Transaxillary Robotic Thyroidectomy Research Articles

Analysis of Initial Outcomes of Gas-insufflation One-step Single-port Transaxillary (GOSTA) Robotic Thyroidectomy for Thyroid Cancer.

This study compared the initial outcomes of gas-insufflation one-step single-port transaxillary (GOSTA) robotic thyroidectomy with traditional open thyroidectomy for thyroid cancer at a single institution. A retrospective analysis was conducted on 77 patients who underwent thyroidectomy for differentiated thyroid cancer from January to June 2024. Exclusion criteria included benign nodules, Graves' disease, and previous thyroid surgeries. Two surgeons performed the procedures, with one having no prior robotic surgery experience. Of the 77 patients, 48 underwent open thyroidectomy and 29 underwent GOSTA thyroidectomy. The GOSTA group had a significantly lower mean age (40.1 vs. 47.6 years, p=0.002) and a higher proportion of female patients (p=0.040). The open group patients had more harvested lymph nodes than the GOSTA group patients (7.9 vs. 2.4, p<0.001). The GOSTA group patients had longer operation time (156.4 vs. 80.6 min, p<0.001), and had extended hospital stay than the open group patients (5.9 vs. 3.4 days, p<0.001). Complication rates were similar between the groups. GOSTA robotic thyroidectomy provides comparable safety and effectiveness to open thyroidectomy, with improved cosmetic outcomes despite longer operation times and hospital stays. This technique is feasible for surgeons without prior robotic experience, offering a viable alternative for patients prioritizing cosmetic results.

2215P Gas-insufflation one-step single-port trans-axillary robotic thyroidectomy (GOSTA)

2215P Gas-insufflation one-step single-port trans-axillary robotic thyroidectomy (GOSTA)

Clinical application of pectoralis nerve block ii for flap dissection-related pain control after robotic transaxillary thyroidectomy: preliminary results of a randomized controlled trial

Clinical application of pectoralis nerve block ii for flap dissection-related pain control after robotic transaxillary thyroidectomy: preliminary results of a randomized controlled trial

Intraoperative monitoring of the recurrent laryngeal nerve in thyroid gland surgery

In Thyroid surgery, the two novel approaches are the trans-axillary Robotic thyroidectomy and the trans-oral and sub-chin techniques.During these surgical approaches is mandatory to recognise the Anatomy. The lower laryngeal nerves originate from the X cranial nerve (vagus nerve) and innervate all the intrinsic muscles of the larynx except for the cricothyroid muscles (which are innervated by the superior laryngeal nerve instead). The "recurring" name is due to the course in the opposite direction to the nerve of origin.Neuro-monitoring of recurrent laryngeal nerves is the most important of the recent technological innovations. However it is of fundamental importance for the operator to remember that this method does not prevent recurrent nerve injury. On the other hand a two stage thyroidrctomy can avoid a tracheostomy thanks to neuro-monitoring.

Robotic thyroidectomy. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire).

Transaxillary robotic thyroidectomy is hardly the approach of reference. It is occasionally proposed for carefully selected patients with a small-sized (2cm maximum), exclusively cervical unilateral nodule without lymph node involvement, in a small thyroid lobe (6cm maximum) in a thin individual wishing to avoid a cervical scar. Potential candidates must be informed on the risks specific to this technique and about the scarceness of evidence of its equivalence to cervicotomy in terms of quality of life and patient satisfaction. Shall be excluded from robotic surgery: malignant nodules (or nodules suspected of malignancy>2cm), cancers with microscopic nodal metastases, plunging goiter, patients with previous cervical surgery or overactive thyroid. Robotic thyroidectomy must be performed in centers with expertise in both thyroid surgery and robotic surgery.

Robotic transaxillary thyroidectomy: time to expand indications?

In 2016, the American Thyroid Association published a statement on remote-access thyroid surgery claiming that it should be reserved to patients with thyroid nodule ≤ 3 cm, thyroid lobe < 6 cm and without thyroiditis. We retrospectively enrolled all patients who underwent robotic transaxillary thyroidectomy between February 2012 and March 2022. We compared surgical outcomes between patients who presented a thyroid gland with a nodule ≤ 3 cm, thyroid lobe < 6 cm and without thyroiditis (Group A) and patients without these features (Group B). The rate of overall complications resulted comparable (p = 0.399), as well as the operative time (p = 0.477) and the hospital stay (p = 0.305). Moreover, bleeding resulted associated to thyroid nodule > 3 cm (p = 0.015), although all bleedings but one occurred in the remote-access site from the axilla to the neck. In experienced hands, robotic transaxillary thyroidectomy is feasible and safe even in patients with large thyroid nodules or thyroiditis.

Efficacy and Safety of Minimally Invasive Thyroid Surgery: A Network Meta-Analysis.

Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods. The PubMed, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar. The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed. EO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding. It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470-2479, 2023.

The learning curve for single-port transaxillary robotic thyroidectomy (SP-TART): experience through initial 50 cases of lobectomy.

The new da Vinci® single-port (SP) robotic system, which utilizes a smaller incision and work space compared to the previous versions, is suitable for thyroidectomy. This study aimed to evaluate the learning curve for SP transaxillary robotic thyroidectomy (SP-TART) in a single-center. Fifty consecutive patients who underwent SP-TART between October 2021 and April 2022 in Seoul St. Mary's Hospital in Seoul, Korea, were included in this retrospective analysis. We examined the clinicopathological characteristics and short-term surgical outcomes and assessed the learning curve for SP-TART using cumulative summation analysis. The mean operation time was 57.8 ± 14.1min, and the mean tumor size was 1.0 ± 0.7 (range, 0.3-3.7) cm. The patients were discharged approximately 2days after surgery, and only two (4%) patients developed postoperative complications, including drainage-site bleeding and surgical site infection. Risk factors for long operation time were thyroiditis, amount of blood loss, and lymph node metastasis. The learning curve for SP-TART was 20 cases for the experienced robotic surgeon. SP-TART is technically feasible and safe with a short incision length and short operation time. It is a valuable alternative operative option with good surgical outcomes and outstanding cosmetic results.

Safety and Feasibility of Single-Port Trans-Axillary Robotic Thyroidectomy: Experience through Consecutive 100 Cases.

Background and Objectives: Recently, the single-port (SP) robotic system was introduced for minimally invasive operative techniques. Thus, this study aimed to validate the safety and feasibility of SP trans-axillary robotic thyroidectomy (SP-TART) through experiences in a single tertiary institution. Materials and Methods: This study retrospectively analyzed 100 consecutive patients who underwent SP-TART from October 2021 to June 2022 in Seoul St. Mary’s Hospital in Seoul, Korea. We analyzed the clinicopathological characteristics and perioperative outcomes, including complications. Results: Less than total thyroidectomy (LTT) was performed in 81, total thyroidectomy (TT) in 16, and TT with modified radical neck dissection (mRND) in 3 patients. The mean operation time (min) was 53.3 ± 13.7, 86.3 ± 15.1, and 245.7 ± 36.7 in LTT, TT, and TT with mRND, respectively. The mean postoperative hospital stay was 2.0 ± 0.2, 2.1 ± 0.3, and 3.7 ± 1.5 days, respectively. A total of 84 cases of thyroid cancer were included, and 97.6% of them (82 cases) were papillary carcinoma and the rest were follicular and poorly differentiated carcinomas. Regarding complications, five cases had major complications, including three cases of vocal cord palsy and two cases of transient hypoparathyroidism. Conclusions: SP-TART is safe and feasible with a short operation time and a short length of hospital stay.

Postsurgical complications after robot-assisted transaxillary thyroidectomy: critical analysis of a large cohort of European patients

In the last decade, robot-assisted trans-axillary thyroidectomy has spread rapidly and has been proven to be a safe and effective procedure. However, several case series have reported new complications that have led to criticism regarding this approach. This study analyzed the incidence of complications in a large cohort of European patients. We enrolled all patients who underwent robot-assisted trans-axillary thyroidectomy from 2012 to 2020 at the University Hospital of Pisa Department of Endocrine Surgery. We analyzed complications and divided them into 2 groups. Group A included conventional complications, such as transient or permanent recurrent laryngeal nerve palsy, transient or permanent hypocalcemia, hemorrhage, and tracheal injury. Group B included unconventional complications, such as brachial plexus palsy, track seeding, seroma, great vessels injury, and skin flap perforation. There were 31 postsurgical complications (5.7%). Group A included 25 complications (4.6%): transient and permanent recurrent laryngeal nerve palsy occurred in 7 patients (1.3%) and in 1 (0.2%), respectively; transient and permanent hypocalcemia occurred in 9 patients (1.7%) and in 1 (0.2%), respectively. Postoperative bleeding occurred in 6 patients (1.1%) and tracheal injury in 1 (0.2%). Group B included 6 complications (1.1%): 1 patient with brachial plexus injury (0.2%), 1 with track seeding (0.2%), and 4 with seroma (0.7%). Robotic trans-axillary thyroidectomy is a safe approach with a risk of postoperative complications comparable to the conventional technique. Almost all complications after a novel introduction are anecdotal. With an accurate patient selection, high-volume institutions with experienced surgeons can perform this technique safely.

Safety and Feasibility of Robotic Transaxillary Thyroidectomy for Graves' Disease: A Retrospective Cohort Study.

Despite the increase in experience and understanding of robotic thyroidectomy, its application for Graves' disease (GD) remains controversial. This study aimed to assess the safety and feasibility of robotic transaxillary thyroidectomy (RTT) for GD in comparison with the conventional open thyroidectomy (open group: OG) approach. A total of 192 patients who underwent surgical resection for GD were retrospectively reviewed. Among them, 51 patients underwent RTT and the remaining 141 patients were in the conventional OG. All robotic operations were performed successfully without open conversion. Patients who underwent RTT were significantly younger (P < 0.001) and predominantly of the female sex. Operative time was longer for RTT than for the OG (182.5 ± 58.1 vs. 112.0 ± 29.5; P < 0.001). The mean intraoperative blood loss was not statistically different between RTT and the OG (113.3 ± 161.6 vs. 95.3 ± 209.1, P = 0.223). The mean weight of the resected thyroid was reduced in those who underwent RTT compared with open thyroidectomy (P = 0.033). The overall complication rate for RTT and open thyroidectomy was not significantly different (33.3% vs. 22.7%, P = 0.135). In RTT, the most common complication was transient hypocalcemia (21%). Permanent hypocalcemia and recurrent laryngeal nerve injury occurred in only one patient in each group. The weight of the resected thyroid was not related to the incidence of complications in patients receiving RTT. Considering excellent cosmesis, findings of this study support the safety and feasibility of RTT. Nevertheless, it should be performed by expert surgeons with extensive robotic surgery experience.

Single-port transaxillary robotic thyroidectomy (START): 200-cases with two-step retraction method

BackgroundThis study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce our novel two-step retraction method.MethodsSTART was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed.ResultsAmong the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13–58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m2 (range: 15.9–37.0 kg/m2). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method.ConclusionsSTART is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.

Robotic Transaxillary Hemithyroidectomy Using the da Vinci SP Robotic System: Initial Experience With 10 Consecutive Cases.

Background: Many studies have shown the operative feasibility and safety of robotic thyroidectomy. However, there is still a concern on the operative invasiveness of robotic thyroidectomy owing to the wide flap dissection. The aim of this study was to introduce our novel robotic technique, which can minimize the dissection extent using the da Vinci SP robotic system. Methods: Ten patients underwent robotic transaxillary thyroidectomy using the da Vinci SP robotic system between December 2018 and April 2019 at Yonsei University Hospital (Seoul, Korea). All procedures were performed successfully using the single-port robotic system. Results: All 10 patients were women and diagnosed with papillary thyroid carcinoma. The mean operative time was 148.7 ± 26.8 minutes. The mean operative time using the gasless method was shorter than that using the gas insufflation method (130.5 ± 14.1 vs 176.0 ± 12.8 minutes). All patients were discharged on the third day after operation without any complications. Conclusions: Robotic transaxillary thyroidectomy using the da Vinci SP robotic system is technically feasible and safe with a short length of incision, shorter than what earlier reported. To our knowledge, this is the first study to use a single-port robotic system for thyroidectomy. To verify the superior operative outcomes, further clinical trials are necessary.

Impact of body mass index on robotic transaxillary thyroidectomy

Obesity is associated with increased operating times and higher complication rates in many types of surgery. Its impact on robotic thyroidectomy however, is not well documented. The aim of this study was to investigate the relationship between body mass index (BMI) and robotic transaxillary thyroidectomy (RTAT). A retrospective review of prospectively collected data of all patients who underwent RTAT at Yonsei University Health System from October 2007 to December 2014 was performed. Patients were divided into three groups based on BMI (Group 1: BMI < 25, Group 2: BMI 25–29.99, Group 3: BMI ≥ 30), and compared. A total of 3697 patients were analyzed. No differences between the three groups were observed in clinicopathological factors, extent of surgery or length of stay. After multivariate analysis, only seroma and transient voice hoarseness were related to increasing BMI. Total operative time was significantly longer for Group 3 patients with less-than-bilateral total thyroidectomy (BTT), but was not significantly different for patients with BTT. Although obese patients undergoing RTAT have a slightly higher risk of seroma, transient voice hoarseness, and longer operative times, BMI did not influence the other important surgical outcomes of thyroidectomy. Therefore, obesity should not be a contraindication for performing RTAT.

Detailed comparison of robotic and endoscopic transaxillary thyroidectomy

Robotic thyroidectomy is increasingly used for patients with papillary thyroid carcinoma (PTC). We compared the differences between robotic and endoscopic transaxillary thyroidectomy with regard to surgical procedures. This retrospective study enrolled 40 patients with PTC who underwent robotic hemithyroidectomy (robot group) using the Da Vinci S system and 37 patients (endoscopic group) who underwent endoscopic hemithyroidectomy. Video files of surgery for all patients were analyzed to compare the operation procedures: (flap creation, docking [only for robot group], dissection of the superior pole, dissection of the inferior pole, identification of parathyroid glands [PTGs] and the recurrent laryngeal nerve [RLN], dissection of the thyroid along the trachea, bleeding control, application of a drain, and wound closure). The duration of each procedure and the clinicopathological characteristics were analyzed. Procedure time for patients in the robot group was shorter for inferior pole dissection and for identification of the PTGs and RLN (37.5min vs. 50.5min, p=0.008). Mean total operative times for the two groups were comparable (153.0min vs. 150.2min, p=0.732); however, excluding the docking procedure, operation time was shorter for the robot group (133.3min vs. 150.2min, p=0.038). The number of sacrificed PTGs was also significantly smaller in the robot group (0.35±0.53 vs. 0.65±0.68, p=0.036). Compared to endoscopic thyroidectomy, robotic transaxillary thyroidectomy involved a shorter time for inferior pole dissection and PTGs and RLN identification; moreover, more PTGs were spared using this procedure.

Robot Assisted Trans Axillary Thyroidectomy: A Subcontinent Experience.

To evaluate the outcome and initial hurdles of transaxillary robotic thyroidectomy in the Indian subcontinent. A total of seven (n = 7) patients were operated from August 2016 to February 2017. Ultrasonography was used as a tool to decide the size of thyroid lobe and fine needle aspiration cytology for the type of lesion. All patients underwent ipsilateral brachial plexus nerve conduction studies preoperatively. Two arm positions were evaluated. The robot was docked at the contralateral side of the surgical field. Before discharge from hospital, all patients were given a questionnaire evaluate outcome. Set 1 was answered on the day of discharge and Set 2 at one-month follow up. The most common pathology in our case series was colloid goiter (n = 4) followed by follicular lesion (n = 3). The mean console time was 167min, with initial two cases taking more than 200min. The maximum and minimum length of the axillary tunnel was 16 and 27cm respectively. There was no difference with regard to complication rate with either arm position. None of the patients developed brachial plexus injury and was confirmed by normal nerve conduction study done on postoperative day three. In our experience with transaxillary robotic thyroidectomy, the problems we faced in our population were unique considering the varied physical parameters. Use of malleable retractors comes handy in these situation and we recommend the use of these over the rigid ones. Though both the arm positions had similar outcomes, the one with sideways position was more favorable.

Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience

Objectives: Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising. Study Design: This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6–12 months later and at the last available visit. Results: A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk). Conclusion: In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

The current status of robotic transaxillary thyroidectomy in the United States: an experience from two centers.

Few studies exist regarding the state of robotic transaxillary thyroidectomy (RT) and its outcomes at high-volume institutions. Eighty-nine patients underwent RT between January 2009 and September 2015 at two tertiary centers. Data were collected from prospectively-maintained IRB-approved databases. Patient demographic and clinical data, and trends were evaluated. Indications for RT included biopsy-proven or suspicion for malignancy in 20.2%, atypical cells or follicular neoplasm in 27.7%, multinodular goiter in 26.6%, thyrotoxicosis in 8.5%, need for completion thyroidectomy in 5.3%, and non-diagnostic FNA in 3.2%. 56% underwent total thyroidectomy and 44% lobectomy. Operative time (OT) was 153.5 minutes for lobectomies and 192.6 minutes for total thyroidectomy. The complication rate was 11.7%: temporary RLN neuropraxia in 2 patients, permanent hypoparathyroidism in 1 patient, temporary hypoparathyroidism in 6 patients, flap seroma in 1 patient, and flap hematoma in 1 patient. Pathology showed malignancy in 43 patients. At a mean follow-up of 31.9 months, there were no recurrences. Since 2013, the number of RTs performed has risen. The number of out-of-state patients increased from 18% to 37% after 2011. RT was performed without compromising outcomes in selected patients. There remains interest among patients seeking this procedure in expert centers.

Gasless trans-axillary robotic thyroidectomy: the introduction and principle.

A historic review of the main stages of evolution of the minimally-invasive techniques in thyroid surgery. The endoscopic era is divided into direct and indirect approaches. Examples are the minimally invasive video-assisted thyroidectomy (MIVAT) and the minimally invasive lateral approach. The indirect approach is divided into transaxillary and chest/breast incisions. A brief historic review of the advent of robots to the medical and mainly surgical field. And finally, an introduction to transaxillary robotic thyroidectomy.

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.