Truly scarless three-port transoral robotic thyroidectomy: a feasible and efficient alternative to the four-port approach for thyroid cancer patients

Truly scarless three-port transoral robotic thyroidectomy: a feasible and efficient alternative to the four-port approach for thyroid cancer patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Truly scarless three-port transoral robotic thyroidectomy: a feasible and efficient alternative to the four-port approach for thyroid cancer patients Moon Young Oh, A Jung Chu, Young Shin Song, Ka Hee Yi, Young Jun Chai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6159729/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Transoral robotic thyroidectomy (TORT) has traditionally been performed using a four-port technique. A newer three-port technique, which eliminates the axillary port, makes TORT truly scarless. However, there is a limited number of studies comparing the two approaches. This study evaluates the outcomes of four-port versus three-port TORT. Methods: A retrospective review was conducted on patients who underwent lobectomy using TORT between August 2021 and October 2024. From August 2021 to January 2024, patients underwent four-port TORT, while from January 2024 to October 2024, patients underwent three-port TORT. Results: Seventy-two patients (31 in the four-port group and 41 in the three-port group) were included. The mean ages were 35.2 years (four-port group) and 39.9 years (three-port group). The mean operative time was significantly shorter in the three-port group compared to the four-port group (107.7 minutes vs. 141.0 minutes, p < 0.001). One patient in the four-port group experienced transient recurrent laryngeal nerve injury, while none occurred in the three-port group. In the three-port group, one patient developed postoperative seroma, and another experienced wound inflammation, whereas no such complications occurred in the four-port group. One patient in the four-port group required an additional mini-incision in the neck for tumor shaving of the trachea due to tumor adhesion. There was no difference in hospital stay between the two groups (1.8 days in the four-port group vs. 2.0 days in the three-port group). Conclusions: Three-port transoral robotic thyroidectomy is a feasible and efficient alternative to the four-port method for selected patients undergoing thyroidectomy. Scarless Transoral Thyroid surgery Robotic system Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Over the years, various thyroid surgery approaches and techniques, particularly remote-access procedures, have been developed to address the aesthetic concern of visible neck scars left after surgery.[ 1 ] Among these, transoral thyroidectomy has gained popularity as the only truly scarless option, offering cosmetic advantages without compromising postoperative outcomes compared to conventional open thyroidectomy or other remote-access methods.[ 2 , 3 ] With the advancements in surgical robotic systems and instruments, the robotic system has been integrated into the transoral approach.[ 4 ] The transoral robotic thyroidectomy (TORT) typically involves four ports—three placed in the lower lip and one in the axilla.[ 5 ] This four-port technique improves surgical visibility by retracting surrounding muscles and counter-traction. Introduction of 4th arm facilitates precise dissection around key structures such as the parathyroid gland and recurrent laryngeal nerve (RLN), and allows for the removal of larger thyroid glands through the axillar incision, which is more flexible than the lower lip incision.[ 6 ] However, the four-port TORT approach has certain limitations. It is not entirely scarless due to the 1–2 cm axillary incision, requires more extensive flap dissection to retrieve the specimen, and often results in longer operative times.[ 7 ] Recently, some surgeons have adopted a three-port TORT approach, omitting the axillary incision.[ 8 – 10 ] This technique is truly scarless, minimizes flap dissection, and shortens the hospital stay without the need for drainage.[ 8 ] However, the three-port approach presents challenges, particularly in removing larger thyroid specimens and performing fine dissection due to the lack of counter-traction by the fourth robotic arm.[ 6 ] Given that the three-port TORT procedure is relatively new, there is a lack of comparative studies between the three-port and four-port techniques. The aim of this study was to compare the outcomes of four-port and three-port TORT. MATERIALS AND METHODS Patients This study was approved by the Institutional Review Board of Seoul Metropolitan Government-Seoul National University Boramae Medical Center (IRB No. 10-2023-69), and informed consent for this retrospective study was waived. Patients who underwent TORT lobectomy from August 2021 to January 2024 were retrospectively enrolled. From August 2021 to January 2024, patients underwent conventional four-port TORT, while from January 2024 to October 2024, patients underwent three-port TORT, exclusively. Indications for TORT included well-differentiated thyroid carcinomas less than 2 cm. Exclusion criteria included invasion of the trachea, nerve, or esophagus, and lateral lymph node metastasis. Patients requiring total thyroidectomy for bilateral thyroid tumors were excluded to minimize selection bias, as the surgeon determined the choice between four-port and three-port TORT based on factors like tumor size and the presence of thyroiditis, rather than the time period. All of the surgical procedures were performed using the da Vinci X robotic system (Intuitive Surgical, Sunnyvale, CA, USA) by a single experienced surgeon (Y.J.C.). Surgical Procedures The TORT procedure has been described in detail in previous literature.[ 11 , 12 ] The difference between the three-port and the four-port TORT procedure was the use of the axillary port in the four-port TORT. To create the axillary port for the four-port TORT, additional dissection around the medial border of the sternocleidomastoid muscle in the right neck was performed, followed by skin tunneling with a tunneler or long trocar after making a 1 cm incision in the right axilla. Figure 1 – 3 shows thyroidectomy via three-port TORT, and Fig. 4 shows thyroidectomy via four-port TORT. The specimen was extracted through the axillary incision in the four-port TORT whereas it was extracted through the middle incision at the lower lip in the three-port TORT. Intraoperative neuromonitoring was performed using the nerve integrity monitoring (NIM)-response 3.0 system (Medtronic, Jacksonville, Florida, USA), with a cable connected to the Maryland dissector (Intuitive Surgical, Sunnyvale, CA, USA) to enable its use as a stimulator. For the specimen extraction through the midline incision in the three-port TORT, dilation of the midline port with Hegar dilator was needed if the specimen was too large for the incision size. No surgical drain was inserted in either procedure. Vocal cord function was monitored using direct laryngoscopy, on the first follow up visit in the outpatient clinic, two weeks after surgery. Outcome measurement Outcomes analyzed included operative time, length of hospital stay, and complications. Operative time was defined as the time from skin incision to closure. Complications included transient or permanent vocal cord palsy, mental nerve injury, seroma, hematoma, and surgical site infection. Transient vocal cord palsy was defined as reduced mobility of the vocal cord detected on direct laryngoscopy that lasted less than 6 months, while permanent vocal cord palsy was defined as persisting for more than 6 months. Transient mental nerve injury was identified by paresthesia of the chin or lower jaw lasting less than 6 months, and permanent injury was defined as persisting beyond 6 months. Seroma and hematoma were considered postoperative complications if aspiration was required, while surgical site infection was classified as a postoperative complication if antibiotic treatment was necessary. Statistical analyses Continuous variables were analyzed using either the t -test or the Mann-Whitney U test, depending on the data distribution, while categorical variables were evaluated using the chi-square test or Fisher’s exact test for comparisons between two groups. Statistical analyses were conducted using R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria), with a significance threshold set at P < 0.05. RESULTS A total of 72 patients (60 females, 12 males) were included in the analysis. The mean age of 37.9 ± 10.5 years and a mean body mass index of 24.5 ± 8.6 kg/m². The mean size of the thyroid nodules was 0.9 ± 0.4 cm, with 25 (34.7%) located in the left thyroid and 46 (65.3%) in the right. Final histopathological diagnoses included 69 (95.8%) papillary thyroid carcinomas, 2 (2.8%) follicular variant papillary thyroid carcinomas, and 1 (1.4%) follicular thyroid carcinoma. Patient characteristics according to the groups are summarized in Table 1 . Four-port TORT was performed in 31 patients and three-port TORT was performed in 41 patients. The mean body mass index was higher in the four-port TORT group than the three-port TORT group (25.2 vs. 24.1 kg/m 2 , P = 0.004). There were no significant differences in the other patient characteristics between the two groups, including age, sex, nodule size, and histopathology ( P > 0.050). Table 1 Patient characteristics Variables Total (N = 72) Four-port group (N = 31) Three-port group (N = 41) P -value Age, years 37.9 ± 10.5 35.2 ± 8.7 39.9 ± 11.4 0.087 Body mass index, kg/m 2 24.5 ± 8.6 25.2 ± 4.0 24.1 ± 10.9 0.004 Sex Female 60 (83.3) 26 (83.9) 36 (87.8) 0.242 Male 12 (16.7) 7 (22.6) 5 (12.2) Nodule size, cm 0.9 ± 0.4 0.9 ± 0.4 0.9 ± 0.3 0.643 Histopathology Papillary thyroid carcinoma 69 (95.8) 30 (96.8) 39 (95.1) > 0.999 Follicular variant papillary thyroid carcinoma 2 (2.8) 1 (3.2) 1 (2.4) Follicular thyroid carcinoma 1 (1.4) 0 (0.0) 1 (2.4) Location Left 25 (34.7) 12 (38.7) 13 (31.7) 0.537 Right 47 (65.3) 19 (61.3) 28 (68.3) Multiplicity Single 63 (87.5) 30 (96.8) 33 (80.5) 0.068 Multiple 9 (12.5) 1 (3.2) 8 (19.5) Extrathyroidal extension None 41 (56.9) 20 (64.5) 21 (51.2) 0.186 Microscopic 30 (41.7) 10 (32.3) 20 (48.8) Gross 1 (1.4) 1 (3.2) 0 (0.0) Venous invasion No 71 (98.6) 31 (100.0) 40 (97.6) > 0.999 Yes 1 (1.4) 0 (0.0) 1 (2.4) Lymphatic invasion No 59 (81.9) 21 (67.7) 32 (78.0) 0.326 Yes 13 (18.1) 10 (32.3) 9 (22.0) Thyroiditis No 59 (81.9) 24 (77.4) 35 (85.4) 0.385 Yes 13 (18.1) 9 (29.0) 6 (14.6) Central lymph node dissection No 23 (31.9) 7 (22.6) 16 (39.0) 0.138 Yes 49 (68.1) 24 (77.4) 25 (61.0) All values are presented as mean ± standard deviation or N (%) Table 2 demonstrates the surgical outcomes. The mean operation time was significantly shorter in the three-port TORT than the four-port group (107.7 vs. 141.0 minutes, P < 0.001). There was one patient who had transient recurrent laryngeal nerve injury in the four-port group, and no one in the three-port group. In the three-port group, one patient developed a postoperative seroma, and another experienced wound inflammation, while no such complications were observed in the four-port group. In the four-port group, one patient required an additional 2 cm skin incision due to a 1 cm papillary thyroid carcinoma that was firmly adhered to the trachea; the incision was made to facilitate manual tracheal shaving. Table 2 Surgical outcomes of four-port and three-port transoral robotic thyroidectomy groups Variables Total (N = 72) Four-port group (N = 31) Three-port group (N = 41) P -value Operation time, minutes 122.0 ± 30.3 141.0 ± 25.4 107.7 ± 25.7 < 0.001 Number of excised lymph nodes * 3.2 ± 3.5 3.5 ± 3.5 3.0 ± 3.5 0.359 Number of metastatic lymph nodes * 0.9 ± 2.1 1.2 ± 2.6 0.8 ± 1.6 0.640 Vocal cord palsy Transient 1 (1.4) 1 (3.2) 0 (0.0) 0.431 Permanent 0 (0.0) 0 (0.0) 0 (0.0) > 0.999 Seroma 1 (1.4) 0 (0.0) 1 (2.4) > 0.999 Surgical site infection 1 (1.4) 0 (0.0) 1 (2.4) > 0.999 Hospital stay, days 1.9 ± 0.6 1.8 ± 0.7 2.0 ± 0.5 0.062 * Among the patients who underwent central lymph node dissection All values are presented as mean ± standard deviation or N (%) DISCUSSION When TORT was first performed, one of the advantages of TORT over TOETVA and other remote-access thyroidectomies was the advantages associated with the additional axillary port.[ 13 ] The benefits of the axillary port include providing counter-traction of the strap muscles and thyroid tissue, which is facilitated by the insertion of an additional robotic arm.[ 14 ] This counter-traction allows the other robotic arms to be used more effectively for dynamic dissections, ensuring safer manipulation of critical structures, such as nerves, parathyroid glands, and blood vessels.[ 15 ] Additionally, the axillary port serves as a passageway for specimen removal, with the sturdier, more flexible skin of the axilla able to better tolerate the forces required during this process compared to the oral mucosa.[ 16 ] However, the inclusion of the axillary port somewhat diminishes one of the original advantages of TORT, which is the ability to leave no visible cutaneous scars. Although the axillary incision is small (1–2 cm) and typically hidden within the natural folds of the axilla, it still results in a scar.[ 17 ] Additionally, creating space for the axillary port can be time-consuming and may lead to bleeding, as well as increased postoperative pain. Another drawback is the increased cost associated with using an additional robotic arm, which involves extra instruments and materials, such as trocars and robotic tools.[ 18 ] The operation time for three-port TORT was significantly shorter than for four-port TORT. While the learning curve effect may have influenced the outcomes, as the three-port procedures were performed at a later period than the four-port procedures, the additional flap formation for 4th arm in the four-port approach likely also contributed to the increased operative time. A previous study comparing three-port and four-port TORT also found that the operative time for three-port TORT was significantly shorter, although no specific reasons were provided.[ 8 ] The explanations for this difference in that study may be similar to those in our own: patients who underwent three-port TORT were treated later, possibly benefiting from the learning curve with increased experience leading to faster procedures, or the additional time required for flap formation for the fourth arm in the four-port approach. Future studies should specifically measure the time spent on flap formation to help clarify this difference. In the four-port TORT group, one case required an additional skin incision to facilitate tumor removal. This highlights that the number of robotic arms may not necessarily determine the ease of the procedure, but may depend more on the specific case. Careful ultrasound review and strict patient selection is necessary to avoid additional skin incision or open conversion. Importantly, there were no significant differences in complication rates, including recurrent laryngeal nerve injury between the two approaches. While the additional robotic arm through the axillary port can provide useful counter-traction, three-port TORT may be performed safely and similarly in selective cases, such as small tumor size or unilateral procedures, when carried out by an experienced surgeon. One unique concern for TORT is mental nerve injury, which can cause numbness in the lower lip and chin, thereby impairing quality of life.[ 19 ] The risk may be higher with three-port TORT, as the specimen is extracted through the midline vestibular port, potentially leading to excessive stretching of the incision and the mental nerve branch.[ 20 ] For this reason, our study limited the size indication for cancer cases to 2 cm. While larger tumors are technically feasible for three-port TORT, it is preferable to consider four-port TORT in such cases to minimize the risk of mental nerve injury or tumor rupture. In our study, within this size limit, no mental nerve injury occurred in any of the patients in either group, suggesting that the three-port TORT did not increase the risk of this complication. However, further studies with larger sample sizes are needed to definitively determine whether there is any difference in the incidence of mental nerve injury between the four-port and three-port TORT. This study has several limitations. It was conducted at a single center by a highly experienced surgeon who had previously performed 200 cases of bilateral axillo-breast approach robotic thyroidectomy and 120 cases of transoral endoscopic thyroid surgery prior to starting the first TORT case. Since all procedures were performed by a surgeon with significant experience in both robotic and transoral approaches, the findings should be interpreted with caution when applied to other centers with different levels of expertise. Additionally, the small sample size and retrospective design of the study, along with the lack of randomization and matching between the two groups, introduce potential confounding bias. However, by stratifying patients based on the date of surgery, we minimized selection bias. Nonetheless, the fact that the three-port TORT group underwent surgery more recently than the four-port group may have influenced the results due to the learning curve effect. Moreover, despite assigning the two groups by the date of surgery, there may still be some selection bias. In our study, the body mass index was significantly lower in the three-port group. However, since the mean difference in body mass index between the two groups was only 1 kg/m 2 and previous studies have shown that body mass index is not associated with surgical outcomes in remote access thyroid surgeries,[ 21 , 22 ] the impact of the body mass index difference on the results is likely limited. In conclusion, the three-port transoral robotic thyroidectomy is a feasible option with comparable outcomes to the four-port technique. It offers the advantage of being truly scarless and reduces operative time, making it a promising alternative for patients undergoing robotic thyroidectomy in selected patients. Declarations ACKNOWLEDGEMENTS None. DISCLOSURES Moon Young Oh, A Jung Chu, Young Shin Song, Ka Hee Yi, and Young Jun Chai have no conflicts of interest to disclose.. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions Moon Young Oh and Young Jun Chai contributed to the study conception and design, material preparation, data collection and analysis. All authors read and commented on previous versions of the manuscript, and approved the final manuscript. Ethics approval This study was approved by the Institutional Review Board of Boramae Medical Center at Seoul National University Hospital (IRB No. 10-2023-69), and informed consent for this retrospective study was waived. References Oh M.Y., Chai Y.J., Yu H.W., Kim S.J., Choi J.Y., Lee K.E. (2023) Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis. Int J Surg 109: 2467–2477. https://doi.org/10.1097/JS9.0000000000000444 Anuwong A. (2016) Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. 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(2018) Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America. Thyroid 28: 1655–1661. https://doi.org/10.1089/thy.2018.0404 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6159729","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":424401421,"identity":"4c3900cd-ec76-4b2f-92d3-44be7dd009aa","order_by":0,"name":"Moon Young Oh","email":"","orcid":"","institution":"Seoul National University College of Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Moon","middleName":"Young","lastName":"Oh","suffix":""},{"id":424401422,"identity":"bb0dd9e4-97bf-410b-978a-8674b8f3a42b","order_by":1,"name":"A Jung 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Center","correspondingAuthor":false,"prefix":"","firstName":"Ka","middleName":"Hee","lastName":"Yi","suffix":""},{"id":424401425,"identity":"f1e2c066-d86c-44dc-b224-3dfca28371cf","order_by":4,"name":"Young Jun Chai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACCSA+wMADJNkbSNbCc4AELVBWApFaJNt7DA8XyNjImUu+PfiZp+IeA397N37N0jxnDA7P4EkztpydlwzkFDNInDm7Aa8WOYm0hMM8PIcTN9zOMZCc2ZbAYCCRS0CL/DOolptnjH/O/EeEFmkJ5gMQLTd4zCQ+NhChRbInGaQlzdjgTI6ZxYdjCTwE/SJx/GDzZ94eGzmD42eMbyTUJMjxt/fi1wIGjD0INg9h5WDwg0h1o2AUjIJRMDIBANf4RMpEXhHZAAAAAElFTkSuQmCC","orcid":"","institution":"Seoul National University College of Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Young","middleName":"Jun","lastName":"Chai","suffix":""}],"badges":[],"createdAt":"2025-03-05 07:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6159729/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6159729/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78238176,"identity":"2f61edf3-216d-4c1e-b015-b095fdac164e","added_by":"auto","created_at":"2025-03-11 08:42:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":301146,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUpper pole dissection during left thyroidectomy via three-port transoral robotic thyroidectomy. \u003c/strong\u003eThe left arm lifts the thyroid upper pole, while the Maryland bipolar forceps in the right arm preserve the parathyroid (yellow arrow) and perform upper pole ligation.\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6159729/v1/3c7115e2007ce561fee64c6e.jpg"},{"id":78238190,"identity":"41f537b6-7447-4f55-b405-f15e4032e674","added_by":"auto","created_at":"2025-03-11 08:42:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":270395,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNerve identification during left thyroidectomy via three-port transoral robotic thyroidectomy. \u003c/strong\u003eWhile lifting the thyroid with the right arm (not visible), the left arm identifies the recurrent laryngeal nerve (white arrow).\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6159729/v1/dd1eb64a13767df7b3038aee.jpg"},{"id":78238193,"identity":"5ac2da26-821d-42b6-95ce-c9eda957d973","added_by":"auto","created_at":"2025-03-11 08:42:10","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":294531,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThyroid dissection and nerve preservation during left thyroidectomy via three-port transoral robotic thyroidectomy. \u003c/strong\u003eThe right arm lifts the thyroid, while the left arm uses a peanut gauze ball to separate the recurrent laryngeal nerve (white arrow) from the thyroid and trachea, with the thyroid being detached from the trachea using left arm bipolar forceps.\u003c/p\u003e","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6159729/v1/fba5bc93148e5e358ebb2069.jpg"},{"id":78238200,"identity":"a0ebd8ea-e0e6-494d-8b76-37d0aad7c5f9","added_by":"auto","created_at":"2025-03-11 08:42:27","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":293749,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThyroid dissection and nerve preservation during left thyroidectomy via four-port transoral robotic thyroidectomy. \u003c/strong\u003eThe fourth axillary arm (not visible) lifts the thyroid, while the right arm provides traction to preserve the recurrent laryngeal nerve (white arrow), and the left arm performs upper pole ligation with a harmonic scalpel.\u003c/p\u003e","description":"","filename":"Fig.4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6159729/v1/2fb68b5c8676d1cb66b6629f.jpg"},{"id":78241700,"identity":"2cb8e8eb-cc21-4e56-adcd-dd5fc85efdd3","added_by":"auto","created_at":"2025-03-11 09:06:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1932269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6159729/v1/2d027077-6155-41c1-982b-18fe03a248af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Truly scarless three-port transoral robotic thyroidectomy: a feasible and efficient alternative to the four-port approach for thyroid cancer patients","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOver the years, various thyroid surgery approaches and techniques, particularly remote-access procedures, have been developed to address the aesthetic concern of visible neck scars left after surgery.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Among these, transoral thyroidectomy has gained popularity as the only truly scarless option, offering cosmetic advantages without compromising postoperative outcomes compared to conventional open thyroidectomy or other remote-access methods.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWith the advancements in surgical robotic systems and instruments, the robotic system has been integrated into the transoral approach.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The transoral robotic thyroidectomy (TORT) typically involves four ports\u0026mdash;three placed in the lower lip and one in the axilla.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] This four-port technique improves surgical visibility by retracting surrounding muscles and counter-traction. Introduction of 4th arm facilitates precise dissection around key structures such as the parathyroid gland and recurrent laryngeal nerve (RLN), and allows for the removal of larger thyroid glands through the axillar incision, which is more flexible than the lower lip incision.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, the four-port TORT approach has certain limitations. It is not entirely scarless due to the 1\u0026ndash;2 cm axillary incision, requires more extensive flap dissection to retrieve the specimen, and often results in longer operative times.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Recently, some surgeons have adopted a three-port TORT approach, omitting the axillary incision.[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] This technique is truly scarless, minimizes flap dissection, and shortens the hospital stay without the need for drainage.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] However, the three-port approach presents challenges, particularly in removing larger thyroid specimens and performing fine dissection due to the lack of counter-traction by the fourth robotic arm.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eGiven that the three-port TORT procedure is relatively new, there is a lack of comparative studies between the three-port and four-port techniques. The aim of this study was to compare the outcomes of four-port and three-port TORT.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e This study was approved by the Institutional Review Board of Seoul Metropolitan Government-Seoul National University Boramae Medical Center (IRB No. 10-2023-69), and informed consent for this retrospective study was waived. Patients who underwent TORT lobectomy from August 2021 to January 2024 were retrospectively enrolled. From August 2021 to January 2024, patients underwent conventional four-port TORT, while from January 2024 to October 2024, patients underwent three-port TORT, exclusively. Indications for TORT included well-differentiated thyroid carcinomas less than 2 cm. Exclusion criteria included invasion of the trachea, nerve, or esophagus, and lateral lymph node metastasis. Patients requiring total thyroidectomy for bilateral thyroid tumors were excluded to minimize selection bias, as the surgeon determined the choice between four-port and three-port TORT based on factors like tumor size and the presence of thyroiditis, rather than the time period. All of the surgical procedures were performed using the da Vinci X robotic system (Intuitive Surgical, Sunnyvale, CA, USA) by a single experienced surgeon (Y.J.C.).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Procedures\u003c/h3\u003e\n\u003cp\u003eThe TORT procedure has been described in detail in previous literature.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] The difference between the three-port and the four-port TORT procedure was the use of the axillary port in the four-port TORT. To create the axillary port for the four-port TORT, additional dissection around the medial border of the sternocleidomastoid muscle in the right neck was performed, followed by skin tunneling with a tunneler or long trocar after making a 1 cm incision in the right axilla. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows thyroidectomy via three-port TORT, and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows thyroidectomy via four-port TORT. The specimen was extracted through the axillary incision in the four-port TORT whereas it was extracted through the middle incision at the lower lip in the three-port TORT. Intraoperative neuromonitoring was performed using the nerve integrity monitoring (NIM)-response 3.0 system (Medtronic, Jacksonville, Florida, USA), with a cable connected to the Maryland dissector (Intuitive Surgical, Sunnyvale, CA, USA) to enable its use as a stimulator. For the specimen extraction through the midline incision in the three-port TORT, dilation of the midline port with Hegar dilator was needed if the specimen was too large for the incision size. No surgical drain was inserted in either procedure. Vocal cord function was monitored using direct laryngoscopy, on the first follow up visit in the outpatient clinic, two weeks after surgery.\u003c/p\u003e \n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eOutcome measurement\u003c/b\u003e\u003c/div\u003e \u003cp\u003eOutcomes analyzed included operative time, length of hospital stay, and complications. Operative time was defined as the time from skin incision to closure. Complications included transient or permanent vocal cord palsy, mental nerve injury, seroma, hematoma, and surgical site infection. Transient vocal cord palsy was defined as reduced mobility of the vocal cord detected on direct laryngoscopy that lasted less than 6 months, while permanent vocal cord palsy was defined as persisting for more than 6 months. Transient mental nerve injury was identified by paresthesia of the chin or lower jaw lasting less than 6 months, and permanent injury was defined as persisting beyond 6 months. Seroma and hematoma were considered postoperative complications if aspiration was required, while surgical site infection was classified as a postoperative complication if antibiotic treatment was necessary.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eContinuous variables were analyzed using either the \u003cem\u003et\u003c/em\u003e-test or the Mann-Whitney U test, depending on the data distribution, while categorical variables were evaluated using the chi-square test or Fisher\u0026rsquo;s exact test for comparisons between two groups. Statistical analyses were conducted using R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria), with a significance threshold set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 72 patients (60 females, 12 males) were included in the analysis. The mean age of 37.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 years and a mean body mass index of 24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 kg/m\u0026sup2;. The mean size of the thyroid nodules was 0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 cm, with 25 (34.7%) located in the left thyroid and 46 (65.3%) in the right. Final histopathological diagnoses included 69 (95.8%) papillary thyroid carcinomas, 2 (2.8%) follicular variant papillary thyroid carcinomas, and 1 (1.4%) follicular thyroid carcinoma.\u003c/p\u003e \u003cp\u003ePatient characteristics according to the groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Four-port TORT was performed in 31 patients and three-port TORT was performed in 41 patients. The mean body mass index was higher in the four-port TORT group than the three-port TORT group (25.2 vs. 24.1 kg/m\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). There were no significant differences in the other patient characteristics between the two groups, including age, sex, nodule size, and histopathology (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.050).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFour-port group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThree-port group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (87.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNodule size, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistopathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePapillary thyroid carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollicular variant papillary thyroid carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollicular thyroid carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiplicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtrathyroidal extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (64.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (51.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicroscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGross\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphatic invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (81.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThyroiditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (81.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (85.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (68.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or N (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the surgical outcomes. The mean operation time was significantly shorter in the three-port TORT than the four-port group (107.7 vs. 141.0 minutes, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was one patient who had transient recurrent laryngeal nerve injury in the four-port group, and no one in the three-port group. In the three-port group, one patient developed a postoperative seroma, and another experienced wound inflammation, while no such complications were observed in the four-port group. In the four-port group, one patient required an additional 2 cm skin incision due to a 1 cm papillary thyroid carcinoma that was firmly adhered to the trachea; the incision was made to facilitate manual tracheal shaving.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical outcomes of four-port and three-port transoral robotic thyroidectomy groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFour-port group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThree-port group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time, minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122.0\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e141.0\u0026thinsp;\u0026plusmn;\u0026thinsp;25.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of excised lymph nodes\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of metastatic lymph nodes\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocal cord palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermanent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003e Among the patients who underwent central lymph node dissection\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or N (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWhen TORT was first performed, one of the advantages of TORT over TOETVA and other remote-access thyroidectomies was the advantages associated with the additional axillary port.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The benefits of the axillary port include providing counter-traction of the strap muscles and thyroid tissue, which is facilitated by the insertion of an additional robotic arm.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] This counter-traction allows the other robotic arms to be used more effectively for dynamic dissections, ensuring safer manipulation of critical structures, such as nerves, parathyroid glands, and blood vessels.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Additionally, the axillary port serves as a passageway for specimen removal, with the sturdier, more flexible skin of the axilla able to better tolerate the forces required during this process compared to the oral mucosa.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, the inclusion of the axillary port somewhat diminishes one of the original advantages of TORT, which is the ability to leave no visible cutaneous scars. Although the axillary incision is small (1\u0026ndash;2 cm) and typically hidden within the natural folds of the axilla, it still results in a scar.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Additionally, creating space for the axillary port can be time-consuming and may lead to bleeding, as well as increased postoperative pain. Another drawback is the increased cost associated with using an additional robotic arm, which involves extra instruments and materials, such as trocars and robotic tools.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe operation time for three-port TORT was significantly shorter than for four-port TORT. While the learning curve effect may have influenced the outcomes, as the three-port procedures were performed at a later period than the four-port procedures, the additional flap formation for 4th arm in the four-port approach likely also contributed to the increased operative time. A previous study comparing three-port and four-port TORT also found that the operative time for three-port TORT was significantly shorter, although no specific reasons were provided.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The explanations for this difference in that study may be similar to those in our own: patients who underwent three-port TORT were treated later, possibly benefiting from the learning curve with increased experience leading to faster procedures, or the additional time required for flap formation for the fourth arm in the four-port approach. Future studies should specifically measure the time spent on flap formation to help clarify this difference.\u003c/p\u003e \u003cp\u003eIn the four-port TORT group, one case required an additional skin incision to facilitate tumor removal. This highlights that the number of robotic arms may not necessarily determine the ease of the procedure, but may depend more on the specific case. Careful ultrasound review and strict patient selection is necessary to avoid additional skin incision or open conversion. Importantly, there were no significant differences in complication rates, including recurrent laryngeal nerve injury between the two approaches. While the additional robotic arm through the axillary port can provide useful counter-traction, three-port TORT may be performed safely and similarly in selective cases, such as small tumor size or unilateral procedures, when carried out by an experienced surgeon.\u003c/p\u003e \u003cp\u003eOne unique concern for TORT is mental nerve injury, which can cause numbness in the lower lip and chin, thereby impairing quality of life.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] The risk may be higher with three-port TORT, as the specimen is extracted through the midline vestibular port, potentially leading to excessive stretching of the incision and the mental nerve branch.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] For this reason, our study limited the size indication for cancer cases to 2 cm. While larger tumors are technically feasible for three-port TORT, it is preferable to consider four-port TORT in such cases to minimize the risk of mental nerve injury or tumor rupture. In our study, within this size limit, no mental nerve injury occurred in any of the patients in either group, suggesting that the three-port TORT did not increase the risk of this complication. However, further studies with larger sample sizes are needed to definitively determine whether there is any difference in the incidence of mental nerve injury between the four-port and three-port TORT.\u003c/p\u003e \u003cp\u003eThis study has several limitations. It was conducted at a single center by a highly experienced surgeon who had previously performed 200 cases of bilateral axillo-breast approach robotic thyroidectomy and 120 cases of transoral endoscopic thyroid surgery prior to starting the first TORT case. Since all procedures were performed by a surgeon with significant experience in both robotic and transoral approaches, the findings should be interpreted with caution when applied to other centers with different levels of expertise. Additionally, the small sample size and retrospective design of the study, along with the lack of randomization and matching between the two groups, introduce potential confounding bias. However, by stratifying patients based on the date of surgery, we minimized selection bias. Nonetheless, the fact that the three-port TORT group underwent surgery more recently than the four-port group may have influenced the results due to the learning curve effect. Moreover, despite assigning the two groups by the date of surgery, there may still be some selection bias. In our study, the body mass index was significantly lower in the three-port group. However, since the mean difference in body mass index between the two groups was only 1 kg/m\u003csup\u003e2\u003c/sup\u003e and previous studies have shown that body mass index is not associated with surgical outcomes in remote access thyroid surgeries,[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] the impact of the body mass index difference on the results is likely limited.\u003c/p\u003e \u003cp\u003eIn conclusion, the three-port transoral robotic thyroidectomy is a feasible option with comparable outcomes to the four-port technique. It offers the advantage of being truly scarless and reduces operative time, making it a promising alternative for patients undergoing robotic thyroidectomy in selected patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDISCLOSURES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoon Young Oh, A Jung Chu, Young Shin Song, Ka Hee Yi, and Young Jun Chai have no conflicts of interest to disclose..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoon Young Oh and Young Jun Chai contributed to the study conception and design, material preparation, data collection and analysis. All authors read and commented on previous versions of the manuscript, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Boramae Medical Center at Seoul National University Hospital (IRB No. 10-2023-69), and informed consent for this retrospective study was waived.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOh M.Y., Chai Y.J., Yu H.W., Kim S.J., Choi J.Y., Lee K.E. (2023) Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis. 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(2020) Sensory change in the chin and neck after transoral thyroidectomy: Prospective study of mental nerve injury. Head Neck 42: 3111\u0026ndash;3117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/hed.26351\u003c/span\u003e\u003cspan address=\"10.1002/hed.26351\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark Y., Yu H.W., Lee J.K., Choi J.H., Kim W., Kwak J., Kim S.J., Chai Y.J., Suh H., Choi J.Y., Lee K.E. (2023) Effect of body habitus on surgical outcomes following bilateral axillo-breast approach robotic thyroidectomy: a retrospective cohort study. Int J Surg 109: 1257\u0026ndash;1263. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/JS9.0000000000000279\u003c/span\u003e\u003cspan address=\"10.1097/JS9.0000000000000279\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStang M.T., Yip L., Wharry L., Bartlett D.L., McCoy K.L., Carty S.E. (2018) Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America. Thyroid 28: 1655\u0026ndash;1661. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/thy.2018.0404\u003c/span\u003e\u003cspan address=\"10.1089/thy.2018.0404\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Scarless, Transoral, Thyroid surgery, Robotic system","lastPublishedDoi":"10.21203/rs.3.rs-6159729/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6159729/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eTransoral robotic thyroidectomy (TORT) has traditionally been performed using a four-port technique. A newer three-port technique, which eliminates the axillary port, makes TORT truly scarless. However, there is a limited number of studies comparing the two approaches. This study evaluates the outcomes of four-port versus three-port TORT.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA retrospective review was conducted on patients who underwent lobectomy using TORT between August 2021 and October 2024. From August 2021 to January 2024, patients underwent four-port TORT, while from January 2024 to October 2024, patients underwent three-port TORT.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSeventy-two patients (31 in the four-port group and 41 in the three-port group) were included. The mean ages were 35.2 years (four-port group) and 39.9 years (three-port group). The mean operative time was significantly shorter in the three-port group compared to the four-port group (107.7 minutes vs. 141.0 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). One patient in the four-port group experienced transient recurrent laryngeal nerve injury, while none occurred in the three-port group. In the three-port group, one patient developed postoperative seroma, and another experienced wound inflammation, whereas no such complications occurred in the four-port group. One patient in the four-port group required an additional mini-incision in the neck for tumor shaving of the trachea due to tumor adhesion. There was no difference in hospital stay between the two groups (1.8 days in the four-port group vs. 2.0 days in the three-port group).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThree-port transoral robotic thyroidectomy is a feasible and efficient alternative to the four-port method for selected patients undergoing thyroidectomy.\u003c/p\u003e","manuscriptTitle":"Truly scarless three-port transoral robotic thyroidectomy: a feasible and efficient alternative to the four-port approach for thyroid cancer patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 08:41:59","doi":"10.21203/rs.3.rs-6159729/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1554244-4e18-497d-af80-6e07a2b361ed","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-11T08:42:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-11 08:41:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6159729","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6159729","identity":"rs-6159729","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}