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Publication Open Access Scarless Thyroidectomy: Transoral Endoscopic Thyroidectomy by Vestibular Approach(2017) Uludağ, Mehmet; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesiİzsiz tiroidektomi: Vestibüler yaklaşımla transoral endoskopik tiroidektomi Vestibüler yaklaşımla transoral endoskopik tiroidektomi (TOETVA) minimal invaziv, görünür yara izi olmayan naturel orifis transluminal endoskopik cerrahi (Naturel orifice transluminal endoscopic surgery (NOTES) tekniktir. Ağız içinden vestibüler bölgeden uygulanan 1 adet 10 mm ve 2 adet 5 mm port yardımı ile düşük CO2 basıncı altında tamamen endoskopik olarak lobektomi veya total tiroidektomi uygulanabilir. Dünyada giderek uygulaması artmaktadır. Deneyimli merkezlerde seçilmiş hastalarda güvenli bir şekilde uygulabilmektedir. Bu çalışmada minimal invaziv tiroit cerrahisinin gelişimi, TOETVA için hasta seçimi ve dışlama kriterleri, bölgesel anatomi, ameliyat tekniği, preoperatif ve postoperatif bakım, yöntemin avantajları, dezavantajları ve olası komplikasyonları tartışılacaktır.Publication Open Access Tiroit cerrahisinde intraoperatif sinir monitorizasyonunun temel prensipleri ve standardizasyonu(2017) Uludağ, Mehmet; Kaya, Cemal; Aygün, Nurcihan; Tanal, Mert; İşgör, Adnan; Oba, Sibel; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir Üniversitesi; T.C. Sağlık BakanlığıTiroit cerrahisinde intraoperatif sinir monitorizasyonunun temel prensipleri ve standardizasyonuTiroit cerrahisi sonrası oluşan sesle ilgili problemler sık ve en önemli komplikasyonlardandır. Cerrahi sonrası hastanın ses ve solunum problemlerini minimalize edebilmek için hem reküren laringeal sinirin (RLS) hem de süperior laringeal sinirin eksternal dalının (SLSE) korunması gerekir. İntraoperatif nöromonitorizasyon (İONM) sinirin gözle görülmesine ek olarak ameliyat sırasında sinirin motor fonksiyonlarının dinamik olarak değerlendirilmesi temeline dayanan bir yöntemdir. Tiroit cerrahisinde İONM 50 yıl önce kullanılmaya başlanmış ve yüzey elektrotlu endotrakeal tüp ile İONM, amaca uygunluk, basitlik, noninvazif olma ve güvenlilik gibi nedenlerle standart uygulanan yöntem haline gelmiş olup, günümüzde tiroit cerrahisinde bu yöntem kullanılmaktadır. Tiroit cerrahisinde RLS ve SLSE için İONM kullanımı giderek artmaktadır. İONM'nin uygun kullanımı için hem anestezist hem cerrah için deneyim ve standardizasyonu şarttır. Bu bağlamda hem cerrahların hem de anestezistler için öğrenme eğrisi yaklaşık 50-100 arası olgudur. İONM hem RLS hem SLSE'nin bulunmasında ve fonksiyonel olarak değerlendirilmesinde önemli katkı sağlar. RLS monitorizasyonu monitorizasyon probu ile aralıklı veya vagusa uygulanan prob yardımı ile sürekli olarak uygulanabilir. RLS monitorizasyonunun standardizasyonu, preoperatif laringoskopi ile vokal kord muayenesi (L1), RLS diseksiyonu öncesi aynı taraf vagustan uyarı alınması (V1), RLS'nin trakeaozefageal olukta ilk bulunduğu noktada uyarılması (R1), diseksiyon bittikten sonra RLS'nin ortaya konduğu en proksimal noktasından uyarılması (R2), cerrahi alanda kanama kontrolü tamamlandıktan sonra vagusun uyarılması (V2), postoperatif laringoskopi ile vokal kord muayenesini (L2) içerir. V2 postoperatif vokal kord fonksiyonunu öngörmede en uygun testtir. RLS aralıklı İONM'sinde sadece sinirin probla uyarıldığı an ve sinirin uyarıldığı nokta distalinin fonksiyonu hakkında bilgi verir. Sürekli İONM ise RLS'nin vagustan ayrılmadan önce boyunda vagusa uygulanan probla yapılan devamlı uyarı sayesinde cerraha tiroidi diseke ederken RLS fonksiyonunun sürekli takip edilmesini sağlar. SLSE monitorizasyonunda primer olarak ameliyat sahasında bulunan ve SLSE'nin motor siniri olduğu krikotiroid kasın kasılması değerlendirilir. İONM hem RLS hem SLSE'nin bulunmasında ve fonksiyonel olarak değerlendirilmesinde önemli katkı sağlaması ile birlikte tiroidektomiye birçok açıdan katkı sağlayan ve tiroidektominin standartlarını arttıran bir yöntemdirPublication Open Access Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide(2018) Aygün, Nurcihan; İşgör, Adnan; Uludağ, Mehmet Emin; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiPapillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumorswith a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosisof PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension tothe tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However,PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increasein thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despitethe sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatmentstrategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate,and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option forPTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillanceof low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression,and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting towardmore conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to activesurveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidenceextended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediatesurgery for appropriately selected patients with PTMC.Publication Open Access Main Surgical Principles and Methods in Surgical Treatment of Primary Hyperparathyroidism(2019) Uludağ, Mehmet; Aygün, Nurcihan; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir ÜniversitesiThe only curative treatment for primary hyperparathyroidism (pHPT) is surgery. The most important factors that increase the success rate of a parathyroidectomy are the establishment of the correct diagnosis and the surgeon’s good knowledge of anatomyand embryology. The lower parathyroid glands develop from the dorsal portion of the third pharyngeal pouch, and the upperparathyroid glands from the fourth pharyngeal pouch. Humans typically have 4 parathyroid glands, however, more than 4 andfewer than 4 have been observed. Typically, the upper parathyroid glands are located in the cricothyroid junction area on theposterolateral portion of the middle and upper third of the thyroid, while the lower parathyroids are located in an area 1 cm indiameter located posterior, lateral, or anterolateral to the lower thyroid pole. Ectopic locations of parathyroid glands outside thenormal anatomical regions due to the abnormal migration during embryological development or acquired ectopy due to migration of enlarged parathyroids are not uncommon. There are various surgical techniques to treat HPT, however, 2 main surgical options are used: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). While there are open, endoscopic,and video-assisted MIP (MIVAP) approaches, most often an open lateral MIP technique is used. In addition, endoscopic or roboticparathyroidectomy methods performed from remote regions outside the neck have been reported. Although currently MIP is thestandard treatment option in selected patients with positive imaging, BNE remains the gold standard procedure in parathyroidsurgery. In 80% to 90% of patients with pHPT, a pathological parathyroid gland can be detected with preoperative imaging methods and MIP can be applied. However, the pathological gland may not be found during a MIP procedure as a result of false positiveresults. The parathyroid surgeon must also know the BNE technique and be able to switch to BNE and change the surgical strategyif necessary. If the intended gland is not found in its normal anatomical site, possible embryological and acquired ectopic locationsshould be investigated. It should be kept in mind that MIP and BNE are not alternatives to each other, but rather complementarytechniques for successful treatment in parathyroid surgery.Publication Open Access Endocrine Surgery during the COVID-19 Pandemic: Recommendations from the Turkish Association of Endocrine Surgery(2020) Teksöz, Serkan; Sormaz, İsmail Cem; İçöz, Recep Gökhan; Makay, Özer; Dural, Ahmet Cem; Hacıyanlı, Mehmet; Şahbaz, Nuri Alper; İşcan, Yalın; Soylu, Selen; Aygün, Nurcihan; İşgör, Adnan; Özdemir, Murat; Aydın, Oğuz Uğur ; Tunca, Fatih; Şenyürek, Yasemin; Uludağ, Mehmet Emin; Emre, Ali Uğur; İstanbul Üniversitesi - Cerrahpaşa; İstanbul Üniversitesi; Ege Üniversitesi; Ege Üniversitesi; Sağlık Bilimleri Üniversitesi; İzmir Katip Çelebi Üniversitesi; Sağlık Bilimleri Üniversitesi; İstanbul Üniversitesi; T.C. Sağlık Bakanlığı; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Ege Üniversitesi; T.C. Sağlık Bakanlığı; İstanbul Üniversitesi; İstanbul Üniversitesi; Sağlık Bilimleri Üniversitesi; T.C. Sağlık BakanlığıThe 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organizationclassified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries andnon-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponedfor a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time shouldnot cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventionscan be described as medically necessary, time-sensitive (MeNTS) procedures.Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after theimmediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant toconstitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinionsof a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage wherethe epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when theoutbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner withsuppression of the outbreak (third stage).In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinionsby considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reportsof many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to thethird stage of the epidemic.We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protectboth patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.Publication Open Access Surgical Indications and Techniques for Adrenalectomy(2020) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir ÜniversitesiIndications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancyand functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secretingadrenal tumors in which adrenalectomy is indicated are as follows: Cushing’s syndrome, arises from hypersecretion of glucocorticoidsproduced in fasciculata adrenal cortex, Conn’s syndrome, arises from an hypersecretion of aldosterone produced by glomerulosaadrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing's disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layerof the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication foradrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the goldstandard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits ofthe surgeon are also important, along with the patient’s characteristics. The most common type of surgery performed in the worldis laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy canbe performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted,which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopicadrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomycan be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multipleadrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%).The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy orsuspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchior modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as ablock. The open retroperitoneal approach can be applied posteriorly or laterally.Publication Open Access Recent Developments of Intraoperative Neuromonitoring in Thyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiAt present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONMand developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although hamplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes. During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG respoPublication Open Access Anatomical, Functional, and Dynamic Evidences Obtained byIntraoperative Neuromonitoring Improving the Standards ofThyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiThe use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage ofIONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standardsof the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrentlaryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations ofRLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquiredregarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innerva tion of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and givesmotor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/ or abductor motor fibers. In 70–80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation tothe anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicatingnerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid musclewhich is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to themotor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is themost common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nervetransection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the lossof signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cordparalysis (VCP) develops in 70–80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min.In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal andpermanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100%of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLNaxis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makessignificant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerveinjury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.Publication Open Access Surgical Treatment of Substernal Goiter Part 1: Surgical Indications, Pre-Operative, and Peroperative Preparation(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiSurgery is one of the most appropriate treatment options for many patients with substernal goiter (SG). However, SG surgery has some technical difficulties and a higher risk of complications compared to normal cervical thyroid surgery. Due to these technical difficulties and complication risks, which we also mentioned in our study, SG surgery should be performed by experienced and high-volume endocrine surgeons in centers with a large team and technical equipment. Pre-operative clinical and radiological evaluation and definitions in SG were evaluated in detail in our previous study. Detailed pre-operative evaluation, pre-operative risk assessment, surgical anatomy, anesthesia, appropriate surgical planning and estimation of surgical width are extremely impor tant in SG surgery, where surgical technical difficulties and increased complication risks compared to cervical thyroid surgery come to the fore. In this study, we aimed to evaluate these preoperative and peroperative preparations in detail.Publication Open Access Substernal Goiter: From Definitions to Treatment(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiThe enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the \rmediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There \rare many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck \rabove the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association \rguideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with \ra slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland \rtoward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate \rto define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent \rof the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms \rof mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. \rIn addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of \rtreatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, \rlaboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the \rtreatment methods, according to the current studies from literature.