Neural monitoring in thyroid surgery

Numerous operating tools and technology transfers are available for thyroid surgery teams performing open, endoscopic and robotic procedures but none, or very few, of them constitutes a mandatory prerequisite. Over the past decade, the choice of intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve (RLN), has been reached certain consensus. Identification and intraoperative assessment of the RLN seems to be more effectively performed with IONM than solely visually or endoscopically. Today, IONM has evolved sufficiently to increase the likelihood of successful functional outcomes in many patients. The transition from the concept of intermitted neural monitoring of the RLN to that of continuous functions evaluation that must be appreciate requires highly skilled knowledge of IONM. This goal will be more likely achieved in Centers highly specialized in thyroid surgery

Which surgery needs to be used in the Differentiated Thyroid Carcinoma?

Surgery for thyroid carcinoma involves a complex decision-making process and technical skills, both related to the experience of the endocrinologist and surgeon. Based on a stratified risk approach for the management of differentiated thyroid carcinoma, therapeutic decisions can now be divided into active surveillance or immediate surgery, e.g. hemithyroidectomy with isthmectomy, total thyroidectomy, or thyroidectomy and locoregional lymphadenectomy. Total thyroidectomy is a surgery associated with high rates of healing and has been considered the gold standard for years. However, thyroid lobectomy, in selected cases, is now recognized as equally oncologically effective and is associated with decreased morbidity in appropriately selected patients. The morbidity of the prophylactic lymphadenectomy of the central compartment is significant in terms of transient and permanent hypocalcaemia. This led to a less aggressive prophylactic surgical approach in the recent guidelines of the American Thyroid Association of 2015.  Re-operations in the central or lateral compartment can be difficult and lead to an increased risk to the patient. Therefore, it is important to perform an optimal initial operation in every patient with thyroid cancer. Consideration should be given to addressing patients with high-risk characteristics (N1 clinical disease, locally invasive disease) to experienced surgeons, both for oncologic completeness and for significant impact on clinical outcomes and complication rates

Endoscopic thyroidectomy: why we need a transoral approach

Transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through three-port technique placed at the  oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles. TT is done fully endoscopically using conventional endoscopic instruments. TT represents probably the best scarless approach to the thyroid due to the short distance between the thyroid and the incisions, respecting the surgical planes

Metachronous bilateral ectopic breast carcinoma: A case report

An incomplete regression of the mammary line during embryogenesis occurs in 0.2-6% of the population, which may result in the presence of ectopic breast tissue (EBT). The development of a carcinoma in the EBT is a rare event. The authors present a case report of a 76-year-old female patient, with a lobular carcinoma in an abdominal wall EBT submitted to surgery and adjuvant chemotherapy

Staged Thyroidectomy: A Single Institution Perspective

BackgroundThe increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy.ObjectivesThis study reviews the experience of the authors in using IONM for planned total thyroidectomy after LOS on the first thyroid lobe. The aims were to estimate the incidence of LOS on the first side of resection and to compare intraoperative strategies applied after this event.Materials and MethodsIntermittent IONM was performed with stimulation of both the vagal nerve and the recurrent laryngeal nerve (RLN) (V1, R1, R2, V2). Patients underwent pre- and postoperative laryngoscopy. Before surgery, patients were informed that staged thyroidectomy might be required.ResultsThis study analyzed 803 consecutive thyroid procedures. Of these, V2 LOS (<100 mcV) occurred after first lobe exeresis in 23 (2.8%) procedures. The surgical procedure was stopped in 20 cases (ie, staged thyroidectomy was performed). In three cases with malignancy and severe comorbidity (ASA score 3-4), total bilateral thyroidectomy was performed as planned. No cases of bilateral RLN palsy occurred. Postoperative laryngoscopy confirmed RLN palsy in 21 of the 23 cases. All true positive patients received speech therapy. Patients who had false positive LOS (n=2) or malignancy (n=8) and patients who were symptomatic (n=7) received completion thyroidectomy within 6 months. One patient received radioactive iodine therapy for hyperthyroidism. Two patients received follow up.ConclusionsNeuromonitoring changes the surgical decision-making process in a multidisciplinary manner. A shared decision-making process involving the patient, anesthesiologist, and endocrinologist is suggested. In the case of intraoperative LOS on the first-operated side in a planned total thyroidectomy, the thyroid surgeon essentially has three options for surgery on the contralateral side: 1) Perform staged thyroidectomy. This option is recommended in bilateral goiter, Graves' disease, or low-risk thyroid carcinoma (differentiated or medullary thyroid carcinoma). The aim is to avoid bilateral vocal cord palsy. Two-stage completion surgery is delayed until recovery of ipsilateral nerve function. 2) Perform subtotal resection on the contralateral side ventrally to the RLN plane at a safe distance from the nerve. The aim is to avoid further disease recurrence and revision surgery. 3) Perform total thyroidectomy as planned for advanced thyroid carcinoma (including undifferentiated thyroid carcinoma). The aim is to improve disease control through radioactive iodine therapy, radiation therapy, or target therapy immediately after surgery.Level of Evidence