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Fig. 47.10 Once the correct plane is identied, a subcutaneous ap is raised supercial to the clavipectoral fascia. The superior and inferior points
of the axillary incision are extended to the thyroid cartilage and sternal notch, respectively. The resulting shape of the ap is that of a trapezoid
ally with a pledget on the 8-mm ProGrasp™ forceps. It is
crucial to maintain the RLN in the operative view at all times
in order to prevent inadvertent injury to it. If the Harmonic
shears need to be used in close proximity to the RLN and
further lateralisation is either unsafe (because of a risk of
traction injury) or not possible, then a pledget is used to
cover the RLN whilst energy is being delivered. (For example, this manoeuvre may be necessary when dissecting the
ligament of Berry.)
Figures 47.18, 47.19, 47.20, 47.21, 47.22, 47.23, 47.24,
47.25, 47.26, 47.27 and 47.28 present a step-by-step narra-
tive of the stages involved in the robotic dissection.
ab
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Fig. 47.11 Once the subcutaneous ap has been raised, dissection is
continued above the pectoralis major muscle and over the clavicle until
the sternal and clavicular heads of the sternocleidomastoid muscle are
encountered. The neck is then entered through the natural dehiscence
between the two tendons, which is opened bluntly with a Fraser Kelly
curved artery forceps
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S
C
Fig. 47.13 Close-up view of the sternal (S) and clavicular (C) heads of
the sternocleidomastoid muscle and the natural dehiscence between the
two tendons. The surgical planes are then developed as in a standard
thyroidectomy, exposing the ipsilateral internal jugular vein, common
carotid artery and omohyoid and sternohyoid muscles (see Fig.47.20)
Fig. 47.12 Schematic representation of the incision and anatomical
boundaries of the trapezoid-shaped subcutaneous ap needed for right
transaxillary robotic thyroidectomy
As with all thyroid surgery, haemostasis must be meticulous.
The anaesthesiologist is asked to bring the blood pressure up to
normal and a reversed Trendelenburg position and Valsalva
manoeuvre are applied. Any remaining bleeding points in the
thyroid bed are addressed at this stage to ensure haemostasis
(Fig. 47.29). As in conventional thyroid surgery, no drain is
applied. We have not found this practice to be a problem.
Following haemostasis, the da Vinci robot is withdrawn,
and two-layer closure is completed with 4–0 subcuticular
Vicryl Rapide™ sutures (Ethicon Products, Inc., Johnson &
Johnson, Cincinnati, OH) followed by application of
Dermabond (Ethicon Products, Inc., Johnson & Johnson,
Cincinnati, OH) tissue glue on the wound (Fig.47.30).
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Fig. 47.14 The Modena retractor in situ. Note the suction tube placed through the special port to prevent subsequent fogging of the robotic dualchannel endoscope
Fig. 47.15 The Modena retractor blade. This is placed under the ap and strap muscles to retract them and create sufcient working space for the
robotic arms to be introduced and for them to be able to move freely during robotic surgery without clashing
496
Robot
surgeon)
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Anesthesiologist
Vision cart
Assistant
surgeon
Scrub nurse
Console (main
Fig. 47.16 Operating room conguration for transaxillary robotic thyroidectomy. The cart is docked at right angles to the operating table on the
contralateral side to the thyroid lobe to be resected
Electrocautery
Endoscopes
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Vision cart
Mouthgag cart Instrument cart
Nurse
Assistant
unit
(bedside
assistant)
Anesthesiologist
Patient-side cart
Surgeon at
console
Fig. 47.16 (continued)
Electrocautery
unit
(Surgeon console
and patient cart)
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Fig. 47.17 All four robotic arms are placed through the single axillary
incision. The 30° down 12-mm dual-channel 3D endoscope is placed at
an angle of 220° and is inserted low laterally, extending high and
upwards medially towards the thyroid gland. The rst and third robotic
arms are then positioned so that they can carry the instruments for dis-
Thyroid lobe
Fig. 47.18 Entering the natural dehiscence between the sternal and
clavicular heads of the sternocleidomastoid muscle. As the ap and
strap muscles are retracted by the Modena retractor, the thyroid lobe is
exposed (lateral approach)
section and haemostasis. The fourth robotic arm is subsequently placed
under (and parallel to) the endoscope; it holds the 8-mm ProGrasp™
forceps to retract the thyroid lobe medially. The rst and third robotic
arms hold a combination of 5-mm Maryland, DeBakey and Harmonic
shears
RLN
Fig. 47.19 Early identication of the recurrent laryngeal nerve (RLN)
with the lateral approach in transaxillary robotic thyroidectomy. The
RLN is exposed in the tracheoesophageal groove following medial
retraction of the thyroid lobe
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RLN
CCA
IJV
499
Fig. 47.20 The great vessels of the neck, the common carotid artery (CCA) and internal jugular vein (IJV), are identied during robotic dissection
while keeping the recurrent laryngeal nerve (RLN) into constant view
Fig. 47.21 Following identication of all adjacent neurovascular
structures, the recurrent laryngeal nerve (circled) is carefully dissected,
stimulated and subsequently gently displaced laterally and protected
with a pledget. It is paramount to keep the recurrent laryngeal nerve
within the operative view at all times to prevent inadvertent injury to it
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Fig. 47.22 The thyroid lobe is then mobilised. Note how the recurrent
laryngeal nerve is kept in constant view and is protected with a pledget.
Similarly, the internal jugular vein and common carotid artery are also
continuously maintained under direct visualisation, as an inadvertent
vascular injury is likely to result in the need for open conversion.
Fig. 47.23 Robotic division of the ligament of Berry to release the recurrent laryngeal nerve (circled)
Arresting haemorrhage from intraoperative injury to the great vessels of
the neck can be challenging with the robot during remote-access thyroidectomy, as neither direct pressure nor vascular clamps can be
applied in a safe and timely manner to attain vascular control above and
below the injury in order to repair it
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Fig. 47.24 Contrary to open thyroidectomy, in transaxillary robotic
thyroidectomy, the thyroid lobe is rst released laterally and inferiorly
(lateral approach). The parathyroid glands are identied and preserved
Fig. 47.25 Following lateral and inferior release of the thyroid lobe, the superior pole is dissected
(circle indicates an inferior parathyroid gland being carefully separated
from the thyroid capsule), along with their blood supply, by ensuring
that the inferior thyroid artery is ligated distally
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