1. 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

2. 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.

5. IONM

6. 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

9. Upper pole dissection
Identify recurrent laryngeal n.

10. Identify EBSLN

11. 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: /SLE.0b013e3181a4ccae 2

13. 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.

14. 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.

15. 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
( )
15.4±11.25
( )
.741
Specimen weight, mean± SD gm
15.41±22.63
( )
13.52±11.33
( )
.696
Nodular size, mean± SD cm
2.22±1.18
( )
1.78±0.93
( )
.134
Pathology, no. (%)
malignancy
7 (19.4)
9 (34.6)

16. 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. (%)

17. 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

18. 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

19. Comparisons of Three Techniques of Thyroidectomy
MIVAT
BABA robotic
conventional
Op position
supine
neck extension
incision location
neck
bilateral axilla and areola
Incision length cm cm
>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

20. 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.