Robot-assisted Thyroid Surgery Research Articles

New Approaches for Robot-Assisted Neck Surgery: Clavicular and Submental Approaches Using the da Vinci SP System.

Minimally invasive robot-assisted thyroid surgery or neck dissection can improve cosmetic results and reduce surgical trauma. Several approaches have been described but each has both advantages and limitations. We aimed to determine the feasibility of performing robot-assisted neck surgery using the da Vinci SP system. The clavicular approach using the da Vinci SP system was done in 1 cadaveric model. Lateral neck dissection was carried out with parapharyngeal space dissection, lateral thyroid gland exposure, and anatomical references. The submental approach was performed in the same cadaveric model. Total thyroidectomy plus lateral neck dissection was performed. The required 2.5-cm skin incision, minimal flap development to insert the SP Access Port plus docking was done in 5 minutes for each procedure. The neck dissection by clavicular access took 77 minutes, the parapharyngeal dissection 60 minutes, and hemi-thyroidectomy 30 minutes. The neck dissection by submental access took 60 minutes and the total thyroidectomy took 45 minutes. We have demonstrated the feasibility of single-incision clavicular and submental approaches in neck surgery using the da Vinci SP system. The amount of skin flap dissection was minimal, the system docking was rapid, and no additional ports or retractors were required. Further studies on patients are warranted.

Bibliometric analysis of research trends and hotspots on robot-assisted thyroid surgery.

Thyroid surgery involves the partial or complete removal of the thyroid gland and is a frequently performed surgical procedure. The adoption of robots, equipped with flexible and stable operating systems, has garnered acceptance among numerous surgeons for their capability to enable precise anatomical dissection in thyroid surgery. To gain a comprehensive insight into the present research landscape of robot-assisted thyroid surgery, this paper endeavored to conduct a thorough analysis of the field through bibliometric analysis. Relevant literature pertaining to robot-assisted thyroid surgery was retrieved from the Web of Science Core Collection (WOSCC) database, spanning from the inception of WOSCC to October 17, 2022. Visual analyses of publication quantity, distribution across countries/regions, institutions/organizations, authorship, journals, references, and keywords were conducted using Microsoft Excel, the bibliometrix package in R, Citescape, and VOSviewer software. A total of 505 articles from 406 institutions in 36 countries/regions were included. South Korea emerged with highest number of publications. Notably, Professor CHUNG WY from Yonsei University in South Korea and the journal "Surg Endosc" stood out with the most publications. The current research landscape indicated significant interest in endoscopic thyroidectomy, surgical procedures, and the axillary approach. In addition, transoral robotic thyroidectomy (TROT), and learning curve (LC) were recognized as research frontiers, representing potential future hotspots in this field. This study marks the first bibliometric analysis of the literature on robot-assisted thyroid surgery. The results highlight endoscopic thyroidectomy, surgical procedures, and the axillary approach as current research hotspots, with TROT and LC identified as potential future research hotspots.

Conversion rates in robotic thyroid surgery: A systematic review and meta-analysis.

ObjectiveTo define the conversion risk to open procedure during robot‐assisted thyroid surgery (RATS) identifying potential specific subclasses of procedures or accesses at higher conversion risk.MethodsIn a PRISMA‐compliant framework, all original prospective studies providing RATS conversion rates from multiple databases were pooled in a random‐effects meta‐analysis. Conversion rates were compared between different typologies of thyroid surgery and robotic access.Results13 studies were deemed eligible. Four conversions from two studies were reported out of 398 procedures. No significant heterogeneity was observed (Cochran's Q p = 0.932; I2 = 0%). The pooled conversion rate was 1% (95% confidence interval, 0.1%–2%). The ANOVA‐Q test failed to show significant differences when comparing type of thyroid surgery or robotic access (respectively p = 0.766 and p = 0.457).ConclusionWhile the conversion rate appears consistently low across studies, prospective data collection and systematic reporting of procedural complications are required for framing high‐risk procedures and accesses.

Robotic thyroid surgery using bilateral axillo-breast approach: From a trainees' point of view.

Background:Across surgical disciplines, the demand for cosmetically superior procedures is stronger than ever and patient-centered health care has become the standard of care. Endoscopic thyroidectomy has revolutionized the field of minimal access endocrine surgery and akin to other surgical disciplines, there has been a natural progression towards robot-assisted thyroidectomy. Amongst the many described approaches, bilateral axillo-breast approach (BABA) and transaxillary are most widely practiced.Aims and Objectives:Our aim was to describe the technique of robot-assisted thyroid surgery (RATS) using BABA.Methods:This is based on the corresponding authors' training and experience of over 50 cases of RATS using BABA, at the Seoul National University, Republic of Korea.Results:Post-operative outcomes were excellent with lesser pain, better cosmesis and similar oncological outcomes in carefully selected thyroid cancers in comparison to conventional thyroidectomy.Conclusion:RATS using BABA is easy to master for endoscopic thyroid surgeons and offers excellent postoperative outcomes, ergonomics, vision and dexterity.

Extracervical Approaches to Thyroid Surgery: Evolution and Review.

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.

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

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/

Gasless trans-axillary robotic thyroidectomy: the technique and evidence

Robot assisted thyroid surgery has the advantage of a superior field vision and technical advancements of robotic technology that have permitted novel remote access thyroid surgical approaches. Gasless trans-axillary robot-assisted thyroidectomy has been proved to be among the most current feasible approaches. This approach offers an excellent cosmetic outcome, with comparable outcomes to conventional surgical approaches. This review aims to provide details of this specific remote access technique for thyroid resection with most recent evidences in the literature.

Robot-assisted transaxillary thyroid surgery-retrospective analysis of anthropometric features.

The vast majority of studies published on robot-assisted thyroid surgery are South Korean. This study aims to assess the impact of certain anthropometric parameters on performing robot-assisted thyroid surgery on Caucasian patients. A total of 91 patients underwent robot-assisted surgery by the axillary approach in the Fifth Surgical Clinic, City Hospital Cluj-Napoca, between 2010 and 2015. Besides the specific clinical and pathological parameters, a series of anthropometric parameters and the postoperative occurrence of skin disorders in the cervical or subclavicular region were determined for each patient. There was an increase in dissection time and console time, which was directly proportional to the patients' body mass index. There were no statistically significant differences in the incidence of postoperative complications in patients with different body mass indices. The postoperative drainage volume was significantly higher in overweight or obese patients. The time needed to visualize the thyroid lodge was longer in patients with wider shoulders, and there was a negative correlation between neck length and console time. A statistically significant direct correlation was found between the clavicle length-neck length ratio and the duration of the entire intervention. There was no significant influence of any of these parameters on the duration of hospitalization or the occurrence of other postoperative complications. The nutritional status of the patients and the other anthropometric parameters influenced the duration and difficulty of the intervention, without affecting its safety in terms of intra- and postoperative- complications.

What's good for the goose is not always good for the gander-are conclusions from a clinical trial always universally exportable?

Minimally invasive approaches have revolutionized how surgery is performed and as technology and instrumentation continue to improve, the use of minimally invasive surgery (MIS) will be successfully applied to more complex surgical procedures. When considering a MIS approach, the first question a surgeon must ask is whether MIS provides at least equivalence in terms of short- and long-term outcomes compared to its open counterpart. As an example, the use of MIS approach for appendectomy approaches clinical equipoise compared to the open procedure, and only when applied to certain subset of patients do we see superiority of the MIS approach (1). On the other hand, the use of robotics for thyroidectomy [using the amusingly appropriate acronym, robotic assisted thyroid surgery (RATS)] remains, at best, controversial. Although still championed by a small number of surgeons, the robotic approach converts a straightforward, low complication, open surgery, to a complex and potentially morbid MIS procedure. The disadvantages (including longer operative time, and increased cost compared to conventional open thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea) must be weighed against the effort to compensate for minor cosmetic improvements (2). For the most part however, the literature suggests that MIS for a variety of surgical procedures does provide equivalence, if not improvement over open surgery, especially in terms of postoperative pain, length of stay and return to the patient’s baseline activities of daily living. Cholecystectomy is an early and prime example.

Remote access thyroid surgery.

Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed their various advantages in terms of post-operative outcomes; however, the associated financial burden and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.

Retroauricular Robotic Thyroidectomy with Concomitant Neck-Lift Surgery

Robotic-assisted thyroid surgery using a retroauricular approach was reported as a novel remote access technique for hemithyroidectomy. We report our experience with this remote access technique using a single incision in the retroauricular crease and occipital hairline incision. For the first time, we show additional neck-lift surgery performed concomitantly to achieve better cosmetic outcomes. Robotic retroauricular left hemithyroidectomy with concomitant neck-lift surgery was performed in a 59-year-old female patient who was referred for management of a 1.7 cm thyroid nodule located in the mid-lower right thyroid lobe, with fine-needle aspiration biopsy suggestive for follicular neoplasm. The patient had redundant submental skin in her neck, and was planning for a future neck-lift surgery. A concomitant neck lift was performed by the plastic surgeon using the same retroauricular approach to perform the operation. The patient agreed to participate in Institutional Review Board approved protocol. Total operative time was 115 min-flap creation time was 50 min, robot docking time was 10 min, operative console time was 25 min, and concomitant neck-lift surgery extended for 30 min. Estimated blood loss was approximately 30 ml. The patient was discharged home on the same day of surgery and had no postoperative complications. Final pathology confirmed benign follicular adenoma. Our experience with robotic retroauricular thyroidectomy showed that it is a feasible and safe remote access approach. We suggest that concomitant neck lift can be done in a select group of patients with excess skin on the neck. This approach can be offered to patients with benign and indeterminate thyroid lesions, and future prospective studies are warranted to evaluate the oncological efficacy of this approach in patients with thyroid cancer.

Operative outcomes of robot-assisted transaxillary thyroid surgery for benign thyroid disease: early experience in 50 patients

The main benefits of robot-assisted transaxillary thyroid surgery are to overcome the technical limitations of other endoscopic procedures for this surgical pathology and to avoid any cervical skin incision. This article describes the first experience of a Romanian team with the endoscopic robot-assisted thyroid surgery. We used the da Vinci SI intuitive surgical system to carry out 50 thyroid operations: 33 unilateral total lobectomies with isthmectomy (TL), 8 unilateral total lobectomies, with contralateral subtotal lobectomy, and 9 total thyroidectomies. Preoperatively, the patients were diagnosed with nodular goiter in 42 cases, nodular autoimmune thyroiditis in 3 cases, Basedow disease in 2 cases, toxic thyroid adenoma in 2 cases, and diffuse goiter in 1 case. We analyzed the clinical characteristics, size and location of the nodules, surgery duration, postoperative complications, pain medication, histopathological findings and postoperative cosmetic results. All surgical procedures were carried out without major incidents. One case required conversion to open approach. The mean length of surgery was 159 ± 38.2min and the average console time was 68 ± 39.9min; postoperatively, we recorded one case of transient brachial plexus neurapraxia, one transient vocal cord paresis, one transient hypocalcemia, and four postoperative wound complications. The final histopathological examination revealed two cases of well-differentiated carcinoma. This paper reports the largest series to date in Southeast Europe about robot-assisted transaxillary thyroidectomy. On a group of selected Caucasian patients, postoperative results were similar to open cervicotomy in terms of postoperative complications. The major cosmetic advantage is the absence of scar in the anterior cervical region.

Single-Incision Robot-Assisted Transaxillary Surgery for Early-Stage Papillary Thyroid Cancer

We describe the surgical details, results, and learning curve of a proposed technique for single-incision transaxillary robot-assisted thyroid surgery for early-stage thyroid cancer. We performed single-incision transaxillary robot-assisted total thyroidectomy with the da Vinci surgical system in 29 patients (5 male, 24 female; median age, 45 years; age range, 19 to 69 years) with papillary thyroid cancer (cT1 NO) using our proposed technique with selected instrumentation. Preoperative ultrasound examination, fine-needle aspiration cytology, and contrast computed tomographic scanning were performed in all subjects. Ultrasound examination was carried out 1 month after surgery to assess the amount of residual thyroid tissue. No procedure was converted to conventional open surgery. The mean total operation time was 178.51 +/- 24.18 minutes, and the mean console time was 126.10 +/- 14.47 minutes. A progressive reduction of console time was noted (160 minutes for the first procedure versus 102 minutes for the last one). No cases of permanent hypocalcemia, recurrent laryngeal nerve palsy, or postoperative bleeding occurred. The mean amount of postoperative residual thyroid tissue on ultrasound examination was 8.93 +/- 2.15 mm. The single-incision transaxillary robot-assisted total thyroidectomy we propose is a feasible and relatively safe procedure in selected patients with early-stage thyroid cancer.

Rupture of endotracheal tube cuff during robot-assisted endoscopic thyroidectomy -A case report-.

We encountered a case of a rupture of an endotracheal tube cuff during robot-assisted thyroid surgery in a 35-year-old male patient. Two hours after commencing surgery, the bellows of the ventilator were not filled and a rupture of the endotracheal tube cuff was suspected. Once the robot-manipulator is engaged, the position of the operating table cannot be altered without removing it from the patient. Reintubation with direct laryngoscopy was performed with difficulty in the narrow space between the patient's head and robot-manipulator without moving the robot away from the patient. The rupture of the endotracheal tube cuff was confirmed by observing air bubbles exiting from the balloon in water. The patient was discharged 3 days after surgery without complications. In robot-assisted thyroid surgery, a preoperative arrangement of the robot away from the patient's head to obtain easy access to the patient is essential for safe anesthetic care.