Transoral robotic thyroidectomy using the da Vinci single-port surgical system

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.

Single-port endoscopy-assisted thyroidectomy via cervical gas-insufflation approach for papillary thyroid carcinoma: A pilot retrospective comparative study

PURPOSE

This study aims to investigate the safety and efficacy of our novel technique of single-port endoscopy-assisted thyroidectomy via cervical gas-insufflation approach (SPEAT, also called the Huang procedure) in the treatment of papillary thyroid carcinoma (PTC).

MATERIALS AND METHODS

We perform a retrospective comparative study from a prospectively maintained database. A cohort of 82 patients with PTC who underwent total thyroidectomy and central neck dissection were included. Of these patients, 48 underwent SPEAT and 34 underwent conventional open thyroidectomy (COT). The differences in surgical outcome and oncological completeness were compared.

RESULTS

Compared with the COT group, the SPEAT group had obviously shorter incision (P < 0.001), less postoperative pain (P = 0.036), better cosmetic satisfaction (P = 0.001)and slightly longer operating time (P = 0.041). In intraoperative bleeding, postoperative drainage, postoperative hospital stay, surgical complications, number of dissected or positive lymph nodes per patient, and postoperative non-stimulated or stimulated thyroglobulin levels, there were no significant differences.

CONCLUSIONS

SPEAT (the Huang procedure) is a minimally invasive, safe and oncologically complete surgical option for PTC in selected patients.

Learning curve of transoral robotic thyroidectomy

BACKGROUND

Transoral thyroidectomy has superior cosmesis and better postoperative voice outcomes than conventional thyroidectomy. However, it usually requires a steep learning curve and longer operative time. The transoral robotic thyroidectomy (TORT) learning curve has not been well investigated. This study aimed to evaluate the TORT learning curve and factors affecting operative time.

METHODS

We retrospectively studied 173 consecutive patients who underwent TORT with or without central neck dissection from July 2017 to August 2021. We assessed the TORT learning curve using operative time, complication rate, and surgical success (procedure conversion) rate. The operative time and surgical success rate learning curves were calculated using the cumulative summation (CUSUM) method. Additionally, we analyzed factors affecting operative time in TORT.

RESULTS

Total thyroidectomy operative time was significantly longer than those of lobectomy and isthmusectomy (p < 0.001). In correlation analysis, a significantly positive correlation was observed between body mass index (BMI) and operative time (R² = 0.04, p = 0.025). The TORT learning curve was 52 cases in the CUSUM operative time analysis. In the CUSUM surgical success rate chart, the turning point was the 55th case. Complication and procedure conversion rates were significantly decreased after the learning curve.

CONCLUSIONS

The CUSUM learning curve of TORT was about 52-55 cases, and the operative time, total complication rate, and procedure conversion decreased significantly after the learning curve. The operative time was associated with the extent of thyroidectomy and BMI.

Feasibility of robotic thyroidectomy via hairline incision using da Vinci single port system: Initial experience with 40 consecutive cases

BACKGROUND

This study aimed to introduce our robotic technique, which can minimize dissection extent using the da Vinci SP robotic system via hairline incision.

METHODS

Forty patients underwent robotic thyroidectomy using the da Vinci SP robotic system via a hairline incision between February 2020 and April 2021 at Ulsan University Hospital. All procedures were performed successfully by one surgeon using the SP robotic system.

RESULTS

Hemithyroidectomies were performed in 32 patients and total thyroidectomies in eight patients. Central neck dissection was performed in 32 patients. The overall mean operative time was 140.2 ± 50.7 min, and the mean console time was 74.0 ± 42.7 min. All patients were discharged on the second or third day after operation without any complications.

CONCLUSIONS

Robotic thyroidectomy using the SP robotic system via hairline incision is technically feasible and safe, with a shorter incision length when compared with that of the Xi system.

Comparative study of transaxillary, bilateral axillo-breast, unilateral axillo-breast with gas insufflation, retroauricular, and transoral endoscopic thyroidectomy approaches in a single institute:retrospective analysis and lessons learnt from experiences

Objectives. This study aimed to present our experiences with various approaches for endoscopic thyroidectomy (ET) and to offer lessons for choosing an approach.Method. The medical records of 701 patients who underwent ET via different approaches such as transaxillary (TA), bilateral axillo-breast (BABA), unilateral axillo-breast with carbon dioxide insufflation (UABA), retroauricular (RA), or transoral vestibular (TO) between May 2008 and March 2020 were retrospectively reviewed.Results. The mean operative time of UABA was the shortest among five approaches (TA 194.65

Learning curve for robotic thyroidectomy using BABA: CUSUM analysis of a single surgeon's experience

BACKGROUND

This study assessed the safety and oncologic outcomes of robotic thyroidectomy via the bilateral axillary breast approach (BABA RT) for conventional open procedures. The learning curves of BABA RT were further evaluated.

METHODS

An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between robotic thyroidectomy and conventional open surgery. Learning curves were assessed using cumulative summation analysis.

RESULTS

There was no significant difference in general characteristics, short time outcomes (including transient hypoparathyroidism, transient postoperative hoarseness, hematoma/seroma, mean postoperative hospital stay, and other complications), the number of retrieved central lymph nodes, and recurrence rates between robotic BABA and conventional groups. The mean number of retrieved lateral LNs in the robotic group was significantly less than those in the conventional group. The learning curve for working space making, robotic lobectomy, and total thyroidectomy are approximately 15, 30, and 20 cases, respectively. No differences except for operation time were found between the learning group and the proficient group.

CONCLUSIONS

Robotic thyroidectomy and neck dissection via BABA are feasible in terms of surgical completeness, surgical safety, and oncological safety. Our results provide a criterion for judging whether the surgeon has entered the stable stage of robotic thyroidectomy via BABA in terms of the operative time.

Preoperative application of carbon nanoparticles in bilateral axillo-breast approach robotic thyroidectomy for papillary thyroid cancer

BACKGROUND

Carbon nanoparticles (CNs) have been used intraoperatively in open thyroid surgery to facilitate central neck dissection and parathyroid protection. However, little attention was paid to the preoperative injection of CNs. Its safety and feasibility remain to be evaluated in bilateral axillo-breast approach robotic thyroidectomy (BABA RT).

METHODS

In this retrospective cohort study, 114 papillary thyroid cancer patients (PTC) undergoing BABA RT were enrolled from March 2020 to March 2021. In the CNs group (n=64), 0.15 mL of CNs was injected into the thyroid lobules with malignant nodules the day before surgery. Medical records were reviewed and analyzed, including complications of CNs usage, surgical outcomes, central lymph node (CLN) retrieval, and parathyroid glands (PGs)-related parameters.

RESULTS

No significant differences were found between the CNs and the control groups in terms of general characteristics and surgical parameters. Complications of CNs were rare in the CNs group. The mean number of retrieved CLN was significantly higher in the CNs group than in the control group (9.48±4.88 vs. 5.40±2.67, P<0.001), as was the mean number of metastatic CLN (2.00±2.56 vs. 1.04±1.70, P=0.018). There were no differences in PGs preserved in situ, PGs autotransplantation, and postoperative PTH levels on the first day and first month (all P>0.05).

CONCLUSIONS

In patients with PTC undergoing BABA RT, preoperative application of CNs is a safe and feasible method to facilitate central neck dissection. However, the value of the preoperative application of CNs in robotic thyroidectomy needs to be further studied because it has no significant benefit for parathyroid protection.

Complications of Transoral Thyroidectomy: Overview and Update

Transoral thyroidectomy via the vestibular approach has become popular worldwide, with advantages including less surgical morbidity, excellent postoperative cosmesis, and superior functional voice outcomes. Several studies have reported that the surgical outcomes of the transoral approach were comparable to those of the conventional transcervical approach in selected patients. However, unusual complications, such as CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been noted in transoral thyroidectomy. This paper aims to review and provide updated information on these complications and their management. Routine intraoperative neural monitoring is required to avoid laryngeal nerve palsy in the transoral approach. To prevent CO2 embolism, surgeons need to be careful not to injure the anterior jugular vein, and the CO2 insufflation pressure should be set as low as 4-6 mmHg. To avoid mental nerve injury, vestibular incisions should be placed in the safety zone, and dissection of the vestibular area and chin should be minimized. In conclusion, recognizing the possibility of complications and understanding their prevention and management are important for patient safety and the success of the transoral approach.

Pure transoral robotic thyroidectomy; institutional adaptation and early results from a tertiary endocrine surgery centre

PURPOSE

Novel thyroidectomy techniques have been described to minimize the visible scar. Hereby, we aim to present our experience with transoral robotic thyroidectomy (TORT) without axillary access.

MATERIAL AND METHODS

Between August 2018 and March 2019, six eligible patients were enrolled to undergo TORT. Procedures were performed by using the Da Vinci Xi platform under intermittent intraoperative nerve monitoring.

RESULTS

All patients were female, and the mean age was 40.0 ± 14.4 years. Three patients underwent total thyroidectomy, and lobectomy was performed for the remaining three patients. In one patient, the procedure was converted to conventional open thyroidectomy due to bleeding. The mean docking time, console time and total operative time were 22.8 ± 5.2 min, 118.5 ± 48.7 min and 218.29 ± 50.6 min for total thyroidectomy and 21.8 ± 4.1 min, 68.6 ± 6.1 min and 177.6 ± 15.1 min for lobectomy, respectively. All patients were discharged uneventfully.

CONCLUSIONS

Pure TORT is a safe procedure, when performed in carefully selected patients by experienced surgeons, but further prospective studies with larger number of patients are required.