 1 androgen-producing tumor, 29 pheochromocytomas, and 37 nonfunctioning tumors. Mean tumor size was 32 mm (range 7–110 mm). LA was performed by a transperitoneal flank approach in the lateral decubitus position. Mean operating time was 129 minutes (range 48–300 minutes) for unilateral LA and 228 minutes (range 175–275 minutes) for bilateral LA. There was no mortality. Twelve patients had a significant complication (7.5%): three peritoneal hematomas requiring (in two cases) laparotomy and (in one case) transfusion; one parietal hematoma; three intraoperative bleeding episodes without need for transfusion; one partial infarction of the spleen; one pneumothorax; one capsular effraction of the tumor; and two deep venous thromboses. Eight tumors were malignant at final histology (4.7%), of which four were completely removed laparoscopically. Conversion to open surgery was required in eight cases (5%): for malignancy in four cases, difficulty of dissection in three cases, and pneumothorax in one case. With a mean follow-up of 26.58 months (range 6–60 months) all patients are disease-free. We conclude that LA is a safe procedure. With increasing experience the morbidity becomes minor. To avoid complications LA should be converted to open surgery if local invasion is suspected or if there is difficulty with the dissection.

Immunocytochemical evaluation of thyroid neoplasms on thin-layer smears from fine-needle aspiration biopsies.

Fine‐needle aspiration biopsy (FNAB) is the most reliable diagnostic tool for thyroid nodules. A difficult cytologic diagnosis may be supported by an immunocytochemical study. The efficacy of a panel made up of RET, HBME‐1, and Galectin‐3 antibodies was evaluated in smears processed by thin‐layer cytology (TLC).

Minimally invasive video-assisted parathyroidectomy: lesson learned from 137 cases

BACKGROUND Since February 1997, a technique of minimally invasive video-assisted parathyroidectomy (MIVAP) was developed at our institution for the treatment of sporadic primary hyperparathyroidism (sPHPT). In this study we analyzed the entire series of patients who underwent MIVAP during the last 3 years. STUDY DESIGN One hundred thirty-seven patients with sPHPT were selected for MIVAP. Selection criteria were: diagnosis of single adenoma based on preoperative localization studies (ultrasonography, sestamibi scintigraphy, or both), and no previous neck surgery or concomitant large multinodular goiter. The procedure, already described, is performed by a gasless video-assisted technique through a single 1.5-cm central skin incision above the sternal notch. Quick, intraoperative parathyroid hormone assay was used in 134 cases (97.8%) to confirm the complete removal of all hyperfunctioning parathyroid tissue. RESULTS Mean operative time was 54.3 +/- 22.6 minutes. The conversion rate was 8.8%. One laryngeal nerve palsy was registered (0.7%), as was one case of persistent hyperparathyroidism. In six patients (4.4%) a transient symptomatic postoperative hypocalcemia was observed. Two thyroid lobectomies were associated using the same minimally invasive access. At a mean followup of 15.4 +/- 10.6 months, all but two patients were normocalcemic. The cosmetic result was considered excellent by most of the patients (92.8%). CONCLUSIONS Although not all patients with sPHPT are eligible for MIVAP, this approach can now be proposed in a bigger proportion (67% of patients). As already demonstrated in a previous study, also in a large series of patients, after greater experience has been achieved, the results and the operative time are the same as in traditional surgery, with better cosmetic result and a less painful course.

Safety of video‐assisted thyroidectomy versus conventional surgery

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.

Follicular thyroid neoplasms can be classified as low- and high-risk according to HBME-1 and Galectin-3 expression on liquid-based fine-needle cytology

DESIGN Fine-needle aspiration biopsy (FNAB) is the most reliable diagnostic tool in the diagnosis of thyroid nodules. A cytologic diagnosis of follicular neoplasm with atypical cells of undetermined significance (FN/AUS) implies that the selection of patients between surgery and follow-up is difficult. In this setting immunocytochemical stainings might be helpful. The efficacy of a panel made up of HBME-1 and Galectin-3 antibodies is evaluated in cases processed by liquid-based cytology (LBC). METHODS Out of 7091 thyroid FNAB processed by LBC method, 120 cases undergoing surgery successively were selected. These cases were classified as benign lesion (BL, eight cases), FN, including the ACUS category of the Bethesda classification (FN/AUS, 50 cases), suspicious for malignancy (SM, 59 cases), and malignant neoplasm (MN, three cases). Immunostains for HBME-1 and Galectin-3 were carried out on the LBC slides. RESULTS All MN and BL were histologically confirmed. FN/AUS and SM showed a malignancy risk of 24 and 72.9% respectively. The complete immunocytochemical panel was positive in 83.3% of the cases resulting in malignancy and negative in 87.5% of cases resulting in benign histology. Among the FN/AUS, the complete positive immunocytochemical panel was detected in 76.9% of cases resulting as malignant and the complete negative immunocytochemical panel was observed in 96.8% of cases resulting as benign at histology. CONCLUSIONS The expression of HBME-1 and Galectin-3 in cases classified as FN/AUS on LBC-processed FNABs can effectively distinguish lesions, which need immediate surgery (high risk or FNH or Thy 3h) from those which can be followed-up (low risk or FNL or Thy 3l).

Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms.

BACKGROUND Voice and swallowing symptoms are frequently reported early after thyroidectomy even in the absence of laryngeal nerves injury. We evaluated the short-term and long-term outcomes of these functional alterations. METHODS Consenting patients undergoing total thyroidectomy (TT) were enrolled. Videolaryngostroboscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) were performed pre-operatively, 3 months postoperatively, and >1 year postoperatively. Subjective evaluation of voice (Voice Impairment Score=VIS) and swallowing (Swallowing Impairment Score=SIS) were obtained pre-operatively, as well as 1 week, 1 month, 3 months, and >1 year postoperatively. RESULTS The long-term evaluation was completed in 110 patients. The percentage of patients with symptoms 1 week after operation was significantly higher than preoperatively, whereas it was significantly lower at long-term evaluation. VIS was significantly worse than pre-operatively, 1 week, 1 month, and 3 months after surgery, but it was similar to pre-operative >1 year after TT. SIS was significantly worse 1 week after thyroidectomy but not 1 month and 3 months after thyroidectomy, and it was significantly lower than the pre-operative >1 year after TT. CONCLUSION Vocal and swallowing symptoms are frequent after TT. In the absence of laryngeal nerve injury, after an initial impairment, late after operation, patients experienced subjective amelioration of their voice and swallowing performances, which may be related to the resolution of compressive symptoms.