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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 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 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 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 Non-Toxic Multinodular Goiter: From Etiopathogenesis to\rTreatment(2022) Ünlü, Mehmet Taner; Aygün, Nurcihan; Uludağ, Mehmet; Köstek, Mehmet; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir ÜniversitesiGoiter term is generally used for defining the enlargement of thyroid gland. Thyroid nodules are very common and some of these\rnodules may harbor malignancy. Multinodular goiter (MNG) disease without thyroid dysfunction is defined as non-toxic MNG.\rThere are many factors in etiology for development of MNG. They can be classified as iodine dependent and non-iodine dependent\rfactors basically. Beyond this basic classification, the effect of many environmental and acquired factors is also effective on the\rdevelopment of goiter.\rMany methods have described for diagnosis and treatment for non-toxic MNG. Biochemical tests, imagining methods, invasive and\rnon-invasive methods have been used for diagnosis for many years. Each method has advantages and disadvantages, separately.\rAlthough the best method for diagnosis is still debatable, distinguishing malignant nodules from benign nodules is the first and\rmost important step for MNG.\rBiochemical tests such as serum thyroid stimulating hormone (TSH) measurement, thyroid hormone measurement, and thyroid\rultrasonography are used for diagnosis of MNG, traditionally. Nowadays, there are some new techniques were developed like\rultrasound-elastography. Furthermore, thyroid scintigraphy may be used if there is abnormal TSH measurement. Fine-needle as-\rpiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron\remission tomography) could be used, too.\rAfter a certain diagnosis is made, treatment options should be evaluated. Many treatment methods have been used for goiter\rfrom ancient times upon today. From non-invasive methods such as medical follow-up to invasive methods such as lobectomy\ror thyroidectomy are options for treatment. Patients with compression symptoms due to an enlarged thyroid gland are usually\rcandidates for surgery. In this study, it is aimed to determine the most appropriate treatment for the patient by discussing the\radvantages and disadvantages of all these methods.\rThe present review discusses definition of goiter term, etiology, epidemiology, pathogenesis, diagnostic methods, and treatment\rmethods for nontoxic MNG.\rPublication 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.