Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform

Francesco Paolo Prete,Rinaldo Marzaioli,Maria Vittoria D'Addetta,Giovanni Tomasicchio,Daniele Paradies,Angela Pezzolla,Graziana Barile,Serafina Lattarulo,Angela Gurrado

doi:10.1186/s12893-019-0473-0

Abstract

BackgroundRobotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy.MethodsWe conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter).ResultsTwelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy.ConclusionsSince the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial.Trial registrationRetrospectively registered on 20 july 2018 . Trial registration number: researchregistry4272.The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/

Highlights

Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results
Improvements in operating techniques and minimally invasive instruments, and an advanced understanding of the endoscopic anatomy of the neck, helped thyroid procedures move from conventional to transcervical endoscopic-assisted thyroidectomy [1], transaxillary [2],bilateral axillo-breast [3] and retroauricular approaches [4]. The research behind these transitions was fuelled by the aim to limit or avoid a neck scar: while many patients may well tolerate a cervical scar, potential complications of a scar such as paraesthesia/dysesthesias, local pain, hypertrophy of the scar and keloid formation have all been described as adverse outcomes of an open thyroidectomy
This study presents an initial experience with robotic-assisted gasless transaxillary thyroidectomy (RATS) on the Da Vinci Surgical System (DVSS) Xi platform, based on the first12 consecutive cases performed in an academic Institution in Italy

Summary

Introduction

Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. Improvements in operating techniques and minimally invasive instruments, and an advanced understanding of the endoscopic anatomy of the neck, helped thyroid procedures move from conventional to transcervical endoscopic-assisted thyroidectomy [1], transaxillary [2],bilateral axillo-breast [3] and retroauricular approaches [4]. The research behind these transitions was fuelled by the aim to limit or avoid a neck scar: while many patients may well tolerate a cervical scar, potential complications of a scar such as paraesthesia/dysesthesias, local pain, hypertrophy of the scar and keloid formation have all been described as adverse outcomes of an open thyroidectomy. Before the introduction of surgical robots, the implementation of endoscopic thyroidectomy from a remote access was associated with a number of technical difficulties [5, 6]

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