Objective: Conventional cervical lymph node dissection often leaves large surgical scars, which seriously compromises the postoperative aesthetic effect and can affect the quality of life of patients. In this study, the safety and feasibility of robotic-assisted endoscopic thyroidectomy with central neck dissection (CND) and lateral neck dissection (LND) via a combined transoral and breast approach are discussed in detail. Materials and methods: A retrospective analysis was made of the data of 26 patients with stage cN1b papillary thyroid carcinoma who were admitted to the Thyroid Surgery Department of the Hunan Cancer Hospital from March 2021 to September 2022 and who underwent robotic-assisted endoscopic thyroidectomy with LND via a combined transoral and breast approach. The demographic data, surgical indicators, postoperative data, and the postoperative complication rate of the patients were analyzed, and the learning curve was analyzed by cumulative summation. Results: All the patients underwent endoscopic surgery without any conversion to open surgery. The mean operation time was 313.7±50.3 min and the mean number of total positive/retrieved lymph nodes was 11.2±8.1/36.8±13.7. Two patients developed temporary laryngeal recurrent nerve palsy and three patients developed temporary hypoparathyroidism, all of whom recovered within 3 months postoperatively. No tumor recurrence occurred during follow-ups that ranged from 6 to 24 months. The mean postoperative quality of life (QOL) score was 189.1±118.2, test results ranging from 0 to 1300 with a lower score indicating a higher QOL, and the aesthetic satisfaction score was 4.2±0.7, test scores ranging from 0 to 5 with higher scores indicate higher satisfaction. The turning point of the learning curve was in the 11th case. Conclusions: The robotic-assisted endoscopic thyroidectomy with CND and LND via a combined transoral and breast approach is safe and feasible, and the improved cosmetic effect is remarkable, which is conducive to improving the postoperative QOL of patients. It provides a new surgical option for patients.

Importance: With advancements in robotic surgery, robotic-assisted thyroidectomy is gaining popularity. The introduction of the 3-port transoral robotic thyroidectomy (T-TORT) offers an alternative approach with potential benefits in postoperative recovery compared to traditional methods. Objective: To assess the safety and feasibility of T-TORT in comparison to the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Design: A retrospective cohort study with 1:1 propensity score matching was conducted to compare perioperative outcomes between T-TORT and TOETVA. The learning curve was analyzed using cumulative summation (CUSUM). Setting: Tertiary A hospital. Participants: One hundred sixty-two patients who underwent either T-TORT or TOETVA were included. Intervention or Exposures: The T-TORT group underwent three-port robotic thyroidectomy, while the TOETVA group received standard transoral vestibular endoscopic thyroidectomy. Main Outcomes and Measures: Demographics and perioperative data were compared. The learning curve was evaluated using CUSUM. Results: Compared with the TOETVA group the operation time in minutes of the T-TORT group was relatively longer (136.14 ± 36.52 vs 122.49 ± 34.85, P = .012), the postoperative stay, in days, was shorter (2.77 ± 0.78 vs 3.51 ± 0.95, P < .001), the drainage volume on a postoperative day 1 (POD1) and POD2, in milliliter, was less (POD1 56.57 ± 23.29 vs 65.12 ± 26.04, P = .029 and POD2 27.43 ± 25.29 vs 38.21 ± 25.09, P = .008). The other statistics, including bleeding amount, retrieved and metastatic central lymph nodes, visual analog scale score, and drainage volume on an operative day were comparable between the 2 groups. Meanwhile, there were no significant differences between the 2 groups in postoperative complication rates. The turning point of the learning curve was in the 16th case with a hemithyroidectomy with central neck dissection (CND) and the 21st case with a bilateral thyroidectomy with CND. Conclusions and Relevance: T-TORT is a safe and feasible option with enhanced postoperative recovery compared to TOETVA. It may be a preferable choice in specific clinical situations. Trial Registration: This study was registered at the Chinese Clinical Trial Registry (UIN: ChiCTR2300069021, https://www.chictr.org.cn ) in accordance with the World Medical Association’s Declaration of Helsinki, 2013.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has recently become a hot research topic due to the advantage of leaving no scar, but, according to most centers, its indication is restricted to the size of thyroid gland. Here we report a case of a female patient with Class III goitre who successfully underwent TOETVA (video attached). A 53-year-old woman with a previous history of chest keloidosis presented with a history of neck swelling for 3 years and was diagnosed as Hashimoto’s thyroiditis with no nodules. The patient insisted that she undergo a TOETVA procedure in our hospital. Compared to the traditional TOETVA, several techniques were applied in this operation to ensure the resection and removal of the thyroid gland: with the dissection of the mental nerve and using the lateral approach to the thyroid gland. The total volume of thyroid gland was 205 mL. The operating time was 195 min. No complications were incurred. The numbness of the lip and chin was measured by the “two-points discrimination” method with several aspects (touch, pain, temperature) at different times to evaluate mental nerve injury. She felt the numbness during the first operative day but it was almost completely relieved in the third postoperative month. To our knowledge, this is the largest thyroid gland reported removed with TOETVA procedure. By carefully designing the operative steps, it is feasible to use the transoral approach in patients who have a benign thyroid disease with a Class III goitre if the patient strongly desires that operation.

This review analyzes the learning curves of various endoscopic thyroidectomy approaches, aiming to guide surgeons in improving training efficiency, reducing learning time, and enhancing surgical safety and outcomes. A literature search in PubMed and Web of Science for studies published from January 2014 to April 2024 on the learning curves of endoscopic thyroidectomy was conducted. Studies involving human subjects with specific case data were included; duplicates, non-English publications, animal studies, reviews, and unrelated thyroid conditions were excluded. A total of 47 studies were reviewed, covering various endoscopic thyroidectomy techniques. The trans-axillary procedure showed a learning curve peak between 30 and 90 cases (average 45.5 for endoscopic, 34.17 for robotic). The trans-breast/chest approach peaked between 25 and 60 cases (average 34.88). Transoral procedures peaked between 12 and 71 cases (average 37 for endoscopic, 28.63 for robotic). The bilateral axillo-breast approach (BABA) peaked at 30 cases for endoscopic surgeries and 15-51 cases for robotic-assisted surgeries (average 36.44). This study highlights the learning curve differences among various approaches to endoscopic thyroidectomy, providing valuable insights for improving training and increasing the adoption of these techniques.