In March 2016, the American Thyroid Association Surgical Affairs Committee published a literature review that defines various categories of remote-access thyroid surgery as well as optimal patient selection criteria, outcomes, and barriers to adoption of these procedures. EndocrineWeb spoke with Eren Berber, MD— lead author of the statement—to discuss highlights from the review. Dr. Berber is a Associate Professor of Surgery and Director of Robotic Endocrine Surgery at the Cleveland Clinic in Cleveland, Ohio.
Q: What are the most common remote-access thyroid procedures used in the United States?
Dr. Berber: The transaxillary and retroauricular approaches are the most commonly used remote-access procedures for thyroid surgery in the United States. At this time, the transaxillary approach is used most often, with a smaller percentage of procedures being performed using the retroauricular approach.
Dr. Berber: We determined in our review that these procedures, if done by experienced surgeons in well-selected patients, have similar safety and short-term outcomes compared with conventional thyroidectomy. However, when performed by inexperienced surgeons, the risk for complications may be increased with remote-access approaches, and the outcomes also might be negatively affected.
Q: What is the learning curve with remote-access thyroid surgery?
Dr. Berber: Our review demonstrated that the learning curve for robotic thryoidectomy is 40 cases. In addition, the surgeon must have a consistent volume of cases annually to be considered experienced. Unfortunately, because the annual volume of remote-access surgery is low in the United States, there are not many centers with this level of experience.
Internationally, there are more experienced surgeons in South Korea, where this procedure is done on a routine basis because of a more appropriate patient population. Patients in South Korea tend to have thin body habitus, and have smaller nodules and cancers, which are all indications for remote-access procedures.
Q: Which patients are the best candidates for remote-access thyroid surgery?
Dr. Berber: Selection criteria include patients who are thin, have relatively simple pathology (ie, preferably unilateral nodules without inflammation and that are ≤3 cm), and who are interested in cosmetic outcomes of their surgery.
Q: Is remote-access thyroid surgery cost-effective?
Dr. Berber: Remote-access thyroid surgery is more expensive compared with conventional surgery, because of the additional instrumentation that is necessary. However, the value of the remote-access approach depends on the value to the patient.
For patients with a history of bad wound healing, such as those with keloid or hypertrophic scars, or for whom the cosmetic appearance of the wound is very important, the additional cost of robotic-assisted thyroid surgery needs to be weighed against its value to the patient. In addition, the price of these surgeries might decrease with the introduction of newer systems in the future and with more competition in the robotics industry.
Q: What is the overall take-away message from this statement?
Dr. Berber: We concluded in the review that these procedures are more complex compared with conventional surgery; however, in experienced hands and with appropriate patient selection, these procedures result in similar outcomes compared to conventional procedures and should be regarded as a niche operation. Remote-access thyroid surgery is not better than conventional procedures, but there are certain subgroups of patients for whom this approach might be considered under certain indications.
April 27, 2016