Robotic Thyroid Surgery Research Articles

Dr. Kyu Eun Lee: Special need makes robotic thyroid surgery more and more popular

The 2017 Annual Congress of International Society of Oncoplastic Endocrine Surgeons (ISOPES) was successfully held during April 20–23 in Hangzhou, China. Many renowned surgeons, abroad and at home attended this congress, presenting their personal clinical experience and sharing the state of art in endocrine surgery field.

A novel robotic surgical technique for thyroid surgery: bilateral axillary approach (BAA).

Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT) is proven to be a feasible method for the treatment of well-differentiated thyroid cancers in terms of oncology as well as cosmesis. However, BABA RT causes postoperative sternal discomfort and needs an incision over the nipple areolar area. Here, we suggest a novel robotic surgical technique for thyroid surgery that does not need a breast incision-bilateral axillary approach (BAA). We recruited 51 patients who were willing to undergo the novel BAA robotic thyroid surgery. We performed a propensity score-matched analysis to compare the BAA robotic thyroid surgery group (BAA group) with the conventional open thyroid surgery group (open group). Mean operation time in the BAA group (129.7min) was significantly longer than that in the open group (103.1min) (p<0.001). However, no significant differences in the mean number of metastatic lymph nodes (LNs), mean number of retrieved LNs, vocal cord palsy, hypoparathyroidism, and mean stimulated thyroglobulin level were observed between the two groups. There was no case of postoperative bleeding or chyle leak. Of the 51 patients who had undergone the BAA procedure, 27 patients answered the questionnaire. The mean scale, ranging from 0 to 10, at postoperative 1day/2weeks was as follows: voice change score, 3.0/1.6; swallowing difficulty score, 4.0/2.0; anterior neck pain score, 4.6/3.6; anterior neck numbness score, 5.4/4.3; right chest pain score, 3.8/2.1; left chest pain score, 3.6/2.3; right chest numbness score, 3.2/2.8; left chest numbness score, 2.4/2.7; right breast pain score, 0.9/0; left breast pain score, 1.2/0; right breast numbness score, 1.7/0; and left breast numbness score, 2.6/0, respectively. BAA robotic thyroid surgery is a novel, safe, and feasible oncoplastic method, especially for patients who have fear of procedures around the nipple areolar complex.

Comparing transaxillary robotic thyroidectomy with conventional surgery in a UK population: A case control study

IntroductionTransaxillary robotic thyroid surgery was pioneered in South Korea where cultural factors, anthropometry and remuneration favour this. Small thyroid nodules account for the majority of cases due to a national thyroid cancer screening programme. However, the technique has not been evaluated in the United Kingdom where larger thyroid nodules tend to undergo surgery in a patient population with a higher body mass index (BMI). MethodsLong term prospective non-randomised study. Sixteen consecutive robotic hemithyroidectomy patients were compared to 16 open controls. ResultsThere were no robotic conversions to open and no significant difference regarding pain, voice, or quality of life (QoL). In the robotic group, long term. scar cosmesis at 3 years was superior (p = 0.02) although the operative time was significantly longer (228 min vs. 85 min, p = 0.01). One patient had a transient recurrent laryngeal nerve paresis and another had temporary shoulder dysfunction. Both resolved in 4 weeks. DiscussionThis study highlights the considerable difference between a Western patient population compared to South East Asia. Despite this robotic thyroidectomy is feasible and safe in a UK population. ConclusionsDespite a low uptake in the UK compared to the Far East, robotic thyroidectomy represents a viable option for selected patients, achieving superior cosmesis compared with conventional thyroidectomy at the expense of time and cost. The key is careful patient selection. A randomised study is needed to establish the clinical efficacy compared to conventional surgery in this population.

Video Presentation Abstracts

ABSTRACT BACKGROUND AND AIMS In recent times, robot thyroid surgery has been performed worldwide in thyroid tumors, and reducing surgical complication is also an important factor in robot surgery besides thyroidectomy. This study presents the surgical technique of preserving the recurrent laryngeal nerve and parathyroid gland in transaxillary robot thyroid surgery. METHODS The drawback of robot thyroid surgery is that it cannot tell how strong the surgeon is holding and retracting the tissues or feels the thermal change when energy device is activated. Dissection or manipulation should be performed by layers and structures. The surgeon should not advance to the next procedure immediately after activating the coagulating energy device when related to tissues for preservation since there could be a thermal injury. After the activation, pause or make contact to a gauze placed in the operative field to check the spread of remaining heat. The shielded side of the device should be placed to the remnant structure side. By doing so, the thermal spread could be minimized. When coagulating vessels, the surgeon should not impatiently manipulate the grasped tissues since they could tear before fully coagulated and encounter bleeding. When preserving the recurrent laryngeal nerve and parathyroid gland, these surgical tips are very important to minimize the injury. RESULTS Applying such surgical techniques, the result of preserving the recurrent laryngeal nerve and parathyroid gland is safe and secure in robot thyroid surgery as presented in our video clip. CONCLUSION Endocrine surgeons perform functionally safe thyroidectomy and reduce the surgical complications in any type of thyroid surgery. The above-mentioned techniques will help preserve the recurrent laryngeal nerve and parathyroid gland in robot thyroid surgery

Oral Presentation II

ABSTRACT BACKGROUND AND AIMS To compare robot vs open thyroid surgery using inverse probability of treatment weighting (IPTW) with regard to oncologic safety in papillary thyroid carcinoma (PTC) patients. METHODS We enrolled 722 patients with PTC who underwent a total thyroidectomy with central compartment node dissection (CCND) at the Asan Medical Center in Korea from January 2009 to December 2010. These patients were classified into open thyroid surgery (n = 610) or robot thyroid surgery (n= 112) groups. We verified the impact of robot thyroid surgery on clinical recurrence and ablation/control-stimulated thyroglobulin (sTg) levels predictive of non-recurrence using weighted logistic regression models with IPTW. RESULTS Age, sex, thyroid weight, extent of CCND, and TNM stage were significantly different between the two groups (p &lt; 0.05); however, there was no significant difference in the recurrence rate between the open and robot groups (1.5 vs 2.7%; p = 0.608). The proportion of patients with ablation sTg &lt; 10.0 ng/mL and control sTg &lt; 1.0 ng/mL was comparable between the two groups (p &gt; 0.05). Logistic regression with IPTW using the propensity scores estimated by adjusting all of the parameters demonstrated that robot thyroid surgery did not influence the clinical recurrence (OR: 0.784; 95% CI: 0.150–3.403; p = 0.750), ablation sTg (OR: 0.950; 95% CI: 0.361–2.399; p = 0.914), and control sTg levels (OR: 0.498; 95% CI: 0.190–1.189; p = 0.130). CONCLUSION Robot thyroid surgery is comparable to open thyroid surgery with regard to oncologic safety in PTC patients.

Transoral Endoscopic Thyroid Surgery through Vestibular Approach

ABSTRACT Scarless neck surgery for thyroid became popular after the advancement of endoscopic and robotic thyroid surgery. Different approaches have been practiced for endoscopic thyroid surgery in different parts of the world. How to cite this article Chand G, Mishra SK. Transoral Endoscopic Thyroid Surgery through Vestibular Approach. World J Endoc Surg 2016;8(2):179-182.

Transaxillary Robot Thyroid Surgery: Recurrent Laryngeal Nerve and Parathyroid Gland Preservation

Introduction: Recently, robot thyroid surgery is performed worldwide in thyroid tumors1 and to reduce the surgical complication is also an important factor in robot surgery besides thyroidectomy.2–4 This video presents the surgical technique of preserving the recurrent laryngeal nerve and parathyroid gland in transaxillary robot thyroid surgery. Materials and Methods: Robot thyroid surgery has a problem of not knowing how strong the surgeon is holding and retracting the tissues or feel the thermal change when energy device is activated. Dissection or manipulation should be performed by layers and structures. The surgeon should not advance to the next procedure immediately after activating the coagulating energy device when related to tissues for preservation since there could be a thermal injury. After the activation, pause or make contact to a gauze placed in the operative field to check the spread of remaining heat. The shielded side of the device should be placed to the remnant structure side. By doing so, the thermal spread could be minimized. When coagulating vessels, surgeon should not impatiently manipulate the grasped tissues since it could tear before fully coagulated and encounter bleeding. When preserving the recurrent laryngeal nerve and parathyroid gland, these surgical tips are very important to minimize the injury. Results: By applying such surgical techniques, the result of preserving the recurrent laryngeal nerve and parathyroid gland is safe and secure in robot thyroid surgery5 as presented in our video. Conclusion: Endocrine surgeons are to perform functionally safe thyroidectomy and reduce the surgical complications in any types of thyroid surgery. Above-mentioned techniques will help preserve the recurrent laryngeal nerve and parathyroid gland in robot thyroid surgery. No competing financial interests exist. Runtime of video: 4 mins 57 secs

Automatic periodic stimulation of the vagus nerve during single-incision transaxillary robotic thyroidectomy: Feasibility, safety, and first cases.

Automatic periodic stimulation (APS) of the vagus nerve during thyroid surgery may provide the patient with increased safety to prevent impending thermal or stretch-related injury to the recurrent laryngeal nerve (RLN). Vagal stimulation would be of particular interest in remote access robotic thyroid surgery, where the RLN may be exposed to more conducted heat because of the exclusive use of the Harmonic scalpel. Using APS, the console surgeon may adjust the dissection technique according to the signal changes to avoid impending thermal damage to the nerve. In 2 transaxillary robotic thyroidectomy cases, we placed the vagus electrode onto the ipsilateral vagus trunk through the single-incision transaxillary access before docking the da Vinci robot. APS of the ipsilateral nerve has been conducted without complications. APS of the ipsilateral vagus is feasible and safe during transaxillary robotic thyroidectomy, and may contribute to prevent impending thermal injury to the RLN.

The Efficacy of Intraoperative Neuromonitoring During Robotic Thyroidectomy: A Prospective, Randomized Case-Control Evaluation.

This study evaluates the efficacy of intraoperative neuromonitoring (IONM) on voice performance in robotic thyroidectomy. The study was based on a prospective randomized series. Between June 2011 to September 2012, 50 patients with thyroid cancer who underwent robotic thyroidectomy were enrolled. The IONM and non-IONM groups consisted of 25 patients each. Voice Handicap Index (VHI), voice range profile (VRP), and laryngoscopy were used to assess voice function before surgery and at 2 weeks, 3 months, and 6 months after the operation. No palsy was diagnosed by laryngoscopy in either group. VHI values were similar in both groups. In the IONM group, there was significantly earlier recovery in VRP minimum intensity compared with the non-IONM group. However, there were no differences of mean change of VRP maximum frequency and intensity or minimum frequency between the two groups. We found that IONM facilitated more rapid recovery of voice function, especially in VRP minimum intensity, during robotic thyroid surgery.

Trends in Robotic Thyroid Surgery in the United States from 2009 Through 2013

The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013. The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another U.S. institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed. Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, U.S. annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher-volume centers reported lower complication rates (p<0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. More than 10% of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in <1% of cases. Mean cost for a total RT was $13,287 ($5,125-42,444). From 2009 through early 2011, there was a steady increase in RT volume, especially among high-volume institutions. In mid-to-late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower-volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the United States.

Prospective, randomized controlled trial on use of ropivacaine after robotic thyroid surgery: Effects on postoperative pain.

We evaluated the effects of ropivacaine for pain relief after robotic thyroid surgery. One hundred eight patients scheduled for robotic thyroid surgery were randomized into ropivacaine (n = 54) or control (n = 54) groups. After surgery, 40 mL of 0.25% ropivacaine or 0.9% saline (control) was instilled into the skin flap. Postoperative pain intensity (visual analog scale [VAS]), analgesic requirements (fentanyl), and adverse events were assessed at 1, 2, 4, 8, 16, and 24 hours postoperatively. One hundred three patients completed the study protocol. VAS scores were lower in the ropivacaine group than the control group (p = .010); however, VAS scores were not significantly different after 8 hours postoperatively. Total analgesic consumption was higher in controls than ropivacaine-treated patients (p = .01). Adverse events did not differ between the 2 groups. Ropivacaine instillation after robotic thyroid surgery reduces acute postoperative pain and analgesic requirements without adverse events. © 2015 Wiley Periodicals, Inc. Head Neck 38: E-E, 2016.

Transoral robotic thyroid surgery.

There is currently significant demand for minimally invasive thyroid surgery; however the majority of proposed surgical approaches necessitate a compromise between minimal tissue dissection with a visible cervical scar or extensive tissue dissection with a remote, hidden scar. The development of transoral endoscopic thyroid surgery however provides an approach which is truly minimally invasive, as it conceals the incision within the oral cavity without significantly increasing the amount of required dissection. The transoral endoscopic approach however presents multiple technical challenges, which could be overcome with the incorporation of a robotic operating system. This manuscript summarizes the literature on the feasibility and current clinical experience with transoral robotic thyroid surgery.

Robotic thyroid surgery for papillary thyroid carcinoma: lessons learned from 100 consecutive surgeries.

To evaluate the feasibility and safety of robotic thyroidectomy using the da Vinci surgical system. Between July 2008 and April 2011, the data revealed an initial series of 100 consecutive patients who underwent robotic thyroidectomy with the da Vinci-S surgical system using the bilateral axillo-breast approach for thyroid cancer. Prospectively collected data were analyzed retrospectively. There were 88 cases of total thyroidectomy, 11 cases of lobectomy, and 1 case of total thyroidectomy with modified radical neck dissection. There was no conversion. The mean total operation time was 287.15±45.19 minutes for total thyroidectomy and 236.27±48.98 minutes for lobectomy. Nineteen patients experienced transient hypocalcemia and 3 patients experienced transient vocal fold palsy. All of the patients recovered within 3 months. Robotic thyroid surgery for patients with thyroid malignancy is safe and results in fewer postoperative complications than open thyroid surgery.

Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during robotic thyroid surgery: a preliminary prospective study.

PurposeThe aim of this study was to evaluate the feasibility of monitoring external branch of the superior laryngeal nerve (EBSLN) during robotic thyroid surgery.MethodsA total of 10 patients undergoing bilateral axillo-breast approach (BABA) robotic thyroid surgery were enrolled. The nerve integrity monitor (NIM Response 2.0 System) was used for EBSLN monitoring. We performed voice assessments preoperatively and at 1 and 3 months postoperatively using Voice Handicap Index-10 (VHI-10), maximal phonation time (MPT), phonation efficient index (PEI), and laryngeal electromyography (EMG).ResultsA total of 19 EBSLNs were at risk and 14 EBSLNs (73.7%) were identified using neuromonitoring. VHI-10 showed a change of voice over time (0.1 vs. 3.6 vs. 1.3); however, this was not statistically significant. VHI-10 scores normalized at 3 months postoperatively compared to the preoperative scores. MPT (a) (16.0 vs. 15.6 vs. 15.4), and MPT (e) (20.1 vs. 15.4 vs. 18.5) showed no significant differences preoperatively compared to the values obtained 1 and 3 months postoperatively. There was a significant change of PEI over time (4.8 vs. 1.1 vs. 4.6) (P = 0.036); however, the values normalized at 3 months postoperatively. Laryngeal EMG results showed 4 cases (21.2%) of neuropathy of EBSLNs at 1 month postoperatively, and electrodiagnostic studies revealed nearly complete recovery of the function of EBSLNs in 4 patients at 3 months postoperativelyConclusionIt is suggested that neuromonitoring of EBSLNs during BABA robotic thyroid surgery is feasible and might be helpful to preserve voice quality.

Quality of Life Outcomes after Robotic Thyroid Surgery

Quality of Life Outcomes after Robotic Thyroid Surgery

Modified Approach for Robotic Retroauricular Thyroidectomy: Preclinical Simulation and a Surgical Case.

Recently, a single remote access retroauricular robotic technique has been described for thyroid lobectomy. We aimed to explore the feasibility and safety of modifying this novel approach using preclinical cadaver model followed by performing the same operation in a real patient. The modified retroauricular approach was performed by creating a working space between the 2 heads of the sternocleidomastoid muscle, instead of that anterior to muscle. This was performed to create a wider working space. Two operations were initially performed in human cadavers. Subsequently, robotic-assisted thyroid lobectomy was performed using this novel modified retroauricular approach. Robotic-assisted hemithyroidectomy was performed successfully in 2 cadavers and subsequently in one patient using modified approach. The patient was discharged on the same day of surgery and had no complications. The modified retroauricular approach with creation of a working space between the 2 heads of sternocleidomastoid muscle is safe and feasible, and offers a wider working space for robotic thyroid surgery.

Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique

A new approach to modifying facelift incision was recently developed for robotic thyroid surgery that seemed to be advantageous over other existing approaches. In this study, we aimed to investigate the feasibility and safety of the facelift approach not only for robotic thyroid surgery, but also for endoscope-assisted thyroid surgery. Endoscope-assisted facelift thyroid lobectomy was performed for 11 patients with papillary microcarcinoma. All 11 operations were successfully performed endoscopically. This approach through a modified facelift incision provided safe dissection of the laryngeal nerves and exposed an adequate working space. We identified and preserved all neighboring critical structures (parathyroid gland and superior and recurrent laryngeal nerves) during surgery. The operative duration for simple thyroid lobectomy with central lymph node dissection in 11 patients was 120-180 min (average duration: 140 min). Sensory change around the earlobe occurred in three patients and was recovered within 2 months after surgery in all patients. No patient displayed laryngeal nerve palsy or a low-pitched voice. The facelift approach seems to provide a shorter and more direct route to the thyroid, requiring minimal dissection, and an adequate workspace not only for robotic surgery but also for endoscopic surgery. It is worthwhile to develop and refine the surgical techniques of endoscopic facelift thyroid surgery.

Cerebral tissue O2 saturation during prolonged robotic surgery in the steep Trendelenburg position: an observational case series in a diverse surgical population.

Demands associated with the Trendelenburg position (TP) are well known yet there is little attention given to regional cerebral tissue O2 saturation (SctO2) in those undergoing robotic surgery in the TP with CO2 insufflation (C-INSF). This is the first study to report on SctO2 in a wide range of patients undergoing lengthy TP and robotic surgery. We measured SctO2 during robotic surgery in patients in the TP with C-INSF, as well as a control robotic thyroid surgery group who were supine with no C-INSF. We recorded relevant variables and periods of cerebral desaturation (CD). We studied 42 patients in 25°-45° of TP for ≥125 min. Management was at the providers' discretion. The INVOS(®) 5100C Cerebral Oximeter (Covidien, Boulder, CO) recorded SctO2. CD was defined as a >20 % decrease from baseline SctO2 or a value ≤55 % for ≥10 min. Patients were assessed for adverse outcome. The sample consisted of 13 males and 29 females aged 22-73, BMI 22-36 had general (N = 3), urological (N = 14) and gynecological (N = 25) surgery; two patients had CD lasting 150 and 190 min and two had episodic CD lasting 10-35 min. The four were female aged 22-60 in 38°-45° of TP. Eleven cases had multiple episodic CD for ≤15 min, 27 TP cases had no CD. Other observations included a consistent fall in SctO2 with phenylephrine; an increased SctO2 with ephedrine; and FiO2 and EtCO2 being generally strong, direct modifiers of SctO2. High MAP was inconsistently associated with high SctO2. BMI had no observed effect on SctO2. Pulse oximetry was ≥97 % in all cases. We observed no adverse cerebral events on follow-up. Additional clinical studies are warranted.

Robotic thyroidectomy for cancer in the US: patterns of use and short-term outcomes.

We describe nationally representative patterns of utilization and short-term outcomes from robotic versus open thyroidectomy for thyroid cancer. Descriptive statistics and multivariable analysis were used to analyze patterns of use of robotic thyroidectomy from the National Cancer Database (2010-2011). Short-term outcomes were compared between patients undergoing robotic versus open thyroidectomy, while adjusting for confounders. A total of 68,393 patients with thyroid cancer underwent thyroidectomy; 225 had robotic surgery and 57,729 underwent open surgery. Robotic thyroid surgery use increased by 30% from 2010 to 2011 (p=0.08). Robotic cases were reported from 93 centers, with 89 centers performing <10 robotic cases. Compared with the open group, the robotic group was younger (51 vs. 47years; p<0.01) and included more Asian patients (4 vs. 8%; p=0.006) and privately-insured patients (68 vs. 77%; p=0.01). Tumor size was similar between patients undergoing robotic versus open surgery. Total thyroidectomy was performed less frequently in the robotic group (67 vs. 84% open; p<0.0001). Patients were relatively more likely to undergo robotic surgery if they were female (odds ratio [OR] 1.6; p=0.04), younger (OR 0.8/10years; p<0.0001), or underwent lobectomy (OR 2.4; p<0.0001). In adjusted multivariable analysis, there were no differences in the number of lymph nodes removed or length of stay between groups; however, there was a non-significant increase in the incidence of positive margins with robotic thyroidectomy. Use of robotic thyroidectomy for thyroid cancer is limited to a few institutions, with short-term outcomes that are comparable to open surgery. Multi-institutional studies should be undertaken to compare thyroidectomy-specific complications and long-term outcomes.

Modified robotic-assisted thyroidectomy: An initial experience with the retroauricular approach

New approaches for robotic-assisted thyroidectomy, including the retroauricular approach, were recently described. We have modified the established surgical approach for retroauricular robotic thyroidectomy. Herein, we report our initial experience to identify challenges and limitations of this new surgical approach. Prospective case series. This study was performed under institutional review board approval for patients who underwent retroauricular robotic hemithyroidectomy at an academic North American institution. The retroauricular approach was modified by using the space between the two heads of the sternocleidomastoid muscle as our working space. Additionally, selected patients underwent concomitant neck lift surgery with robotic thyroid surgery. Clinical characteristics, total operative time, blood loss, surgical outcomes, and length of hospital stay were evaluated. Twelve female patients were included in this study. Mean age was 45 ± 4.43 years, and mean body mass index was 28.6 ± 2.15. Mean thyroid nodule size was 1.15 ± 0.26 cm(3). All cases were completed successfully via single retroauricular incision. There was no conversion to an open approach. Four out of 12 patients (33%) underwent additional concomitant neck lift surgery, with a mean total operative time of 156 ± 15.88 minutes. The mean operative time for the remaining eight patients who underwent the robotic approach without additional neck lift surgery was 145.4 ± 10.08 minutes. There were no cases of permanent vocal cord paralysis or permanent hypoparathyroidism. Mean blood loss was 22.4 ± 4.32 mL. Four patients (33%) were discharged home on the same day of surgery, and the remaining eight patients were discharged after an overnight stay. Single-incision retroauricular robotic hemithyroidectomy can be a safe and feasible alternative to other remote access techniques. Neck lift surgery can be performed safely in a select group of patients. However, future studies are warranted to further evaluate the benefits and limitations of this novel approach.