Feasibility and safety of a new robotic thyroidectomy through a gasless, transaxillary single-incision approach

Current and Future of Robotic Surgery in Thyroid Cancer Treatment

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Expansion of thyroid surgical territory through 10,000 cases under the da Vinci robotic knife

With the progress of robotic transaxillary thyroid surgery (RTTS), the indications for this procedure have gradually expanded. This study presents the insights gained from performing 10,000 RTTS cases at a single institution, along with the expansion of indications over time. RTTS was performed on 10,000 patients using the da Vinci robot system between October 2007 and April 2023 at the Yonsei University Health System, Seoul, Korea. Among 10,000 patients, 9461 (94.0%) were diagnosed with thyroid cancer, whereas 539 (5.4%) had either a benign thyroid nodule or Graves' disease. Surgical procedures were performed using four-arm-based robots (da Vinci S, Si, or Xi) for 8408 cases (84.1%), with the remaining 1592 cases (15.9%) being performed using the da Vinci SP surgical robotic system. Notably, for 53 patients with nodules ≥ 5 cm, which were not included in the eligibility criteria of the previous study, RTTS was performed safely without significant complications. The most common postoperative complication was transient hypoparathyroidism (37.91%), and recurrence occurred in 100 patients with thyroid cancer (1.1%). In conclusion, RTTS appears safe and feasible from both surgical and oncological perspectives, and the spectrum of indications suitable for RTTS surgery is progressively expanding.

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

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

Single-Port Transaxillary Robotic Modified Radical Neck Dissection (STAR-RND): Initial Experiences

OBJECTIVES

This study aimed to demonstrate the usefulness of single-port transaxillary robotic modified radical neck dissection (STAR-RND) for metastatic thyroid cancer, and its potential to make small and invisible surgical wounds possible compared to open modified radical neck dissection.

METHODS

Between January 2020 and July 2021, 30 thyroid cancer patients who underwent lateral neck dissection surgery with the da Vinci SP at Yonsei University Health System (Seoul, Korea) were studied.

RESULTS

All 30 patients, diagnosed with papillary thyroid cancer were women. The average operating time was 293.80 ± 36.58 (min), and the average postoperative hospital stay was 4.77 ± 0.57 (days). All patients were discharged after the expected number of hospitalization days without major complications.

CONCLUSION

STAR-RND is technically feasible and safe with a short length of the incision. To our knowledge, this is the first report on the use of a single-port robotic system for modified radical neck dissection. LEVEL OF EVIDENCE BY USING 2011 OCEBM: 4 Laryngoscope, 133:709-714, 2023.

Robot-Assisted Total Thyroidectomy with or without Robot-Assisted Neck Dissection in Pediatric Patients with Differentiated Thyroid Cancer

Pediatric thyroid cancer more frequently develops cervical node metastasis than adult thyroid cancer, even in differentiated thyroid carcinoma (DTC). Thus, cervical neck dissection often needs to be performed simultaneously with thyroidectomy in pediatric patients. Herein, we describe our experience with robot-assisted total thyroidectomy with/without robot-assisted neck dissection in pediatric patients compared with the conventional operated group. A total of 30 pediatric patients who underwent thyroidectomy for DTC between July 2011 and December 2019 were retrospectively reviewed. Among them, 22 underwent robot-assisted operation, whereas 8 underwent conventional operation. There was no statistical difference in the mean operation times, blood loss, drainage amounts, and hospital stay length between the robot-assisted and conventional operation groups; however, the operation time was less in the retroauricular approach subgroup (robot-assisted operation group) with better satisfaction on cosmesis. No postoperative complications, such as seromas, hemorrhages, or hematomas were observed. Our experience suggested that robot-assisted thyroidectomy with or without neck dissection through the retroauricular approach is a feasible and safe alternative treatment, producing outstanding esthetic results compared to the conventional approach, especially in pediatric patients with DTC.

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.

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.

Comparison of Surgical Outcomes between Robotic Transaxillary and Conventional Open Thyroidectomy in Pediatric Thyroid Cancer

Thyroid cancer in children is very uncommon. For pediatric thyroid cancer, robotic surgery has served as a minimally invasive surgical alternative to conventional open surgery. Our study aimed to evaluate the results of robotic versus open surgical treatment for patients with thyroid cancer younger than 20 years of age at the time of diagnosis. This retrospective review included 161 pediatric patients who underwent robotic transaxillary or conventional open thyroidectomy at our institution from 2008 to 2019. Of these patients, 99 comprised the robotic group and 62 the open group. Patient demographics, surgical outcomes, and disease-free survival rates were compared between the two groups. Patients in the open group were more likely to have advanced stage diseases with a larger tumor size and higher tumor-node-metastasis stage than those in the robotic group. Operation time and follow-up period were similar in both groups. Patients in the robotic group had a lower rate of postoperative complications and a shorter length of hospital stay, but they also had a lower average number of retrieved central lymph nodes. However, there were no significant between group differences in recurrence rates and disease-free survival. In the hands of an experienced surgeon, robotic thyroidectomy is a feasible and safe option for pediatric patients.

Recent Trends in Surgical Approach to Thyroid Cancer

Over the past decade, the incidence of thyroid cancer has rapidly increased worldwide, and thyroid surgery has become one of the most common performed surgical procedure. Even though conventional open thyroidectomy remains the gold standard, this approach leaves a neck scar which could be worrying mainly for young women. The recent progress in surgical technology, as well as patient cosmetic requests, have led to the development of alternative access to the thyroid lodge. Thus, alternative techniques have been established in order to potentially provide a more appealing cosmetic result, both with a minimally-invasive cervical or remote-access approach. However, the introduction of these new techniques was initially approached with caution due to technical challenges, the introduction of new complications and, above all, skepticism about the oncologic effectiveness. Among several alternative approaches proposed, the minimally invasive video-assisted thyroidectomy and the robot-assisted transaxillary thyroidectomy became popular and obtained the favor of the scientific community. Moreover, the recent introduction of the trans-oral endoscopic thyroidectomy with vestibular approach, although the safety and the efficacy are still under discussion, deserves particular attention since it represents the only technique truly scarless and provides the best cometic result. The purpose of this article is to provide an overview of the current main alternative approaches for the treatment of thyroid cancer with particular focus on the oncological effectiveness of the procedures.

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.

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.

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.

Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these 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.

The effect of robot-assisted transaxillary thyroidectomy (RATT) on body image is better than the conventional approach with cervicotomy: a preliminary report

BACKGROUND

Cosmetic satisfaction is not only based on the patient's perception of the scar itself but is also related to body image self-evaluation. Cosmetic superiority of Robot-assisted transaxillary thyroidectomy (RATT) over conventional thyroidectomy (CT) has not yet been clearly demonstrated. Aim of our study was to compare body image in patients undergoing CT versus RATT.

METHODS

The study included 160 (80 CT and 80 RATT) patients undergoing thyroidectomy between August 2014 and March 2018 at the Endocrine Surgery Department. The inclusion criteria were age 18 to < 60 years, female sex, thyroid volume < 30 mL, and nodule diameter < 5 cm. Scar length, operative time, and complications were analyzed. The body image questionnaire (BIQ) was used 3 months postoperatively. The Student t test was used for statistical analysis.

RESULTS

Age was lower in RATT group (38.2 vs 41.4 years) (P < 0.0001). The nodule diameter was larger in RATT group (27.1 vs 23.1 mm) (P = 0.028). Operative time was longer in RATT group (93.7 vs 47.6 min) (P < 0.0001). The scar was longer in RATT group (59.9 vs 37.7 mm) (P < 0.0001). The groups had similar complication rates. BIQ showed that RATT patients answered more favorably to question 2, "Do you feel the operation has damaged your body?" (P = 0.042) and to question 3, "Do you feel less attractive as a result of your treatment?" (P = 0.024). Also self-global satisfaction was better in RATT group (P = 0.019).

CONCLUSIONS

In our experience, RATT has a significantly better impact on body image than the conventional approach.

Impact of body mass index on robotic transaxillary thyroidectomy

Obesity is associated with increased operating times and higher complication rates in many types of surgery. Its impact on robotic thyroidectomy however, is not well documented. The aim of this study was to investigate the relationship between body mass index (BMI) and robotic transaxillary thyroidectomy (RTAT). A retrospective review of prospectively collected data of all patients who underwent RTAT at Yonsei University Health System from October 2007 to December 2014 was performed. Patients were divided into three groups based on BMI (Group 1: BMI < 25, Group 2: BMI 25-29.99, Group 3: BMI ≥ 30), and compared. A total of 3697 patients were analyzed. No differences between the three groups were observed in clinicopathological factors, extent of surgery or length of stay. After multivariate analysis, only seroma and transient voice hoarseness were related to increasing BMI. Total operative time was significantly longer for Group 3 patients with less-than-bilateral total thyroidectomy (BTT), but was not significantly different for patients with BTT. Although obese patients undergoing RTAT have a slightly higher risk of seroma, transient voice hoarseness, and longer operative times, BMI did not influence the other important surgical outcomes of thyroidectomy. Therefore, obesity should not be a contraindication for performing RTAT.

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.

Gasless, transaxillary robotic neck dissection: the technique and evidence

Robotic neck dissection (ND) for the thyroid cancer with lateral neck metastasis case is one of the emerging surgical techniques, and has been highlighted as minimally invasive surgical technique recently. Gasless, transaxillary robotic approach enabled the surgeon to do meticulous and precise dissection in the complex procedure, such as ND, eventually showed favorable surgical safety and outcomes, as well as superior functional and cosmetic benefits. In this article, the author would like to introduce the detailed techniques and secure evidences for the gasless, transaxillary robotic ND.

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.

Yonsei Experience of 5000 Gasless Transaxillary Robotic Thyroidectomies

BACKGROUND

Since the use of robot systems in thyroid surgery was introduced in 2007, we have advanced a novel method of robotic thyroidectomy (RT) using a gasless transaxillary approach (TAA). We report our experience with this technique and detail the surgical outcome of 5000 robotic thyroidectomies.

METHODS

From October 2007 to May 2016, we successfully performed 5000 robotic thyroidectomies using a gasless TAA at the Department of Surgery, Yonsei University Health System. The medical records of the patients are reviewed retrospectively, and the details of clinicopathologic characteristics, operation times, perioperative complications, and oncologic outcomes are analyzed.

RESULTS

The 5000 patients with thyroid tumor (4804 with cancer and 196 with benign tumor) underwent RT using a gasless TAA. Mean operation time was 134.5 ± 122.0 min. The most common histologic subtype of thyroid cancer was papillary (98%), and the mean tumor size was 8.0 ± 6.0 mm. Stage I was found in 85.4% patients regarding tumor nodes metastasis staging. The 196 benign tumors consisted of 104 adenomatous hyperplasias (53.0%), 43 follicular adenomas (21.9%), 30 Graves' diseases (15.3%), and 19 others (9.7%). Postoperative complication occurred in 24.1% without any serious one, and overall morbidity tended to decrease over time. No disease-specific mortality was observed during the follow-up period. Locoregional recurrence was developed in 26 patients (0.5%).

CONCLUSION

The authors have tried to improve RT technique using gasless TAA and achieved acceptable surgical outcomes. The rapid evolution of surgical robot technology and our constant effort to advance RT technique using gasless TAA would make it possible to reduce the perioperative morbidity and gain the best possible operative and oncologic outcomes.

Comparison of Postoperative Neck Pain and Discomfort, Swallowing Difficulty, and Voice Change After Conventional Open, Endoscopic, and Robotic Thyroidectomy: A Single-Center Cohort Study

Background: The objective of this study was to compare the postoperative neck pain and discomfort, swallowing difficulty, and voice change after conventional open thyroidectomy (COT), endoscopic thyroidectomy (ET), or robotic thyroidectomy (RT) performed by a single surgeon. Methods: From January 2013 to December 2017, 254 patients underwent COT, ET, or RT performed by a single surgeon and completed a postoperative symptom survey conducted in the outpatient clinic by three nurses. The survey collected information on postoperative neck pain and discomfort, swallowing difficulty, and voice change. Results: Of the 254 patients, 169 underwent COT, 32 underwent ET, and 53 underwent RT. The mean age in the COT, ET, and RT groups was 50.1, 44.5, and 41.6 years, respectively. The mean interval between thyroidectomy and survey in the COT, ET, and RT groups was 42.7, 50.2, and 9.2 months, respectively. Postoperative neck pain was significantly higher in the ET and RT groups than in the COT group (p = 0.026). The average neck impairment index score in the RT group was significantly higher than that in the COT group (p < 0.001). There were no significant differences in pain scale scores, swallowing difficulty, swallowing impairment index, voice change, and voice hand index among the three groups. Conclusions: There were no significant differences in postoperative voice change or swallowing difficulty among the COT, ET, and RT groups, whereas neck pain and discomfort were more common after ET and RT than COT.

Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience

Aim:

Since last decades, more and more thyroidectomies have been performed by the minimally invasive method. Compared to conventional thyroidectomy, minimally invasive thyroidectomy has a superior cosmetic result. However, the outcome depends, in a large extent, on the skill of the operator and the learning curve is relatively long. Robotic thyroidectomy (RT) is a relatively new approach in treating thyroid lesions with improved ergonomics and surgical outcomes.

Purpose:

We performed a prospective study of robotic-assisted transaxillary approach for thyroidectomy in Indian patients to examine the feasibility of the procedure.

Materials and Methods:

A total of 35 patients underwent RT. Demographics, surgical indications, operative findings, postoperative functional outcome, local complications and pathological outcomes were recorded and analyzed.

Results:

The median age of the cohort was 28.6 years and 31 of the patients were women. The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). Eighteen patients underwent less than total thyroidectomy and 17 patients underwent total thyroidectomy, with no conversion. The mean console time standard deviation was 115 min initially, and with experience, it reduced to 106 min for subsequent cases. The mean blood loss was 13 ml. Post-operative outcome was good with no serious complication noted in our series.

Conclusion:

Robotic-assisted thyroidectomy using a gasless transaxillary approach is a feasible, safe and noninferior surgical alternative for selected patients. We believe with time RT will be widened and it will be performed more often.

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.

Postoperative Pain Evaluation After Robotic Transaxillary Thyroidectomy Versus Conventional Thyroidectomy: A Prospective Study

BACKGROUND

Robot-assisted transaxillary thyroidectomy (RATT) is an emerging technique with excellent cosmetic results but is supposedly more invasive and painful than conventional thyroidectomy (CT). This prospective study compared pain after RATT and CT.

METHODS

Inclusion criteria were a nodule <5 cm and volume <30 mL. Patients received the same analgesia. Pain was evaluated by visual analog scale (VAS) in the recovery room (VASrr), on the first postoperative day at 8:00 a.m. (VAS 8 a.m.) and 8:00 p.m. (VAS 8 p.m.), at 8:00 a.m. on the second postoperative day (VAS 8*a.m.), and after 7 days (VAS 7). Operative time and complications were evaluated.

RESULTS

From May 2015 to September 2015, 124 patients (all women) underwent thyroidectomy: 62 underwent RATT and 62 underwent CT. Mean age was 39.7 ± 10.2 years in the RATT group and 41.4 ± 12.5 years in the CT group. Groups were comparable for thyroid volume and nodule diameter. Operative time was longer in the RATT group than in the CT group (119.4 ± 25.5 versus 70.3 ± 11.0 minutes). Complications were three transient hypocalcemia in RATT and four in the CT group. No definitive complications occurred. VASrr was lower in the RATT group (1.79 ± 2.06 versus 2.5 ± 1.18; P < .0001). There was no difference between groups for VAS 8 a.m., VAS 8 p.m., and VAS 8*a.m., but VAS 7 was higher in the RATT group (0.85 ± 1.77 versus 0.17 ± 0.52; P < .010).

DISCUSSION

RATT is as safe and effective as CT. Patients undergoing RATT, surprisingly, experienced less pain in the immediate postoperative period. However, the VAS 7 score was higher in the RATT group, probably because the intact neck is favorable in the early phase of recovery, but the large dissection takes longer for healing.

Endoscopic thyroidectomy: retroauricular approach

The incidence of thyroid cancer has abruptly increased recently, with a female predominance. Conventional thyroidectomy using transcervical incision inevitably leaves an unfavorable neck scar; therefore, various extracervical approaches have been introduced to improve cosmetic satisfaction after thyroidectomy. Several reports demonstrated that these extracervical approaches have advantages not only in terms of cosmesis but also in terms of surgical outcomes and postoperative functional preservation. The retroauricular approach has advantages as the dissection area is smaller than that in the transaxillary approach (TA) and surgical anatomy is familiar to the head and neck surgeons. In addition, there is no concern about paresthesia around the nipple or anterior chest, and surgical direction makes central neck dissection easier than with the other extracervical approaches. Herein, we aim to introduce the surgical procedure of retroauricular approach thyroidectomy and present our experiences of postoperative outcomes.

Approaches of robot-assisted neck dissection for head and neck cancer: a review

Robot-assisted surgery is being increasingly used by surgeons because of its enhancement of visualization, precision, and articulation compared with conventional minimally invasive techniques. In recent years, robot-assisted neck dissection (RAND) has begun to be used as an alternative method of neck dissection, one of the classic surgical procedures in the area of head and neck surgery. Currently, there are four kinds of approaches for RAND: (1) modified facelift or retroauricular incision, (2) combined transaxillary and retroauricular incision, (3) transaxillary incision, and (4) transoral incision. RAND may help perform minimally invasive surgery and achieve excellent cosmetic results as well as the desired oncologic outcomes, and this requires selecting an appropriate approach based on the different needs of neck dissections. Although experienced surgeons wishing to avoid large cervical incisions in patients can safely perform RAND, there are still quite a few limitations; in particular, surgical morbidity and oncologic outcomes should be verified by further prospective clinical trials with longer follow-up periods. Also, RAND needs to be standardized and its use disseminated. In this review, we introduce the applications of different approaches for RAND and their indications and determine whether RAND can be more beneficial compared with conventional surgeries.

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.

Transaxillary single-incision robotic neck dissection for metastatic thyroid cancer

In head and neck area, neck dissection (ND) is one of the most complex and precision-needed procedure. The long cervical scar and post-operative neck discomfort have been also inevitable brands after this procedure. Heretofore, few dare to try endoscopic surgical technique to the ND mainly due to its complexity and jeopardy of complication. Although, there have been several reports about the endoscopic approaches for functional ND or ND, they had so many technical and instrumental limitations. The dexterities of the surgical robotics have advanced the techniques of endoscopic surgery, and have facilitated the most precise and delicate endoscopic surgical procedure in head and neck area. The technical feasibility and early surgical outcomes of robotic ND using the transaxillary approach for the management of metastatic thyroid cancer have already been reported as satisfactory. Robotic ND can allow complete compartment-oriented lymph node (LN) dissection without any fatal complications, or compromising oncologic principles. We previously described a novel method of robotic thyroidectomy with ND using a gasless transaxillary approach for metastatic thyroid cancer, and here, we firstly introduce a less invasive robotic procedure which has been modified from the original one, which we refer to as the transaxillary single-incision robotic ND.

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.

A prospective 1-year comparative study of endoscopic thyroidectomy via a retroauricular approach versus conventional open thyroidectomy at a single institution

OBJECTIVE

The objective of this study was to evaluate the feasibility and safety of performing an endoscopic thyroidectomy (ETE) via a retroauricular approach.

METHODS

Forty-seven patients who underwent ETE via a retroauricular approach were included, and a total of 47 patients who underwent conventional open thyroid lobectomy in the same period were analyzed as a control group. All patients underwent prospective functional evaluations before the operation and 1 week, and 1, 3, 6, and 12 months postoperatively using a comprehensive battery of functional assessments.

RESULTS

The mean total operative time was 152 ± 48 min, with a mean endoscopic procedure time of 58 ± 18 min. One patient developed temporary vocal fold paralysis. Although most of the parameters for the functional outcome were worse in the ETE group, these differences were transient. Subjective worsening on the voice handicap index and dysphagia handicap index normalized by 3 months postoperatively. The average pain score on a visual analog scale at 1 week after surgery was 2.84, representing a tolerable range of discomfort. The mean paresthesia/hyperesthesia score was worse in the ETE group than the open surgery group by postoperative month 6; however, these differences eventually disappeared. Thirty-six of the 47 patients in the ETE group were satisfied or extremely satisfied with the retroauricular incision by 6 months after surgery.

CONCLUSIONS

ETE via a retroauricular approach is a safe, feasible, and cosmetically desirable treatment option, with outcomes comparable to conventional open thyroidectomy in the longer term.

Contemporary surgical techniques

Recent technologic advances have engendered alternative and innovative approaches to thyroid surgery aimed at reducing cosmetic sequelae. Minimally invasive techniques via small anterior cervical incisions hidden in natural skin creases and remote access approaches that eliminate anterior neck incisions entirely have emerged as viable options for patients who regard cosmesis as a priority. The safe application of these techniques to both benign and malignant thyroid disease has been evaluated.

Alternative approaches to the thyroid gland

Advances in surgical technology and patient-driven demands have fueled exploration into methods to improve cosmetic outcomes in thyroid surgery. This exploration has produced 2 fundamentally different pathways for reducing the visible thyroidectomy scar. Minimally invasive anterior cervical approaches use small incisions hidden in natural skin creases and reduce the overall extent of dissection required to remove the thyroid. Remote access approaches remove the incision from the anterior neck completely but require more extensive dissection to access the thyroid compartment.

Surgery for thyroid cancer

The incidence of thyroid cancer, particularly papillary thyroid cancer, is rising at an epidemic rate. The mainstay of treatment of most patients with thyroid cancer is surgery. Considerable controversy exists about the extent of thyroid surgery and lymph node resection in patients with thyroid cancer. Surgical experience in judgment and technique is required to achieve optimal patient outcomes.

Robotics in general surgery: an evidence-based review

Since its introduction, robotic surgery has been rapidly adopted to the extent that it has already assumed an important position in the field of general surgery. This rapid progress is quantitative as well as qualitative. In this review, we focus on the relatively common procedures to which robotic surgery has been applied in several fields of general surgery, including gastric, colorectal, hepato-biliary-pancreatic, and endocrine surgery, and we discuss the results to date and future possibilities. In addition, the advantages and limitations of the current robotic system are reviewed, and the advanced technologies and instruments to be applied in the near future are introduced. Such progress is expected to facilitate the widespread introduction of robotic surgery in additional fields and to solve existing problems.

The role of the robotic-assisted transaxillary gasless approach for the removal of parathyroid adenomas

BACKGROUND

We sought to describe a robotic technique of transaxillary gasless parathyroidectomy for the management of primary hyperparathyroidism (PHPT) due to a parathyroid adenoma.

METHODS

All consecutive patients who underwent robotic parathyroidectomy for a parathyroid adenoma by a single surgeon were included. Data was obtained by a retrospective review of patients' medical charts.

RESULTS

Nine patients with confirmed PHPT underwent robotic parathyroidectomy. Curative resection was established in all patients with the aid of intraoperative parathyroid hormone monitoring. One patient required bilateral cervical exploration of multiglandular disease. There were no complications. Patients were followed up for a period exceeding 6 months without any evidence of persistent or recurrent hyperparathyroidism.

CONCLUSIONS

Our initial experience demonstrates that this technique is safe and effective for the treatment of PHPT. We believe that the use of robotic technology for endoscopic parathyroid surgeries could overcome the limitations of conventional techniques in the management of parathyroid lesions.

Robotic thyroidectomy for benign thyroid diseases: a stepwise strategy to the adoption of robotic thyroidectomy (gasless, transaxillary approach)

PURPOSE

Thyroid surgery for benign diseases mainly involves young women, and thus, cosmetic considerations have motivated the development of "no scar to the neck" procedures. Endoscopic techniques are often strenuous, and therefore, discouraging to adopt. However, the recent incorporation of robotic technology proposes a feasible, safe, extracervical approach that alleviates most of the technical difficulties associated with endoscopy. Here, the authors present a series of robotic thyroidectomies performed to treat benign thyroid diseases and detail the key issues of initial patient selection.

PATIENTS AND METHODS

From November 2007 to December 2010, 44 patients with benign thyroid disease were operated upon using a robotic procedure. Indications were follicular/Hürthle cell lesions smaller than 5 cm, nodules with an indefinite/suspicious cytology, or Graves disease. All patients underwent robotic gasless, transaxillary thyroidectomy using the da Vinci S system.

RESULTS

Thirty-nine of the 44 patients were women, and the overall mean age was 38.2 years (range, 16 to 60 y). The most common pathology was adenomatous hyperplasia (20 lesions) followed by follicular adenoma (10 lesions). Seven patients had Graves disease. The mean tumor size was 1.68 cm (range, 0.3 to 5 cm). Thirty-nine patients underwent less than total thyroidectomy and 5 underwent total or near total thyroidectomy. The mean total operative time was 129.8 minutes (range, 75 to 242 min) and the mean duration of postoperative hospital stay was 3.1 days (range, 2 to 5 d). Postoperative complications were 1 transient hoarseness, 1 transient hypocalcemia, and 1 permanent recurrent laryngeal nerve injury.

CONCLUSIONS

Robotic thyroidectomy, although novel and sophisticated, has already been used to treat over 4000 thyroid cancer patients in Korea. Female patients with a small to average build, with a follicular lesion and concerned about neck scarring, seem to be the best candidates. Patients with small suspicious nodules without severe thyroiditis are also a rational choice. In contrast, patients with Graves disease should be reserved, unless significant experience has been gained.

New developments in the diagnosis and treatment of thyroid cancer

Thyroid cancer exists in several forms. Differentiated thyroid cancers include those with papillary and follicular histologies. These tumors exist along a spectrum of differentiation, and their incidence continues to climb. A number of advances in the diagnosis and treatment of differentiated thyroid cancers now exist. These include molecular diagnostics and more advanced strategies for risk stratification. Medullary cancer arises from the parafollicular cells and not the follicular cells. Therefore, diagnosis and treatment differs from those of differentiated thyroid tumors. Genetic testing and newer adjuvant therapies have changed the diagnosis and treatment of medullary thyroid cancer. This review will focus on the epidemiology, diagnosis, workup, and treatment of both differentiated and medullary thyroid cancers, focusing specifically on newer developments in the field.