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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
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M. Piccoli et al.
to prevent robotic arms conicts, thus facilitating the excision of large goiters and
for total thyroidectomy, that though could require a further axillary incision for the
extraction. Patients experienced transient sensory impairment due to postoperative
adhesions.
Trans-oral (TO) approach could guarantee a real scarless approach with a completely invisible oral scar. With TO access, there is a good exposure of thyroid’s
lobes and central lymph node compartment, but ap elevation might be technically
challenging. In TO access, it is also more difcult to control massive hemorrhage.
Classic complications of this technique are mental nerve injury and postoperative
infection due to oral environment.
Several different approaches to robotic thyroidectomy are described in literature;
nevertheless, the ideal approach should be based on the patient and tumor characteristics and most importantly on the experience of the surgeon.
Our experience with robotic thyroidectomy started in 2010 tracing the experience of South Korean surgeons that rstly described the advantages of a gasless
transaxillary access for the treatment of papillary thyroid cancer [8].
In this chapter, we describe our hybrid and swing technique for gasless unilateral
transaxillary robotic thyroidectomy and parathyroidectomy with the use of the Da
Vinci Xi System® (Intuitive Surgical, Inc., Sunnyvale), in combination with intraoperative nerve monitoring (IONM).
Indications andContraindications
To date, robotic thyroidectomy isn’t the gold standard technique; it is important to
underline that robotic transaxillary thyroidectomy should be performed in highvolume centers with experience in both endocrine and robotic surgery [17].
Besides, according to international guidelines [5, 6, 11], robotic thyroidectomy
and parathyroidectomy are reserved to highly selective nodules and patients.
Our indications for robotic remote access are benign nodules with a diameter
inferior to 5 cm, little differentiated tumors and parathyroid adenomas superior
to 3cm.
Especially at the initial phase of learning curve, it is important to propose robotic
transaxillary access to patients with benign nodule less than 4cm and thin body
habitus, without thyroiditis for the higher risk of hemorrhage.
Contraindications are large malignant nodules with enlarged lymph node involvement, large plunging goiters, patients with a pacemaker implant in the same side of
the transaxillary unilateral access, and patients with history of neck surgery or
radiotherapy. Relative contraindications are severe obesity, patients with thyroiditis
and Graves’ disease, or patients with previous surgery of the shoulder.
30 Thyroid andParathyroid Surgery
Fig. 30.1 Operative room setup for robotic transaxillary right access
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Fig. 30.2 Operative room setup for robotic transaxillary left access
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M. Piccoli et al.
Operative Room Setup
There is reported disposition of operative room setup for robotic transaxillary access
for right and left access (Figs.30.1 and 30.2).
Patient Position
Transaxillary access is chosen according to the target lesion or the lesion of largest
dimension in case of total thyroidectomy for benign nodule, well- differentiated
tumors, and target parathyroid adenomas.
Patient is placed in a supine position as reported in Fig.30.3. To facilitate slight
neck extension, a soft pillow under the shoulder is placed. The arm on the surgical
Fig. 30.3 Patient position
for robotic transaxillary
thyroidectomy right access
30 Thyroid andParathyroid Surgery
419
access side is raised upon the head with a 90° angle elbow abduction to minimize
the distance between the axilla and the neck; arm position is checked while the
patient is awake before undergoing general anesthesia to avoid wrong position,
reducing the risk of consequent brachial plexus injury and postoperative shoulder
discomfort. Another support is placed near the head to prevent any lateral movements during the procedures.
Surgical Procedure
The procedure is divided into three principal steps:
Step 1: Working space—A transaxillary subcutaneous tunnel is created with a lapa-
roscopic view.
Step 2: Docking time—The robotic cart is positioned in the operative eld and tro-
cars are connected to the robotic arms.
Step 3: Console time—The planned operation is done by a surgeon sitting at the
robotic console.
Step 1: Working Space
Following our experience of minimally invasive laparoscopic surgery, we have chosen the so-called “hybrid technique” for the tunnel’s creation. The “hybrid technique” is a technique that uses the laparoscopic approach for the working space [1]
Fig. 30.4 Working space-incision and visualization of the MPM
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Fig. 30.5 Working space-SCM and up (Modena retractor) on the left; OHM and IGV on the right
Fig. 30.6 Robot
positioning and docking
time in the right
transaxillary access
M. Piccoli et al.
and the robotic for the console time. With the laparoscopic approach, it is possible
to minimize surgical trauma, making the surgical gesture more precise and also
allowing all surgeons in the team to view the creation of the transaxillary tunnel and
identify the anatomical landmarks, favoring the learning curve of these difcult step.
A 5cm incision is performed in the axilla and a subplatysmal skin ap is created
over the anterior surface of the major pectoralis muscle (MPM) till the anterior neck
area (Fig.30.4). Using laparoscopic hook and bipolar forceps, the sternocleidomastoideum muscle (SCM) is identied as the rst landmark (Fig.30.5), and then the
sternal branch is lifted up with an external retractor, the so-called “Modena
Retractor” (CEATEC® Medizintechnik) that is used from the beginning of ap dissection, to facilitate the suspension of skin ap and to reduce fogging. The superior
anatomical landmark of the surgical eld is represented by omohyoid muscle
(OHM) (Fig.30.5). The internal jugular vein (IGV) is dissected from the strap muscles. Finally, the Modena Retractor (CEATEC® Medizintechnik) is positioned
beneath both the sternal branch of the SCM and the strap muscles and the thyroid is
discovered. The contralateral strap muscles are identied and raised if a total
30 Thyroid andParathyroid Surgery
421
thyroidectomy must be performed. During the ap creation, a conventional 30°
laparoscopic high-denition camera and display system is used to magnify the
image and make the surgical gesture more precise, reducing the risk of small
hemorrhages.
Step 2: Robot Positioning andDocking Time
The Da Vinci Xi® robot is docked contralaterally to the axillary access (Fig.30.6).
A four-arm procedure is illustrated [2]. It is possible to perform a three-arm procedure only if the learning curve is overcame (at least 20 robotic lobo- isthmusectomy
have to be done), if the nodules diameter is less than 4cm and if the target is a
parathyroid gland.
Three robotic instruments are introduced into the axilla skin incision and one is
inserted through an independent incision at the inferior part of the axilla incision.
If we consider the right approach as described in Fig.30.6, port 1 is connected to
Maryland forceps and port 2 holds the camera, port 3 a ProGrasp, and port 4 a
Robotic Ultracision (Ethicon). During the console time, Maryland forceps, ProGrasp
forceps, Robotic Ultracision, and 30° camera are all interchangeable (the swing
technique).
Step 3: Console Time
The senior surgeon sits at the console and a junior surgeon sits at the operating table
as assistant. All vessel dissections are performed using the Ultracision device. The
middle thyroid vein is identied and dissected. The upper pole of the thyroid is
drawn downward and medially using Maryland forceps or ProGrasp. The superior
thyroid vessels are identied and divided close to the thyroid gland to avoid any
injury of the external branch of the superior laryngeal nerve. The inferior thyroid
Fig. 30.7 Console time:
correct identication of
RLN, inferior thyroid
artery, and parathyroid
glands
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Fig. 30.8 Console time:
correct identication of
RLN and
intermittent IONM
M. Piccoli et al.
artery (ITA), the recurrent laryngeal nerve (RLN), and the parathyroid glands are
identied (Fig.30.7). The ITA is then divided close to the thyroid gland, and the
whole cervical course of the RLN is traced and preserved. Correct identication and
motility of the RLN is achieved with intermittent intraoperative nerve monitoring
(IONM) (Fig.30.8).
The thyroid lobe is dissected from the trachea and resected with the isthmus. The
resected specimen is extracted through the axillary skin incision.
In case of total thyroidectomy, it will be performed using the same method with
medial traction of the trachea and the thyroid. The identication of contralateral
RLN is the challenging steps of this procedure because it is necessary to go beyond
the trachea. The upper pole is the rst step, with the dissection of the vessel direct
to superior lobe with Ultracision device; afterwards, it is time to identify the RLN
with the so-called “swing technique.” During this procedure, a reusable handmade
laparoscopic suction device is used to get a soft traction on the trachea in order to
obtain a better vision of the RLN.With Da Vinci Xi® System that has 8mm port,
each instrument can be interchangeable, so the camera moves from arm 2 to arm 3
and to arm 4 to follow the correct path of the nerve and then can return to arm 2 at
the end of the procedure. With this “swing technique,” it is possible to dissect the
inferior lobe following the whole cervical course of the RLN especially into the
contralateral thyroid lodge. The dissection results are more precise and surgical
completeness is achieved with direct and frontal vision of the trachea. The correct
function of the contralateral RLN is checked with intermittent IONM.The contralateral thyroid lobe is then resected and extracted through the axillary skin incision.
In case of parathyroidectomy, the 30° camera is introduced in port 2. The thyroid
gland is turned medially with a ProGrasp introduced in port 3. The middle thyroid
vein is identied and dissected with Ultracision device in port 1. The parathyroid
adenoma is then identied, dissected, and excised with the aid of Maryland forceps
in port 4. The inferior thyroid artery (ITA) and the recurrent laryngeal nerve (RLN)
are previously identied. The IONM is used.
After dissection steps, the venous bleeding is checked with the Valsalva maneuver. A closed suction drain is inserted through the separate incision under the
axillary skin incision. The robotic arms are de-docked and the wound is cosmetically closed.
30 Thyroid andParathyroid Surgery
423
Discussion
During the last decade, there was an increasing incidence of thyroid carcinoma, and
it represents the most common endocrine malignancy [16]. Different robotic remote
access techniques for thyroidectomy have been described with the purpose to avoid
a non-cosmetic anterior neck scar and also to overcome some limitations related to
minimally invasive endoscopic procedure. In particular for robotic transaxillary
gasless approach, several studies conrm feasibility and safety [17, 18], reporting a
level 2a of evidence and a better cosmetic result when compared with open thyroidectomy [16].
Robotic transaxillary approach was widely used in East and Asian countries, and
for long time, there has been a debate on its application in the Western population
[3] because of difference in anthropometric characteristics, larger size of goiter, and
also for elevated costs.
The operating time is undoubtedly increased if compared to the conventional
technique, (working space and docking time). However, some authors have reported
that the body mass index (BMI) does not inuence the operating time; therefore,
higher body mass index (overweight and obese patients) cannot be considered an
exclusion criteria for the robotic transaxillary approach. Furthermore, overweight
and obesity do not increase postoperative complication risk of ap hematoma,
wound seroma, neck and chest paresthesia, and also shoulder discomfort, specic
complications of transaxillary approach [7, 17, 18]. Operative time instead was
found to be decreasing as the surgeon acquired experience [7].
Some controversies regarding surgical completeness and oncological safety have
slowed the spread of the technique, but nowadays, several studies demonstrate comparable surgical completeness with open approach in malignant thyroid disease ([9,
12, 14, 16]).
Robotic transaxillary thyroidectomy allows compartment lymphectomy with
good results in terms of lymph nodes sampling [9, 16]. In fact, our approach with
Da Vinci Xi System, hybrid technique, and especially swing technique can enhance
lymph nodes retrieval, RNL motility preservation, and parathyroids’ functionality.
Fig. 30.9 Console time:
intraoperative use of ICG
for easier identication of
parathyroid glands supply
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M. Piccoli et al.
Parathyroids identication is also facilitated with the application of intraoperative indocyanine green (ICG) [13]. Parathyroid surgery requires careful dissection
to preserve blood supply to the gland and to reduce the risk of postoperative transient hypoparathyroidism. The intraoperative injection of ICG permits easier identication of vascular supply to the glands and also permits to test their perfusion
after thyroid dissection (Fig.30.9).
Recent systematic review also conrms safety and feasibility of robotic parathyroidectomy especially in patients diagnosed with primary hyperparathyroidism and
preoperative localized parathyroid adenoma [15].
Regarding postoperative complications, several studies and meta-analysis conrm that remote access to thyroid glands is not inferior to cervical thyroidectomy
with regard to length of hospital stay, transient RLN injury, permanent RLN injury,
transient hypocalcemia, and permanent hypocalcemia [4, 19].
In conclusion, robotic transaxillary thyroidectomy and parathyroidectomy are
safe and feasible in selected patients and nodules in high-volume center with experience in both robotic and endocrine surgery. The application of hybrid and swing
technique, intraoperative nerve monitoring and ICG, could enhance the correct
identication and preservation of RLNs and parathyroids.
References
1. Al Kadah B, Piccoli M, Mullineris B, etal. Modications of transaxillary approach in endoscopic da Vinci-assisted thyroid and parathyroid gland surgery. J Robot Surg. 2015;9:37–44.
https://doi.org/10.1007/s11701- 014- 0486- 8.
2. Boggi U, Bianchi PP, Milone M, Troisi RI.Principi di tecnica in chirurgia robotica. Piccin; 2023.
3. Bonati E, Mullineris B, Del Rio P, etal. Mini-invasive video-assisted thyroidectomy vs robotassisted transaxillary thryoidectomy: analysis and comparison of safety and outcomes. Updat
Surg. 2024;76:573. https://doi.org/10.1007/s13304- 023- 01732- z.
4. De Vries LH, Aykan D, Lodewijk L, etal. Outcomes of minimally invasive thyroid surgery—
a systematic review and meta-analysis. Front Endocrinol. 2021;12:719397. https://doi.
org/10.3389/fendo.2021.719397.
5. Del Rio P, Polistena A, Chiofalo MG, et al. Management of surgical diseases of thyroid
gland indications of the United Italian Society of Endocrine Surgery (SIUEC). Updat Surg.
2023;75:1393–417. https://doi.org/10.1007/s13304- 023- 01522- 7.
6. Haugen BR, Alexander EK, Bible KC, etal. 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. https://doi.org/10.1089/thy.2015.0020.
7. Kandil E, Akkera M, Shalaby H, et al. A single surgeon’s 10-year experience in
remote-access thyroid and parathyroid surgery. Am Surg. 2021;87:638–44. https://doi.
org/10.1177/0003134820950300.
8. Kang S-W, Jeong JJ, Yun J-S, etal. Robot-assisted endoscopic surgery for thyroid cancer: experience with the rst 100 patients. Surg Endosc. 2009;23:2399–406. https://doi.org/10.1007/
s00464- 009- 0366- x.
9. Kang YJ, Stybayeva G, Hwang SH.Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: a network meta-analysis. Surgery.
2023;173:1381. https://doi.org/10.1016/j.surg.2023.02.021.
30 Thyroid andParathyroid Surgery
10. Lee J, Kim S, Hoon; Hong, Hua. Comparison of various thyroidectomy approaches: a retrospective cross-sectional study. Surg Laparosc Endosc Percutan Tech. 2023;33(6):632–9.
https://doi.org/10.1097/SLE.0000000000001243.
11. Marciniak C, Bihain F, Caiazzo R, Brunaud L.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). J Visc Surg.
2023;160:S127–9. https://doi.org/10.1016/j.jviscsurg.2023.04.006.
12. Matteucci V, Fregoli L, Papini P, etal. Comparison of surgical completeness in patients operated on conventional open total thyroidectomy (OT) or trans-axillary robot-assisted total
thyroidectomy (RATT) by a single axillary approach. Updat Surg. 2023;75:1267. https://doi.
org/10.1007/s13304- 023- 01510- x.
13. Pace-Asciak P, Russell J, Solorzano C, etal. The utility of parathyroid autouorescence as an
adjunct in thyroid and parathyroid surgery 2023. Head Neck. 2023;45:3157–67. https://doi.
org/10.1002/hed.27538.
14. Papini P, De Palma A, Ginesini M, etal. Robot-assisted transaxillary surgery for thyroid cancer:
Oncologic and surgical outcomes in long term follow-up. Robot Comput Surg. 2023:e2563.
https://doi.org/10.1002/rcs.2563.
15. Paspala A, Spartalis E, Nastos C, etal. Robotic-assisted parathyroidectomy and short-term
outcomes: a systematic review of the literature. J Robot Surg. 2020;14:821–7. https://doi.
org/10.1007/s11701- 020- 01119- x.
16. Pavlidis ET, Psarras KK, Symeonidis NG, et al. Robot-assisted thyroidectomy versus open thyroidectomy in the treatment of well differentiated thyroid carcinoma.
JSLS. 2021;25:e2021.00032. https://doi.org/10.4293/JSLS.2021.00032.
17. Piccoli M, Mullineris B, Gozzo D, etal. Evolution strategies in transaxillary robotic thyroidectomy: considerations on the First 449 cases performed. J Laparoendosc Adv Surg Tech.
2019;29:433–40. https://doi.org/10.1089/lap.2019.0021.
18. Piccoli M, Mullineris B, Santi D, Gozzo D.Advances in robotic transaxillary thyroidectomy in
Europe. Curr Surg Rep. 2017;5:17. https://doi.org/10.1007/s40137- 017- 0180- 7.
19. Xing Z, Qiu Y, Abuduwaili M, etal. Surgical outcomes of different approaches in robotic
assisted thyroidectomy for thyroid cancer: a systematic review and Bayesian network metaanalysis. Int J Surg. 2021;89:105941. https://doi.org/10.1016/j.ijsu.2021.105941.
20. Yuan Y, Pan B, Tang E, etal. Surgical methods of total thyroidectomy for differentiated thyroid
cancer: a systematic review and Bayesian network meta-analysis. Int J Surg. 2023;110:529.
https://doi.org/10.1097/JS9.0000000000000819.
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