Optimal carbon dioxide insufflation pressure during robot-assisted thyroidectomy in patients with various benign and malignant thyroid diseases

New Approaches for Robot-Assisted Neck Surgery: Clavicular and Submental Approaches Using the da Vinci SP System

BACKGROUND

Minimally invasive robot-assisted thyroid surgery or neck dissection can improve cosmetic results and reduce surgical trauma. Several approaches have been described but each has both advantages and limitations. We aimed to determine the feasibility of performing robot-assisted neck surgery using the da Vinci SP system.

METHODS

The clavicular approach using the da Vinci SP system was done in 1 cadaveric model. Lateral neck dissection was carried out with parapharyngeal space dissection, lateral thyroid gland exposure, and anatomical references. The submental approach was performed in the same cadaveric model. Total thyroidectomy plus lateral neck dissection was performed.

RESULTS

The required 2.5-cm skin incision, minimal flap development to insert the SP Access Port plus docking was done in 5 minutes for each procedure. The neck dissection by clavicular access took 77 minutes, the parapharyngeal dissection 60 minutes, and hemi-thyroidectomy 30 minutes. The neck dissection by submental access took 60 minutes and the total thyroidectomy took 45 minutes.

CONCLUSION

We have demonstrated the feasibility of single-incision clavicular and submental approaches in neck surgery using the da Vinci SP system. The amount of skin flap dissection was minimal, the system docking was rapid, and no additional ports or retractors were required. Further studies on patients are warranted.

Robotic infraclavicular approach for minimally invasive neck dissection in head-neck cancers

Background

In the recent years, there has been a rapid increase in the use of robot assisted neck dissection (RAND) as an alternative method for conventional neck dissection. Several recent reports have emphasized upon the feasibility and effectiveness of this technique. However, substantial technical and technological innovation is still essential in spite of the availability of multiple approaches for RAND.

Materials and Methods

The present study describes a novel technique, i.e., Robotic Infraclavicular Approach for Minimally Invasive Neck Dissection (RIA MIND) used in head and neck cancers with the help of Intuitive da Vinci Xi Surgical System.

Results

After RIA MIND procedure, the patient was discharged on the third post operative day. Also, the total wound size was less than 3.5 cm which enhanced the patient recovery time and required minimal post operative care. The patient was further reviewed 10 days after the procedure for the removal of sutures.

Conclusion

RIA MIND technique was effective and safe for performing neck dissection for oral, head and neck cancers. However, additional detailed studies will be required for establishing this technique.

Gasless endoscopic thyroidectomy via modified areola approach with a simple flap-lifting technique

OBJECTIVE

Studies have shown that carbon dioxide (CO2) insufflation during endoscopic thyroidectomy is associated with many risks. Recently, we have designed a simple lifting tool using Kirschner wire. We aimed to use this tool for flap-lifting in modified areola approach endoscopic thyroidectomy and compare it with conventional CO2 insufflation.

METHODS

In a prospective study, patients who underwent endoscopic thyroidectomy via modified areola approach were randomly assigned into gasless (n = 20) or CO2 groups (n = 22). Pre-operative variables included age, gender, tumor diameter, and clinical diagnosis. Intra-operative hemodynamic monitoring included mean arterial pressure, heart rate, pulse oximetry, end-tidal carbon dioxide (ET-CO2) and arterial pH. Other intra-operative details included total operative time, operative blood loss, conversion from endoscopic surgery to open surgery, intra-operative events, and endoscope video score. Postoperatively, the hospital stay, drainage volume, and complications were recoded.

RESULTS

Patient characteristics were not different between the two groups. During the operation, ET-CO2 levels were significantly higher in the CO2 group (P < 0.05), whereas arterial pH levels were significantly lower (P < 0.05). The CO2 group had longer operation time and higher endoscope clarity VAS score than gasless group. Hospital stay, drainage volume, and postoperative complications did not differ significantly between the two groups (P > 0.05).

CONCLUSIONS

The gasless endoscopic thyroidectomy we performed via our Kirschner wire hook was safe, feasible, and yielded good results.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Our outcomes from Turkey

OBJECTIVES

The Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) was described in 2016 and had its case series published. This study aimed to present the largest TOETVA case series performed in Turkey.

MATERIAL AND METHODS

Data from 52 patients who underwent TOETVA procedure between February 2018 and October 2019 were analyzed retrospectively. Demographic data, duration of operation, blood loss, rate of conversion to open surgery, radiological findings, pathological outcomes, and complications were analyzed.

RESULTS

All patients were female. Mean duration of the operation was 192 ± 45 minutes, mean blood loss was 39 ± 47 mL, and the ratio of surgical site infection was 6% (3/50). In two (4%) patients, TOETVA was converted to open surgery. Temporary and permanent recurrent laryngeal nerve (RLN) paralysis was observed in 2 (4%) and 0 patients, respectively. Temporary and permanent hypoparathyroidism was observed in 10 (20%) and 0 patients, respectively.

CONCLUSION

TOETVA procedure is the most recently defined NOTES technique for endocrine surgery. In experienced healthcare centers, TOETVA can achieve outcomes similar and even better than the ones obtained with open surgery. The complication rates, durations of operation, surgical site infection, and blood loss parameters that we observed in our experience are similar to the ones reported in the literature.

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.

Comparative study of bilateral axillo-breast approach endoscopic and robotic thyroidectomy: propensity score matching analysis of large multi-institutional data

Purpose

The aim of this study was to compare the large multi-institutional data of surgical outcomes of bilateral axillo-breast approach (BABA) robotic (RT) and endoscopic thyroidectomy (ET) and to evaluate the merits of robotic thyroidectomy.

Methods

From 2004 to 2015, 1,029 patients underwent BABA ET, and from 2008 to 2015, 2003 patients underwent BABA RT in 3 large volume centers in Korea. Two groups were retrospectively compared in terms of clinicopathologic characteristics, complications, surgical completeness, and long-term outcomes using propensity score matching analysis.

Results

Both groups had similar demographic characteristics including age, sex, tumor size, pathologic stage, and hospital stay after matching. Each group had similar rate of transient hypoparathyroidism, however, ET showed significantly higher rate of permanent hypoparathyroidism (ET 5.2% vs. RT 2.3%, P = 0.05), and transient vocal cord palsy (ET 14.4% vs. RT 9.1%, P = 0.006). Total operation time was longer in the ET group irrespective of surgical extents, including lobectomy (P = 0.016), total thyroidectomy (P = 0.031), and total thyroidectomy with central lymph node dissection (P = 0.019). The rate of patients with off-Tg under 1.0 ng/mL after 1st ablation was significantly higher in RT than ET group (ET 64.6% vs. RT 92.7%, P < 0.001). In long-term follow-up of cancer patients, 1.4% experienced recurrence after ET (10 cases), while 0.3% cases experienced recurrence after RT (5 cases) (P < 0.001).

Conclusion

Both ET and RT can be safe and effective methods to treat thyroid diseases. However, the application of robotic system may help to overcome the limitations of the instruments and surgeon's skills.

A prospective, randomized controlled study of the safety and efficacy of gasless bilateral axillo-breast approach (BABA) robotic thyroidectomy

BACKGROUND

During bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT), carbon dioxide (CO₂) gas is insufflated into the operative cavity, not only triggering hemodynamic and metabolic changes, but also inducing postoperative pain and gas embolism. Here, we explored whether the new gasless BABA RoT approach was as safe and efficacious as conventional robotic surgery using CO₂ insufflation.

PATIENTS AND METHODS

We performed a prospective, randomized controlled trial comparing conventional BABA RoT to gasless BABA RoT (CO₂ group, n = 14; gasless group, n = 14). All clinicopathological and oncological outcomes were evaluated. The hemodynamic parameters [heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and cardiac index (CI)] and metabolic parameters [partial pressure of carbon dioxide (PaCO₂) and pH] were measured at baseline; 30, 60, 90, and 120 min after CO₂ insufflation; and 30 min after desufflation. Pain parameters [numeric rating scale (NRS) score, number of analgesics (NA), and bottom hit count (BHC)] were measured at 2, 24, 48, and 72 h after surgery.

RESULTS

We found no statistically significant differences between the two groups in terms of any demographic or baseline characteristic. The clinicopathological and oncological outcomes did not differ significantly between the two groups, but the operation time was longer for the gasless group (187.50 ± 42.64 vs. 212.50 ± 35.88 min; P = 0.028). In terms of the hemodynamic, metabolic, and pain parameters, the pH fell significantly less in the gasless group (P = 0.047), but there were no significant between-group differences in the HR, MAP, CO, CI, PaCO_2, NRS, NA, or BHC. No safety concerns arose.

CONCLUSION

The new, gasless BABA RoT technique employing the da Vinci robotic surgical system is safe. Although metabolic changes during operation are thereby minimized, gasless BABA RoT should be used carefully when engaging in thyroid surgery; more experience is required.

Robotic-assisted breast-axillo insufflation thyroidectomy (RABIT): a retrospective case series of thyroid carcinoma

OBJECTIVE

To evaluate the feasibility and safety of robotic-assisted breast-axillo insufflation thyroidectomy (RABIT) for differentiated thyroid cancer.

METHODS

In this retrospective case series, patients with differentiated thyroid carcinoma were enrolled in our hospital from January 2018 to December 2018. All patients underwent indirect laryngoscopy to assess the status of vocal cord preoperatively. RABIT was performed with five separate breast-axillo incisions. All the procedures were performed using da Vinci Xi Robotic Surgical System, a single docking method using CO₂ insufflation.

RESULTS

Twelve patients completed RABIT, in which one case needed conversion to open thyroidectomy. The mean age was 30.25 ± 7 with male to female ratio being 1:1. Preoperative diagnosis showed papillary carcinoma (n = 9) and follicular neoplasm (n = 3). The mean operative time for RABIT was 140 ± 50.45 min and average blood loss during surgery was 22.92 ± 9 mL. Mean hospital stay was 4.42 ± 1.08 days. Final pathology confirmed classical papillary thyroid carcinoma (n = 10; 83.3%) and follicular variant of papillary carcinoma (n = 2; 16.7%). None of the cases reported injury or paralysis to the recurrent laryngeal nerves.

CONCLUSION

RABIT is a safe and feasible approach for thyroidectomy. It has several advantages in that it provides similar symmetrical view to conventional open surgery and enables to maintain specimen integrity and use of assistant port permits better handling of the gland. Additionally, the largest operating angles with this technique prevent collision between the robotic arms and provide excellent cosmetic satisfaction due to very small, five separate breast-axillo incisions.

Comparison of postoperative surgical stress following robotic thyroidectomy and open thyroidectomy: a prospective pilot study

BACKGROUND

Robotic thyroid surgery using the da Vinci surgical system has certain cosmetic advantages; however, the invasiveness of robotic thyroid surgery is still a concern to many surgeons. Previous research has not directly compared the surgical stress of robotic thyroidectomy with that of conventional open surgery. The aim of the present study was to evaluate surgical stress using postsurgical measurements of several clinical markers.

METHODS

A pilot study was performed to evaluate surgical stress following robotic and open thyroid surgery. A total of 29 papillary thyroid cancer patients from July to November 2014 were enrolled. Fourteen patients underwent conventional open surgery, and fifteen underwent robotic thyroidectomy. IL-6 levels, serum WBC counts, CRP levels, surgical plethysmographic index (SPI), and visual analogue scale (VAS) score were measured to compare surgical stress between the robotic and the open surgery groups.

RESULTS

No significant differences were seen between the two groups in IL-6 level, WBC count or CRP level (p = 0.380, 0.374, 0.360, respectively). Mean SPI level during the surgery was 41.9 ± 4.7 in open group compared to 39.5 ± 2.2 in robotic group, though this finding showed borderline significance (p = 0.095). VAS score after open surgery was significantly higher than after robotic operation (p = 0.048).

CONCLUSION

The results of this study suggest that robotic thyroidectomy can result in a less than equivocal systemic stress response than is seen in open thyroidectomy. However, further investigation including large-scale, prospective, multicenter studies is warranted for non-inferiority trials.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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