The advancement of video-assisted minimally invasive surgery in this decade fostered the successful attempt at endoscopic thyroidectomy in 1997. This technically demanding surgery is now being evaluated in a small number of specialized centers. The procedure earned the most attention in Japan and is performed in more than 20 centers; a conference dedicated to the technique was held in Japan in 2001. By retrieving information from published or presented articles and direct personal communications, we report on the multitude of surgical strategies designed by different experts to enable relocalization of the surgical wounds to optimize cosmesis to the patient while complying with the gold standard of thyroid surgery.

Background:The technical details of endoscopic exploration of parathyroid adenoma are described here, thereby drawing attention to the enormous potential of this new modality of minimal-access surgery. Methods: Four patients with a parathyroid adenoma that was clearly demonstrated by pre-operative localization imaging techniques were subject to endoscopic exploration using one 11 mm and two 5 mm ports: a technique heretofore undescribed. Results: An adenoma was successfully localized endoscopically in each case and was removed. The postoperative outcome proved most encouraging: no analgesics were required, the hypercalcaemia rapidly corrected and the patients were pleased with the smallness of scars. Conclusions: The described endoscopic approach is a viable and promising alternative to open surgery for parathyroid adenoma; further study would be fruitful.

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Since 1997, successful attempts at endoscopic thyroidectomy have led to controversies. The procedure has, as yet, no alarming operative complication, but its benefits to patients are debatable. By means of very individualized and ingeniously designed approaches, the procedure has proven to be feasible and safe in trained hands. Cautious trials and evaluations of endoscopic thyroid surgery are now in progress internationally at expert centres. The technique itself is undergoing progressive evolution and larger studies are underway. Although endoscopic thyroidectomy has little chance of acquiring the same popularity as open thyroidectomy due to its inherently higher technical demand, it may become a practical and safe alternative option for selected suitable patients.

I thank Dr. Miccoli and his colleagues for the comment, and I admire their success in performing 34 endoscopic parathyroidectomies for primary hyperparathyroidism. As intraoperative parathyroid hormone (PTH) assay is not available in our hospital, we invest great faith in preoperative localization techniques so as to avoid a long operation.Concerning endoscopic thyroidectomy, we received comments similar to yours when we presented our preliminary results locally. Our result, technique, and problems encountered are accepted for international publication [1,3]. I firmly believe that no gold standards of any surgical operation should be compromised just to have it performed endoscopically. For all our 10 cases of endoscopic hemithyroidectomy since 28 February 1997 (with 4 conversions), we performed a standard hemithyroidectomy, including the isthmus with intact capsule. There were no surgical complications.In the early phase of our study, we used the technique of endoscopic neck dissection for thyroid nodules up to 38 mm and retrieved the specimen successfully with some wound extension. A good analog would be the removal of an intact acutely inflamed gall bladder via the 12-mm umbilical wound. Thus, any thyroid specimen smaller than that would not be problematic. As we gained further experience, we concluded that a large specimen and lack of tailored instruments would render the long operation (180-300 min.) less worthwhile. We insisted that the whole course of the recurrent laryngeal nerve should be positively identified and protected (Fig. 1). One of our conversions resulted from inability to identify the nerve, even though we had almost completely mobilized the hemithyroid. We now have a strict limitation requiring that the nodule be smaller than 15-20 mm, and that the thyroid gland itself not hypertrophied. Ultrasonography can provide the necessary information. Apart from the usual lateral dissection for parathyroidectomy, we performed additional central dissection for the final approach to the pretracheal attachment of the thyroid gland [2].We also are aware of hypercapnia's potential complication as mentioned. The end-tidal CO 2 of our patients was monitored closely. However, in only 1 of our 15 endoscopic neck surgery cases, did the ventilator setting of the patient need to be modified to lower the end-tidal CO 2 . We started the first few seconds of insufflation with 15 mmHg of pressure to induce the surgical emphysema, instantly lowering it to 5 mmHg during the whole operation. The actual recorded pressure was even lower due to the persistent leakage from the trocar sites because tissue purchase is much less than with laparoscopic surgery. Furthermore, we encountered no noticeable emphysema in the patients once they recovered from the anesthesia.After the first nine cases of endoscopic thyroidectomy, we followed up the patients for 8-14 months to assess their clinical recovery and satisfaction. In the coming months, we shall be comparing prospectively the result of endoscopic thyroidectomy and open thyroide...