Minimally invasive video-assisted thyroidectomy (MIVAT) and thyroid cancer: a single centre 10-year follow-up

Introduction

Thyroid cancer diagnosis has significantly increased in the last decades. Along with the increase in the number of cases treated, the therapeutic indications and the type of surgical treatment proposed have changed (1,2).

In recent years, there has been a growing interest in conservative approaches such as percutaneous procedures and active surveillance, for benign thyroid nodules, low-risk microcarcinomas and selected high risk patients with thyroid cancer (1). Nevertheless, surgery is still first choice treatment for differentiated thyroid carcinoma, with particular attention to minimally invasiveness.

Recurrence rates after surgery for thyroid carcinoma vary according to different factors, such as patient age and sex, histological characteristics (capsular infiltration, angioinvasion, size, lymph node metastasis), stage of the disease, and quality of surgery associated with hospital volume/year treated (3,4).

Minimally invasive video-assisted thyroidectomy (MIVAT), introduced about 25 years ago (5) and progressively improved over time thanks to laparoscopic technology advances, is still the most widespread minimally invasive endoscopic procedure nowadays. This is a totally gasless technique that provides the thyroid access through a 1.5–2.0 cm central horizontal incision, using a 5 mm 30° endoscope and specific dissection tools (6). The widespread use of this technique permitted to evaluate its safety. Rates of adverse events comparable to the gold standard of traditional surgery, and in some reports better than those, are reported, if inclusion criteria and surgical technique are respected (7-11).

Despite the introduction of several endoscopic or robot-assisted extra cervical techniques, of proven efficacy and safety (7,12-14), such as transaxillary endoscopic thyroidectomy (15), axillary-bilateral breast approach (ABBA) (16), bilateral axillo-breast approach (BABA) (17), retroauricular approach (16), transoral approach (18), these remote access procedures require a large surgical dissection compared to MIVAT (19).

Minimally invasive surgery has developed simultaneously with the increase in diagnoses of thyroid nodules, whether certain or suspected of thyroid carcinoma, which have consequently increased the indication for surgical treatment of nodules smaller than 3 cm in diameter in normal volume thyroids (<25 mL) (20).

We aimed to report the re-evaluation of patients treated with minimally invasive total thyroidectomy technique with a diagnosis of thyroid carcinoma after at least 10 years of postoperative follow-up. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-307/rc).

Methods

In our retrospective monocentric observational study, we enrolled all patients who undergone to MIVAT total thyroidectomy for differentiated thyroid carcinoma, between January 2006 and December 2013 at the General Surgery Unit of the University Hospital of Parma, Italy. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Area Vasta Emilia Nord (AVEN), Italy (No. 644/2022/OSS/AOPR; date of approval 04/10/2022).

Inclusion criteria comply with MIVAT indications: thyroid nodules <35 mm, thyroid volume <30 mL, low and intermediate risk papillary thyroid carcinoma. Contraindications to MIVAT include prior neck surgery, locally advance thyroid carcinoma, preoperative evidence of lymphnode metastases while prior neck irradiation and thyroiditis or Graves disease represents relative contraindications (1).

All patients were contacted in an outpatient setting, signing an informed consent for the processing of personal data. Patients who were untraceable or who refused to participate, with medullary thyroid carcinoma, with RET gene mutation or converted to traditional technique, were excluded from the analysis. Unfortunately, considering the long time elapsed between the intervention and the study, from 10 to 19 years, it was difficult to contact patients, and we experienced a 58% loss of the initial sample.

Follow-up at least 10 years after surgery was assessed through an outpatient interview that evaluated sex, age and time of surgical intervention, familiar and personal oncological anamnesis, ionizing radiation exposure, preoperative ultrasound with uni- or multinodular disease and cytological examination, type of intervention, conversion to traditional surgery, definitive histological examination and nodule diameter, postoperative complications (hemorrhage, permanent recurrent lasyngeal nerve-RLN-lesion, transient hypocalcemia—serum calcium <8 mg/dL—or permanent hypocalcemia—serum calcium <8 mg/dL for more than 6 months), postoperative radio iodine therapy (RAI), keloid and hypertrophic scar, local or lymph node recurrence, re-intervention.

Statistical analysis

Since this is a retrospective study, the sample size was determined by feasibility, i.e., by the patients treated in the period considered.

We conducted a descriptive analysis of continuous variables, calculating means, median, maximum, minimum and standard deviation, and for categorical data we used absolute frequencies and percentages. When applicable, two independent groups of data were compared using Pearson’s correlation coefficient and Spearman’s rho calculator, with “Jamovi” version 2.5.3. (https://jamovi.org/), considering P<0.05 statistically significant.

Results

Between January 2006 and December 2013, 191 patients underwent to MIVAT total thyroidectomy for differentiated thyroid cancer; 107/191 patients answer to phone contact but 81/107 met inclusion criteria and presented for outpatient consent signing and at least 10-year follow-up visit. Twenty-six patients were excluded from the study due to conversion to traditional technique (12/191, 6.3% conversion rate), presence of medullary thyroid carcinoma or RET gene mutation or refusal to go to the hospital for the follow-up visit.

These enrolled patients had a mean age of 45.9 years (range, 27–78 years; standard deviation 11.573) (Table 1); 9 (11.1%) patients were males and 72 (88.9%) females.

Sixteen out of 81 (19.8%) patients reported previous oncological diseases (Figure 1), such as breast cancer (6.2%), endometrium cancer (3.7%), melanoma (2.5%), colon cancer (1.2%), ovarian cancer (1.2%), cervical cancer (1.2%), nasopharyngeal cancer (1.2%). Two patients reported multiple malignancy in personal anamnesis, such as melanoma and cervical cancers (1.2%) and melanoma, ovarian and breast cancers (1.2%). Two out of 81 (2.5%) were previously exposed to radiotherapy for breast cancer. Concerning familiar anamnesis, 7/81 (8.6%) patients reported having first-degree relatives affected by thyroid differentiated carcinoma while 8/81 (9.9%) were affected by goiter (Table 1).

Figure 1 Personal oncological anamnesis.

Preoperative ultrasound described a single nodule in 67 cases (82.7%) and a multinodular disease in 14 cases (17.3%) (Table 2). Fine needle aspiration (FNA) of suspected nodules resulted in Bethesda class II in 3 cases (3.7%), class III in 2 cases (2.5%), class IV in 24 cases (29.6%), class V in 5 cases (6.2%), class VI in 47 cases (58.0%) (21) (Figure 2).

Figure 2 Preoperative fine needle aspiration, using Bethesda classification.

Nodules examined had a mean diameter of 13.8 mm (range, 5–30 mm), in accordance with MIVAT technique inclusion criteria (Table 1).

All patients underwent total thyroidectomy. In one case, a video-assisted central lymphoadenectomy was performed. In all cases, a 5 mm 30° endoscope and specific dissection tools, including thin retractors and a spatula aspirator, were used although intraoperative neuromonitoring was not introduced in our clinical practice yet. A suction drainage was placed intraoperatively in all cases and removed just the following morning. All patients were admitted on the same day of surgery and were discharged from hospital two nights later.

At postoperative histological exam, 38 (46.9%) patients presented usual papillary thyroid carcinoma, 30 (37.0%) follicular variant papillary carcinoma, 4 (4.9%) sclerosis variant papillary carcinoma, 2 (2.5%) tall cell papillary carcinoma, 5 (6.2%) follicular thyroid carcinoma, 1 (1.2%) Hurtle cell carcinoma, 1 (1.2%) poorly differentiated carcinoma (Figure 3).

Figure 3 Postoperative histological examination.

Postoperative adverse events reported were 1 hemorrhage (1.2%), 6 transient hypocalcemia (7.4%), 1 permanent hypocalcemia (1.2%), 1 permanent RLN palsy (1.2%), 2 keloid scar (2.5%) (Figure 4). Permanent hypocalcemia was diagnosed when patient had serum calcium <8 mg/dL for more than 6 months. Permanent RLN palsy was diagnosed with objective laryngoscopic evaluation. Postoperative RAI was executed in 48 cases (59.2%). Only one patient presented lateral cervical lymph node recurrence, 1 year after RAI, and required lateral cervical lymphadenectomy. This was a 37-year-old patient with no personal or familiar oncological anamnesis, who presented with a 20 mm follicular variant papillary carcinoma and was submitted to RAI after intervention.

Figure 4 Postoperative complications. RLN, recurrent laryngeal nerve.

No cases of local recurrence were reported and no patient died for causes correlated with thyroid carcinoma.

All patients previously undergone radiotherapy for breast cancer presented with usual variant papillary carcinomas at histological examination and had no postoperative complications or lymph node recurrences.

We have performed a statistical analysis correlating FNA (Bethesda category) to the onset of postoperative complications, such as hemorrhage (P=0.44), hypocalcemia (P=0.18), permanent dysphonia (P=0.44) and no statistically significant associations were detected (Table 2).

Even the correlation between ultrasound characteristics (mono-multinodular gland) and hemorrhage (P=0.65), hypocalcemia (P=0.83), keloid scar (P=0.52) was not significant while a significant correlation was detected between ultrasound characteristics and permanent dysphonia (P=0.02) (Table 3).

We have also valued the association between nodule diameter and hemorrhage (P=0.26), hypocalcemia (P=0.60), dysphonia (P=0.59) and keloid scar (P=0.68) and no significant association was found (Table 4).

Finally, we have valued the possible association between age and onset of complications, such as hemorrhage (P=0.33), hypocalcemia (P=0.07), dysphonia (P=0.09), keloid scar (P=0.43) but no statistically significant association was found (Table 5).

Discussion

In the present study, 81 patients undergone MIVAT total thyroidectomy for thyroid differentiated cancer have been contacted for at least 10-year follow-up. Only one patient reported lateral cervical lymph nodes recurrence and required a lymphadenectomy. No patient reported local relapses and no one died from thyroid cancer. Since our series refers to a period prior to 2015 American Thyroid Association (ATA) guidelines (2), all patients had indication for total thyroidectomy due to malignant FNA or multinodular disease.

In Western countries, the debate about surgical treatment for thyroid differentiated carcinoma, particularly if major than 1 cm diameter, regards excision extension (lobectomy versus total thyroidectomy). Our population lives in an iodine-deficient area and often presents multinodular thyroid disease and high-volume glands whereby MIVAT technique is indicated only in 15–20% of interventions, as for lobectomies (22). A 2020 review concerning cancer relapses after total or hemithyroidectomy, included 31 studies with a total of 228,746 patients. It showed that recurrence risk after total thyroidectomy and lobectomy was 5.3% and 9.2% respectively, and the site of relapse was local in 52%, in laterocervical lymph node stations in 32% and at distance in 16%. Nevertheless, benefits of prophylactic administration of radioiodine and central compartment lymph node dissection were also evaluated, concluding that, in absence of capsule infiltration and/or angioinvasion, neither of these two routinely performed practices is directly related to a reduction in the risk of disease recurrence (7). Nowadays guidelines agree that both radioiodine and central compartment dissection should be performed only if specific risk factors are present because the low recurrence risk does not justify an higher risk of hypocalcemia and RLN lesion (1,2). 2025 ATA guidelines (23) confirm the trend towards an increasingly conservative approach in the management of differentiated thyroid carcinoma and MIVAT technique, with its low invasiveness, fits well with these recommendations.

Monitoring the results of our MIVAT procedures series with a short, medium and long follow-up, we have found it safe concerning both postoperative complications and oncological outcomes (24-26). Even larger series confirm our results (27,28).

Our series of patients operated with MIVAT presents low postoperative complications rate, comparable with other series and with conventional thyroidectomy (1,7,22,29). Compared to adverse events rate reported in United Italian Society of Endocrine Surgery (SIUEC) thyroid disease management guidelines (1), in our series we described hemorrhage 1.2% vs. 0.1–2%, transient hypocalcemia 7.4% vs. 19–35%, permanent hypocalcemia 1.2% vs. 0–15%, RLN palsy 1.2% vs. 3–12%.

Some studies describe statistically significant association between complications and tumor characteristics, in particular nodule dimension and extrathyroidal tissue infiltration that require a surgical excision with greater extension. In this case, the risk of conversion to open surgery, accidental removal of the parathyroids, damage to adjacent vascular structures resulting in hemorrhage, or accidental injury to the RLN increase (30). In our study we have found a statistically significant association between the preoperative detection of a multinodular thyroid disease and permanent dysphonia, probably connected to a more difficult dissection and a lower working space in case of multiple nodules in the lobe. Nevertheless, the low number of complications makes the statistical analysis little significant. MIVAT inclusion criteria regarding nodule size, not exceeding 35 mm in its largest diameter (11), reduce the treatment of large tumors but intraoperative finding of local invasion requires a conversion to conventional technique. Nodule size could influence the intervention in these minimally invasive gasless procedures, where the working space in often narrow. A large nodule, up to 35 mm, maybe located in Zuckerkandl’s tubercle, is different from a small, centimetric nodule, can require a more difficult dissection and this could correlate with a higher incidence of postoperative complications.

Our series refers to a period prior to the routine introduction of intraoperative neuromonitoring, that has partially modified surgical technique and dysphonia rate (31). All patients underwent preoperative laryngoscopy while postoperative exam was executed in case of intraoperative NLR suspicious or clinical symptoms of dysphonia or dysphagia, to give indication to speech therapy.

American Thyroid Association has identified as risk factors for postoperative hypocalcemia bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions (32).

Among minimally invasive endoscopic or robotic techniques, MIVAT offers the best compromise between postoperative complications, costs, execution times, and cosmetic results. Different systematic reviews and meta-analysis have shown that MIVAT is safe as open thyroidectomy with better cosmesis, no differences in postoperative hypocalcemia, blood loss or RLN injury and decreased pain (20,33-35). Studies have shown that MIVAT costs were similar to those of the open procedure for hemithyroidectomy and total thyroidectomy, including even anesthesia costs, that present the same mean duration for both procedures (36,37). Conversely, Kandil et al. reported that robotic approaches added 43.5 min to the operative time (38) and robotic instruments and platform costs must be considered in addition.

In our series, the evaluation of scar after over 10 years has shown satisfactory results, with a slight skin discoloration without thickness. Only two patients developed precociously keloid scar, that they treated with laser therapy and steroid injection. One patient showed a slightly retracting scar due to the presence of adhesions. To limit the risk of adhesions, post-operative massages with oily solutions are recommended to prevent possible formation of fibrotic tissue, which can cause, in addition to a worse aesthetic result, neck discomfort and swallowing impairment (39).

Many reviews have compared MIVAT cosmetic results, including keloid or hypertrophic scar presentation, and postoperative pain, with conventional thyroidectomy. All report lower rates in patients operated with endoscopic technique (34,40,41).

In another study, the average size of the scar in the open technique and in MIVAT is reported, with results of 6.5 cm for the traditional technique versus 3.1 cm of minimally invasive technique (42). It should be noted that the risk of keloid increases in parallel with the trauma that is inflicted on the skin (43), thus resulting lower in MIVAT. A variable percentage of keloid are reported after MIVAT procedure, varying in different studies from 1% to 11% (44-46). Nevertheless, considering face and neck as an area with difficulty with concealing keloids, neck presents in general a low incidence of keloids (47).

Finally, in literature recommendations to avoid keloid or hypertrophic scar formation suggest keeping distance from the incision to the sternal notch, maintaining a superior position as to being far from the tension lines of the skin (44). In another study, the risk factors for keloid were identified and these are constituted by female sex, high body mass index (BMI), prominent sternocleidomastoid, scar with a distance from the sternal notch of less than 1 cm and previous formation of keloids (45). The use of endoscopic technique allows either to make a small incision and to locate it in the better position, regardless of thyroid height, even in patients with high BMI and short neck, because it ensures image magnification of the entire operatory field.

Considering the limits of the present study, this is a retrospective analysis, which is susceptible to potential patient selection bias. Secondly, we only reached 42% of the initial sample due to problems in contacting patients again, considering the long time elapsed between the intervention and the study, from 10 to 19 years, and this represents a bias too. Despite a very long follow-up period, the sample size is relatively small, especially considering the low incidence of conversion and postprocedural complications. Finally, the absence of a control group is an important limit for the statistical analysis.

Conclusions

Limited dissection, small skin incision of 2–3 cm, image magnification, short operative time after adequate learning curve, low complication rates and oncological safety at long-term follow-up make MIVAT still the best minimally invasive endoscopic technique. These long-term follow-up results comfort us and encourage us to offer this treatment whenever it is indicated.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-307/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-307/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-307/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-307/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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Area Vasta Emilia Nord (AVEN), Italy (No. 644/2022/OSS/AOPR; date of approval 04/10/2022). Written informed consent was obtained from all subjects involved in the study.

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/.

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