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Fig. 46.4 Posterior view of
the RLN course in the neck
and upper chest
Posterior wall
of trachea
(esophagus
not shown)
Left common
carotid and
nal jugular
vein
Left RLN
C. Fundakowski et al.
Right carotid
artery (lower
segment not
shown)
Right inferior
thyroid arter
(extending to
parathyroid
glands)
Right
subclavian
artery
Aortic arch
The operative relevance of this right/left variance is that given
the more ventral positioning of the right nerve caudally, there is
an opportunity for additional nodal tissue to be positioned dorsal to the nerve in this location (Fig.46.4).
Once the thyroidectomy has been performed and the
RLNs are in view, the next recommended step is exposure of
the common carotid artery from the level of the cricoid to
the sternal inlet. At this point, the vagus nerve is readily
identied within the carotid sheath and is available for stimulation to conrm both functioning of the neural monitoring
system and the neurophysiologic intactness of the RLN.On
the right, the RLN can then be dissected 360° to mobilise it
from the surrounding nodal tissue, beginning at the inferior
border of the cricoid cartilage and moving caudally. On the
left side, the RLN may not need to be dissected 360° given
its medial location, which may prevent unnecessary manipulation while still permitting comprehensive dissection of
the compartment. One must keep in mind that, in general,
360° dissection of the RLN increases the risk of traction
neuropraxia. As further caudal dissection is carried out,
retraction of the trachea medially and carotid arteries later-
Right RLN
ally aids in visualisation and removal of the most dorsal
nodal tissue.
Paratracheal dissection commences at the inferior border
of the cricoid and proceeds caudally. As the nodal packet is
elevated off the deep fascia, it must be divided laterally at a
position dorsal to the carotid artery. Similarly, the nodes
must be dissected free from the underlying oesophagus
medially. Attention to retraction of tissue and nerve position
at all times during this dissection minimises injury. Retraction
of the trachea medially and the carotid laterally as the surgeon dissects further caudally aids in visualisation and
removal of the most dorsal nodal tissue.
The superior parathyroid gland may be easily preserved,
as opposed to the inferior gland, which is more intimately
involved within the nodal specimen. If the blood supply to
the inferior parathyroid gland cannot be maintained, it may
be reimplanted after tissue conrmation with frozen section.
Parathyroid viability is of serious concern when operating
within the central compartment, and one must always consider the relative benets versus complications of bilateral
paratracheal compartment dissection.
46 Total Thyroidectomy withLevel VI andVII Neck Dissection
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In cases of bilateral paratracheal dissection, it is important to assess RLN function on the ipsilateral side prior to
proceeding to the contralateral side, in order to prevent the
dreaded complication of bilateral vocal fold paralysis. As
noted previously, an RLN amplitude of 250 μV or greater
shows a high likelihood of normal vocal fold function. If the
ipsilateral RLN amplitude is less than 250μV, the surgeon
must consider staging the completion thyroidectomy, as
against the risk of bilateral vocal fold paralysis. In cases of
well-differentiated thyroid cancer, staging the procedure
with delay of completion thyroidectomy for up to 25weeks
may be considered oncologically safe. RLN injury will typically recover in 2–6 months. If there is no recovery at
6 months, case-by-case considerations should be made in
multidisciplinary fashion, weighing nonoperative options
versus the potential risk of bilateral vocal fold paralysis.
46.4 Outcomes
Oncological outcomes following surgery will depend on the
biology of the disease. Patients with low-risk differentiated
thyroid cancer have excellent long-term outcomes. In contrast, older patients with bulky nodal metastases or distant
disease at presentation have a worse outcome in terms of
both recurrence and survival. Locoregional failure may result
in increased morbidity and may be accompanied by lifethreatening complications. The morbidity and mortality of
the disease must be balanced with the morbidity of the treatment. Consequently, recommendations have begun to shift
away from total thyroidectomy with prophylactic CND for
low-risk patients.
Recommendations for removal of known structural disease in the central compartment at the time of initial thyroidectomy are well established. The indications, risks and
potential benets of prophylactic CND are of great debate,
particularly in low-risk patients. Advocates of prophylactic
CND commonly tout improvement in locoregional recurrence rates, decreased thyroglobulin levels and the availability of information on which to base both the use and dosing
of adjuvant radioactive iodine (RAI) [11–13]. Meanwhile,
the argument against prophylactic CND commonly rests on
lack of improvement in long-term survival, as well as operative morbidity, noting increased hypocalcaemia and RLN
injury, particularly for low-volume settings and/or inexperienced surgeons [14].
A recent meta-analysis noted locoregional recurrence
rates of 6.9% for total thyroidectomy versus 4.6% for total
thyroidectomy with prophylactic CND [15]. In most analyses, the prophylactic CND group preferentially received a
disproportionate amount of post-operative RAI; however, it
is difcult to attribute the benets of locoregional control to
surgery alone. Regardless of the indication for prophylactic
CND, the resulting pathology in differentiated thyroid cancer will upstage approximately 30% of patients. Hence, caution should be used when performing prophylactic CND, to
ensure that it does not lead to unnecessary adjuvant treatment, such as RAI that otherwise would not have been given,
or an escalation in the dose of RAI.The anticipated treatment plan and its implication in terms of adjuvant therapy is
best served with multidisciplinary discussion [1].
In terms of surgical complications, the most signicant
issues involve injury to the parathyroid glands and the nerves
that innervate the larynx. Hypocalcaemia occurs in about
20% of patients who undergo total thyroidectomy. Rates are
higher if it is combined with CND.The reasons for hypocalcaemia are likely to be multifactorial and include issues such
as uid replacement and vitamin D deciency, but injury to
or removal of parathyroid glands is the most signicant factor associated with short-term and long-term hypocalcaemia.
Rates of temporary hypocalcaemia are relatively high, but
permanent hypocalcaemia is less common. Although rates of
about 1% for total thyroidectomy are reported, higher rates
are expected when CND is also performed, owing to the
increased risk of parathyroid excision or devascularisation.
RLN injury remains a signicant issue in terms of morbidity and litigation. Although expert authors have reported
rates of unexpected nerve injury to be as low as 0%, larger
studies at a national level show that overall injury rates are
much higher. Denitive statements regarding the rates of
nerve injury are challenging to make, as they are highly
dependent on the operating surgeon and the rate of postoperative laryngoscopy. Surgeons with the highest nerve
palsy rates are those who routinely assess vocal cord function following surgery, which suggests that a large number of
palsies go undiagnosed in routine clinical practice.
Injury to the EBSLN is more difcult to diagnose. Patients
will report difculty in raising the pitch of their voice, owing
to loss of cricothyroid muscle function, which acts to
lengthen the cord by exing the cricothyroid joint. On laryngoscopy, however, adduction and abduction of the cord will
still be visible if the recurrent nerve remains intact.
Despite the difculty in determining the specic rate of
complications following thyroid surgery, there is now convincing evidence that rates are higher for bilateral versus unilateral thyroid surgery, regardless of the experience of the
operating surgeon.
46.5 Conclusion
The increasing incidence of thyroid cancer, paired with the
ever-improving resolution of imaging techniques applied to
the central neck, is resulting in more patients who require not
only total thyroidectomy but also central compartment neck
dissection. For safety and optimal oncological outcomes,
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C. Fundakowski et al.
surgeons must have an appreciation of disease biology and
an intimate understanding of the anatomy of the central neck.
By applying meticulous technique, supported by assistance
in the form of intraoperative nerve monitoring where appropriate, excellent functional and oncological results can be
achieved.
References
1. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ,
Nikiforov YE, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and
differentiated thyroid cancer: the American Thyroid Association
guidelines task force on thyroid nodules and differentiated thyroid
cancer. Thyroid. 2016;26:1–133.
2. Wells SA Jr, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, etal.
Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25:567–610.
3. Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard G,
etal. British Thyroid Association. Guidelines for the management
of thyroid cancer. Clin Endocrinol. 2014;81(Suppl 1):1–122.
4. Fundakowski CE, Hales NW, Agrawal N, Barczyński M, Camacho
PM, Hartl DM, etal. Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society
Consensus Statement. Head Neck. 2018;40:663–75.
5. Randolph GW.Surgical anatomy and monitoring of the recurrent
laryngeal nerve. In: Randolph GW, editor. Surgery of the thyroid
and parathyroid glands. 2nd ed. Philadelphia: Elsevier Saunders;
2013. p.306–40.
6. Wang LY, Nixon IJ, Patel SG, Palmer FL, Tuttle RM, Shaha A, etal.
Operative management of locally advanced, differentiated thyroid
cancer. Surgery. 2016;160:738–46.
7. Kamani D, Darr EA, Randolph GW.Electrophysiologic monitoring
characteristics of the recurrent laryngeal nerve preoperatively paralyzed or invaded with malignancy. Otolaryngol Head Neck Surg.
2013;149:682–8.
8. Kihara M, Miyauchi A, Yabuta T, Higashiyama T, Fukushima M,
Ito Y, etal. Outcome of vocal cord function after partial layer resection of the recurrent laryngeal nerve in patients with invasive papillary thyroid cancer. Surgery. 2014;155:184–9.
9. Chi SY, Lammers B, Boehner H, Pohl P, Goretzki PE.Is it meaningful to preserve a palsied recurrent laryngeal nerve? Thyroid.
2008;18:363–6.
10. Cunnane M, Kyriazidis N, Kamani D, Juliano AF, Kelly HR, Curtin
HD, etal. A novel thyroid cancer nodal map classication system
to facilitate nodal localization and surgical management: the A to D
map. Laryngoscope. 2017;127:2429–36.
11. Hughes DT, White ML, Miller BS, Gauger PG, Burney RE, Doherty
GM. Inuence of prophylactic central lymph node dissection on
postoperative thyroglobulin levels and radioiodine treatment in
papillary thyroid cancer. Surgery. 2010;148:1100–6.
12. Lang BH, Wong KP, Wan KY, Lo CY.Impact of routine unilateral
central neck dissection on preablative and postablative stimulated
thyroglobulin levels after total thyroidectomy in papillary thyroid
carcinoma. Ann Surg Oncol. 2012;19:60–7.
13. Barczynski M, Konturek A, Stopa M, Nowak W. Prophylactic
central neck dissection for papillary thyroid cancer. Br J Surg.
2013;100:410–8.
14. Hauch A, Al-Qurayshi Z, Randolph G, Kandil E.Total thyroidectomy is associated with increased risk of complications for lowand high-volume surgeons. Ann Surg Oncol. 2014;21:3844–52.
15. Zhao W, You L, Hou X, Chen S, Ren X, Chen G, Zhao Y. The
effect of prophylactic central neck dissection on locoregional
recurrence in papillary thyroid cancer after total thyroidectomy:
a systematic review and meta-analysis: pCND for the locoregional recurrence of papillary thyroid cancer. Ann Surg Oncol.
2017;24:2189–98.
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Thyroidectomy
GeorgeGaras, ConradTimon, andNeilTolley
47
47.1 Introduction: Indications andPatient
Selection
Patient selection is fundamental in surgery, and robotic thyroidectomy (RT) is no exception. All cases where thyroid surgery is
contemplated should be discussed at the institutional thyroid
multidisciplinary meeting and decisions taken based on best
evidence, patient factors, national guidelines and local expertise
[1, 2]. The type of procedure to be recommended by the tumour
board (e.g. thyroid lobectomy, total thyroidectomy, neck dissection) should not be dictated solely by patient wishes regarding
scar cosmesis or by individual surgeon preference in terms of
approach. This principle is especially relevant to RT, for which
no uniform selection criteria or guidelines exist at present [3].
Currently, RT occupies a niche role in endocrine surgery
and can be justied only in a select subset of patients wishing
to avoid a neck scar for biological and/or cultural reasons [4].
RT should be undertaken only by surgeons experienced in
both open and robotic neck surgery who are practicing in
high-volume centres with a dedicated, multidisciplinary
robotic team [5]. Contrary to its limited indications (which
G. Garas (*)
Department of Otorhinolaryngology and Head and Neck Surgery,
Imperial College London, St. Mary’s Hospital, London, England,
United Kingdom
Head & Neck Surgical Oncology Unit, Queen Elizabeth Hospital
Birmingham, University Hospitals Birmingham NHS Foundation
Trust, Birmingham, England, United Kingdom
e-mail: g.garas@imperial.ac.uk
C. Timon
Department of Otorhinolaryngology and Head and Neck Surgery,
Trinity College Dublin, St. James’s Hospital, Dublin, Ireland
e-mail: timonsec@stjames.ie
N. Tolley
Department of Otorhinolaryngology and Head and Neck Surgery,
Imperial College London, St. Mary’s Hospital,
London, England, United Kingdom
e-mail: n.tolley@imperial.ac.uk
Table 47.1
• Solitary nodule exceeding 6cm in diameter on ultrasound (with
• Nodule suspicious for malignancy that exceeds 2cm in diameter
• Malignancy with extrathyroidal extension (T3 and T4 tumours)
• Multiple metastatic lymph nodes in lateral neck compartment(s)
• Presence of nodal extracapsular spread
• Contralateral recurrent laryngeal nerve (RLN) paresis
• Large ipsilateral goitre
• Retrosternal extension or extension to dorsal aspect of the
• Graves’ disease
• Previous surgery to the neck
• Previous radiotherapy to the neck
• Obesity (BMI >30kgm−2)
• Signicant comorbidity (ASA score >2)
• Ipsilateral acromioclavicular joint osteoarthritis
• Previous glenohumeral joint dislocation
• Body dysmorphic disorder
• Connective tissue disorder(s)
ASA American Society of Anesthesiologists, BMI body mass index
a
Relative (as opposed to absolute) contraindication
Contraindications to transaxillary robotic thyroidectomy
benign features)
on ultrasound
(levels II–V)
thyroid
a
a
a
a
a
a
a
relate primarily to cosmesis), there are several contraindications for RT (Table47.1). Beyond those relating to the size of
the nodule, pathology and disease stage (note that thyroid
cancer per se is not a contraindication for RT), it is important
to also consider factors relating to body habitus, patient
comorbidities and patient psyche when it comes to clinical
decision-making [5]. Similar to open thyroidectomy, all
patients require preoperative and post-operative breoptic
laryngoscopy to assess vocal cord mobility.
The optimal RT patient would be a slim and healthy individual with a solitary nodule that is small (<4cm in diameter)
and exhibits benign features on ultrasound and cytology.
Individuals with a predisposition to hypertrophic scarring or
keloid formation constitute ideal candidates, as the avoidance
of a neck scar is particularly desirable for these patients [4].
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_47
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G. Garas et al.
47.2 Preoperative Checklist: Informed
Consent, Positioning andIncision
Planning
47.2.1 Informed Consent
Informed consent is undertaken by the attending surgeon.
The pros and cons of the conventional cervical approach
should be discussed rst, prior to exploring alternatives. If
the patient is a candidate for RT and expresses an interest in
it, other approaches should also be mentioned, including
video-assisted thyroidectomy (with the patient made aware
that this minimally invasive approach would result in at least
one neck scar—though smaller than the scar for conventional
thyroidectomy). RT, on the other hand, involves no neck
scar, but this advantage is at the expense of a greater area of
subcutaneous dissection and longer operative time [5].
The risks of RT are the same as for conventional thyroidectomy with regard to the recurrent laryngeal nerve (RLN),
the external branch of the superior laryngeal nerve (EBSLN),
infection, hematoma, seroma, hypoparathyroidism and the
need for revision surgery [5, 6]. The literature does not support an increased infection rate with RT compared with cervical approaches despite the anaerobic nature of the axilla [7].
It is essential to reiterate to the patient that all thyroidectomy approaches (including the transoral one, which involves
mucosal incisions in the oral cavity) inevitably involve at
least one scar; the advantage of RT being that the scar is ‘hidden’ at a remote site, most commonly the axilla. The patient
should be prepared to expect dysesthesia over where the subcutaneous ap is raised (i.e. the chest for the transaxillary
approach). Though this is likely to last several months, the
patient can be reassured that it almost always resolves and
rarely presents a signicant problem in the long term. Pain is
not a particular problem with RT [8]. Another risk that should
be discussed with the patient relates to the possibility of
developing post-operative brachial plexus neurapraxia, but
this complication is rare; the risk becomes almost ‘theoretical’ when the ipsilateral arm is placed in the ‘extended
salute’ position, as illustrated below [9, 10].
Prior to seeking informed consent, the surgeon must
ensure that the patient understands that the axillary scar, chest
dysesthesia and risk of brachial plexus neurapraxia are unique
to RT and are not associated with conventional or videoassisted thyroidectomy. This should be clearly documented in
the patient’s electronic medical records, along with the possibility of need for open conversion—an uncommon occurrence in RT, associated with minimally invasive and
remote-access surgery in general [11]. Finally, the evidence
supports that there is no difference between robotic and nonrobotic approaches regarding hospital stay and time needed
off work, something important for most patients [5, 12, 13].
47.2.2 Patient Positioning andIncision
Planning
The patient’s ipsilateral arm should be positioned and
marked on the operating table with the patient fully awake,
to ensure that the position adopted is comfortable for the
length of the procedure, thus minimising traction to the brachial plexus and the risk of developing post-operative neurapraxia [14]. The ipsilateral arm must be free of identication
bracelets, lines, blood pressure cuffs and EKG leads. The
arm should be positioned with the back of the hand on the
patient’s forehead, a position referred to as the ‘extended
salute’ position (Fig.47.1). This position has been shown to
signicantly reduce the risk of brachial plexus neurapraxia
following RT [5].
An incision 5–6cm in length is then marked on the ipsilateral axilla about 1–2cm posterior to the posterior border
of the pectoralis major tendon, along a natural skin crease.
This marking is also done with the patient awake, asking
them to stand and abduct and adduct their ipsilateral glenohumeral joint to ensure that the resulting scar will remain
‘hidden’ in the anatomical position and subsequent migration is prevented. If extra space is required during surgery to
stop the robotic arms from clashing, then the incision can be
extended superiorly in a curvilinear fashion so that it remains
in the original natural skin crease, to minimise subsequent
tension and the associated tendency towards hypertrophic
and pigmented scarring. Before general anaesthesia is
administered, laterality is indicated by a skin marker and
rechecked with the patient against both the electronic medical records and imaging.
A transoral endotracheal tube with electrodes (NIM®
EMG endotracheal tube; Medtronic, Jacksonville, FL) is
used for intubation and ventilation. The correct positioning
of the NIM® EMG endotracheal tube with the electrodes at
the level of the glottis is conrmed by direct laryngoscopy.
Visualisation of the electromyographic waveform on the
nerve integrity monitor (NIM®) following insertion of the
stimulator and earth leads serves as additional conrmation.
An extended tip of the NIM® is required because of the long
distance between the axillary incision and the neck. At induction, the patient is routinely administered intravenously 1.2g
amoxicillin/clavulanic acid (co-amoxiclav) and 4 mg
dexamethasone.
In contrast to conventional thyroid surgery, a shoulder roll
is not placed under the shoulders, as the resulting neck extension would move the thyroid further away from the axilla.
Instead, a pillow is placed under the patient’s head and shoulders to provide adequate and comfortable support in a subtle
‘snifng the morning air’ position. The head of the table is
then dropped about 20° to widen the angle between the arm
and chest.
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Fig. 47.1 The ‘extended
salute’ position for
transaxillary robotic
thyroidectomy. This position
minimises traction to the
brachial plexus and thus the
risk of post-operative
neurapraxia. Patient
positioning and incision
placement must all be done
with the patient awake to
ensure maximum comfort
(and thus least traction to the
brachial plexus) and that the
incision will remain ‘hidden’
in the anatomical position,
with subsequent migration
prevented
487
Fig. 47.2 Non-robotic instruments used for establishing the transaxillary route to the neck for robotic thyroidectomy. These include a Bovie
(monopolar electrocautery) with a long extension and insulated tip,
47.3 Surgical Technique
47.3.1 Surgical Equipment
The surgical equipment consists of the non-robotic trays
(used for establishing the transaxillary route to the neck) and
the robotic instruments, as illustrated in Figs. 47.2, 47.3,
47.4, 47.5, 47.6 and 47.7.
Harmonic scalpel (Ethicon Endo-Surgery, Johnson & Johnson,
Cincinnati, OH), pledgets (Teleex® Inc., NC), and Langenbeck
retractors
47.3.2 Establishing theTransaxillary Route
totheNeck
Following patient positioning in the ‘extended salute’ position, sterilisation and draping of the operative eld are performed, ensuring that the axilla, neck and chest are exposed
to just above the nipple line (Fig.47.8). This part of the operation, aimed at creating the route needed to access the neck
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Fig. 47.3 Self-illuminating retractor used for raising the subcutaneous ap to gain access to the neck in robotic thyroidectomy
G. Garas et al.
Fig. 47.4 The Modena surgical modular retractor (CEATEC®
Medizintechnik) is introduced once the ap has been raised and prior to
docking the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). It incor-
Fig. 47.5 The three robotic arms used in transaxillary robotic thyroidectomy: Harmonic ACE curved shears, DeBakey forceps and Maryland
dissector. The fourth robotic arm holds the 8-mm ProGrasp™ forceps
from the axilla, is performed without the robot. This position
shortens the distance between the incision site and the thyroid by elevating and externally rotating the clavicle whilst
protecting the brachial plexus from traction injury. It represents a modication to Chung’s method for transaxillary RT,
in which the arm is fully extended over the head [15]. We
porates a suction tube to its blade to prevent intraoperative fogging of
the robotic dual channel endoscope
and serves mainly for retraction (see Fig.47.17). Following positioning
into their trocars, all robotic arms and the camera are inserted through
the axillary incision
advise against the fully extended arm position, as it puts the
brachial plexus at risk through prolonged traction. We have
had no such problems since modifying Chung’s method of
arm positioning [5]. Adjusting the position of the ipsilateral
arm with the patient awake to assess for comfort and marking the incision immediately prior to surgery constitute vital
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Fig. 47.6 A 30° down, 12-mm dual-channel endoscope is used. The endoscope and all robotic arms are inserted through the axillary incision
489
Fig. 47.7 The extended tip of the nerve integrity monitor (NIM®) required during robotic dissection for stimulation of the recurrent and external
laryngeal nerves, owing to the long distance between the axillary incision and the neck
components of preoperative planning. The pre-marked axillary incision is re-checked once the patient is positioned on
the operating table. In our experience, this is the optimal way
to plan where to place the incision and prevent subsequent
migration.
Figures 47.9, 47.10, 47.11, 47.12, 47.13, 47.14 and
47.15 present a step-by-step narrative of this stage. The
axillary incision should be down to just over the fascia covering the pectoralis major muscle (Fig.47.9). Once the correct plane is identied, a subcutaneous ap is raised
supercial to the clavipectoral fascia (Fig.47.10). In taller
patients, if the distance from the axilla to the sternal notch
the clavicle until the sternal and clavicular heads of the
sternocleidomastoid muscle are encountered. The neck is
entered through the natural dehiscence between the two
tendons (Figs.47.11, 47.12 and 47.13). The surgical planes
are then developed as in a standard thyroidectomy. The
Modena retractor (Figs.47.14 and 47.15) 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 without clashing.
No gas insufation is required. When adequate visualisation and space have been conrmed, the da Vinci robot is
docked.
exceeds the limit of the instruments, the robot can be
docked in earlier to perform the last (most distal) part of the
subcutaneous ap raising. This technique for entering the
47.3.3 Docking theSurgical Robot
neck is identical to the one described below but is performed robotically. This modication expands the range of
patients in whom transaxillary robotic thyroidectomy can
be offered [16].
Once the subcutaneous ap has been raised, dissection
is continued above the pectoralis major muscle and over
The schematic setup of the operating room (OR) for transaxillary robotic thyroidectomy is illustrated in Fig. 47.16.
Figure47.17 shows the introduction and orientation of the
robotic arms and 3D endoscope through the axillary
incision.
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Fig. 47.8 Sterilisation and draping of the operative eld are performed, ensuring that the axilla, neck, and chest are exposed to just
above the nipple line. Note the NIM® EMG endotracheal tube, eye
protection, and special arm rest to support the arm, which is abducted
47.3.4 Robotic Surgery
Following docking of the da Vinci surgical robot and insertion of the 30° down 12-mm dual-channel 3D endoscope, the
surgical instruments are inserted through their corresponding
and exed with the forearm pronated so that the back of the hand rests
on the central portion of the forehead. A Velcro coin is attached to the
hand and forehead to maintain the position
ports in the robotic arms. Initially, the fenestrated bipolar
forceps is placed in the right robotic arm and the 5-mm
Maryland dissector in the left. (If the robotic surgeon is lefthanded, the opposite orientation applies.) In the third robotic
arm, the DeBakey forceps is placed; it can be interchanged
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491
a
b
Fig. 47.9 The axillary incision should be down to just over the fascia covering the pectoralis major muscle
with the clutch on the robotic platform with the fenestrated
bipolar forceps. Once the thyroid lobe and its vascular pedicles have been delineated, this can be replaced with the
Harmonic® shears by the assistant surgeon so that the robotic
surgeon has a combination of 5-mm Maryland, DeBakey and
Harmonic® shears for dissection and haemostasis.
It is important to appreciate that in RT, the lateral approach
for thyroidectomy is employed. This is essentially the same
approach as that used for revision surgery in open thyroidectomy as well as in minimally invasive video-assisted parathyroidectomy [17, 18]. With the lateral approach, the RLN
is identied early in the operation and gently displaced later-
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