Endoscopic thyroidectomy via axillary-breast-shoulder approach

(1)

Surgical Oncology 34 (2020) 318–323

Available online 4 July 2020

Original Research Article

Endoscopic thyroidectomy via axillary-breast-shoulder approach: Early experience of 42 cases

Erwin Danil Yulian

^*

, Ahmad Kurnia, Diani Kartini, Putri Arum Melati

Surgical Oncology Division, Department of Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia

A R T I C L E I N F O Keywords:

Endoscopic thyroidectomy Axillary-breast-shoulder approach Minimally invasive thyroid surgery

A B S T R A C T

Background: Most patients in Indonesia present with large-sized thyroid nodules, which need surgical removal to exclude malignancy. Many surgeons prefer endoscopic thyroidectomy to avoid a large and visible surgical scar on the neck and to reduce postoperative complications. This study aims to evaluate and analyze surgical feasibility, safety, oncologic outcome, and patient satisfaction of endoscopic thyroidectomy via the axillary-breast-shoulder approach.

Methods: Between August 2010 and September 2015, 42 endoscopic thyroidectomies via the axillary-breast- shoulder approach with carbon dioxide insufflation up to 8–10 mmHg were performed and retrospectively reviewed.

Results: Mean tumor size and operative time were 3.11 ±0.99 cm and 189 ±45 min, respectively. Mean blood loss was 68.3 mL. There were temporary complications such as hoarseness (19%), emphysema (2.3%) and hematoma (2.3%). Mean hospital length of stay was 3.98 days. Most subjects (61.9%) were very satisfied with the postoperative scar. The visual analog score of postoperative pain decreased from 4.83 on day-1 to 2.28 on day-7.

The tumor recurrence was 9.6%.

Conclusions: Endoscopic thyroidectomy via the axillary-breast-shoulder approach is feasible, safe, and minimally invasive with excellent postoperative results.

1. Introduction

For a century, Kocher’s transverse incision on the anterior neck has been widely used as the surgical approach for thyroid nodules. However, dissection in the neck region leads to scar formation and may cause problems, such as hypesthesia, paresthesia, and deglutition. The resulting scar is deemed aesthetically unpleasant, which may lead to issues in confidence and self-esteem [1,2].

Another approach is using endoscopy, namely endoscopic thyroidectomy (ET). After Gagner introduced the procedure in 1996 [1], other techniques were developed, including the axillary, breast, and anterior chest approach [3–5]. In recent years, the combination of axillary-breast approach (ABA) is the most popular method [6].

ABA requires invasive dissection, which may increase postoperative complications [7,8]. However, most patients in Indonesia present with clinically late appearance and large-sized tumors, which was defined by Pemayun et al. (2016) as tumors measuring 4 cm or greater [9]. More- over, Kartini et al. at Dr. Cipto Mangunkusumo General Hospital in

Indonesia found most (72%) of their subjects’ baseline tumor size was larger than 4 cm [10]. Large-sized tumors are regarded as a limiting factor in ET procedure [11]. To manage this limitation and minimize postoperative hematoma and pain, we performed ET using a unilateral axillary-breast-shoulder (ABS) approach with carbon dioxide (CO2) insufflation as introduced by Luong [6,12,13]. The present study aimed to evaluate and analyze surgical feasibility, safety, and patient satisfaction of postoperative scar. We focused on tumor recurrence in subjects with suspicion of malignancy.

2. Methods

This study was a cohort study that enrolled women with thyroid nodules, conducted from August 2010 to September 2015 at Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

* Corresponding author. Surgical Oncology Division, Department of Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hos- pital, Jakarta, Indonesia.

E-mail address: [email protected] (E.D. Yulian).

Contents lists available at ScienceDirect

Surgical Oncology

journal homepage: http://www.elsevier.com/locate/suronc

https://doi.org/10.1016/j.suronc.2020.05.007

Received 13 October 2019; Received in revised form 17 May 2020; Accepted 22 May 2020

(2)

2.1. Subjects

The candidates underwent routine preoperative diagnostic procedures, including clinical examinations, neck ultrasound, thyroid function tests, chest x-ray and fine needle aspiration biopsy (FNAB). Preoperative laryngoscopy was performed in subjects with voice hoarseness to assess vocal cord mobility.

The subjects selected for the ET procedure had met the following inclusion criteria: 1) benign tumor (predominant thyroid nodule less than 5 cm in diameter); 2) malignant thyroid nodule less than 2 cm in size; 3) no evidence of metastasis to the lymph node, nor local invasion;

4) normal thyroid function; 5) highly motivated subjects, who were concerned about the aesthetical results in a particular region [14,15].

We excluded candidates who had underwent surgery and irradiation, extrathyroidal extension, adjacent organ invasion, retrosternal extension, suspicion of distant metastases (as estimated on the preoperative imaging), and poor general condition.

The subjects were thoroughly briefed about surgical procedure, risks, and complications that may occur. Any preoperative comorbidities were controlled before surgery. In addition, we confirmed that they were euthyroid and fit for general anesthesia.

2.2. Surgical procedure

We adopted the Luong technique [6,12,13]. Under general anesthesia, subjects were positioned in supine anti-Trendelenburg position with the neck extended, head turned to the contralateral lesion. The sternocleidomastoid muscle (SCM), thyroid nodule, sternal notch, and the port sites were marked. The ipsilateral arm was positioned and immobilized perpendicular to the body axis. The first longitudinal 10 mm-long incision (optical port) was made at the anterior axillary fold.

The second and third incisions were 5 mm long at the 1 o’clock position on the areola and shoulder in the same triangulation. A 10 mm 0⁰scope was inserted to the optical port, followed by CO₂insufflation at the 10 mm port, maintained at 8–10 mmHg. The shoulder and areola was the insertion site of the L-Hook and the suction, respectively (Figs. 1 and 2).

Next, dissection was made in the subplatysmal space over the great pectoral muscle towards the sternal notch. The operator identified the SCM, and dissection continued to the anterior plane of SCM to separate it from the strap muscles. After identifying and moving the omohyoid muscle upward, the dissection continued to the inferior pedicle to identify the recurrent laryngeal nerve (RLN) and inferior parathyroid gland. The vessels were divided using a harmonic scalpel. The isthmus was transected, mobilized, and freed up (Fig. 3). The superior pole was identified, and the superior thyroidal vessel was divided. The specimen

was placed in the endobag and removed through the axillary port, by moving the scope to one of the 5 mm ports to guide the procedure.

Hemostasis was achieved in a controlled manner, and the surgical field was irrigated using normal saline. The author assessed RLN and drain placement before wound closure. All surgical procedures were performed by a group of surgeons.

2.3. Data collection and management

Subjects’ characteristics were obtained from the medical record, including age, tumor size, and preoperative histological findings. In addition to subjects’ characteristics, we also collected data on surgical outcomes.

2.4. Surgical outcomes

Surgical outcomes were evaluated from two perspectives; surgical parameters and the subjects’ perspective of scar satisfation.

2.4.1. Surgical outcomes

We classified the surgical outcomes into four categories. Intra- operative outcomes consist of surgery duration, estimated blood loss, and conversion to open surgical procedure. Postoperative outcomes include hospital length of stay, duration of drain placement, pain quality measured by Visual Analog Scale (VAS), and patient satisfaction of the scars’ aesthetics. The following complications were analyzed: voice hoarseness, hypocalcemia, hematoma, seroma, emphysema, and surgical site infections. A permanent RLN injury was defined as an injury that did not recover within 6 months. Seroma that required aspiration was recorded. Hypocalcemia was defined as calcium level lower than 2.1

Fig. 1. Instruments placement; white arrow shows the 5 mm shoulder port, black arrow shows the 10 mm axillary port, red arrow shows the 5 mm areolar port.

Fig. 2. L-Hook in shoulder port.

Fig. 3. White arrow shows the thyroid lobe.

(3)

mmol/L, measured 24 h postoperatively. Surgical site infections include postoperative local abscess or high-grade fever with evidence of sys- temic bacterial spread that required treatment. Oncologic outcomes included of the final histopathological diagnosis and the recurrence of the tumor.

2.4.2. Subjects satisfaction

Subjects’ satisfaction was evaluated within six months following a surgical procedure. Evaluation was performed using a scoring system, consisting of 4 point scales of satisfaction (1. Very satisfied; 2. Satisfied;

3. Unsatisfied; 4. Dissatisfied) as per Elzahaby et al. [16].

2.5. Follow-up

Subjects were monitored physically, through ultrasound, and through thyroid function test at six months intervals up to five years to evaluate recurrence. All subjects took oral levothyroxine once a day (dose 50 μg/day) to maintain a normal level of thyroid-stimulating hormone, and the dose was adjusted according to their thyroid function.

3. Results

A total of 42 subjects enrolled in this study. Most subjects were young adults with 2–4 cm tumors. Preoperative histological findings found 33 (78.7%) of them had benign nodules (Table 1).

The most performed procedure was isthmolobectomy in 31 (73.8%) subjects. Two of the 42 subjects had to undergo open thyroidectomy (OT) due to uncontrolled hemorrhage from strap muscles in one patient and due to tracheal injury in another patient. ABS procedure duration decreased from the first case to the last case (Fig. 4).

Mean operative time was 189 ±45 min; more than 180 min in the first 22 cases and less than 180 min in the last 20 cases (Table 2). As experience increased, we tended to complete the procedure in a pro- gressively shorter period. The average amount of bleeding was 68.3 ± 4.5 mL. From the aspect of postoperative pain, mean VAS on the first day showed a decreasing trend to the seventh day. The mean duration of drain placement was 3.37 ±0.14 days after surgery.

Voice hoarseness caused by temporary RLN injury, which was diagnosed by laryngoscope, occurred in 8 (19%) subjects (see Table 3).

It was the most common complication found in this study (Table 3).

During the follow up period, all of the complications, including the RLN injury, were temporary and had no permanent effect on the patients’

overall condition.

Final histopathological findings are shown in Table 4. This study found 28 (66.6%) patients had nodular goiter — no frozen biopsies were sent during surgery. In 3 subjects with papillary carcinoma, two subjects had the tall cell variant and underwent completion thyroidectomy via transcervical approach. One patient underwent an endoscopic completion thyroidectomy, while the other chose to have open surgery because they preferred not to have another endoscopic procedure. The other patient had low-risk carcinoma, therefore they did not have completion

surgery based on the American Thyroid Association’s (ATA) guideline.

Subjects’ satisfaction is shown in Table 5. A total of 26 subjects (61.9%) answered “Very Satisfied”, 14 subjects (33.3%) answered

“Satisfied”, two subjects (4.7%) answered “Unsatisfied,” and none answered “Dissatisfied.” The postoperative scar appearance is shown in Fig. 5.

Recurrence was evaluated based on the subjects’ clinical symptoms and routine imaging such as thyroid ultrasound, in 45.82 ± 1.375 months of follow-up. Four subjects (9.6%) had local recurrence; two (2.3%) on the tumor bed, and two (2.3%) on the contralateral side (see Table 6). Cervical ultrasound showed no thyroid remnants on the tumor Table 1

Subjects characteristics.

Variable Findings (N =42)

Patient age, mean ±SD (range), years 33.7 ±1.18 (21–50) Tumor Size

<2 cm 6 (14.3%)

2–4 cm 32 (76.2%)

>4 cm 4 (9.5%)

Tumor size, mean ±SD (range), cm 3.11 ±0.99 (1.4–6) Preoperative histological findings

Benign 33 (78.7%)

Atypia of Undetermined Significance (AUS) 4 (9.5%) Follicular neoplasm or suspicious for follicular neoplasm 2 (4.7%)

Suspicious for Malignancy 3 (7.1%)

Fig. 4.ABS duration of 42 cases.

Table 2

Surgical outcomes.

Variable Findings

Surgical Procedure

Isthmolobectomy 31 (73.8%)

Lobectomy 9 (21.4%)

Converted to open 2 (4.8%)

Intraoperative Outcomes

Operative Time, mean ±SD (range), minutes 189 ±45 (105–290)

First 22 cases 224 ±30 (190–290)

Last 20 cases 150 ±23 (105–175)

Blood Loss, mean ±SD (range), mL 68.3 ±4.5 (25–125) Postoperative Outcomes

Length of stay, mean ±SD (range), days 3.98 ±0.166 (3–6) Drain placement, mean ±SD (range), days 3.37 ±0.14 (2–5) VAS day one, mean ±SD (range) 4.83 ±0.13 (4–7) VAS day seventh, mean ±SD (range) 2.28 ±0.071

Table 3 Complications.

Complication N (%)

Voice hoarseness/Temporary RLN injury 8 (19%)

Hypocalcemia 0

Seroma 2 (4.7%)

Skin bruising/Hematoma 1 (2.3%)

Subcutaneous emphysema 3 (7.1%)

Tracheal injury 1 (2.3%)

Surgical site infection 0

Hypertrophic scar 3 (7.1%)

Table 4

Final histopathological findings.

Histopathology N (%)

Nodular goiter 28 (66.6%)

Cystic lesion 4 (9.5%)

Follicular adenoma 2 (4.7%)

Papillary microcarcinoma 5 (11.9%)

Papillary carcinoma 3 (7.2%)

(4)

bed, contralateral side, nor lymph node involvement in any of these subjects.

4. Discussion

The first endoscopic neck surgery was introduced by Gagner (1996) and developed by Huscher (1997) [1]. Since then, surgeons have performed other endoscopic methods, including transoral, retroauricular, axillary, breast, and anterior chest approaches [3–5], with different advantages and disadvantages of each of the approach. Better aesthetic results are observed in the transoral and retroauricular approach, but these approaches have difficult learning curves due to the different anatomical view [17]. The anterior chest approach has good surgical view, but it is known as the predilection site of hypertrophic scar and keloid [18]. Axillary-breast approach is the most popular technique among others since it provides good surgical view and acceptable postoperative scar [6].

However, ABA requires invasive tissue dissection, which might increase the incidence of postoperative complications [8,19,20]. Koh et al.

found some subjects experienced temporary vocal cord palsy (6,9%), hematoma (3,4%), and seroma (13,8%) following ABA [19]. In another study, Lee noted that postoperative complications occurred in 5,8% of their ABA patients; half of them experienced temporary vocal cord palsy, while the other half had seroma. They observed several possible complications, such as permanent vocal cord palsy, hemorrhage, and wound infection, but none occurred during the study [20]. Irawati noted that temporary shoulder discomfort and neck swelling disappeared after 7–10 postoperative days. No seroma, hypocalcemia, and permanent recurrent laryngeal nerve paralysis occurred during the study [8].

In Indonesia, most patients come with clinically late appearance and

large-sized thyroid nodules. Therefore, this study performed the combination of ABS approach with CO₂insufflation, as introduced by Luong to overcome the tumor size, and also to minimize postoperative complications [6,12,13]. Reunmarkkaew in 2018 noted that intraoperative blood loss and postoperative pain was less severe after ABS when compared to OT, even though there was not any statistically significant difference in complication rate between ABS and OT, including hematoma, vocal cord dysfunction, dysphagia, prolonged subcutaneous emphysema, and infection [6].

All subjects in this study were women, with a mean age of 33 years old. The present study found the feasibility, safety, and scar satisfaction resulting from the ABS approach. In consideration of suspicion for malignancy, we followed a follow-up period of five years.

Even though ET and conventional OT use the same basic principles of thyroid surgery, they have differences in the anatomical view used. Our study, which described our early experience of performing ET with ABS approach, found there was a learning curve for ET. Learning curve refers to the number of cases a surgical team member needs to perform before the surgery duration and complication rate becomes minimal [21]. We showed that the team overcame the learning curve after the first 22 cases. After that, it took less than 3 h for each surgery. The mean surgery duration was 189 ±45 min for all 42 cases. Cao et al. had surgery speed improvement after the first 25 cases, and Kwak et al. reached the learning curve after 60 lobectomies and 38 total thyroidectomies [21, 22]. Meanwhile, a study by Liu et al. reported that proficiency and stability during the surgery were reached after 150 cases [23].

The mean tumor size in this study was 3.11 ±0.99 cm and the surgery duration tended to be longer when removing the larger tumors.

This study had four cases of >4 cm tumors, including the largest one (6 cm), which took more than 3 h of surgery to remove. The subject with the largest nodule expressed a strong preference to have minimal and hidden postoperative scar. Therefore, we managed to perform endoscopic surgery on the subject despite the difficulty. In large-sized tumor management, several studies have reported success of removing them through the transaxillary approach and 3D endoscopy, considering 3D endoscopy has better depth perception and magnification [11,24].

Meanwhile, Johri et al. reported no significant difference between ≥6 cm nodules and smaller nodules in surgery duration as long as it was performed by trained hands [25].

Nevertheless, the speed of surgery is not a parameter of a successful surgery. Patient safety is the priority, in order to minimize mortality and complications. Even though this study reports our early experience, no mortality occurred and complications were minimal and temporary. The most common complication was voice hoarseness, which was diagnosed by laryngoscopy. Preoperative laryngoscopy was only performed on subjects with voice hoarseness to assess vocal cord mobility. Post- operatively, all of the subjects underwent laryngoscopy on the second week after surgery to evaluate the vocal cord. Total of eight subjects (19%) had postoperative hoarseness, which was temporary and recovered within 3 months. One subject had spontaneous recovery on the second week of postoperative period, five subjects recovered on the eighth week, and the remaining subjects recovered after 3 months of surgery. No subjects had to redo the surgery. All of the 8 subjects received conservative therapy (anti-inflammatory, neurotropic drugs and speech physiotherapy) and monthly follow-up for up to 6 months post-surgery. A recent study reported that RLN palsy following ET might occur due to thermal damage caused by the ultrasonic scalpel, or due to the unfamiliar anatomical approach compared to conventional thyroid surgeries [26]. In this study, we believe that the voice hoarseness/RLN palsy was associated with endotracheal tube injury, postoperative inflammation, and edema. As the surgery itself consists of manipulation of the thyroid gland, the injury may be caused by thermal damage due to harmonic scalpel usage or traction injury during the RLN dissection.

Previous studies reported that Intraoperative Nerve Monitoring (IONM) usage may lower the incidence of permanent RLN injury compared to nerve visualization alone, consequently increasing the cost of surgery Table 5

Subjects’ overall satisfaction.

Scar appearance satisfaction scale (6 months) Value (N =42)

Very Satisfied 26 (61.9%)

Satisfied 14 (33.3%)

Unsatisfied 2 (4.7%)

Dissatisfied 0 (0)

Fig. 5. White arrows show minimal scar appearance; black arrow shows no scar on the anterior neck.

Table 6

Treatment outcome (recurrence).

Recurrence Value (N =42)

No 38 (90.4%)

Yes 4 (9.6%)

Location:

Tumor bed 2 (2.3%)

Contralateral side 2 (2.3%)

Port entry/surgical site 0

Lymph node 0

(5)

[27,28]. Meanwhile, Gremillion et al. compared the number of RLN palsy with and without using IONM which resulted in 4.9% and 2.5%

rate of nerves injured, respectively [28]. IONM was not used in our study, and we found eight (19%) temporary hoarseness which had no permanent effect on the subjects’ overall condition. Another recent study concluded that IONM is potentially helpful, but still depends on the surgeon’s technique to protect and visualize the RLN [28].

In order to maintain good visualization of RLN and overcome diffi- culties in handling the instruments, we used CO2 insufflation to maintain the working area. However, we recognize that subcutaneous emphysema may happen as an adverse effect of CO2 insufflation [29]. We used 8–10 mmHg CO2 pressure in all cases, due to our early experience. There were three (7.1%) subjects who experienced temporary emphysema at 8–10 mmHg CO2 pressure. Chand et al. found no case of emphysema and hypercarbia at 7 mmHg CO₂pressure and Ochiai et al. reported minimal emphysema occurred even at lower CO2 pressure (6 mmHg) [30,31]. A recent study concluded that lower CO2 insufflation pressure, intensive end-tidal CO₂monitoring (EtCO₂), intraoperative arterial blood gas analysis, intermittent insufflation, shorter operative time, and proper patient selection could eliminate the risk of CO2-related complications [31].

There were two subjects (4.8%) who underwent conversion surgery to OT due to bleeding from the nodule’s surface and superior thyroid vessels in the third case, and tracheal injury in the ninth case. One patient experienced tracheal injury in the form of a 1 cm perforation of the anterior side. The injury was detected early during the procedure, and the surgeon swiftly converted to open surgery. The injury healed well during the follow-up period. Another patient experienced primary hemorrhage from strap muscles. The decision to convert to open repair was made due to inability to secure the hemorrhage. The patient later recovered and was in good condition during follow-up. Both patients were among the first 9 patients of this study, early in the learning curve.

We consider the blood loss, length of stay, drain placement, emphysema, postoperative pain, seroma, hematoma observed in our study were within a good range. The average amount of bleeding in our study was 68.3 ±4.5 mL. The mean length of stay and drain placement was 3.98 ±0.166 days and 3.37 ±0.14 days, respectively. This study found the mean postoperative VAS on day-1 was 4.83 ±0.13 and it decreased to 2.28 ±0.071 on day-7. There was one (2,3%) case of a hematoma and seromas found in two (4.7%) subjects which were resolved by needle aspiration without compression dressings. There was no hypocalcemia found in this study.

A previous study reported that most subjects (75%) preferred the extra-cervical “scar-less neck” approach [32]. In this study, all of the subjects were young adult women who were concerned about postoperative scar appearance, and wished to have minimal scarring.

Therefore, this study analyzed the subjects’ satisfaction of their postoperative scars, which were almost invisible (Fig. 4) during the follow-up period. Most subjects (61.9%) scored “Very satisfied” regarding their scars’ appearance. Muthukumar et al. also reported that subjects who underwent ET were happier with their scars than the ones who underwent conventional OT [33].

The follow-up continued for five years after the postoperative period, considering there were five subjects (11.9%) with papillary thyroid microcarcinomas (PTMC), and three subjects (7.2%) with papillary thyroid carcinomas (PTC). Completion thyroidectomy is not always necessary in PTMC, and thyroid lobectomy alone may be sufficient treatment for small (<1 cm) and low-risk PTC [34]. Initially, ET was feasible for benign thyroid nodules and was still controversial for malignancy cases management [35]. Kitano et al. did a study of ET in malignant cases, with the following inclusion criteria [1]: Age <45 years [2], tumor size <2 cm, and [3] no evidence of lymph node or local invasion [36]. Recently, several comparative studies reported no significant differences in technical safety between OT and ET in malignancy, but ET showed more advantages, including better aesthetic result [35, 37,38].

In our study, four (9.6%) out of 42 subjects have local recurrence.

Neither spillage nor tumor seeding was found on tumor bed, tract and subcutaneous tunnel of the port insertion site. The patients who experienced recurrence did not properly consume their suppression medi- cation regiments. Two patients were found to have contralateral recurrence around 8 months after the surgery. Histopathologically, the small nodules were determined as previously-present goiters. Moreover, multicentricity is a common feature of papillary thyroid carcinoma [39].

Kim et al. and Jung et al. reported cases of tumor seeding around the tumor bed and subcutaneous tunnel, due to tumor spillage during tumor manipulation [40,41]. Another cohort study of 31 months on post-endoscopic hemithyroidectomy patients showed multiple bean-sized lesions throughout the insertion port, in addition to PTMC being found in the contralateral gland [42]. Kim et al. concluded that traumatic handling of the tumor and unfamiliarity of the endoscopic technique were the predisposing factors of port site seeding [40]. From a biomolecular aspect, Wang et al. reported both conventional and endoscopic surgery did not significantly differ in regards of the degree of surgical damage, which was shown by the presence of inflammatory markers, including interleukin-6, tumor necrotic factor, C-reactive protein, and cortisol [43].

A surgical technique, however, has both advantages and disadvantages. A recent study noted that the disadvantages of ET were as follows:

the equipment handling requires two to three assistants, longer operative time, harder in larger tumor size, and higher cost [15,44].

In comparison to ABS, the authors have received patients’ concerns regarding the tract of ABA, which may affect imaging that was typically used in early detection of breast nodules. Since the start of this study, newer endoscopic techniques have been proposed, such as transoral endoscopic thyroidectomy vestibular approach (TOETVA) by Anuwong [17]. Concerns about this approach are the possible contamination and infection from the mouth. It may also be difficult to take out larger nodules with this method.

5. Conclusion

This study found that the ABS approach is feasible, safe, and aesthetically acceptable as an alternative to conventional open thyroidectomy. However, this technique requires a surgeon who is also experienced in conventional OT, in order to minimize the number of mortality and complication in ET. It is still too early to evaluate recurrence since the study’s follow-up period was only five years. Thus, we recommend an extended follow-up period up to ten years and a larger case volume to provide a better representation of subjects who receive the ABS approach.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

EDY guarantees the integrity of the study. EDY, AK and DK contributed in study conception, methodology, surgical procedure, and data collection. EDY and PAM contributed in data analysis, drafting the article, writing-reviewing and editing the manuscript.

Disclosure

All authors have no conflict of interest.

Acknowledgements

The authors thank all the operating room crew, surgical oncology training fellowship participants, surgical residents, and the research unit

(6)

of Department of Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

References

[1] C. Christoforides, G. Dionigi, I. Vasileiou, K. Vamvakidis, Erratum: a historical account for thyroid surgery, J Endocr Surg 18 (2) (2018) 171.

[2] S. Sarkar, S. Banerjee, R. Sarkar, B. Sikder, A review on the history of ‘thyroid surgery, Indian J. Surg. 78 (1) (2016) 32–36.

[3] M. Ohgami, S. Ishii, Y. Arisawa, T. Ohmori, K. Noga, T. Furukawa, et al., Scarless endoscopic thyroidectomy: breast approach for better cosmesis, Surg. Laparosc.

Endosc. 10 (1) (2000) 1–4.

[4] Y. Ikeda, H. Takami, M. Niimi, S. Kan, Y. Sasaki, J. Takayama, Endoscopic thyroidectomy by the axillary approach, Surg. Endosc. 15 (11) (2001) 1362–1364.

[5] K. Shimazu, E. Shiba, Y. Tamaki, S. Takiguchi, E. Taniguchi, S. Ohashi, et al., Endoscopic thyroid surgery through the axillo-bilateral-breast approach, Surg.

Laparosc. Endosc. Percutaneous Tech. 13 (3) (2003) 196–201.

[6] D. Reunmarkkaew, P. Sittitrai, Endoscopic thyroid lobectomy via axillary-breast- shoulder approach versus open thyroid lobectomy, Surg. Sci. (2018) 8–16, 09(01).

[7] H. Lee, J. Lee, K.Y. Sung, Comparative study comparing endoscopic thyroidectomy using the axillary approach and open thyroidectomy for papillary thyroid microcarcinoma, World J. Surg. Oncol. 10 (2012) 1–7.

[8] N. Irawati, Endoscopic right lobectomy axillary-breast approach: a report of two cases, Int J Otolaryngol 2010 (2010) 1–4.

[9] T.G.D. Pemayun, Current diagnosis and management of thyroid nodules, Acta Med.

Indones. 48 (3) (2016) 247–257.

[10] D. Kartini, G. Wibisana, Accuracy of triple diagnostic test in patients with thyroid nodule at Dr. Cipto Mangunkusumo general hospital, eJournal Kedokt Indones 5 (1) (2017).

[11] S. Puntambekar, V. Sharma, S. Kumar, S. Mitkare, G. Joshi, A. Dokrimare, et al., Management of large size MNGs and STNs using 3D endoscopic technique: a review of 10 cases, Indian J. Surg. 78 (2) (2016) 117–120.

[12] Nhan Dan Online, Dr Luong thyroid laparoscopy technique honoured with Vietnam record [Internet] [cited 2020 Feb 3]. Available from: https://en.nhandan.com.

vn/society/health/item/7658302-dr-luong-thyroid-laparoscopy-technique-hono ured-with-vietnam-record.html, 2019.

[13] Tuoi Tre News, A Doctor for Goiter Patients [Internet], 2012 [cited 2020 Feb 3].

Available from: https://tuoitrenews.vn/charity/856/a-doctor-for-goiter-patients.

[14] Y.S. Kim, K.H. Joo, S.C. Park, K.H. Kim, C.H. Ahn, J.S. Kim, Endoscopic thyroid surgery via a breast approach: a single institution’s experiences, BMC Surg. 14 (2014) 49.

[15] Y. Yang, X. Gu, X. Wang, J. Xiang, Z. Chen, Endoscopic thyroidectomy for differentiated thyroid cancer, Sci. World J. 2012 (2012).

[16] I.A. Elzahaby, A. Fathi, K. Abdelwahab, O. Eldamshiety, I.H. Metwally, A. Abdallah, et al., Endoscopic thyroidectomy using the unilateral axillo-breast approach versus the modified anterior chest wall approach: a prospective comparative study, Surg. Laparosc. Endosc. Percutaneous Tech. 28 (6) (2018) 366–370.

[17] A. Anuwong, H.Y. Kim, G. Dionigi, Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences, Gland Surg. 6 (3) (2017) 277–284.

[18] Y.U. Cho, I.J. Park, K.H. Choi, S.J. Kim, S.K. Choi, Y.S. Hur, et al., Gasless endoscopic thyroidectomy via an anterior chest wall approach using a flap-lifting system, Yonsei Med. J. 48 (2007) 480–487.

[19] Y.W. Koh, J.H. Park, J.W. Kim, S.W. Lee, E.C. Choi, Endoscopic hemithyroidectomy with prophylactic ipsilateral central neck dissection via an unilateral axillo-breast approach without gas insufflation for unilateral micropapillary thyroid carcinoma:

preliminary report, Surg. Endosc. 24 (1) (2010) 188–197.

[20] M. Lee, J. Mo, I. Choi, B. Lee, G. Lee, New endoscopic thyroidectomy via a unilateral axillo-breast approach with gas insufflation: preliminary report, Head Neck 35 (4) (2013) 471–476.

[21] F. Cao, K. Jin, B. Cui, B. Xie, Learning curve for endoscopic thyroidectomy: a single teaching hospital study, OncoTargets Ther. 6 (2013) 47–52.

[22] H.Y. Kwak, S.H. Kim, B.J. Chae, B.J. Song, S.S. Jung, J.S. Bae, Learning curve for gasless endoscopic thyroidectomy using the trans-axillary approach: CUSUM analysis of a single surgeon’s experience, Int. J. Surg. 12 (12) (2014) 1273–1277.

[23] S. Liu, M. Qiu, D.Z. Jiang, X.M. Zheng, W. Zhang, H.L. Shen, et al., The learning curve for endoscopic thyroidectomy: a single surgeon’s experience, Surg. Endosc.

23 (8) (2009) 1802–1806.

[24] R.S. Rao, T.D. Duncan, Endoscopic total thyroidectomy, J. Soc. Laparoendosc.

Surg. 13 (4) (2009) 522–527.

[25] G. Johri, G. Chand, N. Gupta, C. Sonthineni, A. Mishra, G. Agarwal, et al., Feasibility of endoscopic thyroidectomy via axilla and breast approaches for larger goiters: widening the horizons, J. Thyroid Res. 2018 (2018). September 2012.

[26] C. Chen, S. Huang, A. Huang, Y. Jia, J. Wang, M. Mao, et al., Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis, Therapeut. Clin. Risk Manag. 14 (2018) 2349–2361.

[27] M. Barczynski, A. Konturek, K. Pragacz, A. Papier, M. Stopa, W. Nowak, ´ Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study, World J. Surg. 38 (3) (2014) 599–606.

[28] G. Gremillion, A. Fatakia, R.G. Amedee, A. Dornelles, Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it worth the cost? Ochsner J. 12 (4) (2012) 363–366.

[29] I.J. Choi, N.Y. Kim, K.H. Kim, B.-C. Lee, G.-H. Lee, M.-C. Lee, Comparative study of unilateral axillo-breast approach with gas insufflation versus gasless transaxillary approach for endoscopic thyroidectomy in a single institute, Korea J. Otorhinol.

Neck Surg. 59 (12) (2016) 848–855.

[30] R. Ochiai, J. Takeda, J. Noguchi, M. Ohgami, S. Ishii, Subcutaneous carbon dioxide insufflation does not cause hypercarbia during endoscopic thyroidectomy, Anesth.

Analg. 90 (3) (2000) 760–762.

[31] V. Aggarwal, B.K. Raja, M. Garg, D. Khandelwal, B. Agarwal, Endoscopic thyroidectomy- preliminary experience from a tertiary care center in Delhi, India, US Endocrinol. 13 (1) (2017) 27–29.

[32] A. Arora, C. Swords, G. Garas, K. Chaidas, A. Prichard, J. Budge, et al., The perception of scar cosmesis following thyroid and parathyroid surgery: a prospective cohort study, Int. J. Surg. 25 (2016) 38–43.

[33] R.P. Muthukumar, V. Vishwanath, A. Prathap, M. Ibrahim, Transaxillary endoscopic hemithyroidectomy versus open hemithyroidectomy for solitary thyroid Nodule : a randomized study 4 (6) (2016) 79–82.

[34] D.S. Cooper, G.M. Doherty, B.R. Haugen, R.T. Kloos, S.L. Lee, S.J. Mandel, et al., Revised American thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer, Thyroid 19 (11) (2009) 1167–1214.

[35] G. Sgourakis, G.C. Sotiropoulos, M. Neuh¨auser, T.J. Musholt, C. Karaliotas, H. Lang, Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: is there any evidence-based information?

Thyroid 18 (7) (2008) 721–727.

[36] H. Kitano, M. Fujimura, T. Kinoshita, H. Kataoka, M. Hirano, K. Kitajima, Endoscopic thyroid resection using cutaneous elevation in lieu of insufflation, Surg Endosc Other Interv Tech 16 (1) (2002) 88–91.

[37] J.J. Jong, S.W. Kang, J.S. Yun, Y.S. Tae, C.L. Seung, S.L. Yong, et al., Comparative study of endoscopic thyroidectomy versus conventional open thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients, J. Surg. Oncol. 100 (6) (2009) 477–480.

[38] Y.S. Chung, J.H. Choe, K.H. Kang, S.W. Kim, K.W. Chung, K.S. Park, et al., Endoscopic thyroidectomy for thyroid malignancies: comparison with conventional open thyroidectomy, World J. Surg. 31 (12) (2007) 2302–2306.

[39] X.J. Zhang, T. Yang, S.H. Li, D. Liu, D Bin Xu, H. Li, et al., Multicentric papillary thyroid carcinoma: a clinical analysis of 221 patients, Int. J. Clin. Exp. Pathol. 9 (5) (2016) 5680–5686.

[40] H. Kim, T.H. Kim, J.-H. Choe, J.-H. Kim, J.S. Kim, Y.L. Oh, et al., Patterns of initial recurrence in completely resected papillary thyroid carcinoma, Thyroid 27 (7) (2017) 908–914.

[41] J.S. Jung, S.Y. Kim, H.Y. Jung, S.W. Han, J.E. Lee, D.Y. Lee, Simultaneous seeding of follicular thyroid adenoma both around the operative bed and along the subcutaneous tunnel of the upper chest wall after endoscopic thyroidectomy, J Korean Soc Radiol 76 (2) (2017) 138.

[42] S.M. Hur, S.H. Kim, S.K. Lee, W.W. Kim, J.H. Choi, J.H. Kim, et al., Is a thyroid follicular neoplasm a good indication for endoscopic surgery? Surg. Laparosc.

Endosc. Percutaneous Tech. 21 (3) (2011) 148–151.

[43] M. Wang, T. Zhang, Z. Mao, F. Dong, L. Jianwen, L. Aiguo, et al., Effect of endoscopic thyroidectomy via anterior chest wall approach on treatment of benign thyroid tumors, World J Laparosc Surg with DVD 19 (2) (2008) 13–16.

[44] S.V. Dhiman, W.B. Inabnet, Minimally invasive surgery for thyroid diseases and thyroid cancer, J. Surg. Oncol. 97 (8) (2008) 665–668.