Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
Surg Laparosc Endosc Percutan Tech. 2023 Dec 1;33(6):632-639. doi: 10.1097/SLE.0000000000001243.
To avoid anterior neck scarring, numerous remote-access techniques to approach the thyroid gland (Remote access approach) have been described, including the transaxillary approach (TA), bilateral axillo-breast approach (BABA), and transoral robotic thyroidectomy (TORT). Popular worldwide, Remote access approachs have unique characteristics, advantages, and disadvantages. Herein, we investigated the characteristics of these distinct thyroidectomy approaches to aid surgeons in selecting the most appropriate method for patients.
In total, 2351 cases of patients who underwent thyroidectomy between 2019 and 2021 were reviewed, including 1973, 281, 66, and 31 patients who underwent the conventional transcervical approach (TCA), TA, BABA, and TORT, respectively. Demographic characteristics, outcomes, and complications associated with these procedures were compared. The data were analyzed using the Student t test and the χ 2 test. Kruskal-Wallis and Mann-Whitney U tests were used if normality was not found.
Central lymph nodes (LNs) were retrieved mostly in patients who underwent lobectomy through TORT (mean: 9.4, P < 0.001). Metastatic central LNs were found more frequently (mean: 1.9 in lobectomy, 3.7 in total thyroidectomy) in patients who underwent lobectomy through TCA and TORT than in those who underwent lobectomy through other approaches (mean: 1.4 and 2.4, respectively, P < 0.05). BABA group patients had significantly fewer central LNs retrieved than those in other groups in lobectomy and total thyroidectomy (mean: 4.8 and 6.2, respectively, P < 0.05). Stimulated thyroglobulin levels did not differ among the 4 groups. The incidence of transient vocal cord palsy was statistically higher in the BABA group (5 cases, 7.5%) than in the other groups; however, all patients recovered. No difference was found in permanent vocal cord palsy (0.4% in TCA) or hypoparathyroidism (1.3% to 3.1%) among the 4 groups. The tumor size was significantly larger in the BABA group than in the other groups, with 10.6% of the patients having tumors larger than 4 cm. Total thyroidectomy was performed more frequently in the BABA group (51.8%) than in the other groups ( P = 0.005). The path of the external branch of the superior laryngeal nerve was more evident in TA, and the Cernea type was confirmed and preserved in 90.6% of TA cases.
Owing to the differences in working space and direction of the surgical field, TA was advantageous for preserving the external branch of the superior laryngeal nerve, whereas BABA was effective for total thyroidectomy and excision of large goiters. TORT was beneficial for central compartment neck dissection. These characteristics should be considered when choosing the best approach to improving cosmesis, function, and recurrence.
为避免颈部前方出现疤痕，已经描述了许多用于接近甲状腺的远程访问技术（远程访问方法），包括经腋窝入路（TA）、双侧腋窝-乳房入路（BABA）和经口机器人甲状腺切除术（TORT）。在全球范围内广受欢迎，远程访问方法具有独特的特点、优势和劣势。在此，我们研究了这些不同的甲状腺切除术方法的特点，以帮助外科医生为患者选择最合适的方法。
共回顾了 2019 年至 2021 年间接受甲状腺切除术的 2351 例患者的病例，包括分别接受常规经颈入路（TCA）、TA、BABA 和 TORT 的 1973、281、66 和 31 例患者。比较了这些手术的人口统计学特征、结果和并发症。使用学生 t 检验和 χ 2 检验分析数据。如果发现不符合正态分布，则使用 Kruskal-Wallis 和 Mann-Whitney U 检验。
通过 TORT 行甲状腺叶切除术的患者中，中央淋巴结（LNs）的检出率最高（平均值：9.4，P<0.001）。通过 TCA 和 TORT 行甲状腺叶切除术的患者中，中央 LN 转移的发生率（平均：1.9 在甲状腺叶切除术，3.7 在甲状腺全切除术）明显高于其他方法（平均：1.4 和 2.4，分别，P<0.05）。BABA 组患者在甲状腺叶切除术和甲状腺全切除术时的中央淋巴结检出量明显少于其他组（平均值：4.8 和 6.2，分别，P<0.05）。4 组间刺激甲状腺球蛋白水平无差异。BABA 组暂时性声带麻痹的发生率（5 例，7.5%）明显高于其他组，但所有患者均恢复。4 组间永久性声带麻痹（TCA 组 0.4%）或甲状旁腺功能减退症（1.3%至 3.1%）无差异。BABA 组肿瘤大小明显大于其他组，有 10.6%的患者肿瘤大于 4cm。BABA 组行甲状腺全切除术的比例明显高于其他组（51.8%，P=0.005）。TA 中喉上神经外支的路径更为明显，90.6%的 TA 病例可确认和保留 Cernea 类型。
由于手术野的工作空间和方向不同，TA 有利于保护喉上神经外支，而 BABA 有利于甲状腺全切除术和大甲状腺肿的切除。TORT 有利于中央隔区颈部清扫。在选择改善美容、功能和复发的最佳方法时，应考虑这些特征。
