Robotic Transoral Thyroidectomy: Right Thyroidectomy and Ipsilateral Central Neck Dissection with da Vinci Si Surgical System

Transoral approach for thyroidectomy recently gains a lot of attention among the thyroid surgeons, with the merits of cosmetic outcomes and minimal flap dissection. We've successfully introduced the robotic surgical system to the transoral approach for thyroidectomy. For transoral robotic thyroidectomy, we made 3 incisions in the gingival-buccal sulcus for three intraoral ports. An additional axilla port was inserted for counter-traction and later drain insertion. Herein, our unique procedures of transoral robotic thyroidectomy (TORT) are described in the treatment of a patient with papillary thyroid carcinoma.

Robotic transoral thyroidectomy for papillary thyroid carcinoma

Transoral robotic thyroidectomy (TORT) is well consistent with the primary goal of remote-access thyroid surgery, which is to avoid a visible cervical scar. Additionally, the extent of transoral thyroidectomy dissection is less than that of other remote-access surgical procedures. Owing to these merits of the transoral approach, several institutions around the world are now performing this procedure. Since transoral thyroidectomy is performed in a confined, narrow space, and is characterized by a close distance from the ports to the working space, more benefits can be derived from multiarticulation of robotic instruments. Especially when performing left lobectomy by TORT, the surgeon can use right-handed robotic instruments over the thyroid cartilage with the merits of multiarticulation. In this study, we present our unique procedure of left lobectomy by TORT in detail.

Transoral Robotic Thyroidectomy

Transoral approach for thyroidectomy recently gains a lot of attention among the thyroid surgeons, with definite merits over previously developed remote-access approaches. The approach not only resulted in the ideal cosmetic outcome but less postoperative pain with smaller dissection plane in comparison with other approaches. We have successfully introduced the robotic surgical system and its related techniques to this transoral surgical approach for thyroidectomy, which enables the surgeon to have the three-dimentional operative vision and to use the articulating instruments to enhance th eoptimal surgical outcomes. Herein, our unique procedures of transoral robotic thyroidectomy (TORT) are described, and possible advantages and disadvantages of the operation are discussed.

A comparative study of postoperative pain for open thyroidectomy versus bilateral axillo-breast approach robotic thyroidectomy using a self-reporting application for iPad

PURPOSE: Postoperative pain for robotic thyroid surgeries including bilateral axillo-breast approach (BABA) has not been well studied. In this study, we have developed a self-reporting application (SRA) for iPad and prospectively collected pain scores from open thyroidectomy (OT) and BABA robotic thyroidectomy (RT) patients. METHODS: Female patients who underwent total thyroidectomy for papillary thyroid carcinoma were included. Patients recorded pain scores for throat, anterior neck, posterior neck, chest, and back on postoperative days 1, 2, and 3. Once discharged, on postoperative day 14, a survey was also conducted on satisfaction of SRA and cosmesis. RESULTS: A total of 54 patients were enrolled (27 BABA RT and 27 OT). There were no significant differences between the 2 groups in clinicopathological characteristics and postoperative complication rates. Postoperative pain scores at days 1, 2, 3, and 14 were not significantly different between the groups for throat, anterior neck, posterior neck, or back. Postoperative analgesic requirements were similar between the 2 groups. Wound satisfaction scores were significantly higher in the BABA RT group (BABA RT 7.4 vs. OT 5.7; P = 0.016). Satisfaction scores for the usefulness of SRA were above 7.2 for all four questionnaire items on the 10-point scale. CONCLUSION: Postoperative pain for BABA RT is equivalent to OT but offers greater cosmetic satisfaction for patients. A mobile device application such as SRA may facilitate proper assessment and management of pain in postoperative patients.

Robotic thyroidectomy: Evolution and Outcomes / 한양의대학술지

Recently robotic thyroidectomy has gained its popularity for the treatment of differentiated thyroid cancer and benign thyroid tumors. It has been developed to overcome the drawbacks of conventional open trans-cervical thyroidectomy, which is an apparent neck wound that is visible unless concealed with clothes. Robotic thyroidectomy provides surgeons with three-dimensional magnified view and multiarticulated robotic arms that can stabilize hand tremors. It also has advantages over conventional trans-cervical thyroidectomy that include recovery of voice symptoms and acoustic parameters along with superior cosmetic outcomes. Robotic thyroidectomy results in equivalent surgical outcomes including oncologic safety and complications compared with conventional thyroidectomy. Various approaches including transaxillary, postauricular facelift, and breast-axillary approaches have been developed for robotic thyroidectomy. Recently, the indication of robotic surgery has been extended to neck dissection of the lateral compartment. Herein we summarize the indication, procedures, and efficacy of robotic thyroidectomy, and also introduce our experience with robotic thyroidectomy.

Influence of body habitus on the surgical outcomes of bilateral axillo-breast approach robotic thyroidectomy in papillary thyroid carcinoma patients

PURPOSE: Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. The purpose of this study was to analyze the influence of body habitus including obesity on the surgical outcomes of the Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) in papillary thyroid carcinoma (PTC) patients. METHODS: The medical records of 456 PTC patients who underwent BABA RoT between January 2011 and December 2012 were reviewed, and 310 women PTC patients who had undergone BABA robotic total thyroidectomy with central lymph node dissection were examined. Body habitus were evaluated by measuring body mass index (BMI), body surface area, and neck circumference. We divided the patients into BMI < 25 kg/m2 and BMI ≥ 25 kg/m2 groups. Clinicopathological data, surgical outcomes, and postoperative complications were evaluated. RESULTS: Clinicopathological characteristics did not differ between the 2 BMI groups. The creation of working space time (P = 0.210) and other surgical outcomes showed no significant differences between the groups. There were no statistically significant differences between body habitus indexes and postoperative length of hospital stay, number of retrieved central lymph nodes, postoperative thyroglobulin levels, occurrence of hypoparathyoidism, recurrent laryngeal nerve injury and wound complication. CONCLUSION: Patient with large body habitus undergoing BABA RoT were not at an increased risk of surgical complications and showed good surgical outcomes. BABA RoT may be a good alternative operative method for PTC patients for whom cosmetic outcome is an important consideration.

Influence of body habitus on the surgical outcomes of bilateral axillo-breast approach robotic thyroidectomy in papillary thyroid carcinoma patients

PURPOSE: Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. The purpose of this study was to analyze the influence of body habitus including obesity on the surgical outcomes of the Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) in papillary thyroid carcinoma (PTC) patients. METHODS: The medical records of 456 PTC patients who underwent BABA RoT between January 2011 and December 2012 were reviewed, and 310 women PTC patients who had undergone BABA robotic total thyroidectomy with central lymph node dissection were examined. Body habitus were evaluated by measuring body mass index (BMI), body surface area, and neck circumference. We divided the patients into BMI < 25 kg/m2 and BMI ≥ 25 kg/m2 groups. Clinicopathological data, surgical outcomes, and postoperative complications were evaluated. RESULTS: Clinicopathological characteristics did not differ between the 2 BMI groups. The creation of working space time (P = 0.210) and other surgical outcomes showed no significant differences between the groups. There were no statistically significant differences between body habitus indexes and postoperative length of hospital stay, number of retrieved central lymph nodes, postoperative thyroglobulin levels, occurrence of hypoparathyoidism, recurrent laryngeal nerve injury and wound complication. CONCLUSION: Patient with large body habitus undergoing BABA RoT were not at an increased risk of surgical complications and showed good surgical outcomes. BABA RoT may be a good alternative operative method for PTC patients for whom cosmetic outcome is an important consideration.

Preliminary Study on Safety of Robotic or Endoscopic Thyroidectomy via Bilateral Axillo-breast Approach (BABA) without Drainage Procedure: Multicenter Trial / 대한내분비외과학회지

PURPOSE: The aim of this study was to evaluate the safety of robotic or endoscopic thyroidectomy via bilateral axillo-breast approach (BABA) without a drainage procedure. METHODS: A total of 64 patients who underwent robotic or endoscopic thyroidectomy via BABA without a close suction drain between February and March 2012 were enrolled. We checked postoperative symptoms or signs including change of vital signs, dyspnea, swelling or fluctuation of anterior chest and neck and compression symptoms at 1, 6, 24, and 48 hours and 1 month after surgery. Postoperative ultrasonography was performed in patients with at least one or more postoperative symptoms or signs in order to confirm hematoma or fluid collection. RESULTS: None of the enrolled patients had dyspnea or change of vital signs. Two of 64 patients had swelling, 1 of 64 patients had fluctuation on the anterior chest, and 1 of 64 patients had compression symptoms. Fluid collection was confirmed in 2 of 4 of the above mentioned patients and the collected fluid was aspirated. The amounts of aspirated fluid were 25 mL and 8 mL. Thereafter, the follow up ultrasonography showed no more fluid collection in all patients. In addition, we rechecked the above mentioned symptoms or signs at 1 month after surgery; none of the enrolled patients had symptoms or signs. CONCLUSION: Robotic or endoscopic thyroidectomy via BABA without a closed suction drain shows no serious seroma or hematoma collection. Therefore, we expect that robotic or endoscopic thyroidectomy via BABA without a closed suction drain can reduce the pain, discomfort or longer hospital stay as a result of closed suction drain using this method.

Robotic Thyroidectomy: Pros and Cons of Various Surgical Approaches / 대한내분비외과학회지

Robotic thyroidectomy has been a good option in the treatment of benign and early stage differentiated thyroid cancers, with several functional benefits. In the last few years, many surgeons have established their own robotic thyroidectomy techniques, and published many reports on the feasibility, safety and benefits of their robotic procedures. Although there are many different surgical techniques, robotic thyroidectomy can be classified according to the different means of remote access to the thyroid gland. Each method has advantages and disadvantages, and surgeons have modified each procedure in an effort to eliminate its shortcomings. With the remarkable innovation of robotic instruments and patient selection based on the appropriate indications, robotic thyroidectomy may usher a paradigm shift for thyroid surgery in the near future.

Can Robotic Thyroidectomy Be Performed Safely in Thyroid Carcinoma Patients?

Since the adoption of the Da Vinci robotic system for remote access thyroid surgery, robotic thyroidectomy (RT) has become a popular surgical option for patients who want to avoid neck scars. Surgeons in South Korea pioneered this surgical technique and have reported successful outcomes. Although many studies have reported that RT is a feasible and safe therapeutic alternative, concerns over the surgical and oncological safety of RT remain. This article reviews the advantages and disadvantages of RT and compares the surgical safety and oncological completeness of RT with conventional open thyroidectomy.

Comparison of robotic thyroidectomy through the trans-axillary and the anterior chest approach in a por-cine model / 中华内分泌外科杂志

Objective To evaluate the safety of the da Vinci Si surgical system in thyroid surgery and to accumulate operation experience .Methods The da Vinci Si surgical system consists of a surgeon's console, a patient-side robotic cart, and high-definition 3D vision system.The robot arm tips were introduced via a single axillary incision or small chest wall ports and attached to the arms of the robot .The surgeon , sitting at the con-sole, manipulated the EndoWrist instruments and endoscope view that transfer the surgeon 's movements to the arm tips.The so called EndoWrist'technology offers seven degrees of movements ( up, down, left, right, twist, et al) , thus exceeding the capacity of a surgeon's hand in open surgery .The da Vinci Si surgical system was used to perform thyroidectomy in two small pigs .The animals were intubated and kept anesthetized with halothane .Re-sults Four surgical procedures were done using the da Vinci Si system from beginning to the end , including 2 thyroidectomies and 2 thymectomies .No conversions to open or laparoscopic procedure was used .The procedure length was 61 minutes and 50 minutes, respectively.Conclusions Robotic thyroidectomy can be performed safe-ly by the experienced surgeons after short-term da Vinci Si surgical system training .The learning curve for robotic thyroidectomy is shorter .

Comparison Study of Endoscopic Thyroidectomy Versus Robot-assisted Thyroidectomy by a Cervico-transaxillary Approach / 대한내분비외과학회지

PURPOSE: Endoscopic and robot-assisted thyroidectomy has shown rapid development worldwide. In addition, there is no treatment of choice for thyroidectomy as usual. We propose an endoscopic thyroidectomy using a cervico-transaxillary approach, comparing its results with those of robot-assisted thyroidectomy. We present this study in order to provide advantages and disadvantages. METHODS: Between January 2010 and March 2012, 132 patients were recruited with clinicopathological data for this study. We divided patients into two groups, the endoscopic and the robot groups, with respect to their clinical characteristics, surgical outcomes. The outcomes were evaluated in terms of operation time, estimated blood loss, hemovac amount, hospital stay, and number of lymph nodes harvested. RESULTS: A total of 132 patients (male 6 and female 126) were recruited with clinicopathological data for this study. Of these, 78 patients underwent endoscopic thyroidectomy (the endo group) and 54 underwent robot-assisted thyroidectomy (the robot group) using a cervico-transaxillary approach. The two groups did not differ significantly in terms of age, estimated blood loss, and complications. None of the patients experienced severe complications. CONCLUSION: Results of the preliminary comparison in this study show that both approaches are safe and feasible, with similar results. However, a smaller hemovac amount was observed with endoscopic thyroidectomy, compared to robot-assisted thyroidectomy. In order to cut costs, part of robot-assisted thyroidectomy could be replaced by endoscopic thyroidectomy.

Robotic Thyroidectomy and Modified Radical Neck Dissection: Present and Future / 대한내분비외과학회지

Since the introduction of robotic thyroid surgery in 2007, robotic thyroidectomy has become an effective and acceptable treatment for patients with thyroid cancer. Although Conventional open thyroidectomy is safe; the operative time is short and good oncologic outcomes are attained and robotic thyroidectomy is as yet not greatly advanced, many surgeons now use the modality in routine practice. Moreover, the results of robotic thyroidectomy have generated worldwide interest in minimally invasivesurgery and have encouraged several centers in Korea and the United States to develop aims identical to those set when conventional surgery is employed; the postoperative outcomes are better and cosmetic satisfaction is improved. Robotic procedures originated from open and endoscopic thyroidectomy procedures, and advances in the field should be compared with those of conventional open and endoscopic thyroidectomy. Short- and long-term oncologic outcomes must be assessed carefully, and cosmetic results and functional outcomes, such as voice and swallowing changes, require accurate objective analysis. The clinical reports on the conduct of robotic thyroid surgery via a gasless transaxillary approach showed that robotic surgery performed by experienced specialized endocrine surgeons afforded identical or superior levels of surgical radicality and oncologic safety compared to use of conventional open or endoscopic surgery in patients with thyroid carcinoma. The short-term oncologic effectiveness of thyroid surgery is assessed by measuring serum thyroglobulin (Tg) concentration via [131I] iodine (131RI) scanning, whereas long-term effectiveness is evaluated via lack of tumor recurrence. Moreover, functional outcomes increasingly emphasize high scores on validated quality-of-life (QOL) instruments. Several large-volume centers have reported the “functional and QOL” outcomes of patients who have undergone robotic thyroidectomy. In such patients, the clinical benefits of robotic thyroidectomy include excellent cosmetic results, reduced pain, improvement in swallowing function, and low morbidity rates. From the viewpoint of surgeons, robotic surgery shortens the surgical learning curve, and causes less musculoskeletal discomfort compared with the conduct of open or endoscopic surgery. The accumulated evidence to date suggests that robotic thyroidectomy and MRND are both safe and feasible in thyroid cancer patients, and can benefit both patients and surgeons.

Initial Experience Using Gasless Transaxillary Robotic Thyroidectomy by a Single Surgeon / 대한내분비외과학회지

PURPOSE: Various endoscopic thyroidectomy procedures have been designed to minimize visible cervical scarring. However, endoscopic thyroidectomy is a technically challenging procedure that is performed by a limited surgeon. Robotic systems aida surgeon in performing minimally invasive head and neck surgery by offering superior visualization and dexterity. This study reports the initial experience of one surgeon with robotic thyroidectomy to assess the technical feasibility and safety of the approach. METHODS: One hundred four thyroid cancer patients (97 females, 7 males; mean age of 39.8±8.1 years) underwent robotic thyroidectomy using gasless transaxillary approach between November 2008 and October 2009 in Ajou University Hospital. All the procedures were completed successfully using the da Vinci surgical system without open conversion. Patient characteristics, postoperative clinical results, complications, and pathologic details were assessed. RESULTS: Total thyroidectomy was performed in 25 (24.0%) patients, subtotal thyroidectomy in 13 (12.5%) patients, and unilateral lobectomy in 66 (63.5%) patients. All patients underwent ipsilateral central compartment neck dissection, and two patients underwent selective lymph node (LN) dissection. The mean operation time was 134.5±47.2 min (range 61~310 min), in which the actual time for the thyroidectomy with lymphadenectomy (console time) was 56.4 min. (range 31~270). The mean number of LN resected was 3.9 (range 0~28). There were no serious complications. The mean hospital stay was 2.9±0.9 days (range 2~7). CONCLUSION: Robotic thyroidectomy is a feasible, safe, and cosmetically excellent procedure. The application of robotic technology for thyroid surgeries could be an alternative to endoscopic or conventional open thyroidectomy.

Robotic Thyroidectomy / 대한이비인후과학회지

Conventional open thyroidectomy provides direct exposure to perform safe and quick operations with minimal morbidity and almost no mortality. However, the procedure leaves a scar on the anterior neck. Thyroid nodules are common in young women, who are interested not only in treatment of the disease but also in aesthetic results. As a result, a variety of minimally invasive techniques to minimize neck scars and surgical morbidity have been developed. The minimally invasive thyroidectomy technique includes mini open incision thyroidectomy, video assisted minimally invasive thyroidectomy, and pure endoscopic thyroidectomy. However, there are some limitations to endoscopic thyroidectomy in obtaining adequate surgical viewing angles, precisely manipulating endoscopic instruments and meticulously dissecting tissues. These limitations result from the narrow working space, two-dimensional operative views and the use of inadequate endoscopic instruments. Recently, robotic technology using the da Vinci surgical system robot has been applied to minimally invasive thyroid surgery to overcome the limitations of endoscopic thyroidectomy. The da Vinci surgical system robot provides a three-dimensional 10-12 x magnified view of the surgical area. It also provides hand-tremor filtration, fine motion scaling, and precise and multi-articulated hand-like motions. Robotic thyroidectomy by a gasless unilateral axillo-breast or axillary approach using da Vinci surgical system robot is safe, feasible and cosmetically excellent procedure in properly selected patients. It might have an advantage in the preservation of recurrent laryngeal nerve and parathyroid gland with magnified view. However, it is more invasive than open thyroidectomy. The postoperative pain or discomfort is comparable with open thyroidectomy. The oncologic safety of robotic thyroidectomy should be verified with long-term follow-up data.