**6. Surgical Technology: A Cost-Effective Addition?**

As stated above, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. In part this may be caused by the increasing use of technology aimed to improve outcomes. The morbidity after thyroid surgery is low when performed by high-volume surgeons [50,51] and the real-world results suggest a gross underreporting of surgical morbidity [52]. Hypoparathyroidism, recurrent laryngeal nerve palsy, and post-operative haemorrhage reduce QoL and add cost to the overall treatment of thyroid cancer [52]. Costs can be reduced with appropriate postoperative hypocalcaemia protocols [53] and the cost of care is consistently lower in high-volume hospitals in the USA mainly due to reduced length of stay but other variations remain unexplained [54]. One possible variable relates to the use of technological adjuncts.

To reduce the morbidity of thyroid surgery, many technical aids have been developed and advocated. These include nerve monitoring devices, vessel sealing devices, autofluorescence technology, and new surgical approaches, such as robotic thyroid approaches and more recently transoral surgery. Naturally, these devices may have advantages to offer in some cases, possibly reducing morbidity or the time of surgery, but always at a cost. The technology adds to the total costs associated with thyroid surgery, as was demonstrated using the Nationwide Inpatient Sample (NIS) database [55] and Premier Healthcare Database [43]. However, often the enthusiasm for new technology has meant that a rigorous cost-effectiveness/value analysis is not performed until the devices have become ingrained in surgical practice. It is clear that some technology may be expensive but more cost-effective than cheaper solutions [56]. For example, energy-based devices for sealing, cutting, and/or secondary haemostasis are now widely used and preferred to the clamp-and-tie approach for this reason [57]. The various technologies (ultrasonic, bipolar, and advanced bipolar) have proven efficacy and safety [57–61] and a pooled costeffectiveness meta-analysis showed an 8.7% reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures (*p* = 0.029) [62].

The efficacy data on intraoperative neuromonitoring (IONM) of the RLN and EBSLN in thyroidectomy are now extensive, but it remains controversial whether the use of IONM can reduce the rate of permanent RLN injury in thyroid surgery. Most device users are reluctant to return to thyroid surgery without the device [63] but there has been an attempt

to address the value of IONM [64–66]. The most recent one evaluated the cost-effectiveness of IONM using a Markov chain model, in the setting of a bilateral thyroidectomy [64]. The ICER between the use and non-use of IONM was £33,401 per QALY with the conclusion that this is an acceptable cost in avoiding bilateral RLN palsy and tracheostomy. However, the cost-utility analysis did not confirm these results completely, reporting visual identification of the RLN led to a cost saving of £129 and £496 per patient, and an improvement of 0.001 and 0.004 QALY, over selective IONM and universal IONM, respectively. It was concluded that if the RLN injury were decreased by 50.4% or more with IONM compared to visual identification, the selective use of IONM in high-risk cases would be the most cost-effective solution [65]. Another analysis failed to demonstrate cost-effectivity in a realistic clinical setting [66]. The use of IONM has however become the standard of care irrespective of the value considerations in most developed countries and has a key role in training to which a price cannot be attached as cannot the value of avoidance of bilateral nerve palsy provided by IONM [67].

Autofluorescence of the parathyroid glands and the use of indocyanine green (ICG) to evaluate their vascularisation is another new surgical technique that recently has been developed [68–70]. Time will tell whether this adds value in the event that hypoparathyroidism can be prevented with the associated costs of life-long supplements and end-organ damage including renal impairment.

The costs of novel surgical approaches such as robotic transaxillary thyroidectomy and transoral endoscopic thyroidectomy vestibular approach (TOETVA), which have as the main feature avoiding a neck scar [71], are yet to be evaluated from a health economics point of view. The widespread use of robotic thyroid surgery in Korea has been ascribed to extensive government support, economic interests, and the higher surgical fees associated with the technique [72]. One analysis has compared transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy but omitted conventional surgery as a control. Differences in mean variable direct cost for lobectomy and total thyroidectomy were £918 and £745, respectively, due to the longer operating time and different energy-based devices (open versus keyhole) used [73].
