The inclusion criteria and the main contraindications are summarized in the following text. The most significant limit is represented by the size of both the nodule(s) and/or the gland as measured by means of an accurate ultrasonographic study obtained preoperatively. In countries where goiter is endemic, the gland volume can be relevantly independent from the nodule volume, and this aspect might be responsible for the necessity of converting the procedure.

Ultrasonography can also be useful to exclude the presence of thyroiditis, which might make the dissection troublesome. In case ultrasonography only gives the suspicion of thyroiditis, autoantibodies should be measured in the serum. If thyroiditis is diagnosed preoperatively, this is a consideration to MIVAT.

One of the most controversial aspects regarding the appropriateness of MIVAT is in the treatment of malignant thyroid disease. “Low-risk” papillary carcinoma constitutes an ideal indication for MIVAT,^2,3 but it is important to take into account the possibility of lymph node involvement in the neck. Great caution should be taken when there is the possibility of either metastatic lymph nodes or extracapsular invasion of the gland, both of which represent a contraindication to the minimally invasive endoscopic procedure.

Indications

Contraindications

All patients should undergo (1) neck ultrasound in order to evaluate thyroid gland total volume (this should be less than 25 mL) and diameter of nodule/s (these should be less than 3 cm); (2) fine needle aspiration cytology of suspicious nodules; (3) blood tests in order to exclude thyrotoxicosis and acute thyroiditis before surgery; (4) basal serum calcitonin dosage is strongly suggested in order to exclude medullary carcinoma, which is a contraindication to MIVAT; (5) routine preoperative laryngoscopy is strongly recommended in all patients in order to identify asymptomatic vocal cord palsy.