Tension-free thyroidectomy (medial thyroidectomy)-a prospective study: surgical technique and results of 259 operations.

Background: Thyroid surgery is associated with a number of surgical complications including recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. The existing methods share the same principle-the mobilization of the thyroid from the lateral side. The aim of this study was to evaluate the safety of a novel technique of thyroidectomy-tension-free thyroidectomy (TFT) based on the medial approach to the laryngeal nerves and parathyroid glands (PTGs). Methods: The study was conducted between August 2021 and July 2022 in Saint Petersburg State University Hospital. A total of 261 patients with thyroid diseases were enrolled in the study and operated on using the TFT technique. Results: The operations with the use of TFT technique were completed in all but two cases which required the conversion to the standard lateral approach. Of 259 TFT cases unilateral laryngeal paresis was registered in 6 (2.3%) cases or in 1.7% of the number of RLNs at risk. In all but one case the vocal fold function recovered in less than 6 months of the follow-up. Among 87 patients who underwent total thyroidectomy transient postoperative hypoparathyroidism was found in 10 cases (11.5%), rate of persistent hypoparathyroidism was 0%. One case of postoperative bleeding was recorded (0.4%). Conclusions: The TFT technique demonstrated high safety and several advantages over the traditional method of performing operations on the thyroid gland.

Persistence of primary hyperparathyroidism: a single-center experience.

BACKGROUND: Parathyroidectomy is the only definitive treatment for primary hyperparathyroidism (PHPT). Precise localization of abnormal glands is a key to a successful surgery. Most patients are expected to be successfully treated with focused parathyroidectomy. However, this approach is associated with a risk of existing multiglandular disease which may lead to the postoperative persistence of PHPT. METHODS: Eight hundred ten patients who underwent an initial surgery for PHPT at SPBU Hospital in 2017-2018 were included in the study. Preoperative imaging results were evaluated. Multivariate logistic regressions were calculated to estimate predictive values of preoperative data for the risk of postoperative persistence and risk of MGD. RESULTS: Multiglandular disease was found to be a leading cause of persistent hyperparathyroidism. An anamnesis of thyroid surgery was found to be a significant risk factor for the persistence of hyperparathyroidism. The rate of persistence did not differ significantly between groups with bilateral neck exploration and focused parathyroidectomy. Age, sex, body mass index as well as negative results of preoperative US, MIBI, and 4D CT were not independently associated with a higher risk of MGD. All preoperative imaging modalities showed from low to moderate sensitivity for the detection of MGD. The frequency of cases of a missed second adenoma did not differ significantly between patients with concordant and discordant preoperative data. There were 7 cases with previously unsuspected second adenomas found solely due to bilateral neck exploration. CONCLUSIONS: None of the combination of preoperative visualization modalities was able to rule out the MGD and reliably identify patients for focused parathyroidectomy. Additional preoperative visualization failed to improve overall results. Bilateral neck exploration appeared to have a slight benefit for the patients with concordant preoperative imaging results.

Tension-free thyroidectomy (TFT): initial report.

The safety of thyroid surgery in terms of recurrent laryngeal nerve palsy and hypoparathyroidism has increased over the last decade. In this study, we present a new method of tension-free thyroidectomy (TFT), which could be used to further decrease the complication rate after a thyroidectomy. The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of the isthmus and successive complete dissection of Berry's ligament. In total, 92 patients (127 nerves at risk) underwent "tension-free thyroidectomy" (TFT) between August and November 2021. All the procedures were performed by a single surgeon at Saint Petersburg State University Hospital. There were 74 females and 18 male patients (ratio 4.1:1) with a mean age of 46.9 (range from 17 to 74). A lobectomy was carried out in 57 (62%) patients and a total thyroidectomy in 35 (38%). In 27 cases, patients additionally underwent central and/or lateral neck dissection. Indications for surgery were papillary carcinoma (N = 34), medullary cancer (N = 2), follicular neoplasia (N = 43), Grave's disease (N = 9), multinodular toxic goiter (N = 3), and multinodular nontoxic goiter (N = 1). Mean thyroid volume was 24.6 ml (ranged 12-70 ml). Intraoperative neuromonitoring was used in all the cases (5 mA). Translaryngeal ultrasound (TLUS) or direct laryngoscopy were routinely used prior and after surgery to evaluate vocal cords mobility. Calcium and parathormone levels were measured in patients after thyroidectomy on the first, 14th and 30th postoperative days. No recurrent laryngeal nerve palsy was observed. One patient exhibited hypoparathyroidism which was resolved in 2 weeks using substitution therapy with calcium and alfacalcidol. The mean operating time for lobectomy was 54 ± 14 min (range: 30-95 min) and for total thyroidectomy 99 ± 28 min (range: 55-158 min). There was no conversion to the conventional lateral-to-medial approach. TFT can be considered a safe and feasible operation. Comparative (randomized studies) with conventional dissection technique should be performed to investigate the hypothesis that this approach can provide a lower complication rate.