Minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional parathyroidectomy for renal hyperparathyroidism: a retrospective multicenter study.

To compare minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional surgery for renal hyperparathyroidism (rHPT). Between 2006 and 2020, 53 patients underwent MIVAP and 182 underwent conventional parathyroidectomy for rHPT at the Kliniken Essen-Mitte and Knappschaftskrankenhaus Bochum, respectively. Two propensity score-matched groups were retrospectively analyzed: the MIVAP group (VG; n = 53) and the conventional group (CG; n = 53). To assess long-term results, the patients were questioned prospectively (VG; n = 17, and CG; n = 26). The VG had a smaller incision (2.8 vs. 4.8 cm), shorter operation duration (81.0 vs. 13.9 min), and shorter duration of stay (2.4 vs. 5.7 days) (p < 0.0001) but a smaller drop in parathyroid hormone (PTH) postoperatively (81.3 vs. 85.5%. p = 0.022) than the CG. The conversion rate was 9.4% (n = 5). The VG had better Patient Scar Assessment Scale (PSAS) scores (10.8 vs. 11.7 p = 0.001) but worse SF-12 health survey scores (38.7 vs. 45.8 for physical health and 46.7 vs. 53.4 for mental health) (p < 0.0001). The PTH level at follow-up was higher in the VG (162.7 vs. 59.1 ng/l, p < 0.0001). There were no differences in morbidity, number of removed parathyroid glands, disease persistence, late rHPT relapse and need for repeat surgery between groups. MIVAP was superior to conventional parathyroidectomy regarding aesthetic outcomes and cost effectiveness. Conventional surgery showed better control of PTH levels and health scores on follow-up than MIVAP, without any impact on rHPT relapse and need for repeat surgery.Trail registration number and date of registration: DRKS00022545 on 14.12.2020.

Tailored Approach in Adrenal Surgery: Retroperitoneoscopic Partial Adrenalectomy.

The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique.

Fluorescence Image-Guided Surgery for Thyroid Cancer: Utility for Preventing Hypoparathyroidism.

Background: Hypoparathyroidism is one of the most frequent complications of thyroid surgery, especially when associated with lymph node dissection in cases of thyroid cancer. Fluorescence-guided surgery is an emerging tool that appears to help reduce the rate of this complication. The present review aims to highlight the utility of fluorescence imaging in preserving parathyroid glands during thyroid cancer surgery. Methods: We performed a systematic review of the literature according to PRISMA guidelines to identify published studies on fluorescence-guided thyroid surgery with a particular focus on thyroid cancer. Articles were selected and analyzed per indication and type of surgery, autofluorescence or exogenous dye usage, and outcomes. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included articles. Results: Twenty-five studies met the inclusion criteria, with three studies exclusively assessing patients with thyroid cancer. The remaining studies assessed mixed cohorts with thyroid cancer and other thyroid or parathyroid diseases. The majority of the papers support the potential benefit of fluorescence imaging in preserving parathyroid glands in thyroid surgery. Conclusions: Fluorescence-guided surgery is useful in the prevention of post-thyroidectomy hypoparathyroidism via enhanced early identification, visualization, and preservation of the parathyroid glands. These aspects are notably beneficial in cases of associated lymphadenectomy for thyroid cancer.

Adrenal Tumors: Are Gender Aspects Relevant?

The distribution of malignant tumors is strongly related to gender due to sex-related organ and tissue differentiation. Neoplasias of the adrenal glands are relatively common and typically benign. Mainly based on our recently published contributions, we analyzed the influence of gender on type of tumors, complexity of surgery, and long-term outcome. Cortisol-secreting adrenal tumors are more often diagnosed in female patients, while the incidence of Conn's syndrome and pheochromocytoma is similar between male and female patients. Adrenalectomy is more difficult in male patients because of longer operating time and higher blood loss. The probability of cure in male patients with Conn's syndrome is significantly lower. Gender does not influence long-term results in adrenal hypercortisolism and pheochromocytomas.

Retroperitoneal adrenalectomy-learning curve, practical tips and tricks, what limits its wider uptake.

The minimally invasive retroperitoneal approach to the adrenal surgery has been described in the early 90s following the first description of laparoscopic adrenalectomy. Although the advantages of the technique compared to laparoscopic surgery have been demonstrated in many studies, it remained for a long period confined to few centers. The operation has been standardized over the years into a safe and reproducible procedure that finally gained worldwide acceptance in the last 10 years. The present paper summarizes the surgical steps of the procedure focusing on the recent technical developments. Retroperitoneoscopic adrenalectomy should be part of the surgical armamentarium of any center dedicated to endocrine surgery.

Minimally Invasive Parathyroidectomy without Intraoperative PTH Performed after Positive Ultrasonography as the only Diagnostic Method in Patients with Primary Hyperparathyroidism.

BACKGROUND: A positive and concordant result of at least two diagnostic modalities is generally recommended prior to focused parathyroidectomy. The aim of this study was to analyze the results of surgery and the accurateness of preoperative ultrasonography (US) as single localization modality in patients who underwent parathyroidectomy without the adjunct of intraoperative Parathormone (PTH) measurement. METHODS: The cases with a preoperative US as the only localization technique, who underwent parathyroidectomy between 10/1999 and 12/2017, were selected from a prospectively maintained database. Therefore, a total number of 242 patients with a mean age of 58.6 ± 13.7 years were included in the present study. US was performed by referral endocrinologist or by the surgeon during office visits. RESULTS: The overall "cure rate" was 99.2% (240 out of 242 patients). In 228/242 patients (94.2%), a drop of perioperative PTH levels consistent with the definition of cure was observed on the day of surgery. In four of the remaining 14 patients, healing was confirmed by PTH level dropping into the normal range on the first postoperative day. Eight patients were cured after a reoperation was performed at our department. Postoperative complications included one case of permanent recurrent laryngeal nerve palsy (0.4%). CONCLUSIONS: If performed by an experienced endocrinologist and/or endocrine surgeon, a positive US could be the only preoperative localization study in patients with pHPT. Moreover, the add-value of intraoperative PTH is limited. Major advantages of US are a very high accuracy, the ease of performance (accessibility) and its cost-effectiveness compared with Sesta-MIBI scintigraphy.

A New Minimally Invasive Approach to the Posterior Right Segments of the Liver: Report of the First Two Cases.

Background: Minimally invasive liver surgery has gained increasing popularity over the past decade. Nevertheless, laparoscopic treatment of lesions located in the posterior-superior locations remains challenging because of the difficulty to reach a safe exposition of those regions of the liver. We present a new retroperitoneoscopic approach for the minimally invasive treatment of posterior tumors. Materials and Methods: Between May and July 2018, 2 patients with solitary liver metastasis of colorectal origin underwent retroperitoneoscopic liver resection in the prone position. The operation was conducted with three to four trocars, the CO2 insufflation pressure was set at 20 mmHg. Liver transection was carried out by alternating bipolar coagulation and clips, without clamping of the hepatic inflow. Results: There were no intra- or postoperative complications. The procedure was completed in both cases without conversion after 120 to 180 minutes, respectively. Complete resection was achieved in both cases. Hospital stay was 3 and 5 days. Conclusions: Retroperitoneoscopic liver resection is feasible and safe. This approach could be suggested as an additional therapeutic option, especially in cases of redo resection at the posterior segments.

Pattern and impact of metastatic cardiophrenic lymph nodes in advanced epithelial ovarian cancer.

BACKGROUND: Cardiophrenic lymph nodes (CPLN) define FIGO stage IVB disease. We evaluate the pattern of CPLN metastases, their prognostic impact and the potential role of CPLN resection in patients with epithelial ovarian cancer (EOC). METHODS: Analysis of 595 consecutive patients with EOC treated in the period 01/2011-05/2016. CT scans were re-reviewed by two radiologists. Positive CPLN were defined as ≥5 mm in the short-axis diameter. The role of CPLN resection was evaluated in a case-control matched-pair analysis. RESULTS: Of 595 patients 458 had FIGO stage IIIB-IV disease. We excluded patients undergoing interval surgery (n = 54), without debulking surgery (n = 32) and without sufficient pre-operative imaging (n = 22), resulting in a study cohort of 350 patients. Of these, 133 (37.9%) had negative CPLN and 217 (62.0%) had radiologically positive CPLN. In patients with postoperative residual tumor, enlarged CPLN had no impact on survival. In patients with complete resection (n = 223), 98 (44.0%) had negative CPLN and a 5-year OS of 69% and a 5-year PFS of 41%; in contrast, in the 125 patients (56.0%) with positive CPLN, 5-year OS was 30% and 5-year PFS was 13%. In 52 patients we resected CPLN. The matched-pair case-control analysis did not demonstrate any significant impact on survival of CPLN resection. CONCLUSION: CPLN metastases are associated with impaired PFS and OS in patients with macroscopically completely resected tumor. Intraabdominal residual tumor has a greater prognostic impact than positive CPLN. The impact of the resection of CPLN remains unclear.

Skeletal Muscle Attenuation (Sarcopenia) Predicts Reduced Overall Survival in Patients with Advanced Epithelial Ovarian Cancer Undergoing Primary Debulking Surgery.

BACKGROUND: Sarcopenia was reported as a prognostic factor in cancer patients. Using computed tomography (CT), we analyzed the impact of sarcopenia on overall survival (OS) in patients with advanced epithelial ovarian cancer (EOC) after primary debulking surgery (PDS). METHODS: Preoperative CT scans of consecutive EOC patients (n = 323) were retrospectively assessed for skeletal muscle index (SMI) and muscle attenuation (MA; Hounsfield units [HU]). The optimal cut-off point for MA (32 HU) was calculated using the Martingale residuals method, and previously reported cut-offs for SMI were used. Logistic regression was used to determine univariate and multivariate factors associated with OS. RESULTS: Sarcopenia defined as SMI < 38.5, < 39, and 41 cm2/m2 was detected in 29.4, 33.7, and 47.1% of patients, respectively; however, none of these SMI cut-off levels were associated with OS. MA < 32 HU was present in 21.1% (68/323) of the total cohort. Significant differences between patients with MA < 32 and ≥ 32 HU were detected for median age (67 vs. 57 years), Eastern Cooperative Oncology Group (ECOG) > 0 (13.2 vs. 3.1%), comorbidity (age-adjusted Charlson Comorbidity Index [ACCI] ≥ 4; 36.8 vs. 13.3%), median body mass index (BMI; 27 vs. 24 kg/m2), International Federation of Gynecology and Obstetrics (FIGO) stage, histology (high-grade serous 95.6 vs. 84.7%), and complete resection (38.2 vs. 68.2%). MA < 32 HU remained a significant prognostic factor for OS in multivariate Cox regression analysis (hazard ratio 1.79, p = 0.003). Median OS in patients with MA < 32 HU versus MA ≥ 32 HU was 28 versus 56 months (p < 0.001). Furthermore, MA < 32 HU was significantly associated with OS in the prognostically poor population of patients with residual tumor (p = 0.015). CONCLUSIONS: Low MA was significantly associated with poor survival, especially in patients with residual tumor after PDS. MA assessment could be used for risk stratification after PDS.

Prognostic Value of the Age-Adjusted Charlson Comorbidity Index (ACCI) on Short- and Long-Term Outcome in Patients with Advanced Primary Epithelial Ovarian Cancer.

BACKGROUND: We evaluated the prognostic impact of the age-adjusted Charlson Comorbidity Index (ACCI) on both postoperative morbidity and overall survival (OS) in patients with advanced epithelial ovarian cancer (EOC) treated at a tertiary gynecologic cancer center. PATIENTS AND METHODS: Exploratory analysis of our prospectively documented tumor registry was performed. Data of all consecutive patients with stage IIIB-IV ovarian cancer who underwent primary cytoreductive surgery (PDS) from January 2000 to June 2016 were analyzed. Patients were divided into three groups, based on their ACCI: low (0-1), intermediate (2-3), and high (≥4), and postoperative surgical complications were graded according to the Clavien-Dindo classification (CDC). The Fisher's exact test, log-rank test, and Cox regression models were used to investigate the predictive value of the ACCI on postoperative complications and OS. RESULTS: Overall, 793 consecutive patients were identified; 328 (41.4%) patients were categorized as low ACCI, 342 (43.1%) as intermediate ACCI, and 123 (15.5%) as high ACCI. A high ACCI was significantly associated with severe postoperative complications (CDC 3-5; odds ratio 3.27, 95% confidence interval 1.97-5.43, p < 0.001). Median OS for patients with a low, intermediate, or high ACCI was 50, 40, and 23 months, respectively (p < 0.001), and the ACCI remained a significant prognostic factor for OS in multivariate analysis (p = 0.001). The same impact was observed in a sensitivity analysis including only those patients with complete tumor resection. CONCLUSION: The ACCI is associated with perioperative morbidity in patients undergoing PDS for EOC, and also has a prognostic impact on OS. The potential role of the ACCI as a selection criteria for different therapy strategies is currently under investigation in the ongoing, prospective, multicenter AGO-OVAR 19 trial.

Surgical management of cardiophrenic lymph nodes in patients with advanced ovarian cancer.

OBJECTIVE: Debulking surgery for advanced ovarian cancer does not routinely include opening of the thorax. Even systematic lymphadenectomy does not commonly extend to lymph nodes above the diaphragm. We evaluated the outcome of systematic resection of suspicious cardiophrenic lymph nodes detected on preoperative CT-scan in patients with advanced epithelial ovarian cancer (EOC). METHODS: Single-center, prospective series of 196 consecutive patients with EOC undergoing primary debulking surgery between June 2013 and June 2015. Suspicious cardiophrenic lymph nodes were defined as ≥10mm on the short axis diagnosed in pre-operative CT-scan and were removed if intra-abdominal debulking resulted in complete resection or residual tumor <10mm and the patients' performance status allowed this additional procedure. Removal of suspicious cardiophrenic lymph nodes was performed via a trans-diaphragmatic approach. RESULTS: Thirty (15%) out of 196 EOC patients had radiologically suspicious cardiophrenic lymph nodes ≥10mm and complete resection or residual tumor <10mm. Twenty-seven out of the thirty patients had at least one confirmed metastatic cardiophrenic lymph node. Metastatic cardiophrenic lymph nodes were associated with extensive intra-abdominal tumor spread in the upper abdomen. CONCLUSIONS: Patients with suspicious cardiophrenic lymph nodes detected by preoperative CT-scan had histologically confirmed metastasis in 90% of cases. The surgical procedure is feasible without major complications if performed by experienced gyneco-oncologists. The prognostic value of this procedure should be evaluated in larger controlled studies.

Feasibility of video-assisted bilateral neck exploration for patients with primary hyperparathyroidism and failed or discordant localization studies.

PURPOSE: Minimally invasive video-assisted parathyroidectomy (MIVAP) is generally adopted for patients affected by primary hyperparathyroidism (pHPT) with clear preoperative localization. Standard bilateral neck exploration (BNE) is considered the obligate surgery for patients with unlocalized glands. We reviewed our experience of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies. METHODS: From a prospective series of 576 MIVAP for pHPT, 107 patients (19 males, 88 females; mean age 58 years) with failed localization studies underwent BNE using the video-assisted technique. Operative time, complications, conversions to standard cervical exploration, and cure rate were analyzed. RESULTS: MIVAP with BNE was successfully completed in 99 (93 %) patients with 8 conversions. Mean operative time was 57 ± 37 min (range 20-180 min). Permanent recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 104 patients (97 %). Five patients required a reoperation in the immediate postoperative period, which achieved cure in four. Two patients remained with persistent disease; one developed recurrence disease 3 years after the first exploration. CONCLUSION: In experienced hands, video-assisted BNE for pHPT is feasible and safe and provides results equivalent to the conventional open technique.

Minimally invasive cortical-sparing surgery for bilateral pheochromocytomas.

INTRODUCTION: Cortical-sparing adrenalectomy in bilateral pheochromocytomas offers a postoperative corticoid-free course and has to be balanced against the risk of local recurrence. In this study we report our experience with the minimally invasive cortical-sparing adrenalectomy in patients with bilateral pheochromocytomas. METHODS: From January 1996 to February 2011, 66 patients (45 men, 21 women; mean age 36 ± 16 years) were treated for bilateral pheochromocytomas. Fifty-seven patients (88%) were affected by genetic diseases. In 32 patients surgery was synchronously performed on both side, in 34 cases adrenalectomy followed previous surgery. All in all, 101 operations (47 right, 54 left) were conducted using the retroperitoneoscopic access (n = 97) or the laparoscopic route (n = 4). RESULTS: The mortality in our series was zero. Postoperative complications included one patient with a bleeding requiring reoperation and one patient developing a cerebral stroke on the fifth postoperative day. The mean operative time was 67 ± 26 min for unilateral adrenalectomy and 128 ± 68 min for bilateral surgery (range 25-300 min). A cortical-sparing resection was possible in 89 procedures resulting in a corticoid-free postoperative course in 60 patients (91%). A postoperative corticosteroid substitution therapy was necessary in six patients. During a median follow-up period of 48 months, one patient showed a persistent disease and needed reoperation, none developed a recurrent disease. CONCLUSION: Cortical-sparing surgery for bilateral pheochromocytomas has a low recurrence rate and avoids lifelong cortisone substitution therapy in the majority of cases.

Evaluation of postoperative pain after minimally invasive video-assisted and conventional thyroidectomy: results of a prospective study. ESES Vienna presentation.

BACKGROUND: One of the advocated benefits of minimally invasive video-assisted thyroidectomy (MIVAT) is reduction of postoperative pain. We compared in a prospective study pain after video-assisted and conventional thyroidectomy (CT). METHODS: One hundred sixty-nine patients (56 men, 113 women, mean age: 50 ± 14 years) operated between November 2007 and February 2008 were included. MIVAT was performed if thyroid volume was <30 ml or the nodule diameter < 35 mm. Postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 100 = unbearable pain) at 8, 24, 36, and 48 h after surgery. Additionally, postoperative analgesic consumption was registered. RESULTS: Seventy-five patients (17 men, 58 women, mean age: 45 ± 15 years) underwent MIVAT and 94 (39 men, 55 women, mean age: 54 ± 15 years) CT. The mean overall VAS score at 8, 24, 36 and 48 h did not significantly differ between the groups (26 ± 21 vs. 26 ± 19 at 8 h, 17 ± 15 vs. 21 ± 18 at 24 h, 11 ± 13 vs. 10 ± 11 at 36 h and 7 ± 12 vs. 6 ± 8 at 48 h in MIVAT and CT group, respectively) [p = ns]. Twelve vs. 13 patients (16% vs. 14%) required opioid administration on the day of the operation [p = ns]. CONCLUSIONS: The length of the skin incision seems not to influence the perception of pain after thyroid surgery.

Bipolar thermofusion vessel sealing system (TVS) versus conventional vessel ligation (CVL) in thyroid surgery--results of a prospective study.

INTRODUCTION: One of the keystones in surgery of the thyroid gland is accurate hemostasis. This can be achieved by conventional ligations or new instruments as harmonic scissors or bipolar devices. In the present study, we report our experience with a new bipolar thermofusion vessel sealing system (TVS) compared to conventional vessel ligation (CVL). METHODS: This prospective non-randomized study included 186 patients operated on by two surgeons between April and November 2007. Age, gender, preoperative diagnosis, type of surgery, operative time, and complications were prospectively collected. TVS was used in 93 patients (29 M, 64 F; mean age 50+/-14 years, range 11-83) and CVL in 93 patients (27 M, 66 F; mean age 49+/-14 years, range 16-82). Results and postoperative complications were registered. RESULTS: Postoperative complications included two cases of transient hypocalcaemia in both groups 1 (TVS group) and 2 (CVL group) hemorrhages requiring reoperation (p = ns). No recurrent laryngeal nerve palsy was observed in both groups. A drain was used in 25 cases in the TVS group and in 47 patients in the CVL group (p<0.008). Mean operative time for total thyroidectomy was significantly shorter in the TVS group (73+/-18 min, range=35-110) than in the CVL group (18+/-20 min, range = 40 -130; p<0.01). No differences were found for lobectomies or subtotal thyroidectomies. CONCLUSION: TVS is safe with a similar complication rate as CVL. Mean operative time for total thyroidectomy is shortened with TVS.

Predictive factors for recurrence after thyroid lobectomy for unilateral non-toxic goiter in an endemic area: results of a multivariate analysis.

BACKGROUND: The aim of the study was to identify the factors that are predictive of recurrence after thyroid lobectomy for unilateral non-toxic thyroid goiter in an endemic region through a multivariate analysis. METHODS: Two hundred sixty-eight consecutive patients who underwent thyroid lobectomy and who were evaluated by the same endocrinologist were included. Univariate and multivariate analysis analyzed the relationship between sex, age, preoperative thyroid-stimulating hormone, duration of disease, duration of levothyroxine (LT4) preoperative therapy, cytologic results, histologic results, resected thyroid weight, numbers and diameters of thyroid nodules, morphologic alterations of the remnant lobe, follow-up length, postoperative LT4 therapy, ultrasonographic evidence of recurrence, and reoperation. RESULTS: The incidence of recurrence was 33.9% (91/268 patients) after a mean follow-up time of 79.9 months (range, 12-251 months), female sex ( P = .016), multiple nodules ( P = .017), and lack of postoperative LT4 therapy ( P = .0009) were predictive factors of recurrence. Reoperation was performed in 20 patients (7.4%); factors that were predictive of reoperation were the presence of multiple nodules ( P = .008), resected thyroid weight ( P = .00006), and lack of postoperative hormonal therapy ( P = .0005). CONCLUSIONS: Thyroid lobectomy for unilateral non-toxic goiter, when combined with suppressive or substitutive thyroxin therapy, resulted in a low rate of recurrence and reoperation in an endemic area.

Video-assisted thyroidectomy.

OBJECTIVE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained. METHODS: Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules

Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy?

BACKGROUND: Our goal was to determine whether routine oral calcium (OC) and vitamin D (VD) administration can effectively prevent symptoms of hypocalcemia after total thyroidectomy. METHODS: Seventy-nine patients who underwent total thyroidectomy were randomly allotted to one of the following groups: (1) group A, no treatment; (2) group B, OC 3 g per day; (3) group C, OC 3 g + VD 1 mg per day. Treatment was started on postoperative (PO) day 1 in groups B and C. RESULTS: Fewer patients in groups B and C experienced symptoms when compared with group A (P =.005). Patients in groups B and C had only minor symptoms, whereas 2 patients in group A experienced major symptoms and 6 required intravenous calcium (P <.01). The rate of hypocalcemia was slightly lower in group C (P = not significant). Treatment was discontinued by PO day 7 in all but 8 patients. Two patients still required treatment 6 months after operation (2.5%). PO parathyroid hormone levels did not differ in the 3 groups (P = not significant). CONCLUSIONS: Routine supplementation therapy with OC or VD effectively prevents symptomatic hypocalcemia after total thyroidectomy and may allow for a safe early discharge. Further studies are necessary to determine the best treatment. The combination of OC and VD may further reduce the rate of PO hypocalcemia, without inhibiting parathyroid hormone secretion.

Central neck lymph node removal during minimally invasive video-assisted thyroidectomy for thyroid carcinoma: a feasible and safe procedure.

BACKGROUND AND PURPOSE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT) which we proposed using also in patients with small low-risk papillary thyroid carcinomas (PTC). In some cases, enlarged lymph nodes are incidentally found at surgery for PTC. These nodes should be removed because of the risk of metastases. In this paper, we report on the patients in whom we removed enlarged central neck lymph nodes during VAT for PTC and discuss the feasibility and safety of video-assisted central neck lymph node dissection (VALD). PATIENTS AND METHODS: The procedure is performed by a totally gasless video-assisted technique through a single 1.5-to 2.0-cm skin incision above the sternal notch. Dissection is performed under endoscopic vision using a technique very similar to that of conventional surgery. Only enlarged lymph nodes were removed and sent for frozen section examination (FS). No other dissection was performed in case of negative FS. Five patients underwent VALD during VAT for PTC. RESULTS: The mean number of lymph nodes removed was 2.4. No metastases were found at FS or final histology examination. Postoperative complications included two transient postoperative hypocalcemias. No evidence of residual or recurrent disease was observed at postoperative follow-up. The cosmetic result was excellent. CONCLUSION: Our experience demonstrates that removal of central compartment lymph nodes is feasible and safe. Perhaps also complete central neck lymph node dissection can be performed. Some doubts persist about the oncologic validity of this approach. For definitive conclusions, larger series and comparative studies are necessary.

Video-assisted vs conventional thyroid lobectomy: a randomized trial.

HYPOTHESIS: Video-assisted thyroid lobectomy improves the cosmetic outcome of the cutaneous scar and reduces postoperative pain. PARTICIPANTS: Patients admitted to the Division of Endocrine Surgery of the Università Cattolica del Sacro Cuore, Rome, Italy, between March 1999 and December 2000 who were candidates for thyroid lobectomy because of a single, small (< or = 3 cm) thyroid nodule were considered eligible. Of the 62 patients who were randomized, 31 underwent conventional thyroid lobectomy (COS group), and 31 underwent video-assisted surgery without carbon dioxide neck insufflation (VAS group), a new technique created by the authors. RESULTS: The cosmetic outcome was evaluated by scoring patients' satisfaction with their scars. Satisfaction was higher in the VAS group (mean +/- SD, 9.2 +/- 0.5) than the COS group (mean +/- SD, 5.8 +/- 0.7) (P<.001). Postoperative pain in the first and second days after surgery was lower in the VAS group (mean +/- SD, 1.8 +/- 0.2 and 1.2 +/- 0.1, respectively) than in the COS group (mean +/- SD, 6.2 +/- 0.2 and 5.8 +/- 0.2, respectively) (P<.001). There were no significant differences in complications (eg, bleeding, wound infection, permanent recurrent nerve palsy). Postoperative hospital stay was lower in the VAS group (mean +/- SD, 1.1 +/- 0.1 days) than in the COS group (mean +/- SD, 2.2 +/- 0.2 days) (P<.05). CONCLUSION: Video-assisted thyroid lobectomy is a valid alternative to conventional surgery in patients with single, small nodular thyroid lesions.