Comparison of endoscopic surgical approaches for total thyroidectomy: a systematic review and Bayesian network meta-analysis

Introduction

Thyroid cancer, the most common endocrine carcinoma, is mainly treated with surgery (1). Surgical treatment can effectively improve patient prognosis and even achieve a clinical cure (2). Although traditional open thyroidectomy (OT) has demonstrated efficacy, it is burdened by a conspicuous neck incision, which often results in cosmetic concerns for patients. Furthermore, recognizing that a majority of patients with thyroid cancer are young women and the need for less invasive approaches is of importance to improve cosmetic outcomes, endoscopic thyroidectomy (ET) has gained significant attention and advancements in recent years.

Hüscher et al. pioneered the technique of ET in 1997, marking an important milestone in the field of minimally invasive thyroid surgery (3). This endoscopic approach aimed to minimize visible scarring and enhance patient satisfaction. Since then, a diverse range of ET approaches has been developed and refined globally. These common surgical approaches include endoscopic transoral approach (EOA), endoscopic gasless transaxillary approach (EGAA), endoscopic bilateral areola approach (EBAA), minimally invasive video-assisted approach (MIVAA), and endoscopic bilateral axillo-breast approach (EBABA). Each of these approaches has unique advantages and limitations.

We performed a network meta-analysis (NMA) to obtain a comprehensive and objective understanding of the strengths and weaknesses of various endoscopic surgical approaches for total thyroidectomy. By systematically reviewing and synthesizing data from multiple sources, NMA facilitates indirect comparisons among various surgical approaches, particularly when direct comparisons are limited or unavailable. Our findings can assist clinicians and decision-makers in better understanding the relative effectiveness of each surgical approach, which holds significant clinical value. We present this article in accordance with the PRISMA reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-24-424/rc).

Methods

Literature search strategy

This network meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO, ID: CRD42024537828). We performed a systematic literature search across several databases, including PubMed, Medline, Cochrane Library, Web of Science, and EMBASE, up to March 2024, to identify all relevant studies. The keywords were (“Differentiated thyroid cancer” OR “Thyroid malignancy” OR “Thyroid carcinoma” OR “Thyroid cancer”) AND (“Thyroidectomy” OR “Conventional thyroidectomy” OR “Open thyroidectomy” OR “Endoscopic thyroidectomy” OR “Video-assisted surgery” OR “Laparoscopy”). In addition, we carefully examined the reference lists of the retrieved articles to find any additional eligible studies.

Two independent reviewers conducted the literature search, resolving any disagreements through discussion and consensus. We reviewed the abstracts of the retrieved studies and excluded those identified as irrelevant. The full texts of the remaining studies were examined to finalize the selection of eligible articles, and we resolved the discrepancies through discussion with a third reviewer.

Inclusion and exclusion criteria

The inclusion criteria for study selection were as follows: (I) study design: observational study. (II) Population: patients diagnosed with differentiated thyroid cancer and underwent total thyroidectomy. (III) Intervention: studies that compare two or more surgical approaches, including OT and ET. (IV) Outcomes: studies reporting at least one of the specified outcomes listed below: number of retrieved lymph nodes (LNs), operative time, intraoperative bleeding volume, hospital stay, the incidence of transient or permanent hypoparathyroidism, and transient recurrent laryngeal nerve (RLN) palsy rate. (V) Language: studies published in English.

The exclusion criteria included the following: (I) reviews, letters to the editor, case reports, and others; (II) other types of thyroid cancer; (III) patients underwent unilateral or subtotal thyroidectomy; (IV) the duplicate articles.

Data extraction and quality evaluation

The methodological quality of observational studies was assessed using the Newcastle-Ottawa Scale (NOS) (4), which consists of three key subscales: selection of study groups (0–4 points), comparability of groups (0–2 points), and assessment of outcomes (0–3 points). A score ranging from 4 to 6 was classified as moderate, whereas a score of 7 or above was considered to represent high quality. Two reviewers conducted a comprehensive review of the full text, performed quality assessments, and extracted data. In discrepancies, consensus was reached through consultation with a third reviewer and thorough data comparison.

The extracted data included: (I) study information: first author, publication year, country, number of patients, age, sex, surgical approaches, extent of surgery, and study design; (II) surgical outcomes: the number of retrieved LNs, operative time, intraoperative bleeding volume, and hospital days; (III) surgical complications: transient RLN palsy, transient hypoparathyroidism, and permanent hypoparathyroidism.

Meta-analysis

This network meta-analysis adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) guidelines (5,6).

Statistical analysis

Pairwise meta-analysis (PMA)

The PMA were performed for direct comparisons reported at least twice using STATA statistical software (version 14.0; StataCorp, College Station, TX, USA) (7). For continuous data, the analysis used the mean difference (MD) and its corresponding 95% confidence interval (CI). In contrast, dichotomous data were assessed using the odds ratio (OR) along with the associated 95% CI. The heterogeneity of effect sizes among the studies was assessed using the Q statistic and the I² statistic. A P value <0.05 in the Q statistic indicated significant heterogeneity, while an I² value >50% was considered indicative of substantial heterogeneity. If significant heterogeneity was observed, a random-effects model was applied. Otherwise, a fixed-effects model was used for the meta-analysis.

Methods of evidence synthesis in NMA

Bayesian network meta-analysis was conducted using Markov Chain Monte Carlo (MCMC) methods in JAGS version 4.3 to allow indirect comparisons among treatment interventions. The resultant effects were reported as posterior median MD or I with the corresponding 95% credible intervals (CrIs). The analysis was conducted with 2,000 burn-ins, 40,000 iterations, and 20,000 adaptations. After completing these steps, the model’s fit was evaluated using a leverage diagram. The fit of the random-effects and fixed-effects models was compared using the deviance information criterion (DIC), with a lower DIC indicating a better-fitting model (8). The posterior mean deviance contributions of individual data points were plotted for the consistency model versus the inconsistency model to assess inconsistency. The surface under the cumulative ranking curve (SUCRA) and the mean ranks were used to rank treatments for each outcome. SUCRA, a simple transformation of the mean rank, is used to provide a hierarchy of the treatments and accounts both for the location and the variance of all relative treatment effects. The larger the SUCRA value, the better the rank of the treatment. A sensitivity analysis was performed by sequentially excluding each included study to assess whether this affected the overall results. Publication and reporting biases were evaluated using adjusted funnel plots and the Egger test. All statistical analyses were carried out in R version 3.6.2 and STATA version 14.0.

Results

Literature search

According to the systematic literature search strategy described in the Methods section, 1,309 potentially relevant articles were initially identified. After removing duplicates and conducting an initial screening based on the titles and abstracts, 37 articles were retained for further assessment. Subsequently, a full-text review was performed to determine eligibility based on the predefined inclusion criteria. This rigorous selection process included 21 studies in the meta-analysis, comprising 4,361 patients (9-29). The PRISMA flowchart shows the details of the article selection and exclusion procedures (Figure 1).

Figure 1 PRISMA flowchart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study characteristics

The comprehensive details of the studies that were included in the analysis can be found in Table 1. Among the 21 publications, 13 were retrospective studies, five were prospective studies, and three were propensity score-matched retrospective studies. The meta-analysis includes six surgical approaches: OT, EOA, EBAA, EGAA, EBABA, and MIVAA. Most studies (19 of 21, 90.5%) were conducted in Asia-Pacific, specifically in China and Korea.

The quality of the 21 studies was evaluated using the NOS score. All studies were deemed high-quality, with each obtaining a score of six or above. A comprehensive summary of the quality assessment can be found in Table S1. The network relationships among the various surgical approaches are depicted in Figure S1. The size of each circle indicates the number of patients included, whereas the thickness of the lines connecting each surgical approach signifies the number of studies. After 40,000 iterations, the model reached optimal convergence, as shown in Figure S2. The cumulative ranking plots and nomograms for the six surgical approaches are illustrated in Figure 2. The risk of bias is depicted in Figure S3.

Figure 2 The cumulative ranking plots and nomograms for the six surgical approaches. EBAA, endoscopic bilateral areola approach; EBABA, endoscopic bilateral axillo-breast approach; EGAA, endoscopic gasless transaxillary approach; EOA, endoscopic transoral approach; MIVAA, minimally invasive video-assisted approach; OT, open thyroidectomy.

Meta-analysis

Inconsistency, sensitivity analysis, and publication bias

Meta-analysis of the six surgical approaches revealed no significant inconsistencies, as depicted in Figure S4. A sensitivity analysis was performed to assess the robustness of the findings by excluding individual studies and using alternate effect models. Despite these variations, the overall statistical significance remained unchanged, indicating the reliability and stability of the results. Upon visual assessment, no “small-study” effect was evident, except for the operative time (S3). Notably, the Egger test yielded non-significant P values for operative time (P=0.96), as shown in Figure S5.

Surgical outcomes

Number of retrieved LNs

The number of retrieved LNs was reported in seven studies involving 1,578 patients and six surgical approaches. The number of retrieved LNs for the six surgical approaches was estimated using PMA and NMA (Figures 3,4A). No significant differences (P>0.05) among the six surgical approaches in the number of retrieved LNs. Based on the SUCRA value, EOA retrieved the highest number of LNs (SUCRA =0.59) among all endoscopic surgical approaches. Additional results regarding the SUCRA values of other surgical approaches for the number of retrieved LNs are available in Table S2.

Figure 3 Forest plot comparison of the different surgical approaches for all outcomes. OT, open thyroidectomy; EBAA, endoscopic bilateral areola approach; EBABA, endoscopic bilateral axillo-breast approach; EGAA, endoscopic gasless transaxillary approach; EOA, endoscopic transoral approach; MIVAA, minimally invasive video-assisted approach; OR, odds ratio; CI, confidence interval; MD, mean difference.

Figure 4 Heat plots of the league table for the six surgical approaches. (A) Number of retrieved lymph nodes; (B) operative time; (C) intraoperative bleeding volume; (D) hospital stay; (E) transient hypoparathyroidism rate; (F) permanent hypoparathyroidism rate; (G) transient RLN palsy rate. “** **” denotes statistical significance, where the confidence interval excludes 0 (for differences in effects) or excludes 1 (for ratios). EBAA, endoscopic bilateral areola approach; EBABA, endoscopic bilateral axillo-breast approach; EGAA, endoscopic gasless transaxillary approach; EOA, endoscopic transoral approach; MIVAA, minimally invasive video-assisted approach; OT, open thyroidectomy; RLN, recurrent laryngeal nerve.

Operative time

Seventeen studies involving 3,389 patients and six surgical approaches reported operative time. The results of PMA and NMA indicated that EOA and EGAA had longer operative times than OT (Figures 3,4B). The operative time of EOA was more prolonged than that of MIVAA (MD: 61.91, 95% CI: 8.89–115.52) and EBAA (MD: 50.58, 95% CI: 3.16–97.38) according to NMA. MIVAA effectively shortened the operative time (SUCRA =0.77). The SUCRA values of other surgical approaches for operative time can be found in Table S2.

Intraoperative bleeding volume

Seven studies involving 1,005 patients and five surgical approaches reported intraoperative bleeding volume. PMA and NMA showed no significant difference (P>0.05) among the surgical approaches for intraoperative bleeding volume (Figures 3,4C). The surgical approach with the most minor amount of intraoperative bleeding was MIVAA (SUCRA =0.77). The SUCRA values of other surgical approaches for intraoperative bleeding volume can be found in Table S2.

Hospital stay

Hospital stay was reported in seven studies involving 1,540 patients and six surgical approaches. PMA showed no significant difference (P>0.05) among the six approaches for hospital stay (Figure 3). According to the NMA, the hospital stay for EGAA was shorter than for OT (MD: −1.30, 95% CI: −2.55 to −0.05) and EOA (MD: −1.48, 95% CI: −3.00 to −0.09) (Figure 4D). EGAA effectively shortened the hospital stay (SUCRA =0.95), outperforming all other surgical approaches. The SUCRA values of other surgical approaches for hospital stay can be found in Table S2.

Surgical complications

We compare the incidence of surgical complications between different surgical approaches. Our findings indicated no significant differences in the incidence of surgical complications among these approaches (Figures 3,4E-4G). EGAA was the best surgical approach for reducing the rate of transient hypoparathyroidism (SUCRA =0.74). MIVAA was ranked the best surgical approach for reducing the rate of permanent hypoparathyroidism (SUCRA =0.81). EBAA was ranked the most effective surgical approach for preventing RLN palsy (SUCRA =0.92). The SUCRA values of other surgical approaches for surgical complications can be found in Table S2.

Discussion

In this study, we aimed to conduct an NMA to compare different endoscopic surgical approaches to total thyroidectomy, revealing their respective advantages and limitations. To control for the impact of surgery extent on indicators such as surgical complications and operative time, we included only patients who underwent total thyroidectomy. We minimized the potential impact of variations in surgical standards on our conclusions by meticulously reviewing the Methods section of each original study and rigorously classifying them according to their surgical procedures. These methods significantly reduced the heterogeneity among the studies, thereby enhancing the reliability of our findings. Our findings affirm that the outcomes of endoscopic total thyroidectomy are comparable to those of OT.

Given the frequent association of thyroid cancer with central LN metastases (30), it is crucial to optimize the efficiency of LN retrieval. Our results indicated no significant differences among all surgical approaches regarding the number of retrieved LNs. Based on the SUCRA values, EOA had the most significant advantage in LN retrieval (SUCRA =0.59) compared to other endoscopic surgical approaches. This superiority could be explained by the enhanced accessibility of the central compartment facilitated by EOA (31,32). However, EOA had the longest operative time among all endoscopic surgical approaches (SUCRA =0.08), which may be attributed to its steep learning curve (11,33). Although EOA offers benefits in LN dissection and minimizes surgical trauma, we suggest that it is not recommended for elderly patients with multiple underlying diseases or poor physical conditions because of the heightened anesthesia risks and extended operative time. MIVAA had the least advantage for the number of retrieved LNs (SUCRA =0.23). However, it exhibited a shorter operative time (SUCRA =0.77) than other endoscopic surgical approaches. In addition, MIVAA demonstrated the least intraoperative bleeding volume (SUCRA =0.77) than other surgical approaches. Based on these findings, and considering that MIVAA leaves a wound of approximately two centimeters (34,35), we recommend that patients with minimal cosmetic concerns and a low risk of LN metastasis opt for the MIVAA approach.

Regarding surgical complications, we found no significant differences among these surgical approaches. According to our NMA results, EBAA exhibited a significantly higher rate of transient hypoparathyroidism compared to other surgical approaches. Zhang et al. conclude that the obstruction caused by the clavicle and sternum makes it more difficult for surgeons to retrieve the central LNs and increases the likelihood of damaging the vessels of the inferior parathyroid glands (36). Xiang et al. suggested that the use of a harmonic scalpel during node dissection can lead to devascularization of the parathyroid glands, particularly affecting the inferior parathyroid glands (14). These reasons could be the primary cause of the higher incidence of transient hypoparathyroidism. Furthermore, EBAA is more acceptable to young women because of its small incisions within the areola and increased cosmetic satisfaction. Interestingly, EBAA had a significantly lower rate of transient RLN palsy, and MIVAA exhibited the lowest rates of permanent hypoparathyroidism. Undoubtedly, these results need to be confirmed by further large-scale clinical trials. Each endoscopic surgical approach has its benefits and limitations, and the surgeon needs to comprehensively assess the patient’s situation before surgery.

There are some limitations in this study. Firstly, the number of studies that met the inclusion criteria was limited because we defined the extent of surgery as total thyroidectomy. Additionally, due to limited data availability, our network meta-analysis did not include an analysis of recurrence rates or other complications such as hematoma and wound infection. Furthermore, a significant portion of the included studies are retrospective from Asia, potentially introducing selection and reporting biases. Finally, the observed differences in key outcome indicators may be influenced by various factors. For instance, variations in the number of retrieved LNs, intraoperative bleeding volume, and operative time may arise from differences in surgeon proficiency. Therefore, larger clinical trials are essential to substantiate these findings.

Conclusions

Our results demonstrated that the surgical outcomes of endoscopic total thyroidectomy are comparable to those of OT. MIVAA was superior to other endoscopic surgical approaches in controlling the operative time, intraoperative bleeding volume, and permanent hypoparathyroidism rate. EOA showed a significant advantage in LN retrieval. EBAA is superior in protecting the RLN. This study contributes to the understanding of the advantages and limitations of various endoscopic surgical approaches to total thyroidectomy, offering valuable insights for clinicians and decision-makers in selecting the most appropriate approach.

Acknowledgments

Funding: This work was supported by the Key Special Project for Technological Innovation and Application Development of Chongqing (No. CSTB2022TIAD-KPX0177), and the Basic Research and Frontier Exploration Project of Yuzhong District, Chongqing, China (No. 20210162).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-424/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-424/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-424/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016;26:1-133. [Crossref] [PubMed]
2. Boucai L, Zafereo M, Cabanillas ME. Thyroid Cancer: A Review. JAMA 2024;331:425-35. [Crossref] [PubMed]
3. Hüscher CS, Chiodini S, Napolitano C, et al. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877. [Crossref] [PubMed]
4. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603-5. [Crossref] [PubMed]
5. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008.
6. Hutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015;162:777-84. [Crossref] [PubMed]
7. DerSimonian R, Laird N. Meta-analysis in clinical trials revisited. Contemp Clin Trials 2015;45:139-45. [Crossref] [PubMed]
8. Béliveau A, Boyne DJ, Slater J, et al. BUGSnet: an R package to facilitate the conduct and reporting of Bayesian network Meta-analyses. BMC Med Res Methodol 2019;19:196. [Crossref] [PubMed]
9. Lombardi CP, Raffaelli M, De Crea C, et al. Video-Assisted Versus Conventional Total Thyroidectomy and Central Compartment Neck Dissection for Papillary Thyroid Carcinoma. World J Surg 2012;36:1225-30. [Crossref] [PubMed]
10. Hensler MS, Falciglia M, Yaqub A, et al. Elective central node dissection: Comparison of open to minimally invasive video-assisted approach. Laryngoscope 2016;126:1715-8. [Crossref] [PubMed]
11. Anuwong A, Ketwong K, Jitpratoom P, et al. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg 2018;153:21-7. [Crossref] [PubMed]
12. Ahn JH, Yi JW. Transoral endoscopic thyroidectomy for thyroid carcinoma: outcomes and surgical completeness in 150 single-surgeon cases. Surg Endosc 2020;34:861-7. [Crossref] [PubMed]
13. Hong YT, Ahn J, Kim JH, et al. Bi-institutional experience of transoral endoscopic thyroidectomy: Challenges and outcomes. Head Neck 2020;42:2115-22. [Crossref] [PubMed]
14. Xiang D, Xie L, Li Z, et al. Endoscopic thyroidectomy along with bilateral central neck dissection (ETBC) increases the risk of transient hypoparathyroidism for patients with thyroid carcinoma. Endocrine 2016;53:747-53. [Crossref] [PubMed]
15. Zhang D, Wang T, Dionigi G, et al. Central Lymph Node Dissection by Endoscopic Bilateral Areola Versus Open Thyroidectomy. Surg Laparosc Endosc Percutan Tech 2019;29:e1-6. [Crossref] [PubMed]
16. Kim WW, Kim JS, Hur SM, et al. Is robotic surgery superior to endoscopic and open surgeries in thyroid cancer? World J Surg 2011;35:779-84. [Crossref] [PubMed]
17. Kim SK, Kang SY, Youn HJ, et al. Comparison of conventional thyroidectomy and endoscopic thyroidectomy via axillo-bilateral breast approach in papillary thyroid carcinoma patients. Surg Endosc 2016;30:3419-25. [Crossref] [PubMed]
18. Kim EY, Lee KH, Park YL, et al. Single-Incision, Gasless, Endoscopic Trans-Axillary Total Thyroidectomy: A Feasible and Oncologic Safe Surgery in Patients with Papillary Thyroid Carcinoma. J Laparoendosc Adv Surg Tech A 2017;27:1158-64. [Crossref] [PubMed]
19. Huang JK, Ma L, Song WH, et al. Quality of life and cosmetic result of single-port access endoscopic thyroidectomy via axillary approach in patients with papillary thyroid carcinoma. Onco Targets Ther 2016;9:4053-9. [Crossref] [PubMed]
20. Park KN, Jung CH, Mok JO, et al. Prospective comparative study of endoscopic via unilateral axillobreast approach versus open conventional total thyroidectomy in patients with papillary thyroid carcinoma. Surg Endosc 2016;30:3797-801. [Crossref] [PubMed]
21. Koh WR, Chae BJ, Bae JS, et al. Transaxillary Endoscopic Thyroidectomy versus Conventional Open Thyroidectomy for Papillary Thyroid Cancer: 5-year Surgical Outcomes. Korean J Endocr Surg 2016;16:42.
22. Li Y, Liu Z, Wang Y, et al. Is transoral endoscopic thyroidectomy safe for total thyroidectomy compared to open thyroidectomy? A propensity-score matched cohort study with papillary thyroid carcinoma. J Surg Oncol 2023;128:502-9. [Crossref] [PubMed]
23. Qu R, Li J, Yang J, et al. Treatment of differentiated thyroid cancer: can endoscopic thyroidectomy via a chest-breast approach achieve similar therapeutic effects as open surgery? Surg Endosc 2018;32:4749-56. [Crossref] [PubMed]
24. Lee DY, Lim S, Kang SH, et al. A prospective 1-year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising? Surg Endosc 2016;30:1599-606. [Crossref] [PubMed]
25. Sun H, Zheng H, Wang X, et al. Comparison of transoral endoscopic thyroidectomy vestibular approach, total endoscopic thyroidectomy via areola approach, and conventional open thyroidectomy: a retrospective analysis of safety, trauma, and feasibility of central neck dissection in the treatment of papillary thyroid carcinoma. Surg Endosc 2020;34:268-74. [Crossref] [PubMed]
26. Liang T, Wang N, Tsai C, et al. Outcome Comparison between Endoscopic Transoral and Bilateral Axillo‐Breast Approach Thyroidectomy Performed by a Single Surgeon. World J Surg 2021;45:1779-84. [Crossref] [PubMed]
27. Zeng HH, Huang DH. Single-port endoscopy-assisted thyroidectomy via cervical gas-insufflation approach for papillary thyroid carcinoma: A pilot retrospective comparative study. Am J Otolaryngol 2023;44:103903. [Crossref] [PubMed]
28. Liu Z, Li Y, Wang Y, et al. Comparison of the transoral endoscopic thyroidectomy vestibular approach and open thyroidectomy: A propensity score-matched analysis of surgical outcomes and safety in the treatment of papillary thyroid carcinoma. Surgery 2021;170:1680-6. [Crossref] [PubMed]
29. Yuan Y, Pan B, Tang E, et al. Surgical methods of total thyroidectomy for differentiated thyroid cancer: a systematic review and Bayesian network meta-analysis. Int J Surg 2024;110:529-40. [Crossref] [PubMed]
30. Mehanna H, Al-Maqbili T, Carter B, et al. Differences in the recurrence and mortality outcomes rates of incidental and nonincidental papillary thyroid microcarcinoma: a systematic review and meta-analysis of 21 329 person-years of follow-up. J Clin Endocrinol Metab 2014;99:2834-43. [Crossref] [PubMed]
31. Nakajo A, Arima H, Hirata M, et al. Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc 2013;27:1105-10. [Crossref] [PubMed]
32. Dionigi G, Chai YJ, Tufano RP, et al. Transoral endoscopic thyroidectomy via a vestibular approach: why and how? Endocrine 2018;59:275-9. [Crossref] [PubMed]
33. Wang D, Wang Y, Zhou S, et al. Transoral thyroidectomy vestibular approach versus non-transoral endoscopic thyroidectomy: a comprehensive systematic review and meta-analysis. Surg Endosc 2022;36:1739-49. [Crossref] [PubMed]
34. Wu CT, Yang LH, Kuo SJ. Comparison of video-assisted thyroidectomy and traditional thyroidectomy for the treatment of papillary thyroid carcinoma. Surg Endosc 2010;24:1658-62. [Crossref] [PubMed]
35. Del Rio P, Maestroni U, Sianesi M, et al. Minimally invasive video-assisted thyroidectomy for papillary thyroid cancer: a prospective 5-year follow-up study. Tumori 2015;101:144-7. [Crossref] [PubMed]
36. Zhang WD, Dai L, Wang YC, et al. Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Endoscopic Thyroidectomy Via Areola Approach for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study. Surg Laparosc Endosc Percutan Tech 2021;31:550-3. [Crossref] [PubMed]