Qualitative and quantitative differences between 2 robotic thyroidectomy techniques

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.

Global trends in research of endoscopic thyroidectomy from 2013 to 2022: a scientometric and visualization analysis

Introduction

Recently, endoscopic thyroidectomy has been developed and applied to thyroid surgery to achieve minimized neck scar formation and enhanced aesthetic outcomes. Our scientometric research in this paper offers a thorough overview of endoscopic thyroidectomy from 2013 to 2022.

Methods

All pertinent articles on endoscopic thyroidectomy were obtained from the Web of Science Core Collection Database. The data on the number of citations and publications, most prolific countries and institutions, significant authors and journals, top themes, and keywords were analyzed by Biblioshiny, CiteSpace, and VOSviewer.

Results

There were 758 publications, all of that were found from 2013 to 2022. The output of the annual publication showed an upward trend. A series of cases report by Anuwong et al. published in 2016 received the most citations. The country with the most articles published articles was South Korea, and the two countries with the most collaboration were South Korea and the United States. The most productive journal was Surgical Endoscopy and Other Interventional Techniques. Dionigi G, Kim HY, and Anuwong A were the writers with the most articles published, the highest h- and g-indices, and the strongest link strength, respectively. The keywords "endoscopic thyroidectomy", "surgical", "thyroidectomy", "robotic thyroidectomy", "experience", and others were most used.

Conclusion

The innovative surgical technique, transoral endoscopic thyroidectomy vestibular approach (TOETVA), leaves no scars and produces optimal cosmetic results. However, the long-term oncologic results for thyroid cancer performed with this approach are still missing. This scientometric analysis can offer valuable insights into the present research standing and key focal points in this domain, enabling researchers to gain a precise understanding of the state-of-the-art research in this area.

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

OBJECTIVE

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

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Remote-access robotic thyroidectomy: A systematic review

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Robotic retroauricular thyroidectomy with additional axillary port: Early personal experiences

OBJECTIVE

This study aimed to analyze the usefulness of an additional axillary port in robotic retroauricular thyroidectomy by comparing the perioperative data and postoperative function between the operations with and without an additional axillary port.

MATERIALS AND METHODS

A retrospective review of the medical records of 11 patients who underwent robotic thyroid operations using a unilateral retroauricular approach with or without an additional axillary port between 2016 and 2021 was conducted. Patient demographics, operation time, drainage amount, hospital stay, complication, postoperative cosmetic satisfaction, and postoperative neck and shoulder pain were analyzed.

RESULTS

Among the 11 patients who underwent robotic retroauricular thyroidectomy, an additional axillary port was used in 6 patients and not used in 5 patients. The total operation time was significantly shorter in the axillary port group (174.5 ± 23 minutes) compared to the without the axillary port group (207.6 ± 20.1 minutes) (P = .033). The intraoperative estimated blood loss (P = .525), total amount of drainage (P = .172), and postoperative hospital stays (P = .092) were not different between the 2 groups. There was no postoperative recurrent laryngeal nerve palsy, hypoparathyroidism, hematoma, seroma in the two groups. There was no significant difference for either group in the pain score and cosmetic satisfaction at 2 weeks (P = .378, P = .650) and 6 weeks (P = .242, P = .546) postoperatively.

CONCLUSION

Robotic retroauricular thyroidectomy using an additional axillary port was a novel, safe, and feasible procedure. Dissection was easy due to the availability of the fourth robotic arm to retract the thyroid gland.Level of Evidence: 4.

Current concepts in thyroid gland surgery: transoral endoscopic and robotic surgical procedures

The increased incidence of thyroid cancer in young females may raise concerns about visible hypertrophic scarring on the center of the neck after thyroid gland surgery. Therefore, endoscopic surgical procedures have attracted significant interest from patients with thyroid cancer, leading to the development of various endoscopic and robotic approaches. Although the cosmetic outcomes of current endoscopic and robotic thyroid surgeries have been excellent, all the procedures still require a large incision and extensive flap elevation. Transoral endoscopic thyroid surgery is a newly developed surgical method performed by inserting an endoscope through a mucosal opening created in the mouth, obviating the need for a skin incision. Additionally, the dissection area is relatively small and no dressings are required. Showering or shaving may resume the day after surgery and the port created within the oral mucous membrane generally heals within one week. Importantly, this approach is markedly less invasive than other endoscopic approaches. Although transoral endoscopic thyroid surgery has not yet been universally accepted, it may emerge as the preferred method for thyroid surgery in the near future.

Evaluation of YouTube videos as a patient education source for novel surgical techniques in thyroid surgery

Background

Patients and physicians are increasingly utilizing online video sharing sites such as YouTube for obtaining and disseminating health-related information in multimedia format; however, due to its free, open-access platform, YouTube videos fall short in providing validated, up-to-date medical information, and may even convey unintended messages to patients who are seeking additional information on surgeries. We evaluated the relevance, reliability, and quality of YouTube videos on novel surgical techniques in thyroid surgery.

Methods

The top 50 indexed YouTube videos for the queries, "robotic thyroid surgery" and "transoral thyroid surgery", were assessed by two independent reviewers for video quality and reliability for patient understanding. Videos were scored using Global Quality Score (GQS), a scale for video quality, and DISCERN Scoring, a questionnaire for reliability and quality measures of information presented.

Results

The mean ± standard deviation (SD) duration of the videos (n=50) was 8.1±3.7 minutes. Total views were 261,440 and the mean ± SD time since upload was 3.6±2.6 years. The median and interquartile range of video power index (VPI) was 1.9 (0.5-3.7), GQS was 3.0 (2.0-4.0), and DISCERN score was 2.8 (2.3-3.2). Most videos were uploaded by physicians (75.8%) and the highest number of videos (63.6%) uploaded were from the United States (US). Videos with higher quality and reliability scores were uploaded by academic professionals, and included videos of physicians who described procedural information, perioperative instructions, and possible postoperative complications (P<0.05). Adequate medical information on the procedure and discussion of complications in YouTube videos were independent predictors of advanced educational quality and reliability.

Conclusions

Clinical information on new surgical techniques such as transoral and robotic thyroid surgeries in YouTube videos scored low on quality and reliability as a source of patient education. Physicians should provide supplemental educational material online and offline to aid patient understanding of novel procedures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Transoral thyroid surgery vestibular approach: does size matter anymore?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hydrogel-Shielded Soft Tactile Sensor for Biocompatible Drug Delivery Monitoring

Tactile sensing is an emerging technological advancement in surgical robotics in order to probe interactions between confined tissue environments and instruments based on touch information. The tactile sense can assist in improving the efficiency of the whole practice and hence enhance precision, control, and safety during surgery. This paper demonstrates a distinct proof-of-concept therapeutic device equipped with a soft tactile sensor. The tactile sensor was custom-made using flexible piezoresistive materials and conductive ink, wrapped with a biocompatible hydrogel polymer matrix for safer human–tissue interactions. The proposed tactile sensor was then calibrated and its performance was compared with gold standard sensors. It was further tested with a continuous force (5 N) for an extended period of time (about 6 h) to address robustness and repeatability. The sensor showed a sensitivity of 0.833 N−1 and a drift of ≤1%. Successful cadaver experiment demonstrates the efficiency of tactile sensing assistance to clinicians.

Extracervical Approaches to Thyroid Surgery: Evolution and Review

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

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.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.

Remote Access Robotic Facelift Thyroidectomy: A Multi-institutional Experience

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robot-assisted internal mammary lymph chain excision for breast cancer: A case report

RATIONALE

Understanding the status of internal mammary lymph nodes of breast cancer is critical in the accurate staging of breast cancer and the development of accurate therapeutic regimen for selected patients. Current techniques for dissection of internal mammary lymph node biopsy involve endoscopic or Traditional thoracic surgery, An important drawback of the current techniques is the great trauma caused by them.

PATIENT CONCERNS

Da Vinci robotic surgery system (Intuitive Surgical Inc. Sunnyvale, CA) was used to perform the internal mammary lymph chain excision for a breast cancer patient with left internal mammary lymph node metastasis.

DIAGNOSES

Positron emission tomography-computed tomography examination and Ultrasonography examination.

INTERVENTIONS

In this paper, we introduce a Robot-assisted technique for dissection of internal mammary lymph node biopsy with only 3 small trocar ports. This technique reduces the incision size and considerably reduce the trauma.

OUTCOMES

The operation lasted a duration of 1.5 hours. The operation was carried out smoothly with removal of 9 internal mammary lymph nodes in total. The amount of intra operative bleeding was less than 10 ml. The patient's postoperative recovery was fast. 11-month postoperative follow-up showed that the patient recovered well after surgery, no local recurrence or distant metastasis was found, and no obvious discomfort was reported.

LESSONS

Robot-assisted excision of internal mammary lymph chain in breast cancer is a safe, effective and simple operation with minimal invasion.

Aesthetics in Thyroid Surgery: The Patient Perspective

Objectives

To define characteristics that influence patient perceptions of thyroidectomy scar cosmesis.

Study Design

Prospective cohort study.

Setting

Tertiary endocrine surgery practice in an academic medical center.

Subjects and Methods

Institutional review board–approved trial in which 136 subjects were recruited from a population of patients being seen for either thyroid or sinus surgery and evaluated standardized photographs, superimposed with computer-generated thyroidectomy scars of varying lengths (2, 4, and 6 cm) and widths (1 and 2 mm), and graded their perception of the scars using the observer scar assessment scale (OSAS) domains of the patient and observer scar assessment scale.

Results

There were 69 subjects in the thyroid group and 67 in the nonthyroid group. Controlling for width, longer scars were perceived as worse than shorter scars; controlling for length, thicker scars were perceived as worse than thinner scars ( P < .01). Beyond 2 cm, thick scars were judged to be worse than thin scars, even when they were shorter. There was no difference in the mean overall OSAS scores between surgery, sex, or age groups. Nonwhites tended to judge scars as being worse than whites did ( P < .01).

Conclusion

As expected, patients of all demographics prefer shorter scars compared with longer scars and thinner scars over thick scars. Ethnic differences in scar perception were identified and deserve additional study. Surgeons should endeavor to perform thyroid surgery through the smallest incision that allows the operation to be performed safely to minimize the cosmetic impact of the operation.

Robotic surgical systems in maxillofacial surgery: a review

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

Overview of robotic thyroidectomy

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

Robotic 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.

Facelift Approach for Resecting Benign Upper Neck Masses

BACKGROUND

This study evaluated the feasibility of non-magnified resection of various benign lesions of the upper neck using the facelift incision without endoscopic equipment to establish indications for the procedure.

METHODS

This retrospective analysis examined 86 patients who underwent surgery for upper neck masses using the facelift incision or conventional transcervical incision at our institute between January 2012 and December 2015.

RESULTS

We performed 41 operations using facelift incisions (facelift group) and 45 using conventional horizontal incisions (conventional group). All 86 operations were successful. In the facelift group, no patient needed conversion to conventional open resection and no patient required the use of an endoscopic device due to a limited surgical view for safe resection. There were no major surgical complications in either group. Transient sensory changes in the auricle occurred in 26% of the patients in the facelift group, but all patients recovered within 2 months. In all patients in the facelift group, the scars were invisible as they were covered by the auricle and hair, while the surgical scars were noticeable in 91% (41/45) of the patients in the conventional group when they were wearing standard shirts (p < 0.001) at 3-4 weeks after surgery.

CONCLUSIONS

The facelift approach provides a short direct route to upper neck masses, and it enables an adequate workspace not only for endoscopic or robotic surgery, but also for open surgery with the naked eye. The surgical indications for the facelift incision include the removal of most benign tumors occurring in the upper neck at levels II and III.

Robotic retroauricular thyroid surgery

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

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Case series with planned data collection.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

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.

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.

Trends in Robotic Thyroid Surgery in the United States from 2009 Through 2013

BACKGROUND

The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013.

METHODS

The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another U.S. institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed.

RESULTS

Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, U.S. annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher-volume centers reported lower complication rates (p<0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. More than 10% of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in <1% of cases. Mean cost for a total RT was $13,287 ($5,125-42,444).

CONCLUSIONS

From 2009 through early 2011, there was a steady increase in RT volume, especially among high-volume institutions. In mid-to-late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower-volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the United States.

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.

Endoscopic retroauricular thyroidectomy: preliminary results

BACKGROUND

We sought to seek the potential role of endoscopic thyroidectomy with the retroauricular (RA) approach prior to future comparative study with the robotic RA thyroidectomy. Therefore, this study aims to verify the surgical feasibility of endoscopic RA thyroidectomy.

METHODS

Eighteen patients who underwent endoscopic RA thyroidectomy for clinically suspicious papillary thyroid carcinoma or benign lesions from January to December 2013 were retrospectively reviewed and analyzed.

RESULTS

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

CONCLUSION

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

Robotic thyroidectomy: facelift approach

Remote access thyroidectomy procedures, in which the cosmetic impact of traditional thyroid surgery is minimized by removing the incision from the visible neck, have been made possible by advances in endoscopic technology. These techniques initially utilized chest or axillary access points, but were not widely adopted in North American practices. Incorporating robotic technology in remote access thyroid surgery provided significant improvements in visualization and maneuverability, ultimately facilitating the development of the robotic facelift thyroidectomy. This procedure approaches the thyroid compartment from a retroauricular incision and offers many advantages over other remote access approaches. As this technique has been more widely implemented, it is proving to be a safe, attractive alternative for patients seeking to completely avoid a visible neck scar.

Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique

BACKGROUND

A new approach to modifying facelift incision was recently developed for robotic thyroid surgery that seemed to be advantageous over other existing approaches. In this study, we aimed to investigate the feasibility and safety of the facelift approach not only for robotic thyroid surgery, but also for endoscope-assisted thyroid surgery.

METHODS

Endoscope-assisted facelift thyroid lobectomy was performed for 11 patients with papillary microcarcinoma.

RESULTS

All 11 operations were successfully performed endoscopically. This approach through a modified facelift incision provided safe dissection of the laryngeal nerves and exposed an adequate working space. We identified and preserved all neighboring critical structures (parathyroid gland and superior and recurrent laryngeal nerves) during surgery. The operative duration for simple thyroid lobectomy with central lymph node dissection in 11 patients was 120-180 min (average duration: 140 min). Sensory change around the earlobe occurred in three patients and was recovered within 2 months after surgery in all patients. No patient displayed laryngeal nerve palsy or a low-pitched voice.

CONCLUSIONS

The facelift approach seems to provide a shorter and more direct route to the thyroid, requiring minimal dissection, and an adequate workspace not only for robotic surgery but also for endoscopic surgery. It is worthwhile to develop and refine the surgical techniques of endoscopic facelift thyroid surgery.

Stretch of the Minimally Invasive Incision during Thyroid and Parathyroid Surgery

Objective

Identify and quantify changes in length of the skin incision following minimally invasive thyroid and parathyroid surgery and determine whether these changes persist postoperatively.

Study Design

Cohort study.

Setting

Tertiary care teaching hospital.

Subjects and Methods

Between July 2012 and June 2013, a prospective, nonrandomized study was performed on 44 consecutive patients undergoing open cervical minimally invasive thyroidectomy (incision approximately 6 cm or less) or minimally invasive parathyroidectomy (incision approximately 3 cm or less). Incision length was measured following initial incision, immediately after wound closure, and on postoperative follow-up at 2-week and 14-week visits.

Results

Thirty-one patients underwent minimally invasive thyroidectomy or parathyroidectomy with initial incision lengths ranging from 20 mm to 60 mm. Seven patients (21%) underwent total thyroidectomy with a mean length of 45 ± 8 mm, 15 patients (44%) underwent unilateral thyroid lobectomy with a mean length of 37 ± 5 mm, and 9 patients (26%) underwent parathyroidectomy with a mean length of 28 ± 2 mm. On average, the skin incision lengthened by 3.0 ± 0.9 mm during surgery representing an intraoperative stretch of 8.0% ( P < .0001). Incision lengths decreased by an average of 0.3 mm at 2-week postoperative follow-up ( ns) and 6.3 mm at 14-week postoperative follow-up ( P < .0001).

Conclusion

Significant intraoperative incision stretch is likely to occur during minimally invasive thyroid and parathyroid surgery. Postoperative follow-up data suggest that the increase in incision length is not permanent and resolves upon postoperative follow-up.

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.

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.

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.