Prospects of Robotic Thyroidectomy Using a Gasless, Transaxillary Approach for the Management of Thyroid Carcinoma

Abstract

Robotic surgical systems are among the most innovative surgical developments and have radically promoted the use of minimally invasive techniques. Robotic technologies using different approaches have also been applied to thyroid surgery. Recently, the authors described a novel robotic surgical method for thyroid surgery based on a gasless, transaxillary approach (TAA), and have since serially reported on its technical feasibility and safety. Here, the authors report their experience of a consecutive series of 1000 cases treated using robotic thyroidectomy, and demonstrate its use for the surgical management of thyroid cancer. From October 2007 to November 2009, 1000 patients with thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless TAA. All patients were selected using predetermined inclusion criteria after considering surgical risk, and all procedures were completed successfully using the da Vinci S or Si surgical system (Intuitive Surgical, Sunnyvale, CA). Patient's clinicopathologic characteristics, operation types, operation times, numbers of retrieved lymph nodes (LNs), postoperative hospital stays, complications, and short-term follow-up results were analyzed. Mean patient age was 39.1 ± 9.6 years and the male-to-female ratio was 1:12.6 (73:927). Six hundred twenty-seven patients underwent less than total and 373 patients underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all 1000 cases and additional lateral neck node dissection was conducted in 36 of the 1000 patients. Mean operation time was 136.7 ± 44.4 minutes and mean postoperative hospital stay was 3.0 ± 0.45 days. No serious postoperative complication occurred, except 3 cases of recurrent laryngeal nerve injury, and 1 case of Horner syndrome. Mean tumor size was 0.79 ± 0.6 cm and papillary thyroid microcarcinoma was in 752 cases (75.5%). The mean number of retrieved central LNs per patient was 4.62 ± 3.14. Central neck LN metastasis occurred in 361(36.1%) and lateral neck LN metastasis in 36 cases (3.6%). According to tumor nodes metastasis staging, 847 patients (84.7%) were of stage I, 144 patients (14.4%) were of stage III, and 9 patients (0.9%) were of stage IVA. The authors conclude that robotic thyroidectomy using a gasless TAA is a feasible, safe, and promising surgical alternative for selected patients with low-risk thyroid cancer, and recommend that the inclusion criteria of this technique be gradually extended to advanced thyroid cancer given suitable operator experience and future developments in robotic systems and instrumentation.