Single-port lumpectomy for bilateral thyroid surgery via the areolar route 1. Clinical data and methods 1.1 General information There were 12 patients in this group, 11 women and 1 man. Age ranged from 19 to 56 years old, with an average of 27 years old. 11 cases were asymptomatic (only manifested as thyroid lumps), and 1 case slightly felt painful and uncomfortable lumps. The preoperative ultrasound showed bilateral thyroid nodules with regular borders, no abnormal blood flow signal, and no microcalcifications. The larger thyroid nodules ranged from 1.2 to 3.5 cm in diameter, with an average diameter of 57.49999999999999 px; the smaller thyroid nodules ranged from 0.5 to 50 px in diameter, with an average diameter of 32.5 px. No malignant signs such as fine sand-like calcifications were found in the preoperative examinations (including CT examination) (see Figure 1). 8 patients had no malignant cells detected by fine needle aspiration cytology. Thyroid function was normal in all cases. Case selection criteria: maximum diameter of thyroid nodules on the larger side <4 cm, maximum diameter of thyroid nodules on the smaller side <50px< span="">. The preoperative examination considered the possibility of benignity, and 12 patients in this group have been excluded from intraoperative frozen pathology as malignant cases. The patients had a strong cosmetic desire, no previous history of neck surgery or radiotherapy, and no history of severe coagulation mechanism disorders and organomegaly of important organs such as heart, lung and kidney. 1.2 Methods 1.2.1 Surgical instruments 30°10-mm rigid laparoscope (Stryker Endoscopy), ultrasonic knife (Johnson & Johnson, USA, model GEN300), non-invasive subcutaneous detachment rod and general lumpectomy instruments. 1.2.2 Surgical method General anesthesia. The patient’s legs were spread apart, the operator stood between the legs, the assistant stood on either side of the patient, and the TV screen was placed on the side of the patient’s head. The path is marked on the affected side of the body from the areola to the neck (the side with the larger thyroid nodule is chosen for the areolar incision, see Figure 2). A 10-mm lumpectomy incision is made at the upper edge of the areola, and a space is separated superficially in the deep fascia with a subcutaneous detachment rod, and the lumpectomy is inserted with CO2 gas at a pressure of 6 to 8 mm Hg. A 5-mm incision is made adjacent to the lumpectomy hole, and an electric hook and ultrasonic knife are placed to separate the surgical space and reach up to the thyroid cartilage. The electrocoagulation hook is cut through the cervical white line and the strap muscles are separated and the larger side of the thyroid nodule is done first. Suspend this side of the strap muscle with sutures 1 stitch through the lateral skin of the neck and traction outward to reveal the thyroid gland, and ultrasonic knife coagulation to cut the middle thyroid vein. The thyroid gland is suspended by 1 to 2 stitches with sutures through the medial skin of the neck and traction inward (Figure 3), and the tissue on the back of the thyroid gland is pushed away, coagulated by ultrasonic knife, and cut away from the thyroid gland after disconnecting the blood vessels in the upper or lower pole of the thyroid gland. The same method is used to operate on the other side of the thyroid, with care taken to preserve the posterior thyroid envelope during surgery. The specimen was removed in a specimen bag (finally the two adjacent incisions next to the areola were taken out as one and sent for frozen section). Seven cases were bilateral partial thyroidectomies and five cases were subtotal thyroidectomies on one side and partial thyroidectomies on the other side. The intraoperative bleeding was 15-40 ml, with an average of 25 ml; the total amount of postoperative trauma drainage was 80-135 ml, with an average of 110 ml, and the tube was removed 3-4 days after surgery. Postoperative pathology: 4 cases of bilateral thyroid adenoma; 5 cases of bilateral nodular goiter; 3 cases of thyroid adenoma on one side and nodular goiter on the other side (1 of which was combined with Hashimoto’s thyroiditis). There were no symptoms such as choking on water, hoarseness and hand and foot twitching after surgery. The 24-h postoperative pain visual analogue scale (VAS, 0 being no pain and 10 being most painful) [10] ranged from 1 to 5, with a mean score of 3.10. In all cases, at the 2-month postoperative follow-up, there was no significant chest wall trauma pain or numbness, no cervicothoracic skin tightening discomfort, and the patients rated the cosmetic results (0 as very dissatisfied and 10 as very satisfied) as 8 to 10, with an average score of 9.5. The traditional open surgery leaves 6-200px surgical scar on the neck, which is an exposed part of the neck and seriously affects the beauty of the neck and causes some psychological impact on young female patients. Some patients may experience scar hyperplasia, abnormal skin sensation, or even swallowing discomfort due to skin-tracheal adhesions. In 1996, Gagner reported the world’s first lumpectomy for parathyroidectomy, which was the first lumpectomy in the neck; in 1997, Huscher et al. reported lumpectomy for thyroid lobectomy; in 2007, Lundgren et al. reported lumpectomy for In 2009, Jeong et al. reported radical lumpectomy for microscopic papillary thyroid cancer. Miccoli et al. concluded that fully lumpectomized thyroid surgery is a long and traumatic procedure, which is only cosmetic and not minimally invasive. However, some scholars believe that the superficial layer of the deep fascia of the anterior thoracic wall is a layer of loose connective tissue with few blood vessels, which is easy to separate, and as long as the cavity is correctly entered at this level, the procedure is not “massively invasive. Because of these controversies, we designed a single-port lumpectomy of the thyroid via the areolar approach in the hope of finding a minimally invasive procedure with good cosmetic results. Previous reports in the literature on uniportal laparoscopic surgery have been unilateral thyroid surgery, but as we gain experience, the indications for surgery are gradually expanding, and in selected cases, uniportal laparoscopic thyroid surgery via the areola route can be performed bilaterally. Single-port lumpectomy thyroid surgery is performed under single-port, single-channel conditions, and the limited surgical space is characterized by difficult operation, difficult organ retraction, and restricted field exposure. The correct anatomical plane should be mastered when freeing the subcutaneous operating space, and the separation rod should be separated in the superficial layer of the deep subcutaneous fascia (loose tissue and few blood vessels) to avoid damaging small subcutaneous blood vessels or the dermis, which may lead to liquefaction of subcutaneous fat, skin ecchymosis, erythema, and secondary infection. The intraoperative CO2 pressure is very important, because of the specificity of the surgical site, such as too high pressure in the neck may affect the blood flow back to the neck and affect the central brain function, if the pressure is too low, it will affect the surgical field exposure, generally controlled at 6~8 mm Hg. The thyroid gland and the strap muscle are pulled medially and laterally respectively in the operation, so that the surgical field is more clearly revealed and the operation is safer. The application of ultrasonic knife is very important in the operation. It generates less smoke and crust during the operation, thermal damage <1 mm, facilitates precise anatomical separation and hemostasis, and the hemostatic effect is exact. The ultrasonic knife is used to dissect the superior and inferior thyroid vessels by pre-clotting the proximal end first and then coagulating the distal end to make the vessel closure more accurate; when dissecting the back of the thyroid gland, the tissue next to it is pushed away and the ultrasonic knife head should face upward and cut close to the thyroid peritoneum to avoid damaging the parathyroid glands and the recurrent laryngeal nerve. There is a learning curve for performing lumpectomy thyroid surgery, as is the case for single-port lumpectomy thyroid surgery via the areolar route. After performing 10 unilateral thyroidectomies, we began to select cases for bilateral thyroidectomy. The criteria for selecting cases were the largest thyroid nodule on the larger side <4 cm in diameter and the largest thyroid nodule on the smaller side <50 px< span="">, with the areolar incision made on the larger side of the thyroid nodule and the larger thyroid nodule removed first. Since doing the smaller side of the thyroid nodule requires crossing the trachea, there are some obstacles to reveal and operate, so the diameter of the nodule should be less than 50px, and care should be taken to preserve the posterior thyroid envelope intraoperatively to avoid parathyroid gland and laryngeal nerve injury. Single-port lumpectomy bilateral thyroid surgery via the areola route masks the surgical scar with the help of the areola, and the area of subcutaneous separation during surgery is about 3000px2, which is significantly smaller than that of three-port lumpectomy thyroid surgery, and has the advantage of being both cosmetic and minimally invasive. In our group, the mean 24-h postoperative pain visual analog score was 3.10, and the mean cosmetic satisfaction score was 9.5 in 12 patients at the 2-month postoperative follow-up. We appreciate that single-port lumpectomy of bilateral thyroid surgery via the areolar route is safe and feasible, with the advantages of concealed incision, small subcutaneous separation area, and high cosmetic satisfaction.