Publications by authors named "Hoon Yub Kim"

134 Publications

Bilateral axillo-breast approach robotic thyroidectomy: review of a single surgeon's consecutive 317 cases.

Gland Surg 2021 Jun;10(6):1962-1970

Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MA, USA.

Background: Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) is one of the most popular remote-access approaches for thyroid surgery. This study aimed to evaluate the surgical outcomes of BABA RT.

Methods: Medical records of patients who underwent BABA RT between July 2008 and July 2016 were retrospectively reviewed. Surgeries were performed by one surgeon at one institution. Clinicopathological features and postoperative surgical outcomes were evaluated.

Results: A total of 317 patients were enrolled. The mean age was 40.0±9.7 years, and 287 (90.5%) were female. The mean tumor size was 1.02 cm. Papillary thyroid carcinoma (PTC) was most commonly seen (n=282, 88.8%), followed by benign nodules (n=33, 10.5%) and follicular thyroid carcinoma (n=2, 0.6%). Total thyroidectomy was performed in 202 (63.7%) patients, while unilateral lobectomy was performed in 113 (35.6%). Two patients (0.6%) had transient vocal cord palsy, but none showed permanent vocal cord palsy. Thirty-four (16.8%) patients developed hypoparathyroidism, 33 (16.3%) were transient and 1 (0.5%) was permanent. The mean operation time for total thyroidectomy and lobectomy was 264.9±52.4 and 203.4±47.6 min, respectively. A decrease in operation time in total thyroidectomy was observed in 49-51 cases (P=0.015). Four patients (1.4%) had local recurrence during the median follow-up of 61±23 months.

Conclusions: BABA RT can be performed safely in selected patients with thyroid nodules. The learning curve duration for BABA RT was 49-51 cases of total thyroidectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs-21-50DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258871PMC
June 2021

Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy.

Langenbecks Arch Surg 2021 Jul 15. Epub 2021 Jul 15.

Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China.

Introduction: The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated.

Methods: Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100μV with a stimulation level intensity of 1-2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT).

Results: The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope.

Conclusions: A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00423-021-02217-6DOI Listing
July 2021

An Improved Recurrent Laryngeal Nerve-Monitoring Device: Technical Note for NIM Vital™.

Surg Technol Int 2021 Jun 3;38. Epub 2021 Jun 3.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

A new device for monitoring the laryngeal nerves during thyroid surgery has been developed. NIM Vital™ (Medtronic Xomed, Inc., Jacksonville, FL, USA) incorporates (a) a new wireless design, (b) NIM NerveTrendTM (Medtronic Xomed) EMG reporting, (c) intelligent noise-reduction technology that suppresses artifacts, (d) smart troubleshooting pop-up alerts, and (e) NIM Nervassure ™ (Medtronic Xomed) for continuous monitoring. This device offers enhanced stability and flexibility for both intermittent and continuous laryngeal nerve monitoring. The new NIM NerveTrend ™ EMG reporting makes it possible to track the recurrent laryngeal nerve condition throughout a procedure, even when using intermittent nerve monitoring. During both continuous and intermittent monitoring, green, yellow and red status bars provide visual information and associated tones provide audible cues, making it easy to monitor nerve function and interpret EMG trends. This new tool for laryngeal nerve monitoring has the potential to augment nerve dissection during surgery. Measurements of long-term outcome are needed to establish their efficacy.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2021

C2 Xplore® for Intermittent and Continuous Laryngeal Nerve Monitoring: Technical Note.

Surg Technol Int 2021 05 27;38. Epub 2021 May 27.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

Due to the direct anatomical relationship between the recurrent laryngeal nerve (RLN) and the thyroid gland, the function and anatomical integrity of the RLN is fundamentally at risk in every thyroid operation. While a RLN morbidity rate of less than 5% is achieved in specialized clinics, the morbidity rates are significantly higher in non-specialized centers. Thus, the aim is to reduce the complication rate by establishing standardized interventions. Exact knowledge of the anatomical course of the RLN, the nerve-sparing dissection technique and the supportive use of intraoperative neuro-monitoring (IONM) to identify anatomical variations are the basis for nerve-sparing surgery. We tested the new C2 Xplore® system (inomed Medizintechnik GmbH, Emmendingen, Germany) as a tool for performing intermittent and continuous laryngeal nerve monitoring during thyroid surgery. The C2 Xplore® helps to enhance surgeon-IONM interaction, and provides comprehensive digital EMG documentation with EMG quantification. EMG artifacts are removed. Image quality and EMG feedback are highly acceptable for intraoperative monitoring. The C2 Xplore® system does not have a deleterious impact on the proper function of other surgical instruments. C2 Xplore® is effective for intraoperative monitoring, optimizing RLN dissection, and supporting surgical deliberations, and for forensic use and research. A step-by-step C2 Xplore® procedure is described.
View Article and Find Full Text PDF

Download full-text PDF

Source
May 2021

Use of Vivostat® Autologous Fibrin Sealant in Thyroid Surgery.

Surg Technol Int 2021 05 27;38. Epub 2021 May 27.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

Introduction: Post-thyroidectomy hemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. Therefore, intraoperative bleeding control and hemostasis are crucial. However, the most efficient, cost-effective, and standardized way to achieve this is not clear. This study aimed to evaluate the outcome of total thyroidectomy (TT) and partial thyroidectomy (PT) performed using the Vivostat® hemostatic system (Vivostat A/S, Lillerød, Denmark).

Methods: Patients underwent TT and PT for benign and malignant diseases (multinodular goiter, Graves' disease, differentiated thyroid carcinoma). The primary endpoint was 1st-day postoperative drain output and bleeding that required reintervention. Secondary endpoints included surgery duration and postsurgical complications (vocal fold palsy, hypocalcemia, seroma, wound infection).

Results: Between October 2020 and December 2020, 56 patients were enrolled; 69.6% female; mean age 49.5 years. The mean 24-h drain output was 40 ml. No redo surgery was needed. Seroma was present in 5.3% of cases; no permanent vocal palsy or hypocalcemia was observed.

Conclusion: This study shows that the Vivostat® system is both safe and effective for hemostasis during thyroid surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
May 2021

Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series.

Surg Endosc 2021 May 24. Epub 2021 May 24.

ARM - Center for Head and Neck Surgery and Oncology, Assuta Medical Centers, Tel Aviv, Affiliated with Ben Gurion University, Beer Seva, Israel.

Introduction: A cervical scar has been shown to have an impact on the quality of life of children undergoing thyroid surgery. Transoral endoscopic vestibular thyroidectomy via the vestibular approach (TOETVA) offers the absence of a cutaneous incision, and has not been described to date in the pediatric population.

Objective: To describe the first series of TOETVA in a pediatric population.

Patients And Methods: A retrospective, multicenter study, including all patients > 18 years old who underwent TOETVA. Data was prospectively collected and included demographics, preoperative ultrasound, cytology and indications for surgery. Intraoperative parameters included length of surgery and complications, with final pathology and postoperative course also reviewed. TOETVA surgical success was defined as completion of surgery via this approach.

Results: Forty-eight children were included. Of these, 43 (89.5%) were girls. The median age was 16 years (range 10-17). The most common indication for surgery was a benign thyroid nodule (n = 26, 54.1%). Eleven patients (22.9%) had papillary thyroid carcinoma on final pathology, of which 90.9% (10/11) were diagnosed pre-operatively based on FNA cytology. Hemithyroidectomy was performed in 36 patients (75%). All surgeries were completed endoscopically. The mean malignant tumor size was 1.4 ± 0.4 cm and all tumors were completely excised with clean margins. No permanent complications were documented. A single patient (2.1%) had transient RLN injury (1.6%, 1/60 nerves at risk). Transient hypocalcemia was documented in 4 of the 12 patients undergoing total thyroidectomy (33.3%). Transient mental nerve injury/chin hypoesthesia was documented in 2 patients (4.2%).

Conclusions: TOETVA appears to be a feasible and safe approach for thyroidectomy in the pediatric population in carefully selected cases, and may be discussed with patients and parents as an alternative for the trans-cervical approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08537-4DOI Listing
May 2021

Prevention of non-recurrent laryngeal nerve injury in robotic thyroidectomy: imaging and technique.

Surg Endosc 2021 Aug 15;35(8):4865-4872. Epub 2021 Mar 15.

Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, Changchun, 130000, People's Republic of China.

Introduction: The aim of this report was to summarize observations, evaluate the feasibility, provide detailed information concerning proper techniques, and address limitations for non-recurrent laryngeal nerve (NRLN) dissection and release during the robotic bilateral axillo-breast approach (BABA) for thyroidectomy.

Materials And Methods: The BABA approach was used in two cases of thyroidectomy in the setting of NRLN. Preoperative CT imaging findings suggesting the aberrant anatomy are reviewed and technical planning, inclusive of intraoperative nerve monitoring, was employed. Intraoperative videos with narrative discussion of technique for safe dissection are provided, along with supplementary video of additional technical guidance.

Results: In both cases, the NRLNs were identified, dissected, and preserved. We dissected the proximal segment of each NRLN to its origin. We determined that the use of only the NRLN proximal to distal robotic dissection jeopardized the nerve. The BABA approach with the Type I NRLN is similar to the dissection of the recurrent laryngeal nerve (RLN) in transoral thyroidectomy. Due to interference with endoscopic viewing caused by the thyroid cartilage, the Type I NRLN is more challenging to manage both at the laryngeal entry point and its origin from the vagus nerve (VN). For the Type II NRLN, it is essential to identify its point of origin and the reflection of the nerve from the VN. Therefore, modification of nerve dissection to mirror open surgery with bidirectional nerve dissection assisted in avoidance of traction injury to the nerve.

Conclusions: We presented a video, a detailed description of methods, and discussed limits for NRLN management in robotic BABA. This report included (i) a description of the aberrant anatomy and CT scans to inform surgeons of the possible NRLN locations, (ii) a description of a technique for using the nerve monitor in the robotic surgeries, and (iii) a description of the techniques used to isolate and protect the NRLN during the robotic surgery. In robotic BABA, our NRLN-sparing technique and degree included mainly a multi-directional nerve dissection (i.e., medial-grade, later-grade approach together with proximal to/from distal) using athermal technique. The NRLN-sparing technique is predominantly carried out in an anterior dissection plane.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08421-1DOI Listing
August 2021

Detailed comparison of the da Vinci Xi and S surgical systems for transaxillary thyroidectomy.

Medicine (Baltimore) 2021 Jan;100(3):e24370

Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea.

Abstract: Robotic surgical systems have evolved over time. The da Vinci Xi system was developed in 2014 and was expected to solve the shortcomings of the previous S system. Therefore, we conducted this study to compare these 2 systems and identify if the Xi system truly improves surgical outcomes.In this retrospective study, a total of 86 patients with unilateral papillary thyroid carcinoma without central lymph node involvement underwent gasless transaxillary hemithyroidectomy using 2 robotic systems, the da Vinci S and Xi. Forty patients were in the da Vinci S group and 46 patients were in the da Vinci Xi group. All surgeries were performed by 1 surgeon (YWC). All surgery video files were analyzed to compare the duration of each surgical step.The total operation time was significantly shorter in the Xi group than in the S group (153.0 minutes vs 105.7 minutes, P < .01). Time for robot docking was shorter in the Xi group (19.8 minutes vs 10.6 minutes, P < .01), and all procedures performed in the console also required a shorter time in this group. The overall complication rate did not differ significantly (P = .464).The da Vinci Xi system made robotic thyroidectomy easier and faster without increasing the complication rate. It is a safe and valuable system for robotic thyroidectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MD.0000000000024370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837914PMC
January 2021

Comparison of postoperative outcomes between bilateral axillo-breast approach-robotic thyroidectomy and transoral robotic thyroidectomy.

Gland Surg 2020 Dec;9(6):1998-2004

Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: The use of robotic systems for thyroidectomy has increased as it enables more diverse approaches than the conventional open method. The aim of this study was to compare the clinical outcomes of Transoral Robotic Thyroidectomy (TORT) and Bilateral Axillo-Breast Approach-Robotic Thyroidectomy (BABA-RT).

Methods: This study was designed as a retrospective study. The included patients who underwent surgery by BABA-RT or TORT approach in our facility between 2008 and 2018. All surgeries were performed by one surgeon. Total thyroidectomy with central node dissection (CND) was performed only if tumors were >4 cm and had extrathyroidal extension, clinically apparent lymph node or distant metastases. In all other cases, lobectomy ± CND was performed.

Results: The group treated with TORT comprised 248 patients and the group that underwent BABA-RT had 316 patients. The number of retrieved lymph node (LN) was higher in the TORT group (4.9±4.4 4.2±4.9; P=0.01). There were no significant differences between the TORT and BABA-RT groups in concerns to the location of the tumor. Postoperative hospital stay was also shorter in the TORT group when compared with the BABA-RT group (2.8±0.90 3.4±0.97 days, P=0.012). Operative time was significantly shorter in the TORT group (204.11±40.19 243.78±57.16 min, P<0.01).

Conclusions: When comparing a total of 248 patients treated with TORT versus 316 with BABA-RT. TORT not only has advantages in better cosmetic outcomes with minimized postoperative scars, but also shows comparable, or even superior, surgical outcomes with shorter operation time than the BABA-RT procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs-20-468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804553PMC
December 2020

Shaw scalpel use for recurrent laryngeal nerve dissection: safety parameter findings from continuous intraoperative neuromonitoring in swine models.

Gland Surg 2020 Oct;9(5):1363-1369

Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea.

Background: Precise dissection with hemostasis while preserving important structures is critical in thyroid surgeries. In this study, we tested the safety of the Hemostatix Shaw scalpel (HSS) around the recurrent laryngeal nerve (RLN) in porcine models.

Methods: Four piglets were used to obtain continuous intraoperative neuromonitoring data. The HSS was applied at various distances from the RLN, with various temperature settings. Monopolar electrosurgical pencil and Harmonic scalpel were also tested for comparison.

Results: The use of HSS did not show adverse electromyographic (EMG) events when activated at 3- and 5-mm distances from the RLN. At a 1-mm distance, adverse event was observed at 300 °C after 2 seconds of activation. At 210 °C, adverse event was observed when the instrument was directly adjacent to the RLN. For comparison, an electrosurgical pencil, set at coagulation mode (25W), showed an irreversible adverse EMG event during 5 seconds of activation at 1-mm distance from the RLN. Harmonic ACE+, activation power at level 5, was also applied in one RLN and reversable adverse EMG event was observed at <0.1-mm (contact) distance after 3 seconds of activation.

Conclusions: The safety distance of the HSS was 3 mm for the 300 °C setting and >1 mm for the 210 °C setting in the swine models in this study. Surgeons must understand the specific characteristics of various energy devices and apply them appropriately for safe operation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs-20-336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667093PMC
October 2020

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases.

World J Surg 2021 Mar 17;45(3):774-781. Epub 2020 Nov 17.

Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA.

Background: North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA).

Study Design: Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m, overweight 25-29.9 kg/m, and obese ≥ 30 kg/m for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication.

Results: Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively.

Conclusion: TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-020-05874-8DOI Listing
March 2021

Transoral robotic thyroidectomy versus transoral endoscopic thyroidectomy: a propensity-score-matched analysis of surgical outcomes.

Surg Endosc 2020 Oct 27. Epub 2020 Oct 27.

Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.

Background: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been shown to be safe and has similar outcomes as open thyroidectomy for selected patients. It is not clear if transoral robotic thyroidectomy (TORT) may extend transoral endoscopic thyroidectomy to more complex thyroid operations. The study aimed to compare the safety and outcomes of TORT with those of TOETVA.

Methods: We retrospectively reviewed all patients who had TORT and TOETVA performed by a single surgeon from June 2017 to May 2019. Intrathoracic goiter and combined operations were excluded. Surgical outcomes were compared after propensity score matching. Learning curves, as measured by operating time, were evaluated.

Results: A total of 150 patients underwent 154 transoral (55 TORT and 99 TOETVA) thyroidectomy. Of the 154 operations, 28 (18.2%) were bilateral total thyroidectomy and 126 (81.8%) were unilateral thyroid lobectomy. After propensity score matching, we found a longer operative time (median [interquartile range]) for TORT (n = 53) than for the TOETVA (308 [284-388] vs 228 [201-267] min, P < 0.001). Blood loss and visual analog scale scores for pain were not significantly different between the two groups. Central neck lymph node dissection was performed more frequent in the TORT group (28 of 53 [52.8%] vs 10 of 53 [18.9%], P = 0.001), and when performed, the numbers of total and positive lymph nodes did not differ significantly between the two groups. The rates of hypoparathyroidism and recurrent laryngeal nerve injury did not differ significantly between the two groups. There was no conversion to open thyroidectomy, mental nerve injury, or surgical site infection. The learning curve for TORT was 25 cases, but no obvious learning curve was observed for TOETVA.

Conclusions: TORT requires a longer operative time, but is as safe as TOETVA and may be useful for more complex thyroid operations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-08114-1DOI Listing
October 2020

The pros and cons of additional axillary arm for transoral robotic thyroidectomy.

World J Otorhinolaryngol Head Neck Surg 2020 Sep 30;6(3):161-164. Epub 2020 Jun 30.

Department of Surgery, Head and Neck Surgery Division, Santa Casa de Sao Paulo Medical School, Sao Paulo, SP, Brazil.

Background: Transoral vestibular approach thyroidectomy using robotic system has advantages with articulating instrumentation. Transoral robotic thyroidectomy (TORT) can be done either using just two robot arms for instruments and an extra one for the endoscopic camera, or using three robot arms for instruments (third arm through axila) and an additional arm for the camera.

Pros Of Additional Axillary Arm For Tort: The 4th arm through an additional axillary port is mainly responsible for a counter-traction of strap muscles and thyroid tissue. The additional axillary port tract is also an excellent passage for the specimen removal with lower risk of disruption or fragmentation. Ultimately, these merits from the additional axillary arm allows TORT to be performed safely in a wide range of patient groups.

Cons Of Additional Axillary Arm For Tort: One of the issue with the additional axillary arm in TORT is that it leaves a cutaneous scar. Another issue to consider is the cost. In some places, robotic surgery operation fee varies with the number of arms used during the operation. Retraction of strap muscles through subcutaneous stitches applied after establishing the working space may make up for the lack of counter-traction.

Conclusion: TORT can be done safely with or without the transaxillary arm and surgeon may consider pros and cons based on multiple factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wjorl.2020.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548390PMC
September 2020

Full percutaneous intraoperative neuromonitoring technique in remote thyroid surgery: Porcine model feasibility study.

Head Neck 2021 02 7;43(2):505-513. Epub 2020 Oct 7.

Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: In remote thyroid surgery, a reliable intraoperative neuromonitoring (IONM) procedure is an important tool for reducing injury to recurrent laryngeal nerve (RLN). This study proposes an alternative or adjunct technique for performing full percutaneous (PC) IONM and confirms its feasibility in animal experiments.

Methods: This prospective porcine model study enrolled four piglets with eight nerve sides. Evoked electromyography (EMG) was stimulated from PC ball-tip probe, and recorded from EMG endotracheal tube (ETT) and from PC paired long-needle electrodes on the perichondrium of the lateral aspect of thyroid cartilage.

Results: In all RLNs and vagus nerves, typical laryngeal EMG waveforms were successfully evoked by PC probe stimulation and recorded by both ETT and PC needle electrodes.

Conclusions: This study confirms the feasibility of the full PC IONM techniques in porcine model. However, further clinical studies are needed to compare the practicality of different remote-access approaches for thyroid surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.26500DOI Listing
February 2021

Functional Voice and Swallowing Outcome Analysis After Thyroid Lobectomy: Transoral Endoscopic Vestibular Versus Open Approach.

World J Surg 2020 Dec 11;44(12):4127-4135. Epub 2020 Aug 11.

Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea.

Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless remote-access thyroidectomy technique. This study compared subjective and objective voice outcomes and swallowing outcomes of patients who underwent thyroid lobectomy using the TOETVA versus conventional open thyroidectomy (OT).

Methods: In addition to questionnaires, acoustic and aerodynamic analyses were performed to compare subjective and objective voice outcomes of the two groups. Swallowing outcome analyses were conducted using Swallowing Impairment Index-6 (SIS-6) scores. Assessments were performed preoperatively and 3 and 6 months after surgery. Propensity score matching was performed to compare the outcomes of the two groups.

Results: One hundred and two patients were included in this study (52 TOETVA and 50 OT). Excluding two patients who had vocal cord palsy and open conversion in the TOETVA group, 100 patients completed 3-month postoperative surveys. There were no significant differences between the groups in VAS, GRBAS, or VHI-10 scores at the preoperative and 3- and 6-month assessments. For both groups, there were no significant changes in acoustic or aerodynamic parameters during the 3-6-month postoperative period. The TOETVA group had lower SIS-6 scores at the postoperative 6-month assessment, but the SIS-6 scores after 12 months were similar between groups before and after propensity score matching.

Conclusions: Following TOETVA lobectomy, there were no significant changes in voice outcomes 3 and 6 months after surgery, and the outcomes were comparable with those of OT. The TOETVA group also had swallowing outcomes that were comparable with the OT group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-020-05731-8DOI Listing
December 2020

Safety of Ligasure exact dissector in thyroidectomy with continuous neuromonitoring: a porcine model.

Gland Surg 2020 Jun;9(3):702-710

Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: The purpose of this study was to investigate and define safety parameters for using the Ligasure exact dissector (LED) for dissection close to the recurrent laryngeal nerve (RLN) during thyroidectomy.

Methods: Real-time electrophysiologic electromyographic (EMG) tracings were recorded in 16 RLNs (8 piglets) during various applications of LED under continuous intraoperative monitoring in this prospective porcine model study. In the activation study, LED was activated at varying distances from the RLN. In the cooling study, LED was activated with different cooling times or after touching the sternocleidomastoid muscle before application to the RLN.

Results: In the activation study, no adverse EMG events occurred at distances longer than 1 mm. In the cooling study, no adverse EMG events occurred after a 2-second cooling time. Additionally, no adverse EMG events occurred when a sternocleidomastoid muscle touch maneuver was used for cooling.

Conclusions: The LED can be safely used at distance of 1 mm or longer, and it should be cooled for at least 2 seconds or by muscle touch maneuver. Thyroid surgeons can avoid RLN injury if standard procedures for LED use are observed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs.2020.03.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347823PMC
June 2020

Safety parameters of ferromagnetic device during thyroid surgery: Porcine model using continuous neuromonitoring.

Head Neck 2020 10 22;42(10):2931-2940. Epub 2020 Jun 22.

Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: The ferromagnetic (FM) device is a new surgical energy modality. This study investigated dynamic recurrent laryngeal nerve (RLN) electromyographic (EMG) data to define safety parameters for using FM devices in thyroidectomy.

Methods: Real-time EMG tracings obtained under continuous neuromonitoring were recorded from 24 RLNs (12 piglets). In the activation study, FM devices were activated at varying distances from the RLN. In the cooling study, FM devices were cooled for varying time intervals, or muscle touch maneuver was performed, before contact with the RLN.

Results: During the FMwand/FMsealer activation, no adverse EMG events occurred at distances of 2 mm or longer. The cooling study revealed no adverse EMG events after 1-second (FMwand) or 3-second (FMsealer) intervals or after muscle touch maneuver.

Conclusions: An FM device should be activated at a distance of 2 mm from the RLN and should be adequately cooled before further contact with the RLN. Surgeons can avoid RLN injury by observing standard procedures for using FM devices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.26334DOI Listing
October 2020

Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy.

Oral Oncol 2020 09 8;108:104755. Epub 2020 Jun 8.

Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Republic of Korea. Electronic address:

Introduction: The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA).

Methods: The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued.

Results: Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times.

Conclusions: The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2020.104755DOI Listing
September 2020

Single port transoral thyroidectomy.

Gland Surg 2020 Apr;9(2):159-163

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs.2020.01.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225491PMC
April 2020

Feasibility of Attachable Ring Stimulator for Intraoperative Neuromonitoring during Thyroid Surgery.

Int J Endocrinol 2020 30;2020:5280939. Epub 2020 Jan 30.

Department of Internal Medicine, Seoul National University College of Medicine and Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea.

Objective: Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator.

Methods: Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point.

Results: Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500 V. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279 V, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217 V, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99 V, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2.

Conclusion: The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2020/5280939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204267PMC
January 2020

Platysmal Lineaments of the Neck With Emphasis on Endoscopic Endocrine Surgery.

Surg Laparosc Endosc Percutan Tech 2020 Aug;30(4):300-304

KUMC Thyroid Center Korea University, Anam Hospital, Seoul, Korea.

Background: In endoscopic neck endocrine surgery, the subplatysmal plane is an anatomic key structure that must be identified and preserved, to progress with the dissection. We define the prevalence of platysma, in the intermediate plane of the anterior cervical region, and evaluate potential statistical correlations with clinical and pathologic variables.

Materials And Methods: The study included patients who had thyroid surgery. Morphologies, asymmetry, and patterns of the platysma were described. The analysis of the different considered variables was quantitative and qualitative, using multiple data reports.

Results: A total of 23 men and 90 women, aged 19 to 70 (median 41±19) years constituted the study cohort. Their neck circumference and height were 388.5±45 mm (334 to 479 mm) and 200±30 mm (160 to 270 mm), respectively. The hemi-platysmal muscle was bilaterally identified in 109 (96.4%). The mean platysmal thickness was 2.7±1.7 mm (range: 0.7 to 8.2 mm). The intermediate plane between the platysmal muscles was classified into 4 types, depending on the muscle features in the midline: Type A: the left and right platysmal fibers were interlaced with each other in the midline (7%); type B: the platysmal fibers were disconnected by <1 cm (27%); type C: between 1 and 3 cm (52%); and type D separated >3 cm (14%).

Conclusions: We provide descriptive characteristics of the cervical platysma. A better understanding of the anatomic variability in cervical platysma may be useful in performing a more accurate dissection in endoscopic endocrine neck surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLE.0000000000000792DOI Listing
August 2020

Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide.

Surg Endosc 2020 08 7;34(8):3711-3721. Epub 2020 May 7.

Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China.

Background: The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket.

Methods: In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures.

Results: Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches.

Conclusion: Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-07577-6DOI Listing
August 2020

ASO Author Reflections: The Application of Transoral Robotic Thyroidectomy (TORT) for Papillary Thyroid Carcinoma.

Ann Surg Oncol 2020 Oct 6;27(10):3849-3850. Epub 2020 May 6.

Department of Surgery, Korea University Thyroid Center, Korea University College of Medicine, Seoul, Republic of Korea.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-08439-0DOI Listing
October 2020

Does Tumor Size Affect Surgical Outcomes of Transoral Robotic Thyroidectomy for Patients with Papillary Thyroid Carcinoma? A Retrospective Cohort Study.

Ann Surg Oncol 2020 Oct 6;27(10):3842-3848. Epub 2020 Apr 6.

Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.

Background: Transoral robotic thyroidectomy (TORT) for differentiated thyroid carcinoma is increasing in popularity. However, studies are limited to small tumors. This study aimed to compare the outcomes of TORT for papillary thyroid carcinomas smaller than 1 cm and 1 cm or larger.

Methods: The study analyzed 269 patients with papillary thyroid carcinoma who underwent TORT at Korea University Hospital, Korea between January 2001 and December 2017. Surgical outcomes and postoperative complications were compared.

Results: Group 1 (tumor < 1 cm) had 215 patients, and group 2 (tumor ≥ 1 cm) had 54 patients. The majority of the patients underwent lobectomy (95.8% in group 1 and 87.0% in group 2; p = 0.339) and unilateral central neck dissection (96.3% in group 1 and 88.9% in group 2; p = 0.024). The two groups did not differ significantly in terms of gender, age, body mass index, thyroiditis status, Da Vinci model. or operative procedure. The majority of the tumors in group 1 (73%) had T1a staging, whereas the majority of the tumors in group 2 were stage T1b or T3a (44.4% in each group; p = 0.000). Most of the patients in group 1 had N0 staging (59.1%), whereas most of the patients in group 2 had N1a staging (55.6%; p = 0.026). The mean operative time was significantly longer in group 2 (198.0 ± 34.2 min in group 1 vs. 215.7 ± 49.3 min in group 2; p = 0.015). The two groups did not differ significantly regarding length of stay, postoperative pain score, or thyroglobulin level. No patients experienced locoregional or distant recurrence. No statistically significant difference in overall complications was observed (p = 0.214).

Conclusions: Transoral robotic thyroidectomy is a safe and effective procedure and may be a feasible option for patients with papillary thyroid carcinomas larger than 1 cm.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-08429-2DOI Listing
October 2020

Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries.

Head Neck 2020 08 25;42(8):2106-2114. Epub 2020 Mar 25.

Head and Neck Endocrine Surgery Division, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: We evaluated the outcomes of patients with papillary thyroid carcinoma (PTC) who underwent transoral robotic thyroidectomy (TORT).

Methods: We retrospectively analyzed the perioperative outcomes of 200 patients (170 women and 30 men) with PTC who underwent TORT at a single center between March 2016 and February 2018.

Results: There were 182 and 13 cases of lobectomy and total thyroidectomy, respectively, with corresponding mean operative times of 200.6 ± 31.2 and 265.7 ± 63.0 minutes. On average, 5.6 ± 3.45 lymph nodes were retrieved per patient. There were 12 cases of perioperative morbidity. No conversion to endoscopic or conventional open surgery was noted. In a subgroup analysis for predictors of difficult TORT, patient sex was the only factor showing a significant operative time difference between a difficult and a nondifficult thyroidectomy.

Conclusion: TORT can be performed safely in patients with PTC without serious complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.26149DOI Listing
August 2020

Pre-Prototype Stimulating and Recording Endotracheal Tube for Continuous Monitoring of the Recurrent Laryngeal Nerve During Thyroid Surgery.

J Invest Surg 2020 Mar 9:1-11. Epub 2020 Mar 9.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy.

Continuous intraoperative neural monitoring (C-IONM) is a promising technology used to decrease recurrent laryngeal nerve (RLN) damage during thyroid surgery. However, C-IONM use is limited due to its challenging application. C-IONM requires dissection of the carotid sheath and placement of an electrode around the vagus nerve (VN). In our study, we simultaneously stimulated and monitored the proximal RLN trans-tracheally using surface electrodes that were positioned solely on the endotracheal tube. We described the design, implementation, and testing of a pre-prototype, combined stimulating and recording endotracheal tube (SRET) that continually delivered current from tube edge, and tested the function of the RLN at the vocal cords (VC). The SRET was tested in vivo on 10 RLNs using 5 pigs as animal models. The SRET was capable of the following, delivery of continuous trans-tracheal stimulation to the proximal RLN, continuous trans-tracheal stimulation-induced VC movement, and standard ipsilateral RLN biphasic waveforms with latency and amplitude; and recording evoked responses were recorded in the ipsilateral RLN. The pre-prototype SRET represents a possible advancement in technology because it simplified the C-IONM. Thus, the SRET provides a minimally invasive, alternative application to the C-IONM vagal nerve cuff electrodes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/08941939.2020.1734693DOI Listing
March 2020

Transoral robotic thyroidectomy versus conventional open thyroidectomy: comparative analysis of surgical outcomes using propensity score matching.

Surg Endosc 2021 01 10;35(1):124-129. Epub 2020 Jan 10.

Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).

Methods: We retrospectively reviewed and compared the medical records of consecutive patients who underwent TORT or OT for thyroid carcinoma from March 2009 to January 2018. Propensity score matching using 10 clinico-pathologic factors was used to generate two matched cohorts, each composed of 186 patients.

Results: The study included 372 patients who underwent TORT (n = 186) or OT (n = 186). Mean age, tumor size, and gender were not different between both groups. The two groups showed similar surgical outcomes, except for a longer operative time for TORT. There was one patient with immediate postoperative bleeding in the TORT group. The patient underwent re-operation for hemostasis with endoscopic approach. In the OT group, one patient had wound seroma, which was treated by several rounds of needle aspiration without infection. Vocal cord palsy was present in one patient in the TORT group, which was recovered in 3 months.

Conclusions: TORT could be performed safely and had comparable surgical outcomes with OT in the selected patients. TORT may be a suitable operative alternative for patients who do not want to leave scars on the neck.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-07369-yDOI Listing
January 2021

Neural monitoring is not a substitute to laryngeal examination in thyroid surgery.

Surgery 2020 05 15;167(5):883-884. Epub 2019 Oct 15.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi," University Hospital G. Martino, University of Messina, Via C. Valeria 1, Messina, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2019.08.019DOI Listing
May 2020

Cost and training are diffusion patterns limits for neural monitoring in thyroid surgery.

Gland Surg 2019 Aug;8(4):334-335

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs.2018.11.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723017PMC
August 2019

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO insufflation: Preclinical feasibility study.

Head Neck 2019 12 30;41(12):4229-4233. Epub 2019 Aug 30.

Head and Neck Endocrine Surgery Division, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision.

Methods: In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers.

Results: A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands.

Conclusion: In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.25939DOI Listing
December 2019
-->