Robot-Assisted Transaxillary Total Thyroidectomy with Intermittent Intraoperative Nerve Monitoring

Abstract

Introduction: Intraoperative neuromonitoring (IONM) has proven safe and effective for the evaluation of recurrent laryngeal nerve (RLN) integrity during conventional thyroid surgery. IONM progressively gained widespread acceptance as an adjunctive tool to the standard RLN identification.1 Moreover, with the advent of the robot-assisted era, many surgeons apply IONM even during robot-assisted thyroidectomy with the transaxillary approach.2 Materials and Methods: A 32-year-old female presented with a 1.2 cm papillary thyroid carcinoma in the right thyroid lobe in a small multinodular goiter. A robotic total thyroidectomy with the transaxillary approach was planned. The surgical steps are illustrated and the anatomical structures identified. Results: After a 5-cm incision along the posterior border of the right anterior axillary pillar, the dissection of the skin flap begins. The surgical space is maintained using a retractor that elevates the subcutaneous flap and whose position is adapted step by step. The access to the thyroid lodge is then obtained by passing through the two heads of the sternocleidomastoid muscles. After positioning a special robotic thyroidectomy retractor (Modena Retractor; CEATEC® Medizintechnik), the Da Vinci Xi® is docked. First of all, the functionality of the nervous circuit is assessed by opening the carotid sheath and stimulating the vagus nerve with the probe. The upper pedicle is then bluntly dissected and cut by means of the harmonic scalpel. After the identification of the RLN, its integrity is confirmed by means of the stimulation probe. Ipsilateral parathyroid glands are identified and carefully preserved. The thyroid lobe is then divided by cutting the isthmus and the right lobe is removed following the tracheal plane, respecting the noble structures. The thyroid lobe is extracted by using an endobag to avoid potential malignant seeding along the incision. Once the lobe is extracted, the postdissection stimulations were obtained to assess the integrity of the RLN. The contralateral lobe is then removed through the same surgical access and following the same surgical steps. Conclusion: Robot-assisted total thyroidectomy (RATT) with the transaxillary approach is a safe and effective procedure. IONM can be safely and easily used as a helpful tool for the identification and assessment of the functionality of the RLN during RATT. No competing financial interests exist. Runtime of video: 9 mins 53 secs