Postsurgical Outcomes and Surgical Completeness of Robotic Thyroid Surgery: A Single Surgeon's Experience on 700 Cases

Efficacy and Safety of Robotic Bilateral Axillo-Breast Approach Versus Robotic Gasless Axillary Approach for Thyroidectomy: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the comparative efficacy and safety of robotic thyroidectomy techniques, including the robotic bilateral axillo-breast approach (BABA) and the robotic gasless axillary approach (GAA).

DATA SOURCES

A comprehensive literature search was conducted across 5 major electronic databases (PubMed, Embase, Cochrane Library, Web of Science, and Scopus) to identify relevant studies published until May 2024.

REVIEW METHODS

Analysis was conducted using RevMan 5.4 software with pooled mean and rate ratios calculated with 95% CIs.

RESULTS

A total of 73 studies, comprising 70 eligible for meta-analysis, were included. Compared with robotic GAA, robotic BABA was associated with significantly longer operative time (pooled mean: 64.65 min, 95% CI: 51.77-77.53, P<0.00001), increased hospital stay (pooled mean: 1.24 d, 95% CI: 0.92-1.56, P<0.00001), and higher intraoperative bleeding (pooled mean: 44.90 mL, 95% CI: 26.99-62.81, P<0.00001). While no significant differences were observed in the rates of hypoparathyroidism, recurrent laryngeal nerve palsy, chyle leakage, seroma, hematoma, or infection, the incidence of Horner syndrome was significantly higher in the BABA group (pooled risk ratio: 0.01, 95% CI: 0.00-0.05, P=0.003).

CONCLUSIONS

Robotic BABA was associated with longer operative times, increased hospital stays, and higher intraoperative bleeding compared with Robotic GAA, although both techniques demonstrated comparable safety profiles for most outcomes. The higher incidence of Horner syndrome with BABA should be considered when selecting the optimal surgical approach for thyroidectomy.

Surgical outcomes of robotic thyroidectomy for thyroid tumors over 4 cm via the bilateral axillo-breast approach

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

A meta-analysis of unilateral axillary approach for robotic surgery compared with open surgery for differentiated thyroid carcinoma

OBJECTIVE

The Da Vinci Robot is the most advanced micro-control system in endoscopic surgical instruments and has gained a lot of valuable experience today. However, the technical feasibility and oncological safety of the robot over open surgery are still uncertain. This work is to systematically evaluate the efficacy of the unilateral axillary approach for robotic surgery compared to open surgery for differentiated thyroid carcinoma.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were utilized to search for relevant literatures of robotic thyroid surgery using unilateral axillary approach compared to open thyroid surgery, and a meta-analysis was performed using RevMan software version 5.3. Statistical analysis was performed through Mantle-Haenszel and inverse variance methods.

RESULTS

Twelve studies with a total of 2660 patients were included in the meta-analysis. The results showed that compared with the open group, the robotic group had a longer total thyroidectomy time, shorter hospital stay, less intraoperative bleeding, more postoperative drainage, fewer retrieved central lymph nodes, and higher cosmetic satisfaction (all P < 0.05). In contrast, temporary and permanent laryngeal recurrent nerve injury, temporary and permanent hypoparathyroidism or hypocalcemia, brachial plexus nerve injury, number of retrieved central lymph nodes, number of retrieved lymph nodes in the lateral cervical region, number of lymph node metastases in the lateral cervical region, hematoma, seroma, lymphatic leak, stimulated thyroglobulin (sTg) and unstimulated thyroglobulin (uTg), and the number and recurrence rate of patients with sTg <1ng/ml were not statistically different between the two groups (P > 0.05).

CONCLUSIONS

The unilateral axillary approach for robotic thyroid surgery may achieve outcomes similar to those of open surgery. Further validation is required in a prospective randomized controlled trial.

Remote-access robotic thyroidectomy: A systematic review

BACKGROUND

Recently, robotic surgery has been introduced as a new surgical approach to the thyroid.

OBJECTIVES

The primary objective of this systematic review is to critically examine safety and feasibility of the different robotic approaches.

METHODS

The literature on robotic thyroidectomy was systematically reviewed. Primary endpoints were surgery duration, length of hospital stay, complications, postoperative pain and cosmetic satisfaction.

RESULTS

Sixty-eight studies with a total of 14433 patients were included. Depending on the robotic approach used, operative duration ranged between 89 and 230 min and hospitalisation stay between 0.1 and 5.6 days. Complication rates varied between 7.3% and 29%. Postoperative pain visual analogue scores (VAS) ranged from 0.6 to 4.71.

CONCLUSION

Robotic thyroidectomy results in high cosmetic satisfaction and quality of life. No differences in complication rates between robotic and traditional approaches are observed, supporting safety and feasibility of these robotic techniques.

Unilateral axilla-bilateral areola approach for thyroidectomy by da Vinci robot vs. open surgery in thyroid cancer: a retrospective observational study

Background

To compare the efficacy and safety of unilateral axilla-bilateral areola (UABA) approach for robot-assisted thyroidectomy with conventional open surgery in thyroid cancer patients.

Methods

The clinicopathological features and surgical outcomes of 194 thyroid cancer patients treated by robotic surgery using the UABA approach and 217 patients treated by open surgery in our department from January 2017 to August 2018 were analysed and compared.

Results

The operation time was longer in the robotic group than in the open surgery group. The patients' satisfaction with neck appearance was higher in the robotic group than in the open surgery group (91.2% vs. 21.6%, P<0.01). After total thyroidectomy and central lymph node dissection, the incidence of postoperative transient hypoparathyroidism and postoperative permanent hypoparathyroidism in the open surgery group was 29.7% (44/148) and 6.8% (10/148), higher than that [17.9% (27/151) and 2.0% (3/151)] in the robotic group (P<0.05 respectively). No significant difference was observed in the number of dissected lymph nodes or postoperative serum thyroglobulin (TG) levels or incidence of transient or permanent hoarseness of voice between the two groups. No recurrence or metastasis was found.

Conclusions

Compared with open surgery, UABA robotic surgery preserved the neck appearance and effectively reduced hypoparathyroidism by super-meticulous capsular dissection (SMCD).

Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis

PURPOSE

Conventional thyroidectomy has been standard of care for surgical thyroid nodules. For cosmetic purposes different minimally invasive and remote-access surgical approaches have been developed. At present, the most used robotic and endoscopic thyroidectomy approaches are minimally invasive video assisted thyroidectomy (MIVAT), bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET), bilateral axillo-breast approach robotic thyroidectomy (BABA-RT), transoral endoscopic thyroidectomy via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy.

METHODS

A systematic search was conducted in Medline, Embase and Web of Science to identify original articles investigating operating time, length of hospital stay and complication rates regarding recurrent laryngeal nerve injury and hypocalcemia, of the different minimally invasive techniques.

RESULTS

Out of 569 identified manuscripts, 98 studies met the inclusion criteria. Most studies were retrospective in nature. The results of the systematic review varied. Thirty-one articles were included in the meta-analysis. Compared to the standard of care, the meta-analysis showed no significant difference in length of hospital stay, except a longer stay after BABA-ET. No significant difference in incidence of recurrent laryngeal nerve injury and hypocalcemia was seen. As expected, operating time was significantly longer for most minimally invasive techniques.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis comparing the eight most commonly used minimally invasive thyroid surgeries individually with standard of care. It can be concluded that minimally invasive techniques do not lead to more complications or longer hospital stay and are, therefore, not inferior to conventional thyroidectomy.

Robotic lateral cervical lymph node dissection via bilateral axillo-breast approach for papillary thyroid carcinoma: a single-center experience of 260 cases

To evaluate the feasibility and safety of robotic lateral cervical lymph node dissection via BABA, 260 thyroid cancer patients with suspected level II, III, IV, and Vb lymph node metastasis were selected. The lateral cervical compartment was exposed by splitting the sternocleidomastoid muscle longitudinally, and separating between the strap muscles and the anterior margin of the sternocleidomastoid muscle. The procedure was completed in 260 patients. Mean time for robotic lateral node dissection took 80 ± 21 min. The wound catheter was removed 6.3 days. Postoperative transient symptomatic hypocalcemia was observed in 51 patients, transient hoarseness in three, seroma in three, chyle leakage in two, and tracheal injury in one. 124 patients were confirmed to have lymph node metastasis on final pathological report. Average postoperative hospital stay was 6.5 days. Robotic lateral neck dissection by BABA is the acceptable operative alternative for thyroid cancer patients who wished to keep their surgical history private.

Surgical Hypoparathyroidism

Surgical hypoparathyroidism is the most common cause of hypoparathyroidism and the result of intentional or inadvertent extirpation, trauma, or devascularization of the parathyroid glands. Surgical hypoparathyroidism may present as a medical emergency. Pediatric patients, those with Graves disease, and those undergoing extensive neck dissections or reoperative neck surgery are at particular risk for this complication. Extensive surgical expertise, immediate or delayed autotransplantation, and prophylactic and postoperative calcium/vitamin D supplementation in select patients are associated with a reduction in the risk of surgical hypoparathyroidism. Intraoperative parathyroid imaging is among novel strategies being investigated to mitigate surgical hypoparathyroidism in the intraoperative setting.