陳維信 彭正明 楊耀坤 劉信誠 謝慶隆 達文西微創手術中心暨一般外科 中山醫學大學附設醫院 Comparisons of surgical results after minimally invasive video-assisted thyroidectomy (MIVAT) versus robot- assisted bilateral axillo-breast approach (BABA) thyroidectomy: initial experiences of single institute 陳維信 彭正明 楊耀坤 劉信誠 謝慶隆 達文西微創手術中心暨一般外科 中山醫學大學附設醫院

Introduction and Background Both MIVAT and BABA are endoscopic central access operations. But BABA is remote access endoscopic thyroidectomy. Materazzi et al. had reported cosmetic result and overall satisfaction after MIVAT(1.5cm incision) versus robot-assisted transaxillary thyroidectomy (RATT, 5-7cm incision). World J Surg (2014) 38:1282–1288 No studies have compared minimally invasive video-assisted thyroidectomy (MIVAT) and robot assisted bilateral axillo-breast approach (BABA) thyroidectomy regarding surgical outcomes.

IONM

Minimally invasive video-assisted thyroidectomy The American Journal of Surgery, Volume 181, Issue 6, 2001, 567–570 Paolo Miccoli, Piero Berti, Marco Raffaelli, Massimo Conte, Gabriele Materazzi, David Galleri

Upper pole dissection Identify recurrent laryngeal n.

Identify EBSLN

Robot-Assisted BABA Thyroidectomy Endoscopic Thyroidectomy With the da Vinci Robot System Using the Bilateral Axillary Breast Approach (BABA) Technique: Our Initial Experience. Lee, Kyu; Rao, Jaideepraj; Youn, Yeo-Kyu Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 19(3):e71-e75, June 2009. DOI: 10.1097/SLE.0b013e3181a4ccae 2

Materials and Methods Between July 2015 and February 2017, total 36 MIVAT (group A) and 26 BABA (group B) were successfully performed. Seven cases (MIVAT convert to open) were excluded and no conversion occurred in BABA group. Retrospective study with chart review was done.

Results and Discussions A total of 62 patients underwent thyroidectomy (36 in group A and 26 in group B). Seven total thyroidectomies and 29 lobectomies were in group A. Seven total thyroidectomies, 3 lobectomies with subtotal thyroidectomies and 16 lobectomies were in group B. Six men and 30 women were in group A, and 3 men and 23 women were in group B. The mean patient age was 48.9 years (group A) and 46.7 years (group B). Complications included two transient laryngeal nerve injury and one temporary hypocalcemia in each group. The mean volume of resected thyroid glands was 19.8 cc (group A) and 15.4 cc (group B). The mean nodule size was 2.2 cm (group A) and 1.8 cm (group B) without statistically significance.

Baseline characteristics of patients value MIVAT (N=36) BABA (N=26) P value Age, mean ± SD Years 48.94±10.95 (18-70) 46.69±10.70 (22-66) .423 Gender, no. (%) Male Female 6 30 3 23 BMI, median (range) 23.0±2.99 24.2±4.34 .176 Surgical extent, no. (%) Total thyroidectomy Lobectomy + sub. Lobectomy 7 (19.4) 29 (80.6) 7 (26.9) 4 (15.4) 15 (57.7) Thyroid volume, mean± SD cc 16.55±12.70 (1.9-67.9) 15.4±11.25 (5.7-58.7) .741 Specimen weight, mean± SD gm 15.41±22.63 (3.6-131) 13.52±11.33 (5.0-36.8) .696 Nodular size, mean± SD cm 2.22±1.18 (0.5-5.8) 1.78±0.93 (0.4-4.0) .134 Pathology, no. (%) malignancy 7 (19.4) 9 (34.6)

Comparisons of the surgical outcomes between two groups Complication (%) MIVAT (N=36) BABA (N=26) Temp. hypocalcemia, no. (%) 1 (2.8%) 1 (3.8%) Perm. hypocalcemia, no. (%) Temp. RLN dysfunction, no. (%) 2 (5.6%)L,T 2 (7.7%)L Perm. RLN dysfunction, no. (%) Wound infection, no. (%) Hematoma, no. (%) Chyle leakage, no. (%)

Comparison of the surgical outcomes between two groups OP time (min) MIVAT(36) BABA(26) P value 116 228 .000 Lobectomy(29) Total thyroidectomy(7) Lobectomy(15) L .000 T.042 107 155 216 261 Pain score (op day) 1.67±0.96 2.08±1.20 .139 Pain score (POD1) 0.92±0.91 1.08±0.80 .473

Selection Criteria for MIVAT and BABA Thyroid volume, cc ≦30 Nodular size, cm ≦4 Thyroiditis acceptible Substernal extension none Local invasion LN metas. Central neck Nodule pathology Benign & malignancy Prior surgery

Comparisons of Three Techniques of Thyroidectomy MIVAT BABA robotic conventional Op position supine neck extension incision location neck bilateral axilla and areola Incision length 1.5-2.5cm 1.0-2.0cm >4cm Subplatysmal flap No need +++ ++ Nerve identification + Parathyroid iden. Thyroid volume Tumor size limit 4cm any Hospital stay 2-3 days 2-3days OP time ++++ cost Cosmetic result Post-op pain Complication rate

Conclusions The minimally invasive aspect and cosmetic advantage seem to be the most important factor for the patients. We have entered the era of tailored surgery for patients who need thyroidectomy. Both MIVAT and BABA can be safely performed in selected patients undergoing thyroidectomy for benign and malignant diseases. Team work for endoscopic thyroidectomy is very important in shortening OP time.