Robotic thyroidectomy: a framework for new technology assessment and safe implementation

Robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach

BACKGROUND

We conducted this study to report our novel robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach and compare it with a conventional transaxillary (CTA) approach using a retraction method for intraoperative and postoperative outcomes.

METHODS

We retrospectively analyzed 354 patients who underwent robotic thyroidectomy between January 2019 and April 2023. Of these patients, 143 underwent the procedure through the GOSTA approach, which involves a small incision of 3 cm along the axillary folds with both arms down and a gas-insufflation, from skin flap creation to the completion of thyroidectomy as a one-step single-port procedure without the need for a retractor. The remaining 211 patients underwent the CTA approach. We analyzed the GOSTA approach and compared the surgical outcomes of the GOSTA (n = 100) and CTA (n = 167) approaches in patients with differentiated thyroid cancer who underwent thyroid lobectomy.

RESULTS

Out of the 143 patients who underwent the GOSTA approach, 12 underwent total thyroidectomy and 9 underwent lateral neck lymph node dissection with total thyroidectomy. GOSTA-thyroid lobectomy was performed on 122 patients; of these, 100 were diagnosed with differentiated thyroid carcinoma. A comparative study with the CTA approach was only conducted in patients who underwent thyroid lobectomy. No significant differences were found in operative time, hospital stay, or complications between the two groups.

CONCLUSIONS

Despite proceeding in one-step with a single smaller incision, from skin flap creation to the completion of thyroidectomy, the GOSTA approach is as feasible and safe as the CTA approach. Additionally, the GOSTA approach allows for thyroidectomy without using a retractor and reduces the workload for the surgeon and assistants.

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.

Evaluation of Preference and Utility Measures for Transoral Thyroidectomy

BACKGROUND

Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy.

METHODS

In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises.

RESULTS

Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics.

CONCLUSION

Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients-in keeping with the current findings of this study.

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.

Analysis of Risk Factors for Surgical Complications of Endoscopic Thyroidectomy via Total Areola Approach

Background

Increased surgical technology has led broad acceptance endoscopic thyroidectomy and its application in the treatment of thyroid diseases, including thyroid carcinoma. Although the incidence of complications and mortality of thyroid surgery has been significantly reduced, serious complications still occur from time to time. The purpose of this retrospective study is to identify the factors that influence the complications of endoscopic thyroidectomy.

Methods

This study was carried out between January 2012 and December 2019, where a total of 630 patients undergoing endoscopic thyroidectomy via the total areola approach were retrospectively evaluated to identify the key influencing factors of complications.

Results

The study established that the common complications included recurrent laryngeal nerve injury (3.33%), superior laryngeal nerve injury (2.54%), hypocalcemia (8.57%), and the incidence of complications was acceptable. Both univariate and multivariate analysis showed that thyroid carcinoma (P = 0.041), operation time lasting more than 150 minutes (P = 0.034) and operation before 2017 (P = 0.001) were risk factors of recurrent laryngeal nerve injury. We established that operation after 2017 (P < 0.005) was the only protective factor of superior laryngeal nerve injury. Thyroid carcinoma (P=0.04), operation mode (P=0.001), and surgery before 2017 (P<0.001) are risk factors for parathyroid injury. Among the clinical groups, operation before 2017 was an independent risk factor for all complications.

Conclusion

For thyroid specialists, after the early learning curve, with the continuous improvement of endoscopic operation technology, high-definition equipment and more sophisticated operation equipment can be used in clinical practice, which can prevent and reduce the occurrence of complications.

Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement

Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.

Robotic thyroid surgery

Various remote access robotic thyroidectomy techniques have been developed using the da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA) to hide or avoid neck scarring and overcome the limitations of endoscopic thyroidectomy. Among those used today are the gasless transaxillary approach, the bilateral axillo-breast approach (BABA), the gasless postauricular facelift approach, and the transoral approach. Especially, the recently introduced transoral approach (including robotic and endoscopic procedures) is prominent and now popular worldwide. The most significant advantages of remote access robotic thyroidectomy are excellent postoperative cosmesis and voice outcomes. The important limitations to the adoption of robotic thyroidectomy are the difficult technique, high complication rate during the learning curve, and high cost. In addition, cultural differences, longer operative times, and medicolegal issues are a barrier to the diffusion of robotic thyroidectomy. However, remote access robotic thyroidectomy is feasible, and the outcomes are comparable to those of conventional transcervical thyroidectomy if performed by experienced surgeons in highly selected patients. This article reviews the evolution and recent advances in robotic thyroid surgery.

Introducing New Technologies and Techniques into Gynecologic Surgical Practice

The surgery practiced today is not the same as the surgery practiced a generation ago and because of the ever-evolving nature of medicine, ongoing education, and adoption of new technology is vital for all surgeons. New technology has the potential to revolutionize the way we practice medicine; however, it is important to understand the context in which new medical devices arise and to approach new medical devices with a healthy combination of skepticism and optimism. Surgeons should feel comfortable assessing, critiquing, and adopting new technology.

Port-Site Implantation Diagnosed by Iodine-131 Post-Ablation Single-Photon Emission Tomography-Computed Tomography After Robotic Thyroidectomy: A Case Report

Patient: Female, 37

Final Diagnosis: Port-site implantation after robotic thyroidectomy

Symptoms: None

Medication: —

Clinical Procedure: Iodine-131 post-ablation whole body scan and single photon emission tomography-computed tomography

Specialty: Nuclear Medicine

A Propensity Score-matched Comparison Study of Surgical Outcomes in Patients with Differentiated Thyroid Cancer After Robotic Versus Open Total Thyroidectomy

INTRODUCTION

The aim of this study, from a surgical, oncological, and functional perspective, was to identify whether bilateral axillo-breast approach robotic total thyroidectomy (RTT) for differentiated thyroid cancer (DTC) has different surgical outcomes compared to open total thyroidectomy (OTT).

METHODS

Initially, 796 patients who underwent total thyroidectomy were primarily reviewed and 178 who were ineligible for analysis were excluded. Propensity score matching analysis adjusted for clinicopathological characteristics (sex, age, body mass index, extent of central node dissection, tumor size, extrathyroidal extension, and thyroiditis) was conducted, with 246 patients in the OTT group matched with 123 patients in the RTT group.

RESULTS

There were no significant differences in surgical outcomes in terms of surgical safety and oncological safety between the OTT and RTT groups, except in mean operation times (123.51 ± 32.63 vs. 198.39 ± 37.93 min, respectively; P < 0.001). However, the median parathyroid and laryngeal function recovery times were shorter in the RTT group than in the OTT group [88 ± 33.09 (95% CI: 23.148-152.852) vs. 100 ± 16.20 (95% CI: 68.242-131.768) days; P = 0.044 and 87 ± 32.40 (95% CI: 23.489-150.511) vs. 118 ± 49.50 (95% CI: 20.985-215.015) days; P = 0.002].

CONCLUSIONS

The recovery times of laryngeal and parathyroid function were significantly shorter in RTT patients than in OTT patients for DTC. To verify a definitive conclusion about the superiority of robotic total thyroidectomy in terms of parathyroid and laryngeal function recovery, further studies may be necessary.

Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform

BACKGROUND

Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy.

METHODS

We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter).

RESULTS

Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy.

CONCLUSIONS

Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial.

TRIAL REGISTRATION

Retrospectively registered on 20 july 2018 .

TRIAL REGISTRATION NUMBER

researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America

BACKGROUND

Since its introduction nine years ago, gasless transaxillary thyroidectomy with robotic assistance (RT) has achieved a relatively limited application in North America. This study aimed to assess the outcomes of RT in a recent large, diverse North American population.

METHODS

Consenting patients were selected for the RT approach from November 2010 to July 2015 based on patient preference, and their perioperative data were retrospectively reviewed.

RESULTS

Of 301 robotic thyroidectomies completed in 281 patients, 160 were total thyroidectomy and 141 were lobectomy. Women predominated (98.9%), with a mean age of 41 years (range 17-74 years) and a mean follow-up of 24 months (range 3-71 months). The mean body mass index (BMI) was 25.7 kg/m² (range 17-44 kg/m²). However, 33.3% of patients had a BMI 25-29.9 kg/m², 12.4% had a BMI 30-34.9 kg/m², 3.5% had a BMI 35-39.9 kg/m², and 0.7% had a BMI ≥40 kg/m². Excluding 20 completion lobectomy, the indications for surgery were indeterminate cytology (53%), malignant cytology (10%), growth (18%), Graves' disease (12%), and other (5%). The mean size of the largest resected nodule was 2.5 cm (range 0.7-6.4 cm). Mean operating time for robotic lobectomy and total thyroidectomy was 81 and 109 minutes, respectively. One patient was converted to standard cervicotomy for failure to progress endoscopically. Complications included temporary dysphonia (6.0%), permanent recurrent laryngeal nerve deficit (1.3%), hypocalcemia (temporary 8.2%, permanent 1.1%), seroma (0.7%), and hematoma requiring reoperation (0.3%). Complications did not differ in patients with a BMI ≥25 kg/m² compared to those with a BMI <25 kg/m² or with respect to nodules >3 cm or surgery for Graves' thyroiditis. One patient developed grade II arm lymphedema ipsilateral to the axillary incision at two years, which resolved with conservative management. No patient had a surgical site infection or brachial plexopathy. Cancer was present histologically in 133 (48%) patients. Among 91 patients with cancer of the index nodule, 48.4% had papillary, 44.0% follicular variant papillary, 2.2% minimally invasive follicular carcinoma, and 5.5% minimally invasive Hürthle cell carcinoma. One patient had sclerosing variant thyroid paraganglioma. To date, all patients are without evidence of tumor recurrence.

CONCLUSIONS

At a high-volume center, gasless transaxillary endoscopic thyroid surgery done with robotic assistance is a safe, efficient, and effective approach in a diverse North American patient population.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Transoral Thyroid and Parathyroid Surgery Vestibular Approach: A Framework for Assessment and Safe Exploration

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new approach to the central neck that avoids an anterior cervical incision. This approach can be performed with endoscopic or robotic assistance and offers access to the bilateral central neck. It has been completed safely in both North American and, even more extensively, international populations. With any new technology or approach, complications during the learning curve, expense, instrument limitations, and overall safety may affect its ultimate adoption and utility. To ensure patient safety, it is imperative to define steps that should be considered by any surgeon or group before adoption of this new approach.

Initiating a Robotic Thyroidectomy Program in India

Robotic surgery has been successfully used for many surgical indications in head and neck surgery. Robotic thyroidectomy is getting accepted worldwide, but the majority of the literature is from South Korea. The purpose of the paper is to review and give a personal perspective on how a robotic thyroidectomy program was initiated in a tertiary care academic medical institution in India. Advantages of robotic approaches are the three-dimensional visualization, precision, dexterity, and surgeon ergonomics. Cost is an important concern. Training includes basic robotics skill training, cadaveric training, observership, and hands-on training. Sufficient preclinical and clinical training is essential before embarking onto the newer surgical modality. Surgeon credentialing, though institution dependent, has specific guidelines. Case selection is the key, especially in the initial learning curve. The authors prefer the retroauricular approach for robotic thyroidectomy, and our initial experience in the first ten cases of total thyroidectomy was encouraging.

Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature

With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.

Gasless trans-axillary robotic thyroidectomy: the technique and evidence

Robot assisted thyroid surgery has the advantage of a superior field vision and technical advancements of robotic technology that have permitted novel remote access thyroid surgical approaches. Gasless trans-axillary robot-assisted thyroidectomy has been proved to be among the most current feasible approaches. This approach offers an excellent cosmetic outcome, with comparable outcomes to conventional surgical approaches. This review aims to provide details of this specific remote access technique for thyroid resection with most recent evidences in the literature.

Robotic thyroidectomy and parathyroidectomy: An initial experience with retroauricular approach

BACKGROUND

New approaches for robotic-assisted thyroidectomy were recently described. The purpose of this study was to present the report of our initial experience using a retroauricular approach for thyroid and parathyroid surgeries.

METHODS

This is a prospective study that was conducted under institutional review board approval and all surgeries were performed by a single surgeon at a North American academic institution. Some patients underwent an additional concomitant neck lift surgery in addition to the thyroid surgery. Some cases were performed without the use of the robot and they have been evaluated compared with the robotic cases. Clinical characteristics, total operative time, blood loss, surgical outcome, and length of hospital stay were evaluated.

RESULTS

Forty cases representing thirty-eight female patients were included in this study, which includes 37 thyroid lobectomies and 3 parathyroid surgeries. Mean age was 44 ± 13 years, and mean body mass index (BMI) was 26.9 ± 5.31. Mean thyroid nodule size was 2.01 ± 0.94 cm. All cases were completed successfully via a single retroauricular incision. There was no conversion to an open approach. Six of 38 patients underwent additional neck lift surgery with a mean total operative time of 189 ± 45 minutes. The mean operative time for the remaining 34 patients who underwent retroauricular robotic-assisted hemithyroidectomy without neck lift surgery was 156 ± 39 minutes. Five patients underwent an endoscopic, retroauricular approach to the thyroid and parathyroid without using the robot. Two of 38 patients developed postoperative hematoma, in whom one of them needed a surgical evacuation. There were no cases of permanent vocal cord paralysis or permanent hypoparathyroidism. However, 2 patients developed transient hoarseness, which resolved 9 weeks and 10 weeks postoperatively, respectively. Mean blood loss was 19.0 ± 30.93 mL. Twenty-one patients were discharged on the same day of surgery, 17 patients were discharged after an overnight stay, and the remaining 2 patients were discharged after 2 days.

CONCLUSION

Single-incision retroauricular robotic hemithyroidectomy and parathyroidectomy can be safe and feasible and concomitant neck lift surgery can be offered in a select group of patients. In addition, the nonrobotic retroauricular approach can be performed safely; however, future studies are warranted to further evaluate the benefits and limitations of this novel robotic retroauricular surgical approach.

Technical, Oncological, and Functional Safety of Bilateral Axillo-Breast Approach (BABA) Robotic Total Thyroidectomy

BACKGROUND

The aim of this study was to identify whether bilateral axillo-breast approach (BABA) robotic total thyroidectomy (RoTT) is technically, oncologically, and functionally safe.

MATERIALS AND METHODS

One hundred eighteen patients underwent BABA robotic thyroidectomy between July 2010 and February 2013. Ninety-one (77.1%) patients underwent RoTT, and 27 (22.9%) underwent robotic unilateral lobectomy.

RESULTS

RoTT (n=91) resulted in lower rate of surgical complication and in higher rate of transient hypocalcemia comparing with robotic unilateral lobectomy (n=27) (35.16% vs. 3.7%; P<0.013), but not in a permanent hypocalcemia, transient, or permanent recurrent laryngeal nerve palsy (2.2% vs. 0%; P=1.000, 3.3% vs. 0%; P=1.000, and 0% vs. 0%; P=NS), respectively. Successful remnant ablation rate for the patients with RoTT was 100% on a subsequent 6 months follow-up. No significant differences between 2 groups existed in mean Voice Handicap Index-10 scores during postoperative 6 months (P=0.308).

CONCLUSIONS

BABA RoTT might be oncologically safe as well as technically and functionally safe procedure.

Minimally invasive and remote-access thyroid surgery in the era of the 2015 American Thyroid Association guidelines

Thyroid surgery has evolved throughout the years from being one of the most dangerous surgeries to becoming one of the safest surgical procedures performed today. Recent technologic innovations have allowed surgeons to remove the thyroid gland from a remote site while avoiding visible neck scars. There are many endoscopic approaches for thyroidectomy. The most common cervical approach is the minimally invasive video‐assisted technique developed by Miccoli et al. The robotic transaxillary and axillary breast approaches avoid a neck scar and have been demonstrated to be safe and effective in international populations. Novel approaches under investigation include face‐lift robotic thyroidectomy and the transoral approach. This article aims to provide the reader with an overview of the current minimally invasive and alternate‐site approaches used and their capability to assist the surgeons in accomplishing remote‐access thyroid surgery under the scope of the 2015 American Thyroid Association Guidelines.

A novel robotic surgical technique for thyroid surgery: bilateral axillary approach (BAA)

INTRODUCTION

Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT) is proven to be a feasible method for the treatment of well-differentiated thyroid cancers in terms of oncology as well as cosmesis. However, BABA RT causes postoperative sternal discomfort and needs an incision over the nipple areolar area. Here, we suggest a novel robotic surgical technique for thyroid surgery that does not need a breast incision-bilateral axillary approach (BAA).

PATIENTS AND METHODS

We recruited 51 patients who were willing to undergo the novel BAA robotic thyroid surgery. We performed a propensity score-matched analysis to compare the BAA robotic thyroid surgery group (BAA group) with the conventional open thyroid surgery group (open group).

RESULTS

Mean operation time in the BAA group (129.7 min) was significantly longer than that in the open group (103.1 min) (p < 0.001). However, no significant differences in the mean number of metastatic lymph nodes (LNs), mean number of retrieved LNs, vocal cord palsy, hypoparathyroidism, and mean stimulated thyroglobulin level were observed between the two groups. There was no case of postoperative bleeding or chyle leak. Of the 51 patients who had undergone the BAA procedure, 27 patients answered the questionnaire. The mean scale, ranging from 0 to 10, at postoperative 1 day/2 weeks was as follows: voice change score, 3.0/1.6; swallowing difficulty score, 4.0/2.0; anterior neck pain score, 4.6/3.6; anterior neck numbness score, 5.4/4.3; right chest pain score, 3.8/2.1; left chest pain score, 3.6/2.3; right chest numbness score, 3.2/2.8; left chest numbness score, 2.4/2.7; right breast pain score, 0.9/0; left breast pain score, 1.2/0; right breast numbness score, 1.7/0; and left breast numbness score, 2.6/0, respectively.

CONCLUSION

BAA robotic thyroid surgery is a novel, safe, and feasible oncoplastic method, especially for patients who have fear of procedures around the nipple areolar complex.

Track Recurrence After Robotic Transaxillary Thyroidectomy: A Case Report Highlighting the Importance of Controlled Surgical Indications and Addressing Unprecedented Complications

BACKGROUND

Robot-assisted transaxillary thyroid surgery (RATS), widely accepted and used in Asian countries, can be an appealing treatment option both for patients with major concerns regarding a cervical scar and for their surgeons. Patients benefit from scarless neck surgery, while their surgeons benefit from improved dexterity and ergonomics compared with remote-access endoscopic thyroid surgery. However, validating any novel surgical procedure for thyroid pathology should be based on evidence regarding its feasibility, radicality, and safety compared to the time-honored, safe and effective, conventional open thyroidectomy. It should also be evaluated for potential risks that are not present with conventional approaches.

PATIENT FINDINGS

This study reports a patient with surgical track and cervical nodal recurrence, and distant metastasis following a two-stage robot-assisted surgery, and radioactive iodine ablation therapy for a papillary thyroid carcinoma that was initially regarded a single indeterminate nodule.

SUMMARY

This case emphasizes the importance of thoroughly evaluating the oncological safety of RATS, and points out the possibility of "malignant seeding along the surgical access" being an untraditional potential complication associated with the procedure.

CONCLUSIONS

While tailoring the surgical strategy to the patients' concerns and desires is important, adhering to fundamental onco-surgical principles is a priority. Furthermore, unconventional complications associated with novel surgical procedures should be properly evaluated and addressed.

Robotic Thyroidectomy Versus Nonrobotic Approaches: A Meta-Analysis Examining Surgical Outcomes

Background Robotic surgery has been recently used as a novel tool for remote access thyroid surgery. We performed a meta-analysis of the current literature to examine the safety and oncological efficacy of robotic surgery compared to endoscopic and conventional approaches for different thyroid procedures. Methods A systematic search of the online data bases was done using the following (MeSH) terms "robotic surgery," "robotic thyroidectomy," "robot-assisted thyroidectomy," and "robot-assisted thyroid surgery." Outcomes measured included total operative time, length of hospital stay, postoperative thyroglobulin levels, and postoperative complications. Statistical differences were analyzed between groups through the standard means and/or relative risk by using STATA analytical software. Results In this study, 144 articles were identified; of which 18 of them met our inclusion criteria, totaling 4878 patients. Robotic approach was associated with longer total operative time (mean difference of 43.5 minutes) when compared to the conventional cervical approach (95% CI = 20.9-66.2; P < .001). Robotic approach was also found to have a similar risk of total postoperative complications when compared to the conventional and endoscopic approaches. Conclusion Robotic thyroid surgery is as safe, feasible and provides similar periperative complications and oncological outcomes when compared to both, conventional cervical and endoscopic approaches. However, robotic thyroid surgery is associated with longer operative time when compared to the conventional open approach.

Long-term oncologic outcome of robotic versus open total thyroidectomy in PTC: a case-matched retrospective study

PURPOSE

The role of the robot in thyroid surgery remains uncertain, and it is unclear whether robotic total thyroidectomy (R-TT) can be justified as a standard treatment for patients with thyroid cancer. This study compared the long-term operative results and oncologic outcomes of R-TT and conventional open TT (O-TT) after propensity score matching of the cohorts.

METHODS

This study retrospectively evaluated patients with papillary thyroid cancer (PTC) who underwent TT with central compartment node dissection (CCND) by a single surgeon in tertiary medical center. Of the 833 patients, 94 (11.3 %) were lost to follow-up. 245 (33.2 %) underwent R-TT, and 494 (66.8 %) underwent O-TT. The mean follow-up duration was 74 (range 61-91) months. Propensity score matching in age, gender, tumor size, extrathyroidal invasion, multiplicity, bilaterality, and TNM stage identified 206 pairs of patients. The long-term oncologic outcomes were assessed in the R-TT and O-TT groups before and after adjustment for baseline covariates.

RESULTS

After adjustment for baseline covariates, serum thyroglobulin (Tg) (p = 0.746) and anti-thyroglobulin antibody (TgAb) (p = 0.394) concentrations were similar in the two groups 5 years after surgery. Nine patients experienced locoregional recurrence, six in the O-TT and three in the R-TT group, with all recurrences in regional LNs. Disease-free survival (DFS) was similar in the R-TT and O-TT groups before matching (p = 0.890) and after adjustment for baseline covariates (p = 0.882).

CONCLUSION

This represents the first report of 5-year surgical outcomes in patients who underwent R-TT for thyroid cancer. Long-term oncologic quality was similar after R-TT and O-TT.

Remote access thyroid surgery

Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed their various advantages in terms of post-operative outcomes; however, the associated financial burden and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.

Robotic transaxillary thyroid surgery

Recent technological advances have led to a rapid progress in endocrine surgery. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, increased patient satisfaction, improved visualization, arms articulations, eliminating surgeon's natural tremor, thereby increasing precision. The main disadvantages are longer operative time, and increased cost compared to conventional thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea. Large-scale studies, mainly from South-Korea, have proved that in skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications.

Robotic facelift thyroid surgery

Techniques for thyroid surgery have advanced dramatically over the past two decades, driven by a better understanding of thyroid physiology, anatomy, and perioperative management strategies. Improvements in surgical technology have permitted surgeons to perform minimally invasive surgery associated with less dissection, decreased pain, smaller anterior cervical incisions, and most importantly a faster recovery. The advent of robotic surgical technology has allowed the development of remote access thyroidectomy for select patients who wish to avoid a visible cervical incision completely. The robotic facelift thyroidectomy (RFT) approach also offers the advantage of outpatient surgery without the need for postoperative drainage. A growing body of evidence supports the safety and efficacy of the approach, and as a result the technique is now being performed at several centers around the world.

Current status of robotic thyroid surgery in South Korea: a web-based survey

BACKGROUND

More than 8,000 cases of robotic thyroidectomy (RoT) were performed in South Korea from 2007 to 2011 using either a transaxillary approach (TAA) or a bilateral axillo-breast approach (BABA). However, there is no consensus regarding patient selection for RoT. This study used a web-based survey questionnaire to examine the current status of RoT in South Korea.

METHODS

Thirty-two of 50 surgeons (64.0 %) who had performed RoT in South Korea participated in the web-based survey in August 2011. The questionnaires comprised four main domains: surgeon characteristics, surgical approach, patient selection, and future prospects.

RESULTS

In terms of surgical approach, 43.8 % respondents used the TAA method and 53.1 % used the BABA method. The main advantage cited by surgeons using the TAA method was that it made lateral lymph node dissection easier (35.7 %), whereas those using the BABA method cited more cosmesis (100 %) and ease of performing a contralateral thyroidectomy (88.2 %). Papillary thyroid cancer ≤2 cm (65.3 %), intracapsular lesion (76.7 %), nonposterior location (53.6 %), and no clinical evidence of lateral lymph node metastasis (76.7 %) were cited as main indications for RoT. Of respondents, 87.5 % agreed that RoT would play a future role as a treatment modality for thyroid disease.

CONCLUSIONS

Opinions differed regarding the advantages and disadvantages of two approaches for RoT. This may be due to differences in surgical procedure itself between two approach methods. Accumulation of RoT surgeon's experiences might establish consensus regarding patient selection and indications for the RoT will need to be further investigated.

Robotic trans-axillary and retro-auricular thyroid surgery

Remote access approaches for thyroid surgery using surgical incisions placed outside the neck, including the axillary, chest and the retro-auricular region have gained interest due to the social stigmatization of young females with a visible neck scar. These novel approaches have been reported to be safe and feasible approaches for thyroid surgery in a select group of patients. Herein, we will discuss different aspects of the current robotic approaches.

A prospective 1-year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising?

BACKGROUND

The purpose of this study was to evaluate postoperative voice outcomes and functional parameters in total thyroidectomy via a transaxillary (TA) approach.

METHODS

Seventy-six patients who underwent total thyroidectomy via a TA approach (TA group) were included. A total of 204 patients who underwent conventional open total thyroidectomy (conventional group) in the same time period were analyzed as a control group. All patients underwent prospective functional evaluations before surgery and at 1 week and 1, 3, 6, and 12 months postoperatively using a comprehensive battery of functional assessments.

RESULTS

There was no conversion to conventional open thyroidectomy in the TA group. Operation time and the amount of drainage were significantly higher in the TA group than in the conventional group (p < 0.001 and p = 0.033, respectively), while vocal cord paralysis, hypoparathyroidism, and hematoma were not different among two groups (p = 0.215, 0.290, and 0.385, respectively). Regarding GRBAS, the TA group showed a more aggravated tendency postoperatively, although statistical significance was attained only at postoperative 6 months (p = 0.043). The voice handicap index abruptly increased postoperatively in the TA group, showing significant differences with the conventional group at postoperative 1 week and 1 month (p < 0.001 and p = 0.001, respectively). Fundamental frequency and maximal vocal pitch did not significantly change postoperatively in either group. The conventional group showed a more rapid decline in pain than the TA group, and paresthesias on the neck and chest were more aggravated in the TA group during the early postoperative period. The dysphagia handicap index was higher in the TA group, while cosmesis was better in the TA group at all postoperative periods.

CONCLUSIONS

Although cosmetic outcome was better with the TA approach, the longer operation time, aggravated subjective voice outcomes, paresthesia, and swallowing function need to be considered in selecting the operative approach.

Robot-assisted transaxillary thyroidectomy: surgical technique

Robot-assisted transaxillary thyroid surgery avoids the need for a neck incision. It consists of thyroid lobectomy and isthmectomy for moderately large unilateral benign nodules. The surgical imperatives are the same as for conventional surgery, but with differences in terms of patient positioning, surgical incision, equipment, surgical technique and indications. The purpose of this article is to describe the equipment, patient positioning and surgical technique of exclusive robot-assisted transaxillary total thyroid lobectomy and isthmectomy.

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.

A survey of preferences regarding surgical approach to thyroid surgery

BACKGROUND

Transaxillary thyroidectomy (TAT) has gained popularity in East Asian countries; however, to date there have been no attempts to evaluate the preferences regarding TAT in the US population. The aim of this study is to assess the preferences and considerations associated with TAT in an American cohort.

METHODS

Self-administered surveys were distributed to 966 adults at various locations in a single state. Questions assessed preferences for the surgical approach, acceptable risks and extra costs, and willingness to pursue TAT despite reduced cancer treatment efficacy.

RESULTS

The response rate was 84 %, with a mean age of 40 ± 17 years. The majority of respondents were female. Of the respondents, 82 % preferred TAT to a cervical thyroidectomy (CerT), all risks being equal; 51 % of the respondents were willing to accept a 4 % complication rate with TAT, and 16 % stated they would agree to pay up to an additional $US5,000 for the TAT approach. When presented with thyroid cancer, 20 % of all respondents still preferred TAT, even if it would not cure their disease. Patients preferring TAT over CerT were younger, female, more willing to accept complications and spend additional money, and, most significantly, preferred the TAT approach, even if it was less likely to cure their cancer.

CONCLUSIONS

Although this survey presents a hypothetical question for people who do not have thyroid disease, the majority of respondents preferred TAT over CerT. Furthermore, a substantial number were willing to accept higher complication rates and increased costs for TAT.

Robotic thyroidectomy for cancer in the US: patterns of use and short-term outcomes

BACKGROUND

We describe nationally representative patterns of utilization and short-term outcomes from robotic versus open thyroidectomy for thyroid cancer.

METHODS

Descriptive statistics and multivariable analysis were used to analyze patterns of use of robotic thyroidectomy from the National Cancer Database (2010-2011). Short-term outcomes were compared between patients undergoing robotic versus open thyroidectomy, while adjusting for confounders.

RESULTS

A total of 68,393 patients with thyroid cancer underwent thyroidectomy; 225 had robotic surgery and 57,729 underwent open surgery. Robotic thyroid surgery use increased by 30 % from 2010 to 2011 (p = 0.08). Robotic cases were reported from 93 centers, with 89 centers performing <10 robotic cases. Compared with the open group, the robotic group was younger (51 vs. 47 years; p < 0.01) and included more Asian patients (4 vs. 8 %; p = 0.006) and privately-insured patients (68 vs. 77 %; p = 0.01). Tumor size was similar between patients undergoing robotic versus open surgery. Total thyroidectomy was performed less frequently in the robotic group (67 vs. 84 % open; p < 0.0001). Patients were relatively more likely to undergo robotic surgery if they were female (odds ratio [OR] 1.6; p = 0.04), younger (OR 0.8/10 years; p < 0.0001), or underwent lobectomy (OR 2.4; p < 0.0001). In adjusted multivariable analysis, there were no differences in the number of lymph nodes removed or length of stay between groups; however, there was a non-significant increase in the incidence of positive margins with robotic thyroidectomy.

CONCLUSIONS

Use of robotic thyroidectomy for thyroid cancer is limited to a few institutions, with short-term outcomes that are comparable to open surgery. Multi-institutional studies should be undertaken to compare thyroidectomy-specific complications and long-term outcomes.

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

OBJECTIVES/HYPOTHESIS

New approaches for robotic-assisted thyroidectomy, including the retroauricular approach, were recently described. We have modified the established surgical approach for retroauricular robotic thyroidectomy. Herein, we report our initial experience to identify challenges and limitations of this new surgical approach.

STUDY DESIGN

Prospective case series.

METHODS

This study was performed under institutional review board approval for patients who underwent retroauricular robotic hemithyroidectomy at an academic North American institution. The retroauricular approach was modified by using the space between the two heads of the sternocleidomastoid muscle as our working space. Additionally, selected patients underwent concomitant neck lift surgery with robotic thyroid surgery. Clinical characteristics, total operative time, blood loss, surgical outcomes, and length of hospital stay were evaluated.

RESULTS

Twelve female patients were included in this study. Mean age was 45 ± 4.43 years, and mean body mass index was 28.6 ± 2.15. Mean thyroid nodule size was 1.15 ± 0.26 cm(3). All cases were completed successfully via single retroauricular incision. There was no conversion to an open approach. Four out of 12 patients (33%) underwent additional concomitant neck lift surgery, with a mean total operative time of 156 ± 15.88 minutes. The mean operative time for the remaining eight patients who underwent the robotic approach without additional neck lift surgery was 145.4 ± 10.08 minutes. There were no cases of permanent vocal cord paralysis or permanent hypoparathyroidism. Mean blood loss was 22.4 ± 4.32 mL. Four patients (33%) were discharged home on the same day of surgery, and the remaining eight patients were discharged after an overnight stay.

CONCLUSIONS

Single-incision retroauricular robotic hemithyroidectomy can be a safe and feasible alternative to other remote access techniques. Neck lift surgery can be performed safely in a select group of patients. However, future studies are warranted to further evaluate the benefits and limitations of this novel approach.

Robot-assisted transaxillary thyroid surgery-feasibility and safety of a novel technique

Developments in technology have led to a rapid progress in robotic endocrine surgery applications. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, thereby increasing patient satisfaction, and improved visualization, arms articulations, and precision, resulting in fewer surgical complications. The main disadvantages are potential new injuries to the brachial plexus, esophagus, and trachea, longer operative time, and increased cost compared to conventional thyroidectomy. In skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications over time.

Desmoid tumor arising from omohyoid muscle: The first report for unusual complication after transaxillary robotic thyroidectomy

BACKGROUND

Transaxillary robotic (TAR) thyroidectomy has been performed for better aesthetic results by many surgeons. In this report, we describe a rare case of a desmoid tumor developed after TAR thyroidectomy, which is speculated to be a late-term complication.

METHODS AND RESULTS

A 61-year-old woman with a history of papillary microcarcinoma had experienced a large left neck mass that had grown over 2 years. The patient underwent TAR thyroidectomy (right lobectomy and isthmectomy) via the right axilla almost 2.5 years previously. Physical examination revealed a 6-cm, firm mass fixed to the left anterior neck. The mass was fixed to the omohyoid muscle. The 5.9- × 4.7- × 4.5-cm tumor with the surrounding muscles was excised in an en bloc fashion. Pathologic examination confirmed the diagnosis of a desmoid tumor.

CONCLUSION

This case suggests that desmoid tumors could develop late after TAR thyroidectomy. Thus, careful observation of the surgical wound may be necessary after TAR thyroidectomy.