Minimally invasive thyroidectomy: A comprehensive appraisal of existing techniques

Clinical Review Minimally invasive thyroidectomy: A comprehensive appraisal of existing techniques Dimitrios Linos, MD, FACS, Athens, Greece

From the 1st Surgical Clinic, Diagnostic and Therapeutic Center of Athens ‘‘Hygeia,’’ Athens, Greece

MINIMALLY INVASIVE THYROIDECTOMY (MIT) is the result of the efforts of several surgeons to extrapolate the proven benefits of minimally invasive techniques in the abdomen, chest, blood vessels, and joints (less pain and morbidity, shorter hospitalization, and improved aesthetics) compared with the traditional technique of open thyroidectomy. In the last decade, there has been an explosion of papers describing different techniques of minimally invasive thyroidectomy. One common advantage of all these techniques is either a smaller scar in the neck or the complete absence of a scar in the neck, although other theoretic advantages have been reported. The goal of this review is to classify all existing MIT techniques and discuss the future of these approaches based on the current literature and personal experience. CLASSIFICATION OF MIT TECHNIQUES MIT is classified into 2 major categories based on whether a skin incision is made in the neck or away from the neck (Table). Incision in the neck. Complete endoscopic thyroidectomy with gas insufflation: The first complete endoscopic thyroidectomy was performed by Huscher et al1 in 1997. The insufflation of CO2 in the neck created several complications to the initial patients including massive subcutaneous emphysema from the eyelids to the scrotum.2

Accepted for publication February 17, 2011. Reprint requests: Dimitrios Linos, MD, FACS, 1st Surgical Clinic, Diagnostic and Therapeutic Center of Athens ‘‘Hygeia,’’ Fragoklisias 7, Marousi, 15125 Athens, Greece. E-mail: dlinos@ hms.harvard.edu. Surgery 2011;150:17-24. 0039-6060/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2011.02.018

The anterior approach in the neck: Gagner et al3 presented 18 patients with solitary nodules in whom endoscopic thyroidectomy was performed using the anterior cervical approach. The main incision was in the midline just above the sternal notch through which the 5-mm trocar for the endoscope is placed. Three additional trocars were used (two of 2 mm and one of 5 mm) at the superior medial border of the sternocleidomastoid muscle. Cougard et al4 applied a slightly different anterior cervical approach in 40 patients using a 15-mm midline incision above the suprasternal notch, 2 additional trocars on the side and opposite the lesion, and a veress needle in the upper midline. The ultrasonic shears were used with both of these techniques. The lateral approach in the neck: Henry5 developed the ‘‘back door’’ approach to the thyroid lobe using a 15-mm incision for the endoscope for retrieval of the specimen and two 3-mm trocars placed on the medial border of the sternocleidomastoid muscle. This approach is good for lobectomies only; should the frozen section reveal malignancy, the main incision is extended to a standard cervicotomy. A total of 112 cases of endoscopic lobectomies were reported with a mean operative time of 98 min.6 Inabnet et al7 applied a slightly different lateral endoscopic approach in 38 patients. After the initial 10–15-mm incision at the superior lateral area is made and the working space is created by CO2 insufflation, 3 additional trocars are inserted under direct vision. Video-assisted thyroidectomy without gas insufflation. Anterior (lower) approach: In 1999, Miccoli et al8 and Bellantone et al9 developed a technique that combines elements from the endoscopic thyroidectomy and the traditional open technique. The main idea of this minimally invasive videoassisted thyroidectomy (MIVAT) is based on a SURGERY 17

18 Linos

Table. Classification of the different minimally invasive thyroidectomy techniques A. INCISION IN THE NECK 1. Complete endoscopic thyroidectomy with gas insufflation a. Anterior approach b. Lateral approach 2. Video-assisted thyroidectomy without gas insufflation a. Anterior b. Lateral 3. Nonendoscopic minimally invasive thyroidectomy a. Anterior approach b. Lateral approach B. NO INCISION IN THE NECK 1. Complete endoscopic thyroidectomy with gas insufflation a. Axillary approach b. Anterior approach c. Breast approach d. Bilateral axillo breast approach e. Axillo-bilateral breast approach f. Bilateral transaxillary approach g. Robot-assisted bilateral axillary breast approach 2. Video-assisted thyroidectomy without gas insufflation a. Endoscopic axillary approach b. Robot-assisted axillary approach c. Robot-assisted bilateral transaxillary approach d. Anterior approach 3. Experimental approaches a. Transoral robotic-assisted approach b. Dorsal approach

small horizontal cervical incision approximately 1 finger breadth above the sternal notch. The length of this incision varies according from 1.5 to 3 cm.10-15 The working space is created by blunt dissection without gas insufflation. A 308, 5-mm diameter endoscope and external retraction allow visualization of the upper pole of the thyroid. The upper pole vessels are ligated using ultracision Harmonic Shears (Ethicon Endo-Surgery, Cincinnati, OH) or clips. The external branch of the superior laryngeal nerve, the superior parathyroid gland, and importantly, the recurrent laryngeal nerves are visualized. Once the superior pole is mobilized, it is retracted outside the incision and the thyroidectomy is performed without endoscopic assistance but under direct vision. This technique can be applied only when: (1) the thyroid nodule is less than 3.5 cm in maximum diameter; (2) there is absence of thyroiditis; (3) thyroid volume does not exceed 15 mL; (4) there is cytologic and clinical evidence of benign disease, follicular tumor, or low-risk papillary carcinoma; and (5) there is absence of echographically enlarged lymph nodes in the neck.12

Surgery July 2011

Multi-institutional experience of this technique has shown similar results with the standard open technique in terms of complications, but it requires the use of more equipment and several assistants; it takes a longer operative time and can be applied only to a small percentage of patients requiring thyroidectomy.12,16 A prospective study comparing the completeness of MIVAT to conventional thyroidectomy in patients with small papillary thyroid carcinomas showed similar outcomes.17 The ‘‘Sofferman technique’’ described by Terris et al18 is a combination of the transection of the strap muscles and video endoscopic assistance. The need for a 4–6-cm skin incision to complete the thyroidectomy, however, hardly places the technique in the minimally invasive spectrum.19 Lateral (high) approach: A similar, video-assisted approach has been described by Yamashita et al20 in Japan. A 2.5 to 3-cm transverse incision is made in the upper lateral neck along the existing skin wrinkles. The subplatysmal space is dissected bluntly. Resection occurs by direct open control of the vessels and structures of the upper pole of the thyroid and an endoscopically assisted dissection of the remaining thyroid lobe. Nonendoscopic minimal invasive thyroidectomy. Anterior approach: Several experienced thyroid surgeons responded to the patient’s demand for smaller neck incisions and better cosmesis by shortening the length of the traditional Kocher’s incision of 6 cm or longer, in the lower neck to an average of 4–6 cm.21,22 Few others tried successfully even shorter incisions in the range of 2.5–3 cm.23-25 The secret of a successful, minimally invasive, nonendoscopic thyroidectomy (MINET) is to place the initial incision very high in the neck for immediate and direct control of the sensitive structures around the superior pole of the thyroid (Fig). The 2.5-cm (1-in) incision is made above the isthmus in the closest available skin crease, usually slightly caudal to the cricoid cartilage. The superior subplatysmal flap extends just above the notch of the thyroid cartilage, whereas the inferior flap extends to the level of the sternal notch. With sharp dissection initially and blunt dissection thereafter, the strap muscles on each side are retracted. A Kocher clamp that pulls the upper pole inferiorly and laterally opens the space between the cricothyroid muscle and the thyroid, where special attention is paid to protect the external branch of the superior laryngeal nerve. The vessels of the upper pole are cut and ligated selectively using sutures and clips, or coagulated with cautery or other energy devices. At this point, the

Surgery Volume 150, Number 1

Fig. The position and length of the incision in minimally invasive, video-assisted and nonendoscopic thyroidectomy in comparison with the traditional Kocher incision. (Color version of figure is available online.)

superior parathyroid gland is observed easily, and the recurrent laryngeal nerve is indentified as it enters the larynx. The next step is the mobilization of the inferior pole. The inferior parathyroid gland is sought specifically and protected. The dissection is completed between the lower and the superior pole with direct vision of the recurrent laryngeal nerve. A neurostimulator device can be used if the surgeon deems its use to be necessary. Similar steps are followed for the opposite lobe; this dissection is much easier because half of the thyroid gland lies outside the small incision. This technique has no limitations because for larger goiters, the initial 2.5-cm incision can be extended accordingly. Lateral approach: Delbridge’s team from Australia has described a lateral approach for hemi thyroidectomy using a mini-incision up to 2.5 cm.26 This incision is placed laterally to the midline and over the palpable nodule. Limitations of this approach include bilateral thyroid pathology and nodules >3 cm in maximum diameter. MINIMALLY INVASIVE THYROIDECTOMY WITHOUT INCISION IN THE NECK Pure endoscopic techniques. Anterior approach: Ikeda and colleagues27-29 introduced this totally endoscopic approach with CO2 insufflation up to 4 mm Hg. A 3-cm skin incision is made 3 cm caudal

Linos 19

to the inferior border of the clavicle on the side of the lesion. A 12-cm trocar is inserted and a pursestring suture is placed to prevent gas leakage. A flexible laparoscope is inserted through this trocar. Two additional 5-mm trocars are then inserted under endoscopic guidance, 1 caudal to the sternal notch and the other caudal to the ipsilateral clavicle. Endoscopic scissors are used to enlarge the subplatysmal space. The sternothyroid muscle is also divided and the thyroid is exposed. Thyroidectomy starts from the upper pole, which is grasped and retracted toward the operator. After the superior thyroid artery is ligated and the superior pole is mobilized, attention is directed to the lower pole, which is retracted higher and freed from surrounding vessels and tissues. The lobe is then retracted medially and dissected from the surrounding tissues using endoscopic scissors. Finally, the lobe is transected from the trachea at the level of the isthmus and extracted through the 3-cm skin incision. Axillary approach: Ikeda et al27,28 were also the first to advocate this approach. The position of the patient now requires in addition to the neck being slightly extended the patient’s ipsilateral arm placed at 908 angle to the axis of the body exposing the operative axilla. A 3-cm skin incision is made in the axilla, and the lower layer of the platysma is exposed through the upper surface of the pectoralis major under direct vision. A 12- and 5-mm trocar are inserted through this incision and a purse-string suture is placed in order to prevent gas leakage. CO2 insufflation is kept up to 4 mm Hg. A flexible laparoscope is inserted through the 12-mm trocar, and space is created by blunt and sharp dissection to enlarge the subplatysmal space. A second 5-mm trocar is inserted near the 3-cm initial skin incision. As with the anterior approach, the aim is to open the space between the sternocleidomastoid and sternothyroid muscle to reach the thyroid lobe. Duncan et al30 have been using the same approach with minor modifications, such as the initial creation of three 5-mm incisions, greater pressures of CO2 insufflation, and the use of a 5-mm but 458 angled scope. This scope allows an easier identification of the structures (especially the recurrent laryngeal nerve) of the opposite lobe in the case of an attempted near total thyroidectomy. The advantage of the axillary approach is that all incisions and scars are not visible because they are hidden in the axilla when the arm is in the normal postural position. Breast approach: Ohgami et al31 first, as well as other teams subsequently,32,33 have reported on

20 Linos

the totally endoscopic thyroidectomy via a breast approach. Two incisions are made on both upper circumareolar areas. Through these openings, blunt dissections create a working space. One 15-mm trocar is inserted on the side of the thyroid lesion through which the flexible scope is inserted. Another 12-mm trocar is inserted from the opposite breast for the insertion of the working instruments. The CO2 insufflation pressure is kept at 6 mm Hg. After the dissection is completed under direct visualization from the endoscope, a third 5-mm trocar is inserted 3 cm caudal to the clavicle on the side of the thyroid lesion. The dissection of the thyroid starts from the lower lobe, proceeding to the posterior and lateral aspect of the lobe. The lobe is elevated and the upper pole vessels are ligated using ultrasonic devices. The last step is the division of the isthmus and the retrieval of the specimen with the aid of a plastic bag. Bilateral transaxillary approach: The bilateral transaxillary endoscopic approach (BAEA) aims at a safer total thyroidectomy. Two surgical teams start simultaneously, 1 from each axilla. The incisions for 2 trocars are made in each axilla, and with finger dissection, a subcutaneous plane is developed anterior to the pectoralis fascia. Two 10-(or 5-mm) and 5-mm trocars are used on each side and one 12-mm trocar for the camera. The CO2 insufflation pressure is kept at 10 mm Hg. This technique can be also performed using the da Vinci Robot.34 Axillo-bilateral breast approach: Shimazu et al35 modified the already reported breast endoscopic approach to an axillo-bilateral breast approach (ABBA) by the third trocar to the axilla. Good results applying the same technique have been reported by others.36 Bilateral axillo breast approach: A subsequent modification of the previous ABBA technique is the totally endoscopic bilateral axillo breast approach (BABA) with the addition of a controlateral axillary trocar.37 Two 12-mm trocars are inserted via each circumareolar incision and two 5-mm trocars via the bilateral axillary incisions. The working space is produced initially by blunt dissection with the use of a vascular tunnelor. This space is extended to the level of thyroid cartilage superiorly and to the medial border of each sternocleidomastoid muscle laterally. The CO2 insufflation is kept at 5–6 mm Hg. The operation starts with a midline incision and identification of the isthmus and trachea first and then continues with the thyroidectomy. The view with this approach resembles the traditional open thyroidectomy view. Recently, this BABA has been performed with the assistance

Surgery July 2011 of the da Vinci Surgical System38 (Intuitive Surgical, Inc., Sunnyvale, CA). Video-assisted thyroidectomy without gas insufflation. Endoscopic axillary approach: The group from the Yonsei University College of Medicine in Seoul South Korea has used this approach extensively with excellent results.39,40 In a recent paper describing the gasless endoscopic thyroidectomy via the transaxillary approach in 581 patients, the details of this technique and the expected outcome were presented.40 In summary, the technique includes the position of the patient with the neck slightly extended and the ipsilateral arm raised and fixed for the shortest distance from the axilla to the anterior neck. The first step is the creation of a tunnel from the axilla to the thyroid. A 4–6-cm skin incision is made in the axilla and with the help of the cautery, and a space is created anterior to the surface of the pectoralis major muscle until the anterior border of the sternocleidomastoid muscle (SCM) is exposed. The dissection continues through the space between the sternal and clavicular heads of the SCM and beneath the strap muscle until the controlateral lobe of the thyroid is exposed. An external retractor is inserted through the skin incision in the axilla and the flap is raised using a homemade device to keep open the working space. A second skin incision of 0.5 cm in length is recommended on the medial side of the anterior chest wall for the insertion of the endoscopic instruments. Under the endoscopic magnification of a 458 endoscope, the upper pole of the thyroid is retracted caudally and the superior thyroid vessels are divided using the Harmonic scalpel (Johnson-Johnson Medical, Cincinnati, OH). Then, the lower pole is dissected and the inferior thyroid vein is divided. Finally, the thyroid lobe is retracted medially, and the perithyroidal fascia is divided with attention to the detection of the inferior thyroid artery and visualization of the recurrent laryngeal nerve. The thyroid lobe is dissected from the trachea and the isthmus is removed. The contralateral lobe can be resected also using the same method but the operator does not have direct view of the recurrent laryngeal nerve at all times. A prophylactic ipsilateral central compartment node dissection can be undertaken safely and effectively as well as an ipsilateral modified radical dissection. Hemostatic agents and the placement of a drain for a couple of days complete this operation. Robot-assisted axillary approach: The same group from Yonsei University and Professor Chung in particular applied the previously described

Surgery Volume 150, Number 1

technique to a robot-assisted endoscopic thyroidectomy using a gasless transaxillary approach.41 The details of this technique using the da Vinci S newest robot is described in a recent paper based on 200 consecutive patients with a preoperative diagnosis of papillary thyroid carcinoma. Four robotic arms are used, 3 through the axillary opening and 1 through an 8-mm anterior chest incision. Contraindications for this approach are as follows: (1) extrathyroidal tumor invasion; (2) multiple lateral neck node metastases; (3) lesion located in the thyroid dorsal area; (4) obese patients (body mass index > 30); and (5) biochemical and ultrasonographic evidence of thyroiditis. As in the endoscopic transaxillary approach, the exposure of the opposite lobe is limited, although the results of completeness of thyroidectomy presented by Professor Chung’s group are impressive. Of 45 patients who underwent bilateral total thyroidectomy for papillary thyroid cancer, 38 underwent radioactive iodine ablation followed by a whole body scan 2 days later. No patient had upnormal radioactive iodine uptake. At 4 months postoperatively, the serum thyroglobulin in 39 patients (93%) was <1 ng/mL. All patients who underwent neck ultrasonography at 10–18 months after thyroidectomy had no evidence of tumor recurrence.42 Robot-assisted bilateral transaxillary endoscopic approach: To overcome the difficulty of the total thyroidectomy in the transaxillary endoscopic approach, the same group that tried the bilateral transaxillary endoscopic approach described a bilateral robot-assisted technique in 2 children with Graves disease.34 Anterior approach: Similar to the totally endoscopic anterior approach, a gasless video-assisted skin lifting approach has been applied.43-45 Additional small incisions in the neck are occasionally necessary to facilitate the completeness of thyroidectomy. Experimental approaches. Transoral roboticassisted thyroidectomy: This is a technique for approaching the thyroid through the oral cavity.46 A 1.5-cm incision is made along the lingual frenulum just posterior to the mandible. Dissection continues between the geniohyoid and the mylohyoid muscles until the subplatysmal plane is identified. A subplatysmal pocket is created, and 2 more incisions are placed in the gingival buccal sulcus. The da Vinci robot facilitates the continuation the subplatysmal dissection down to the thyroid cartilage notch and beyond. Once the thyroid gland is exposed, the space above is maintained with manual elevation. The thyroid lobes are removed through the midline floor of the mouth.

Linos 21

In addition to reports from human cadavers,47 1 clinical application has been described.48 The dorsal approach: This is a unilateral gasless endoscopic thyroidectomy using a dorsal cephalic approach from the scalp. The incision is made in the scalp behind the ear. Blunt dissection between the superficial and pretracheal cervical fascia to the internal jugular vein and then to the thyroid allows mobilization of the posterior aspect of the thyroid, transection of the isthmus, and extraction of the thyroid lobe. This technique has been applied in human cadavers and 28 patients.49 DISCUSSION As described previously, there have been more than 20 techniques for minimally invasive thyroidectomy proposed over the last 10 years. Two techniques in particular have attracted the attention of the thyroid surgeons---the MIVAT with a neck incision and the video-assisted transaxillary approach without a neck incision. To be worth the increased cost, need for additional staff, and additional operative time, these procedures must have substantive advantages in terms of patient outcomes compared with the standard of the traditional open thyroidectomy. More than 100 papers originated by the Italian surgeons that first described the MIVAT technique8-12,17 and the American group that embraced this approach14,18,16 have appeared in the literature claiming that this technique may become ‘‘an emerging standard of care.’’50 According to these authors, the MIVAT technique does the following: (1) makes patients more satisfied because the neck incision is smaller; (2) is associated with less postoperative pain; (3) shortens the duration of postoperative hospital stay; (4) decreases wound healing time; and (5) improves ‘‘voice and swallowing’’ compared with the traditional open thyroidectomy.51 The main argument of the MIVAT technique is the small neck incision and that ‘‘it seems easy to accept the conclusion that a small scar is better than a long scar.’’12 Although intuitive, no scientific evidence indicates that patient satisfaction improves with a smaller scar. In fact, a paired cohort study by O’Connell et al52 comparing a conventional thyroidectomy incision (medium length 7.5 cm) to smaller incision (medium length 3.4 cm) used for minimally invasive parathyroidectomy concluded that patients with longer neck incisions were more satisfied with their scar results than the ones with the smaller scar. Subsequent studies on quality of life and patient satisfaction based on scar location and size are needed urgently.

22 Linos

The other argument of the proponents of the MIVAT technique is that there is less pain after this procedure compared with the traditional thyroidectomy. In contrast, a recent prospective study53 comparing postoperative pain scores on a visual analog scale and analgesic consumption in 75 patients who underwent MIVAT compared with 94 patients who underwent conventional thyroidectomy concluded that the length of the skin incision does not influence postoperative pain. The disadvantages of the MIVAT are the small percentage of patients with thyroid pathology who are candidates for this technique, the greater operative time, and the greater cost.8-11 The increase in cost is not unique to the MIVAT technique, but it is a common problem for all endoscopic or robot-assisted techniques because of the initial cost of obtaining endoscopic towers and/or da Vinci Robot Systems and because of the obligatory use of disposable instruments for sealing and cutting vessels. Although these disposable instruments offer certain advantages such as less bleeding and less operative time,22 several studies have cautioned against the increased risk because of concerns of thermal injury to adjacent tissues mainly to the recurrent laryngeal nerve and parathyroids,54-56 as well as to the trachea and esophagus.40 No cost-effectiveness comparisons of these techniques have been published, and in the context of increasing health care costs worldwide, more data on this topic are needed. The reaction of many experienced thyroid surgeons to the endoscopic thyroidectomies once described as ‘‘hype’’57 was to try equally small neck incisions (less than 3 cm) but place these much higher than the traditional Kocher incision level in the neck, slightly caudal to the cricoid cartilage.23,25 This nonendoscopic MINET approach provides several advantages in addition to the small incision (<3 cm). These include the following: (1) more safety because of the direct visualization and control of the superior parathyroid gland, and mainly the insertion of the recurrent laryngeal nerve into the larynx; (2) the possibility of handling the majority of thyroid pathology cases independent of size, by simply extending the initial 2.5–3-cm incision when necessary; and (3) less cost because there is no need for the additional endoscopic technology and disposable instruments. The problem though of the unsightly neck scar remains whether the small neck incision is made during an endoscopically assisted or nonendoscopic minimally invasive thyroidectomy. A hypertrophic scar or even worse a keloid in the neck

Surgery July 2011

creates very unhappy patients (and surgeons). This ‘‘ugly’’ thyroidectomy scar can interfere with their communication skills, personal relationships, work, life, and leisure activities.58 Patient quality of life is affected59; thus there has been a growing need for thyroidectomy techniques without a neck incision. Among the several techniques without a neck incision that were discussed previously, the most promising technique seems to be the transaxillary video or robot-assisted technique. This not so ‘‘minimally invasive’’ technique has shown excellent outcomes, especially for the management of thyroid malignancies.40,42,60 This technique has several limitations, including body size and habitus of the patient, the extent of the thyroid pathology, the location of the lesion, and the difficulty of direct visualization of the contralateral thyroid lobe, which makes this approach less appealing to American and European surgeons faced with different patient characteristics. Linos et al61 tried the gasless transaxillary approach using both the da Vinci Robot and a conventional endoscopic tower without specific difficulties after having a preceptorship with Professor Chung in Seoul. It seems that this training approach facilitates the learning curve and ameliorates anxiety of the novice ‘‘axillary’’ thyroid surgeon.62 Evidence supporting the superior benefits of endoscopic thyroidectomies in the neck or outside the neck has been addressed by 2 comprehensive reviews of the existing literature up to 2007. The first one from Professor Henry’s unit in France based on 30 published papers related to endoscopic thyroidectomy and suggested that this technique cannot be recommended based on evidence.6 The other evidence-based review comes from Professor L. Delbridge’s unit in Australia. This review reports on all studies (up to 2007) related to the endoscopic thyroidectomy performed in a site other than the neck. They concluded that scarless (in the neck) endoscopic thyroidectomy provides a safe excision of the thyroid pathology with the absence of a scar on the neck.63 Newer experimental approaches, especially the transoral technique, deserve careful evaluation.46-48 No innovation to date should lower the bar of the established outcomes and negligible morbidity of the long-standing technique of open thyroidectomy.64 PERSONAL OPINION Summarizing this review and based on my personal experience, I would suggest that minimally invasive thyroidectomy can be applied safely in the neck via an incision <3 cm placed higher than the traditional Kocher incision in the existing

Surgery Volume 150, Number 1

skin crease closest to the upper lobe of the thyroid. With this approach, there is no need for additional endoscopic and disposable instrument that would increase the cost without any proven benefit. For a minority of patients, especially those with a known history of hypertrophic scar formation, the endoscopic/robotic-assisted transaxillary thyroidectomy seems to offer a safe thyroidectomy without a scar in the neck. REFERENCES 1. Huscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877. 2. Gottlieb A, Sprung J, Zheng XM, Gagner M. Massive subcutaneous emphysema and severe hypercardia in patient during endoscopic transervica parathyroidectomy using carbon dioxide insufflations. Anesth Analg 1997;84:1154-6. 3. Ganger M, Inabnet BW 3rd, Biertho L. Endoscopic thyroidectomy for solitary nodules. Ann Chir 2003;128:696-701. 4. Cougard P, Osmak L, Esquis P, Ognois P. Endoscopic thyroidectomy. A preliminary report including 40 patients. Ann Chir 2005;130:81-5. 5. Henry JF. Minimally invasive surgery of the thyroid and parathyroid glands. Br J Surg 2006;93:1-2. 6. Slotema ET, Sebag F, Henry JF. What is the evidence for endoscopic thyroidectomy in the management of benign thyroid disease? World J Surg 2008;32:1325-32. 7. Inabnet WB 3rd, Jacob BP, Gagner M. Minimally invasive endoscopic thyroidectomy by a cervical approach. Surg Endosc 2003;17:1808-11. 8. Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C. Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest 1999;22:849-51. 9. Bellantone R, Lombardi CP, Raffaelli M, Rubino F, Boscherini M, Perilli W. Minimally invasive, totally gasless video-assisted thyroid lobectomy. Am J Surg 1999;177: 342-3. 10. Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 2001;130:1039-43. 11. Bellantone R, Lombardi CP, Bossola M, Boscherini M, De Crea C, Alesina PF, et al. Video-assisted vs. conventional thyroid lobectomy: a randomized trial. Arch Surg 2002;137: 301-4. 12. Miccoli P, Bellantone R, Mourad M, Walz M, Raffaelli M, Berti P. Minimally invasive video-assisted thyroidectomy: multiinstitutional experience. World J Surg 2002;26:972-5. 13. Wu CT, Yang LH, Kuo SJ. Comparison of video-assisted thyroidectomy and traditional thyroidectomy for the treatment of papillary thyroid carcinoma. Surg Endosc 2010;24: 1658-62. 14. Terris DJ, Chin E. Clinical implementation of endoscopic thyroidectomy in selected patients. Laryngoscope 2006; 116:1745-8. 15. Lombardi CP, Raffaell M, Crea C, Princi P, Castaldi P, Spaventa A, et al. Report on 8 years experience with video assisted thyroidectomy for papillary thyroid carcinoma. Surgery 2007;142:944-51. 16. Terris DJ, Angelos P, Steward DL, Simental AA. Minimally invasive video-assisted thyroidectomy. Arch Otolaryngol Head Neck Surg 2008;34:81-4.

Linos 23

17. Miccoli P, Elisei R, Materazzi G, Capezzone M, Galleri D, Pacini F, et al. Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness. Surgery 2002;132:1070-3. 18. Terris DJ, Bonnett A, Gourin CG, Chin E. Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope 2005;115:1104-8. 19. Alvarado R, McMullen T, Sidhu SB, Delbridge LW, Sywak M. Minimally invasive thyroid surgery for single nodules: an evidence- based review of the lateral mini-incision technique. World J Sur 2008;32:1341-8. 20. Yamashita H, Watanabe S, Koike E, Ohshima A, Uchino S, Kuroki S, et al. Video-assisted thyroid lobectomy through a small wound in the submandibular area. Am J Surg 2002;183:286-9. 21. Brunaud L, Zarnegar R, Wada N, Ituarte P, Clark OH, Duh QY. Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive? Arch Surg 2003;138:1140-3. 22. Rafferty M, Miller I, Timon C. Minimal incision for open thyroidectomy. Otolaryngol Head Neck Surg 2006;135:295-8. 23. Ferzli GS, Sayad P, Abdo Z, Cacchione RN. Minimally invasive, nonendoscopic thyroid surgery. J Am Coll Surg 2001; 192:665-8. 24. Cavicchi O, Piccin O, Ceroni AR, Caliceti U. Minimally invasive nonendoscopic thyroidectomy. Otolaryngol Head Neck Surg 2006;135:744-7. 25. Linos DA. Minimally invasive thyroid surgery. In: Frezza E, Gagner M, Li MKW, editors. International principles of laparoscopic surgery. Woodbury, CT: Cinemed; 2010. p. 531-7. 26. Sackett WR, Barraclough BH, Sidhu S, Reeve TS, Delbridge LW. Minimal access thyroid surgery: is it feasible, is it appropriate? ANZ J Surg 2002;72:777-80. 27. Ikeda Y, Takami H, Tajima G, Sasaki Y, Takayama J, Kurihara H, et al. Total endoscopic thyroidectomy: axillary or anterior chest approach. Biomed Pharmacother 2002;56(Suppl 1):s72-8. 28. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-40. 29. Takami H, Ikeda Y. Minimally invasive thyroidectomy. ANZ J Surg 2002;72:841-2. 30. Duncan TD, Rashid Q, Speights F, Ejeh I. Transaxillary endoscopic thyroidectomy: an alternative to traditional open thyroidectomy. J Natl Med Assoc 2009;101:783-7. 31. Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000;10:1-4. 32. Park YL, Han WK, Bae WG. 100 cases of endoscopic thyroidectomy: breast approach. Surg Laparosc Endosc Percutan Tech 2003;13:20-5. 33. Yamamoto M, Sasaki A, Asahi H, Shimada Y, Sato N, Nakejima J, et al. Endoscopic subtotal thyroidectomy for patients with Graves ’ disease. Surg Today 2001;31:1-4. 34. Miyano G, Lobe TE, Wright SK. Bilateral transaxillary endoscopic total thyroidectomy. J Pediatr Surg 2008;43: 299-303. 35. Shimazu K, Schiba E, Tamaki Y, Takiguchi S, Taniguchi E, Ohashi S, et al. Endoscopic thyroid surgery through the axillo-billateral breast approach. Surg Laparosc Endosc Percutan Tech 2003;13:196-201. 36. B€arlehner E, Benhidjeb T. Cervical scarless endoscopic thyroidectomy: axillo- bilateral-breast approach (ABBA). Surg Endosc 2008;22:154-7.

24 Linos

37. Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 2007;31:601-6. 38. Lee KE, Rao J, Youn YK. Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique: our initial experience. Surg Laparosc Endosc Percutan Tech 2009;19:e71-5. 39. Yoon JH, Park CH, Chung WY. Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases. Surg Laparosc Endosc Percutan Tech 2006;16:226-31. 40. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al. Gasless endoscopic thyroidectomy using trans-axillary approach: surgical outcome of 581 patients. Endocr J 2009; 56:361-9. 41. Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, et al. Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 2009;146: 1048-55. 42. Kang SW, Jeong JJ, Nam KH, Chang HS, Chung WY, Park CS. Robot-assisted endoscopic thyroidectomy for thyroid malignancy using a gasless transaxillary approach. J Am Coll Surg 2009;209:e1-7. 43. Shimizu K, Akira S, Jasmi AY, Kitamura Y, Kitagawa W, Akasu H, et al. Video-assisted neck surgery: Endoscopic resection of thyroid tumours with a very minimal neck wound. J Am Coll Surg 1999;188:697-703. 44. Kitagawa W, Shimizu K, Akasu H, Tanaka S. Endoscopic neck surgery with lymph node dissection for papillary carcinoma of the thyroid using a totally gasless anterior neck skin lifting method. J Am Coll Surg 2003;196:990-4. 45. Bae JS, Park WC, Song BJ, Jung SS, Kim JS. Endoscopic thyroidectomy and sentinel lymph node biopsy via an anterior chest approach for papillary thyroid cancer. Surg Today 2009;39:178-81. 46. Benhidjeb T, Wilhelm T, Harlaar J, Kleinrensink GJ, Schneider TA, Stark M. Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 2009;23:1119-20. 47. Richmon JD, Pattani KM, Benhidjeb T, Tufano RP. Transoral robotic-assisted thyroidectomy: a preclinical feasibility study in 2 cadavers. Head Neck 2010;33:330-3. 48. Wilhelm T, Metzig A. Video. Endoscopic minimally invasive thyroidectomy: first clinical experience. Surg Endosc 2010; 24:1757-8. 49. Schardey HM, Barone M, Portl S, von Ahnen T, Schopf S. Invisible scar endoscopic dorsal approach thyroidectomy: a clinical feasibility study. World J Surg 2010;34: 2997-3006.

Surgery July 2011

50. Terris DJ, Moister B, Seybt MW, Gourin CG, Chin E. Outpatient thyroid surgery is safe and desirable. Otolaryngol Head Neck Surg 2007;136:556-9. 51. Lombardi CP, Raffaelli M, D’alatri L, De Crea C, Marchese MR, Maccora D, et al. Video-assisted thyroidectomy significantly reduces the risk of early postthyroidectomy voice and swallowing symptoms. World J Surg 2008;32:693-700. 52. O’Connell DA, Diamond C, Seikaly H, Harris JR. Objective and subjective scar aesthetics in minimal access vs. conventional access parathyroidectomy and thyroidectomy surgical procedures; a paired cohort study. Arch Otolaryngol Head Neck Surg 2008;134:85-93. 53. Alesina PF, Rolfs T, R€ uhland K, Brunkhorst V, Groeben H, Wallz MK. Evaluation of postoperative pain after minimally invasive video-assisted and conventional thyroidectomy: results of a prospective study. Langenbecks Arch Surg 2010; 395:845-9. 54. Agarwal BB, Agarwal S. Recurrent laryngeal nerve, phonation and voice preservation-energy devices in thyroid surgery-a note of caution. Langenbecks Arch Surg 2009;394:911-2. 55. Ernam TA, Cuschieri A. How safe is high-power ultrasonic dissection? Ann Surg 2003;237:186-91. 56. Dionigi G. Energy based devices and recurrent laryngeal nerve injury: the need for safer instruments. Langenbecks Arch Surg 2009;394:579-80. 57. Duh QY. Presidential address: minimally invasive endocrine surgery-standard of treatment or hype? Surgery 2003;134: 849-57. 58. Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A. The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg 2008;61:1049-58. 59. Huang SM, Lee CH, Chien LY, Liu HE, Tai CJ. Postoperative quality of life among patients with thyroid cancer. J Adv Nurs 2004;47:492-9. 60. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al. Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients. Surg Endosc 2009;23: 2399-406. 61. Linos D, Kiriakopoulos D, Poulios E. Scarless neck by conducting robot-assisted thyroidectomy: our initial experience. Endocrine Abstracts 2010;22:P832. 62. Landry CS, Grubbs EG, Lee JE, Perrier ND. From scalpel to console: a suggested model for surgical skill acquisition. Bull Am Coll Surg 2010;95:20-4. 63. Tan CT, Cheah WK, Delbridge L. ‘‘Scareless’’ (in the neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques. World J Surg 2008;32:1349-57. 64. Agarwal BB, Sarangi R, Mahajan KC. Outcomes with thyroidectomy: what are they?-patient-reported voice quality, not merely nerve preservation. Surg Endosc 2010;24:735-7.