Robotic versus Open Thyroidectomy for Differentiated Thyroid Cancer: An Evidence-Based Review

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 Thyroid Surgery: A Review of Literature

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Psycho-Oncological Intervention Through Counseling in Patients With Differentiated Thyroid Cancer in Treatment With Radioiodine (COUNTHY, NCT05054634): A Non-randomized Controlled Study

Background

Diagnosis and treatment of differentiated thyroid carcinomas (DTC) cause anxiety and depression. Additionally, these patients suffer hormonal alterations that are associated with psychological symptoms (e.g., changes in mood, emotional instability, and memory loss). This study aims to evaluate the effectiveness of a psycho-oncological intervention based on counseling to reduce anxiety and depression related to the treatment in patients with DTC.

Methods

A non-randomized controlled study, with two groups [experimental group (EG), n = 37, and control group (CG), n = 38] and baseline and posttreatment measures, was designed. Patients in the EG received a psycho-oncological intervention based on counseling in addition to the standard treatment. The independent variable was the assigned group and the dependent one was the evolution of anxiety and depression, which were analyzed separately, and both were evaluated using the Hospital Anxiety and Depression Scale. Other relevant covariables related to the quality of life (QoL) were also analyzed using Short Form-36 Health Survey and Psychological General Wellbeing Index scales.

Results

The difference of the posttreatment-baseline variation showed a statistically significant reduction in anxiety and depression in the EG in relation to the CG (p &lt; 0.001). The mean of the Psychological General Wellbeing Index scales score increased significantly in the EG (p &lt; 0.001) and decreased significantly in the CG (p &lt; 0.001). All the baseline and the posttreatment scores of the variables evaluated showed a statistically significant improvement in the EG vs. the CG.

Conclusion

This study demonstrates significant benefits of psycho-oncological intervention based on counseling in anxiety, depression, QoL, and wellbeing of the patient with differentiated thyroid carcinomas.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma

BACKGROUND

The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease.

DATABASE

This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series.

CONCLUSION

In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Novel robot-assisted thyroidectomy by a transaxillary gas-insufflation approach (TAGA): a preliminary report

Background

Robot-assisted transaxillary approaches to thyroidectomy have been well described. They have an advantage over the breast approach in that a circumareolar incision is avoided. However, they require a single long axillary incision to accommodate all 3 robotic arms and provide adequate visualization of the area around the thyroid. The purpose of this study was to test the feasibility of the robot-assisted transaxillary gas-insufflation approach (TAGA) and to attempt reducing the size of the scar.

Methods

We evaluated 47 patients who underwent robot-assisted thyroid lobectomy via TAGA from July 2015 to Aug 2017. The following variables were studied: patients' demographics, operative time according to each operation step, volume of drainage, duration of hospitalization, and perioperative complications.

Results

The mean age of all patients was 42.4±9.1 years. The mean total volume of drainage was 195.4±70.9 mL, and the duration of postoperative stay was 3.0±1.1 days. Two cases (4.3%) of transient vocal cord palsy and 2 cases (4.3%) of seroma were identified postoperatively. There was no post-operative cosmetic problem at the skin incisions made in the axilla.

Conclusions

Robot-assisted thyroid lobectomy via TAGA is technically feasible while achieving good cosmetic results. TAGA can be an alternative robot-assisted method for thyroidectomy.

A Single Surgeon's 10-Year Experience in Remote-Access Thyroid and Parathyroid Surgery

BACKGROUND

Remote-access thyroid and parathyroid surgery has gained popularity recently due to its benefit of avoiding visible neck scars. Most of these techniques were described and performed in Asia, on patients with different body habitus compared to American patients. We aim to analyze the learning curve in performing these operations in North America. .

METHODS

This is a retrospective cohort study of a 10-year experience by a single surgeon at a North American institute. Patients who underwent thyroid or parathyroid procedures by a transaxillary, retroauricular, or transoral endoscopic thyroidectomy vestibular approach (TOETVA) were included. Cumulative sum (CUSUM) was used to analyze learning curves based on intraoperative blood loss and total operative times and learning phases were divided accordingly.

RESULTS

Three hundred seventy-two remote-access thyroid and parathyroid procedures were performed during the study period. Total operative time for transaxillary procedures was initially reduced after the 69th procedure and then again after the 134th case. For retroauricular procedures, marked reduction in the operative time was observed after 21 procedures. Most patients (57.02%) were discharged home on the same day during the mastering phase. In the transaxillary procedures, only 1 case of brachial plexus injury occurred prior to the routine use of somatosensory evoked potential (SSEP) monitoring.

DISCUSSION

Remote-access thyroid and parathyroid surgeries can be performed safely with minimal complications in a select group of patients. Analysis of the learning curve in performing these operations aids in structuring a safe and effective learning period for endocrine surgeons seeking to venture into this modality of treatment.

Robotic surgery versus open surgery for thyroid neoplasms: a systematic review and meta-analysis

PURPOSE

Robotic surgical system has been gradually applied in thyroid neoplasms as a novel treatment for years, with presenting some superiorities as well as limitations. To compare the effectiveness and safety of robotic surgery with open surgery for the patients with thyroid neoplasms, this review was conducted METHODS: We performed electronic search in CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray, and Sciencepaper Online databases and manual search in specific online databases and according to the reference list of relevant papers to get all the studies that compared the effectiveness and safety of robotic surgery with that of open surgery for patients with thyroid neoplasms. Last update was conducted in March 2020. Randomized-controlled trials, case-control studies, cohort studies, and cross-sectional surveys were all included.

RESULTS

In this review, 59 studies were included: two RCTs, 15 NRSs, 40 cohort studies, and two cross-sectional studies. Robotic surgery was found to be associated with longer operative duration, less retrieved lymph nodes, higher postoperative thyroglobulin before radioactive iodine ablation, similar complication incidence but less blood loss, better functional recovery, and higher cosmetic satisfaction compared to open surgery.

CONCLUSIONS

Robotic surgery is a safe and feasible approach with remarkable superiority in reducing intraoperative damage and improving patients' quality of life compared to open surgery for thyroid neoplasms. Meanwhile, this procedure is also associated with long operative duration, insufficient removal of neck lymph nodes, which need to be given careful consideration.

Surgical approaches to thyroid

Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIX^th century, has become the "gold standard". It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed "new approaches" to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these "new approaches" have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients.

Transoral endoscopic thyroidectomy via vestibular approach: First case in Saudi Arabia

INTRODUCTION

There has been increased interest in applying the principles of minimally invasive surgery in thyroid surgery which was promoted by Miccoli and his colleagues in 1999. Different surgical techniques since then were introduced, transcervical and extracervical approaches.

PRESENTATION OF CASE

A 33-year-old Saudi female presented with a swelling over the left side of her neck and dysphagia for three years. The patient underwent transoral endoscopic left thyroid lobectomy, isthmusectomy and sampling of the central compartment via vestibular approach (TOETVA). To the best of our knowledge, this is the first case underwent TOETVA successfully in Saudi Arabia and gulf cooperation council countries.

DISCUSSION

TOETVA is a novel promising procedure, an adaptation of the concept of natural orifice transluminal endoscopic surgery (NOTES) with advantages of scar-less result in excellent cosmesis while retaining the advantages of minimally invasive surgery and the potential value of the procedure outside the enhanced cosmesis continuous to be defined. The cosmetic superiority in avoiding visible scarring must be balanced against operative time, post-operative hospital stays, increased expense, surgical training, and steep learning curve required. The technique is novel, some thyroid surgeons opted for longer postoperative observation to exclude complications. As experience and confidence in the procedure increase, the length of stay should decrease dramatically.

CONCLUSION

This procedure is feasible and safe with excellent cosmetic result. It is in its initial stage in Saudi Arabia, gulf cooperation council countries and it has a potential to be performed more frequently in near future.

Comparison of the vessel sealer Extend® with harmonic ACE® in robotic bilateral axillary-breast approach thyroid surgery

Background

Harmonic ACE^® (Harmonic) Curved Shears are frequently used for vessel sealing in patients undergoing robotic thyroidectomy. Unlike other robotic devices with articulation, the Harmonic device can only move in a straight-forward direction without articulation. The recently introduced Vessel Sealer Extend^® (VSE) provides bipolar sealing and cutting with articulation movement. This study compared the VSE and Harmonic devices in robotic bilateral axillary-breast approach (BABA) thyroid surgery.

Methods

From December 2018 to March 2019, 35 consecutive patients underwent robotic BABA thyroidectomy, 20 using the VSE and 15 using the Harmonic device. Patient characteristics, pathologic results, and clinical outcomes, including complications, were evaluated.

Results

The characteristics of patients in the two groups were similar. Surgical time from robot docking to completion of lobectomy was longer in the VSE than in the Harmonic group (45.00±9.52 vs. 39.72±12.76 min; P=0.170). The number of camera cleanings during lobectomy was significantly lower in the VSE group (0.55±0.51 vs. 1.93±1.71; P=0.002). Intraoperative blood loss (53.00±43.29 vs. 28.67±41.03 mL; P=0.102), hospital stay after surgery (3.55±0.95 vs. 3.67±0.90 days; P=0.715), and pain scores on the first (2.85±0.37 vs. 2.93±0.26; P=0.458) and second (2.55±0.51 vs. 2.60±0.51; P=0.775) postoperative days were similar in the VSE and Harmonic groups. No patient experienced vocal cord palsy or postoperative bleeding.

Conclusions

VSE can be safely applied to robotic BABA thyroid surgery.

Evolution Strategies in Transaxillary Robotic Thyroidectomy: Considerations on the First 449 Cases Performed

Background: In the past 20 years, the fast spread of new surgical technologies has reached an important peak with the advent of the robotic surgery. Many studies have been run about a cosmetic desire to avoid neck scars after thyroid surgery and this has led to the development of remote access robotic thyroidectomy (RT). Among the various RT approaches, unilateral transaxillary access is one of the most widely used, reporting excellent results in terms of feasibility and patient's compliance. The mini-invasive technique demonstrated many potential shortcoming overcomes with the robotic approach. At our institution a team of 3 skilled endocrine surgeons with experience in laparoscopic and robotic procedures performed RT. Our aim is to report our 8-year single-centre robot-assisted thyroidectomy experience, by applying a gasless unilateral transaxillary approach with the so-called hybrid technique, and to demonstrate its safety and feasibility.

Methods: In the period between September 2010 and June 2018 at our institution, a total of 472 patients underwent thyroid and parathyroid transaxillary surgery. The hybrid technique was applied for all the robotic procedures. A total of 412 procedures were performed with the use of external “Modena Retractor” (CEATEC^® Medizintechnik) and with 3 surgeons. According to international guidelines, our indications for robotic surgery were benign lesions with a diameter <5 cm, Graves' disease, well-differentiated thyroid cancers, and parathyroid adenomas.

Results: In this series, a total of 449 cases were registered. General data of patients were analyzed: gender, age, body mass index, tumor size, preoperative fine-needle aspiration examination, definitive histological examination, operative time, and postoperative complications.

Conclusions: This study confirms the application of robotic approach in thyroid surgery as a feasible technique in terms of safety and complications risk. The hybrid technique, together with a dedicated surgical team, can lead to obtaining the same outcomes of traditional anterior cervicotomic surgery, adding a scarless thyroidectomy.

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.

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.

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.

Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience

OBJECTIVES

Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising.

STUDY DESIGN

This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6-12 months later and at the last available visit.

RESULTS

A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk).

CONCLUSION

In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

Robotic Thyroid Surgery: Current Perspectives and Future Considerations

Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the "fourth generation" in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2-3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient's body habitus (BMI < 30 kg/m2) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.

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.

Bilateral axillo-breast approach robotic thyroidectomy: review of evidences

The bilateral axillo-breast approach (BABA) is one of the most popular contemporary remote-access thyroidectomy techniques. While the initial experiences with BABA endoscopic thyroidectomy (ET) were associated with some technical challenges and safety concerns, many limitations of the technique could now be substantially overcome by BABA robotic thyroidectomy (RT). In this review, the current literature evidences of BABA RT were analyzed. Data regarding the patient selection, the learning curve, and the comparison with open thyroidectomy (OT) and BABA ET were examined. Careful case selection for BABA RT should be undertaken according to factors related to the patient and the thyroid pathology. The learning curve of BABA RT was about 40 cases. Comparing to OT, BABA RT was comparable to OT for the complication profiles and most perioperative outcomes. But it was associated with longer operative time, higher cost and possibly inferior oncological control with lower number of central lymph node (LN) retrieved. When compared to BABA ET, BABA RT was comparable for most perioperative outcomes except longer operative time and higher cost. Yet, BABA RT was superior to BABA ET for better oncological control. BABA RT is a safe and effective procedure for most benign thyroid conditions and low-risk differentiated thyroid cancers (DTC).