Learning Curve for Endoscopic Thyroidectomy Using Video-Assisted Neck Surgery: Retrospective Analysis of a Surgeon's Experience with 100 Patients

Abstract

Background: Endoscopic thyroidectomy offers excellent cosmetic outcomes, but requires a period of time for surgeons to become proficient. We examined the learning curve for the first 100 cases experienced by a single surgeon using a video-assisted neck surgery (VANS) subclavian approach.Methods: We retrospectively studied 100 patients (99 women, 1 man; mean age, 36.2 years) with both benign and malignant thyroid diseases treated between 2016 and 2020.Results: Preoperative diagnosis was papillary thyroid carcinoma (PTC) in 36 cases and other (non-PTC) in 64 cases. All patients underwent lobectomy, with unilateral central node dissection added for patients with PTC. Mean operative time was 125 min for non-PTC cases and 129 min for PTC cases (p = 0.43), with blood loss of 33.8 ml and 7.6 ml, respectively (p = 0.01). Recurrent laryngeal nerve paralysis (RNP) was observed in 12 patients (12%) and hemorrhage in 2 patients (2%). Comparing the first 30 cases with the last 70 cases, no significant differences in operative time or blood loss were evident, although tumor size of non-PTC cases was significantly greater among later cases (32.4 mm vs. 39.5 mm, p = 0.039). RNP was significantly decreased in later cases (26.7% vs. 5.7%, p = 0.003). Multivariate analysis revealed tumor size as a significant risk factor for increased blood loss, and increased experience correlated significantly with the decrease in RNP. Conclusions:In VANS, a certain surgical level was reached after experiencing 30 cases.

Definition of learning curve for thyroidectomy: systematic review on the different approaches

“…The techniques investigated for remote-access thyroidectomy in the selected studies were: transoral endoscopic thyroidectomy trans-vestibular approach) (9 reports (TOETVA) ( 30 - 38 ), breast approach (5 reports) ( 39 - 43 ), transaxillary (3 reports) ( 44 - 46 ), BABA (2 reports) ( 47 , 48 ), subclavian (2 reports) ( 49 , 50 ), retroauricular (1 report) ( 51 ). Bleeding, hypocalcemia and RNL injuries were compared before and after proficiency achievement in eight papers ( 36 , 40 - 43 , 45 , 47 , 50 ) with other trials considering the overall postoperative complication rate. Nine authors reported the use of IONM during surgery ( 30 , 32 , 33 , 36 - 38 , 48 , 50 , 51 ).…”

“…Bleeding, hypocalcemia and RNL injuries were compared before and after proficiency achievement in eight papers ( 36 , 40 - 43 , 45 , 47 , 50 ) with other trials considering the overall postoperative complication rate. Nine authors reported the use of IONM during surgery ( 30 , 32 , 33 , 36 - 38 , 48 , 50 , 51 ).…”

“…Two retrospective studies in the current literature evaluate LC for endoscopic thyroidectomy with a subclavian approach ( 49 , 50 ). Neither author used the CUSUM and in both papers proficiency was established at 30 procedures for a single surgeon.…”

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique

“…As such, there is a higher likelihood of CO 2 gas entering the circulatory system with life-threatening consequences, including subcutaneous emphysema, pneumothorax, pneumomediastinum, and CO 2 embolism ( 8 , 9 ). Video-assisted neck surgery (VANS) using a subclavian approach was proposed as early as 1998, which did not need air insufflation and did not result in CO 2 -related complications ( 22 , 23 ). In recent years, the gasless TOETVA has been reported including ours ( 14 ), while TOaST without CO 2 insufflation has not been studied.…”

Safety and Efficacy of Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Conventional Open Thyroidectomy: A Systematic Review and Meta-analysis

“…With the increase in patients’ demands for cosmetics, various endoscopic thyroid surgeries have emerged, including the subclavian approach, 1 areolar approach, 2 axillary-breast approach, 3,4 and axillary approach 5,6 . However, the feasibility and safety of these approaches are often questioned due to the wide-ranging skin flap clearance and scar hypertrophy at the incision site, 7 as well as difficulties in central lymph node clearance for patients with papillary carcinoma 8,9 …”