Modified robotic-assisted thyroidectomy: an initial experience with the retroauricular approach

Docking Methods for Robot-assisted Rhytidectomy and Platysmaplasty

Background

In recent years, the development of robotic surgery has been rapidly evolving as well as the interest in their use due to the advantages they provide, such as precision in dissection, the ability to magnify the visualization of the operative field up to 20:1, and the ability to operate in hard-to-reach areas that otherwise cannot be achieved using the traditional methods. Research is being published constantly on the utilization of such robots within the fields of general surgery, oncology, and urology, with few cases in maxillofacial surgery.

Methods

There are no docking algorithms or methods for plastic surgery operations, especially those involving the head and neck area. In this article, we explore different docking methods with da Vinci Si, Xi, and 5 surgical systems for aesthetic facial and neck surgery.

Results

The results of the multiple different techniques used highlighted a few possible access points, whereas others were deemed impractical due to certain limitations such as the limited maneuverability of the robot's arms, the angles required for safe access, and the patient's body limiting the movement of the robot. Da Vinci 5 comes with significant advantages compared with its predecessors due to its novel and improved technologies, such as force feedback technology and artificial intelligence greatly enhancing the robot's usability.

Conclusions

Robotic surgery is a viable operative method that is beneficial for improving the outcomes when using the appropriate docking methods.

Evaluating the Efficacy and Safety of Robotic Versus Conventional Completion Thyroidectomy: A 10-year Experience

BACKGROUND

Robotic thyroidectomy is gaining popularity, yet its role in completion thyroidectomy remains unclear. We aimed to compare robotic vs conventional completion thyroidectomy for thyroid nodules.

METHODS

This retrospective study analyzed patients undergoing completion thyroidectomy from 2010-2020, either by conventional open technique (n = 87) or a robotic remote-access approach (n = 44). Outcomes were compared between groups.

RESULTS

A total of 131 patients were included. The robotic cohort was younger (45.3 ± 14.0 vs 55.5 ± 14.5 years, P < 0.001) with a lower BMI (25.9 ± 5.5 vs 33.7 ± 7.8 kg/m2, P < 0.001). Operative time was longer for robotic procedures (139 min vs 99 min, P < 0.001). Hospital stay was shorter after robotic surgery, with 25% discharged the same day as compared to 5.7% in the open thyroidectomy cohort (P = 0.006). Overall rates of complication were comparable (P = 0.65). Transient recurrent laryngeal nerve palsy occurred in 4.6% of patients, which was similar between both cohorts (P = 0.66).

CONCLUSION

Robotic completion thyroidectomy appears safe and effective, achieving shorter hospitalization than conventional open approaches despite longer operative times. Appropriate patient selection and surgical technique optimization are key. Larger prospective studies should investigate costs and long-term patient-reported outcomes.

A scoping review of endoscopic and robotic techniques for lateral neck dissection in thyroid cancer

Introduction

Lateral neck dissection (LND) in thyroid cancer has traditionally been performed by a transcervical technique with a large collar incision. With the rise of endoscopic, video-assisted, and robotic techniques for thyroidectomy, minimally invasive LND is now being performed more frequently, with better cosmetic outcomes.

Methods

The purpose of this paper is to review the different minimally invasive and remote access techniques for LND in thyroid cancer. A comprehensive literature review was performed using PubMed and Google Scholar search terms "thyroid cancer" and "lateral neck dissection" and "endoscopy OR robot OR endoscopic OR video-assisted".

Results

There are multiple surgical options now available within each subset of endoscopic, video-assisted, and robotic LND. The approach dictates the extent of the LND but almost all techniques access levels II-IV, with variability on levels I and V. This review provides an overview of the indications, contraindications, surgical and oncologic outcomes for each technique.

Discussion

Though data remains limited, endoscopic and robotic techniques for LND are safe, with improved cosmetic results and comparable oncologic and surgical outcomes. Similar to patient selection in minimally invasive thyroidectomy, it is important to consider the extent of the LND and select appropriate surgical candidates.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

Facelift thyroid surgery: a systematic review of indications, surgical and functional outcomes

OBJECTIVE

To investigate indications, surgical and functional outcomes of robotic or endoscopic facelift thyroid surgery (FTS) and whether FTS reported comparable outcomes of other surgical approaches.

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

REVIEW METHODS

A literature search was conducted about indications, clinical and surgical outcomes of patients who underwent FTS using PICOTS and PRISMA Statements. Outcomes reviewed included age; gender; indications; pathology; functional evaluations; surgical outcomes and complications.

RESULTS

Fifteen papers met our inclusion criteria, accounting for 394 patients. Endoscopic or robotic FTS was carried out for benign and malignant thyroid lesions, with or without central neck dissection. Nodule size and thyroid lobe volume did not exceed 6, 10 cm, respectively. FTS reported comparable outcome with transaxillary or oral approaches about operative time, complication rates or drainage features. The mean operative time ranged from 88 to 220 min, depending on the type of surgery (endoscopic vs robotic hemi- or total thyroidectomy). Conversion to open surgery was rare, occurring in 0-6.3% of cases. The most common complications were earlobe hypoesthesia, hematoma, seroma, transient hypocalcemia and transient recurrent nerve palsy. There was an important disparity between studies about the inclusion/exclusion criteria, surgical and functional outcomes.

CONCLUSION

FTS is a safe and effective approach for thyroid benign and malignant lesions. FTS reports similar complications to conventional thyroidectomy and excellent cosmetic satisfaction.

Review: Improving quality of life in patients with differentiated thyroid cancer

Well differentiated thyroid cancer is a common malignancy diagnosed in young patients. The prognosis tends to be excellent, so years of survivorship is expected with low risk disease. When making treatment decisions, physicians should consider long-term quality of life outcomes when guiding patients. The implications for treating indolent, slow growing tumors are immense and warrant careful consideration for the functioning years ahead. Surgery is the standard of care for most patients, however for a subset of patients, active surveillance is appropriate. For those wishing to treat their cancer in a more active way, novel remote access approaches have emerged to avoid a cervical incision. In the era of "doing less", options have further expanded to include minimally invasive approaches, such as radiofrequency ablation that avoids an incision, time off work, a general anesthetic, and the possibility of post-treatment hypothyroidism. In this narrative review, we examine the health related quality of life effects that surgery has on patients with thyroid cancer, including some of the newer innovations that have been developed to address patient concerns. We also review the impact that less aggressive treatment has on patient care and overall wellbeing in terms of active surveillance, reduced doses of radioactive iodine (RAI) treatment, or minimally invasive techniques such as radiofrequency ablation (RFA) for low risk thyroid disease.

Surgical treatment of thyroid cancer: Established and novel approaches

Thyroid surgery is one of the most common head and neck procedures. The thyroid can be accessed through an anterior cervical incision, or by remote access techniques such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA) which is favored for its ease, safety and direct plane to the thyroid gland. Other novel approaches for targeting small-localized well-differentiated thyroid cancer are by thermal ablation, namely ultrasound guided radiofrequency ablation. These innovative techniques for minimizing a cutaneous scar or for targeting small cancers directly without removal of the gland have developed alongside our realization that low risk well-differentiated thyroid cancer tends to be slow growing and indolent. Up to date, the most robust data supports offering these therapies primarily to patients who would be eligible for active surveillance protocols. In this paper, we review the traditional surgical approaches for removing well-differentiated thyroid cancer, as well as innovative remote access techniques (namely TOETVA), and minimally invasive thermal ablation (namely RFA).

Conversion rates in robotic thyroid surgery: A systematic review and meta‐analysis

Objective

To define the conversion risk to open procedure during robot‐assisted thyroid surgery (RATS) identifying potential specific subclasses of procedures or accesses at higher conversion risk.

Methods

In a PRISMA‐compliant framework, all original prospective studies providing RATS conversion rates from multiple databases were pooled in a random‐effects meta‐analysis. Conversion rates were compared between different typologies of thyroid surgery and robotic access.

Results

13 studies were deemed eligible. Four conversions from two studies were reported out of 398 procedures. No significant heterogeneity was observed (Cochran's Q p = 0.932; I2 = 0%). The pooled conversion rate was 1% (95% confidence interval, 0.1%–2%). The ANOVA‐Q test failed to show significant differences when comparing type of thyroid surgery or robotic access (respectively p = 0.766 and p = 0.457).

Conclusion

While the conversion rate appears consistently low across studies, prospective data collection and systematic reporting of procedural complications are required for framing high‐risk procedures and accesses.

Single-port transaxillary robotic thyroidectomy (START): 200-cases with two-step retraction method

Background

This study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce our novel two-step retraction method.

Methods

START was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed.

Results

Among the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13–58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m² (range: 15.9–37.0 kg/m²). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method.

Conclusions

START is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08837-9.

Endoscopic cephalic access thyroid surgery (EndoCATS) using the retroauricular approach - a single centre retrospective data analysis

BACKGROUND

Due to improvements in endoscopic as well as robotic technology, and a request for better cosmetic results, there was a significant increase in thyroid surgery using these methods during the past decade.

METHODS

The aim of our study is to evaluate the perioperative short- and long-term outcome as well as the learning curve of EndoCATS and the Quality of Life (QoL).

RESULTS

A total of 150 patients with 152 hemithyroidectomies who underwent endoscopic thyroid surgery by EndoCATS between 2010 and 2016 were enrolled in this study. The mean specimen volume was 15.04 g ± 7.89 g. The mean operation time was 132.79 ± 50.52 min. There is a significant reduction of the operation time after the 53th case. (p < 0.05) There was no acute rebleeding or permanent hypoparathyroidism. Permanent RLN palsy occurred in 3 nerves at risk (NAR) 1.97%. There were no cases of pneumothorax, postoperative infections or skin flap ischemia. 94.11% of the patients describe their state of general health as good as or better than before the surgery.

CONCLUSIONS

EndoCATS is a safe and effective, but a demanding single port access procedure; therefore, extensive training is required. An advantage is the near ideal visualization of the RLN and the parathyroid glands as well as the ability to recover even large specimens without difficulties.

Transoral thyroid surgery vestibular approach: does size matter anymore?

BACKGROUND

Various approaches for endoscopic and minimally invasive thyroid operations have been reported, with some becoming popular to date. The aim of these procedures is to reduce and prevent visible scars in the neck. This led to the transoral endoscopic thyroidectomy vestibular approach (TOETVA) technique applicable in small thyroid specimen. To amend TOETVA and to broaden the indication for transoral thyroid surgery, our aim was to combine the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach.

METHODS

After successful implementation of the TOETVA technique in 2017, we evaluated the transoral technique regarding feasibility and safety in well-selected patients in Germany and Austria. With the combination of TOETVA and EndoCATS, we were able to optimize the extraction process of the specimen by avoiding damage to the thyroid capsule and to broaden the indication of transoral surgery by operating on thyroid glands with higher volume. Patients' characteristics, surgical outcome and complications were determined.

RESULTS

Seventy-one transoral procedures were performed in 70 patients. The TOETVA procedure was performed in 60 patients, and 10 female patients underwent TOVARA with transoral thyroid lobe mobilization and removal of the specimen via the retroauricular access. Overall, median operation time was 205 min (range 96-370 min) and permanent RLNP rate was 1% accordant to 99 nerves at risk (39 hemithyroidectomies, 29 total thyroidectomies, 2 parathyroid resections, and 1 thyroglossal cyst resection). No conversion to conventional open surgery was necessary. Long-term mental nerve injury occurred in two patients. No infection was identified.

CONCLUSIONS

Transoral thyroid and parathyroid surgery via the vestibular approach is both feasible and safe in Western Europe. The combination of the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach, called TOVARA, is a promising opportunity to allow for thyroid surgery without a visible scar in specimen with volume of more than 40 ml also.

Extracervical Approaches to Thyroid Surgery: Evolution and Review

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.

Feasibility, Safety, and Surgical Outcome of Robotic Hemithyroidectomy Via Transaxillary and Retroauricular Approach: an Institutional Experience

The aim of this observational prospective study was to determine the technical feasibility, safety, and adequacy of robotic hemithyroidectomy. From April 2015 to May 2016, 16 patients with solitary thyroid lesion underwent robotic hemithyroidectomy using the Da Vinci® Si Surgical system. Patients were observed and data were recorded on surgical time, blood loss, complications, and functional outcome of the patients. A total of 16 patients (3 males and 13 females; mean age 39.9 years) underwent robotic hemithyroidectomy after evaluation for solitary thyroid nodule with a mean nodule size of 2.2 ± 0.3 cm. Fiber-optic laryngoscopy (FOL) was normal in all cases pre-operatively. Five patients were operated by transaxillary approach, the rest by retroauricular (facelift) approach. Mean pocket dissection time was 42 min for transaxillary and 40 min for retroauricular approach. Mean operative console time was 59.4 min for transaxillary and 52.6 min for retroauricular approach. Average blood loss was 45 ml. Mean hospital stay was 1.5 days. None of the patients had any post-operative complication on follow-up. One patient had restricted left vocal cord mobility which improved in 3 months. Mean pain score was 0.25 ± 0.4 and average speech score was 0.5 ± 0.2 at 3 months. Post-operatively, all patients had adequate swallowing with no episode of aspiration. Robotic hemithyroidectomy is a safe, feasible, and oncologically safe procedure. It has benefits in terms of better scar cosmesis than open surgery.

Robotic Neck Surgery in the Pediatric Population

Introduction:

Thyroid, parathyroid, and thymus surgeries are traditionally performed via a cervical approach. However, robot-assisted procedures can provide a safe alternative for neck surgeries. We report our experiences with robotic transaxillary and retroauricular approaches in pediatric patients.

Case Presentation:

We conducted a retrospective review of pediatric patients who underwent robot-assisted neck surgery by a single surgeon between April 2010 and May 2017. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated.

Management and Outcomes:

Nine surgeries in 7 female patients were reviewed (mean age, 16.0 ± 1.58 years; mean body mass index, 22.5 ± 0.75). Two thyroid lobectomies, 2 complete thyroidectomies, 1 subtotal thyroidectomy, 1 thyroid lobectomy with thymectomy, 2 subtotal parathyroidectomies with thymectomy, and 1 dermoid cyst excision were performed. Two surgeries with the retroauricular approach had a mean surgical time of 142.0 ± 6.13 minutes. Seven surgeries with the transaxillary approach had a mean surgical time of 146.1 ± 21.01 minutes. There were no reported conversions, permanent vocal cord paralysis, permanent hypoparathyroidism, hematoma, or seroma. There was 1 case (11%) of temporary shoulder hypoesthesia and 2 cases of temporary vocal cord paresis (22%).

Discussion:

This series on robot-assisted neck surgeries in children describes procedures performed with robotic transaxillary and retroauricular approaches. In the hands of a high-volume surgeon the techniques are feasible and safe options for operations in the neck in a select group of pediatric patients.

Anterior cervical incision-sparing thyroidectomy: Comparing retroauricular and transoral approaches

Objectives

The robotic retroauricular approach and transoral endoscopic thyroidectomy vestibular approach (TOETVA) have been employed to avoid anterior neck scarring in thyroidectomy with good success. However, outcomes have yet to be compared between techniques. We compare our initial clinical experience with these approaches for thyroid lobectomy at our institution.

Methods

A review of initial consecutive patients who underwent robotic facelift thyroidectomy (RFT) (August 2011–August 2016) at our institution was conducted. This was compared with the same number of initial consecutive patients who underwent TOETVA (September 2016–September 2017) at our institution. Demographics, operative time, pathology, complications, and learning curve were compared between cohorts. Learning curve was defined based on the slope of linear regression models of operative time versus case number.

Results

There were 20 patients in each cohort. There was no statistically significant difference in demographic data between cohorts. One hundred percent of RFT cases versus 95% TOETVA cases (P = .999) were completed without conversion to standard open technique with median operative times of 201 (124–293) minutes versus 188 (89–343) minutes with RFT and TOETVA, respectively (P = .36). There was no incidence of permanent recurrent laryngeal nerve injury in either cohort. The slopes of the regression models were 0.29 versus −8.32 (P = .005) for RFT and TOETVA, respectively.

Conclusion

RFT and TOETVA are safe and feasible options for patients motivated to avoid an anterior neck scar. However, the quicker learning curve without the need for a costly robotic system may make TOETVA the preferred technique for institutions wishing to perform anterior cervical incision‐sparing thyroidectomy.

Level of Evidence

4

Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection

Background

Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection.

Methods

A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study.

Results

Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed.

Conclusions

The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

Factors affecting operative time in robotic thyroidectomy

BACKGROUND

The purpose of this study was to evaluate factors related to operative time in robotic thyroidectomy.

METHODS

We retrospectively analyzed 240 patients who underwent robotic thyroidectomy. The total thyroidectomy cases and lobectomy cases were both categorized into those with long operative times (LOTs; upper 25% of cases) and those with short operative times (SOTs; lower 25%).

RESULTS

Among the total thyroidectomy cases, body mass index (BMI) ≥23 kg/m² (hazard ratio [HR] 5.34; P = .008) and bilateral central neck dissection (CND; HR 14.92; P = .028) were more frequent in the LOT group in multivariate analysis. Among the lobectomy cases, BMI ≥23 kg/m² (HR 12.92; P = .003) and unilateral CND (HR 21.38; P = .017) were the only independent risk factors for prolonged operative time.

CONCLUSION

Body habitus and clinical nodal status in the central compartment should be considered in deciding the indications for robotic thyroidectomy.

Remote Access Robotic Facelift Thyroidectomy: A Multi-institutional Experience

BACKGROUND

Robotic facelift thyroidectomy (RFT) was developed as a new surgical approach to the thyroid gland using a remote incision site. Early favorable results led to this confirmatory multi-institutional experience.

METHODS

Prospectively collected data on consecutive patients undergoing RFT in five North American academic endocrine surgical practices were compiled. Surgical indications, operative times, final pathology, nodule size, complications, and postoperative management (drain use and length of hospital stay) were evaluated.

RESULTS

A total of 102 RFT procedures were undertaken in 90 patients. All but one of the patients (98.9 %) were female, and the mean age was 41.9 ± 13.1 years (range 12-69 years). The indication for surgery was nodular disease in 91.2 % of cases; 8.8 % were completion procedures performed for a diagnosis of cancer. The mean size of the largest nodule was 1.9 cm (range 0-5.6 cm). The mean total operative time for a thyroid lobectomy was 162 min (range 82-265 min). No permanent complications occurred. There were 4 cases (3.9 %) of transient recurrent laryngeal nerve weakness, no cases of hypocalcemia, and 3 (2.9 %) hematomas. There were no conversions to an anterior cervical approach. The majority of patients were managed on an outpatient basis (61.8 %) and without a drain (65.7 %).

CONCLUSIONS

RFT is technically feasible and safe in selected patients. RFT can continue to be offered to carefully selected patients as a way to avoid a visible cervical scar. Future prospective studies to compare this novel approach to other remote access approaches are warranted.

Recent progress of retroauricular robotic thyroidectomy with the new surgical robotic system

OBJECTIVE

Previously, we have reported the feasibility of retroauricular (RA) robotic thyroidectomy. Despite its promising surgical outcomes, there were certain intrinsic mechanical limitations inherent to the da Vinci Si System (Intuitive Surgical, Sunnyvale, California, U.S.A.). Since the advent of an upgraded model, the Xi System (Intuitive Surgical), we have actively incorporated the new model into performing RA thyroidectomy. Here, we intend to verify the feasibility of RA robotic thyroidectomy using the new da Vinci Xi System (Intuitive Surgical) with comparison of the former Si-applied surgery (Intuitive Surgical).

STUDY DESIGN

Comparative analysis.

METHODS

There were total 165 consecutive patients who received RA robotic thyroidectomy from January 2013 to February 2016. The patients were divided into two groups: Si group (n = 125) and Xi group (n = 40). Perioperative and treatment outcomes were compared and analyzed.

RESULTS

Compared with the previous system, new da Vinci Xi system (Intuitive Surgical) enabled insertion of an extra third robotic instrumental arm. Unlike the previous robotic surgical technique, the robotic dissection could be initiated immediately after the establishment of working space and the resulting total operation time could be significantly decreased. There was no difference in the surgical completeness, as confirmed by postoperative thyroglobulin levels. Additionally, flexed EndoWrist (Intuitive Surgical) instruments equipped with the Erbe (Erbe USA Inc., Marietta, Georgia, U.S.A.) system could be mounted, which further facilitated the operation. There were no significant differences in postoperative complications between the two groups.

CONCLUSION

The RA robotic thyroidectomy with the new Xi System (Intuitive Surgical) can greatly facilitate the robotic surgery with comparable or improved surgical outcomes. Its application is expected to open up a new era of robotic neck surgery.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1730-1737, 2018.

Comparative Study between Robotic Total Thyroidectomy with Central Lymph Node Dissection via Bilateral Axillo-breast Approach and Conventional Open Procedure for Papillary Thyroid Microcarcinoma

BACKGROUND

A large proportion of the patients with papillary thyroid microcarcinoma are young women. Therefore, minimally invasive endoscopic thyroidectomy with central neck dissection (CND) emerged and showed well-accepted results with improved cosmetic outcome, accelerated healing, and comforting the patients. This study aimed to evaluate the safety and effectiveness of robotic total thyroidectomy with CND via bilateral axillo-breast approach (BABA), compared with conventional open procedure in papillary thyroid microcarcinoma.

METHODS

One-hundred patients with papillary thyroid microcarcinoma from March 2014 to January 2015 in Jinan Military General Hospital of People's Liberation Army (PLA) were randomly assigned to robotic group or conventional open approach group (n = 50 in each group). The total operative time, estimated intraoperative blood loss, numbers of lymph node removed, visual analog scale (VAS), postoperative hospital stay time, complications, and numerical scoring system (NSS, used to assess cosmetic effect) were analyzed.

RESULTS

The robotic total thyroidectomy with CND via BABA was successfully performed in robotic group. There were no conversion from the robotic surgeries to open or endoscopic surgery. The subclinical central lymph node metastasis rate was 35%. The mean operative time of the robotic group was longer than that of the conventional open approach group (118.8 ± 16.5 min vs. 90.7 ± 10.3 min, P < 0.05). The study showed significant differences between the two groups in terms of the VASs (2.1 ± 1.0 vs. 3.8 ± 1.2, P < 0.05) and NSS (8.9 ± 0.8 vs. 4.8 ± 1.7, P < 0.05). The differences between the two groups in the estimated intraoperative blood loss, postoperative hospital stay time, numbers of lymph node removed, postoperative thyroglobulin levels, and complications were not statistically significant (all P > 0.05). Neither iatrogenic implantation nor metastasis occurred in punctured porous channel or chest wall in both groups. Postoperative cosmetic results were very satisfactory in the robotic group.

CONCLUSIONS

Robotic total thyroidectomy with CND via BABA is safe and effective for Chinese patients with papillary thyroid microcarcinoma who worry about the neck scars.

Robotic surgical systems in maxillofacial surgery: a review

Throughout the twenty-first century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery. However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless, robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications of robotic surgery in the head and neck region and highlights the benefits and limitations of current robotic surgical systems.

Overview of robotic thyroidectomy

With the advancement and adaptation of technology, there has been a tremendous evolution in the surgical approaches for thyroidectomy. Robotic thyroidectomy has become increasingly popular worldwide attracting both surgeons and patients searching for new and innovative techniques for thyroidectomy with a superior cosmetic result when compared to the conventional open procedures. In this review, we describe the following surgical approaches for robotic thyroidectomy: transaxillary, retroauricular (facelift) and transoral. The advantages and disadvantages as well as limitations of each approach are examined, and future directions of robotic thyroidectomy are discussed.

Robotic retroauricular thyroid surgery

Surgery is the gold standard treatment for patients with thyroid cancer or nodules suspicious for cancer. Open conventional approach is the standard surgical approach. However, a visible neck incision could be a concern for most young female patients, especially for patients with a history of healing with keloid or hypertrophic scars. Robotic remote access approaches have evolved into a safe and feasible approach in selected patients, providing a hidden scar with good patient satisfaction. This review will focus on the performance and safety of robotic retroauricular thyroid surgery.

Robotic Thyroidectomy

Objectives

Robotic thyroidectomy using remote access approaches has gained popularity with patients seeking to avoid neck scarring and enhanced cosmetic satisfaction. The aim of this study was to compare the efficacy and advantages of a postauricular facelift approach vs a gasless unilateral axillary (GUA) approach in robotic thyroidectomy.

Study Design

Case series with chart review.

Setting

University tertiary care hospital.

Subjects and Methods

We retrospectively analyzed the data of 65 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUA approach (45 patients) or a postauricular facelift approach (20 patients) between September 2013 and December 2014. We excluded patients who underwent simultaneous lateral neck dissection or completion thyroidectomy.

Results

Robotic procedures were completed without being converted to an open procedure in all patients. There were no significant differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, complications, and postoperative pain between the 2 approaches, except the higher female ratio in the GUA approach group (female ratio, 95.6% vs 75%, P = .042). Cosmetic satisfaction evaluated by a questionnaire was not significantly different between the 2 groups, and most patients of both groups (85.7%) were satisfied with postoperative cosmesis.

Conclusion

Both GUA and postauricular facelift approaches are feasible, with no significant adverse events in patients, and result in excellent cosmesis. However, a GUA approach seems to be superior when performing total thyroidectomy using a unilateral incision based on the preliminary result.

American Thyroid Association Statement on Remote-Access Thyroid Surgery

BACKGROUND

Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption.

METHODS

A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery.

RESULTS

Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision.

CONCLUSIONS

Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.

Comprehensive application of robotic retroauricular thyroidectomy: The evolution of robotic thyroidectomy

OBJECTIVES/HYPOTHESIS

As an evolvement of the robotic application to the thyroidectomy, we sought to seek the potential role of robotic thyroidectomy with the retroauricular (RA) approach prior to future comparative study between RA and transaxillary thyroidectomy. This study aims to verify the surgical feasibility of robotic RA thyroidectomy.

STUDY DESIGN

Case series with planned data collection.

METHODS

A total of 87 patients who underwent robotic RA thyroidectomy for clinically suspicious papillary thyroid carcinoma or benign lesions from January 2013 to May 2014 were retrospectively reviewed and analyzed.

RESULTS

All robotic surgeries via RA approach were successfully performed, without any significant intraoperative complications or conversion to open surgery. Based on patient-reported outcome questionnaires, all patients were satisfied with their postoperative surgical scars.

CONCLUSION

Robotic RA thyroidectomy is technically feasible and safe, with satisfactory cosmetic results for patients where indicated.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1952-1957, 2016.

Initial learning curve of single-incision transaxillary robotic hemi- and total thyroidectomy--A single team experience from Europe

INTRODUCTION

The primary advantage of robotic thyroidectomy is to avoid a neck scar. On the other hand, this sophisticated technique implies some potential risks otherwise not associated with conventional thyroidectomy, increased costs, and prolonged operating times. With all these factors being an important issue, we analysed the data of our initial European series in order to understand the nature of the learning curve for this technique.

METHODS

Ten patients underwent transaxillary robotic thyroidectomy for benign disease, performed consistently by the same surgeon with the same team, within a timeframe of 12 months. There were four total thyroidectomies and six hemithyroidectomies. Operating times broken down into creating the working space, docking the robot, and console work (including wound closure), were prospectively recorded and evaluated.

RESULTS

By the end of the initial learning curve comprising ten patients, the total operating time for a robotic hemithyroidectomy and for a total thyroidectomy has decreased by 49% to 190 min, and by 31% to 229 min, respectively. Intraoperative complications were successfully managed without conversion to open access surgery.

CONCLUSION

The learning curve for transaxillary robotic thyroidectomy is rather steep; reasonable progress in terms of operating times can be achieved within the first ten cases. Consistency in the team and careful patient selection are paramount factors for success.