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10 Robotic Thyroidectomy
135
2. Omohyoid, sternohyoid, and sternothyroid muscles are then sequentially iden-
tied, delineated and retracted to visualise the anterior surface of the thyroid
(Fig.10.7), the isthmus, and the inferior border of the gland.
3. Superior pole vessels are dissected and delineated, coagulated, and cut.
4. The dissection proceeds medially, and the external branch of the superior laryn-
geal nerve is seen entering the cricothyroid muscle. Subsequently, the medial
dissection is done to divide the isthmus.
5. Attention is then turned laterally and inferiorly, retracting the superior pole
medially. The dissection is maintained close to the capsule of the gland without
breaching it. The middle thyroid vein is identied, coagulated, and cut. The
inferior thyroid artery is identied, coagulated close to the gland, and cut. The
dissection in the loose areolar tissue laterally will identify the recurrent laryngeal nerve entry point. The nerve may be followed and preserved. It is not
necessary to dissect the nerve fully.
6. Dissection is further done to release the inferior pole. Finally, the vessels are
coagulated and cut to complete the hemithyroidectomy.
7. Contralateral lobectomy can be done through the same side, but it may be
prudent to do it through a contralateral postauricular route in the initial
few cases.
8. The contralateral superior pole is identied, coagulated, and cut. The lobe is
then released from the trachea by medial dissection, preserving the recurrent
laryngeal nerve and parathyroids to complete the thyroidectomy.
9. Haemostasis is checked meticulously; suction drains are inserted and taken out
behind the hairline.
10. Closure: Surgical wound is irrigated with warm saline, and the Valsalva
manoeuver is applied to check for bleeders. The author preferred to place the
drain and wound closed in layers.
11. Postoperative care is not grossly different from open thyroidectomy. Calcium
levels should be monitored. The suction drain is removed when the drainage
falls below 20mL/day. The patient may be discharged the following day.
10.5.2 Trans-axillary/Breast Approach
Several modications are described in the literature by several authors using the
robot with multiple small port incisions to a single large incision [25]. Here, we
discuss three main standard robotic approaches. (1) Axillo-Bilateral-Breast
Approach (ABBA), (2) Bilateral-Axillo-Breast-Approach (BABA)—This approach
provides a symmetrical view to both lobes of the thyroid and prevents instruments
overcrowding. (3) Robot-assisted breast-axillo insufation thyroidectomy (RABIT)
approach is a modication [26]. A summary of the equipment and surgical techniques is given below [25, 27].
136
10.5.2.1 Surgical Equipment
The main equipment are:
• The da Vinci Si/Xi robot
• The robotic instruments
– Prograsp forceps
– Maryland dissector
– Harmonic scalpel Ethicon
• The 30° endoscope
• Modied Chung retractor
• NIM (nerve integrity monitor) endotracheal tube
• SSEP (Somato Sensory Evoked Potentials)
• Handheld recurrent laryngeal nerve stimulator
• Alexis wound protector/retractor
• Electrocautery with a short, regular and long tip
• Vascular DeBakey
• Army-navy retractors
• Right-angled retractors
• Breast lighted retractors
10.5.2.2 Preparation andProcedure
K. Thankappan et al.
Patient positioning
Patient neck is slightly extended with a small shoulder bag, and the ipsilateral arm
is extended and placed on the patient’s head with exion at the elbow, as described
by Ikeda etal., to avoid a stretch on the upper limb nerves.
Skin preparation and incision
An axillary, 8cm skin incision (Fig.10.8) is made on the lateral border of the pectoralis major muscle, and skin ap (Fig.10.9) elevated supercial to this muscle on
the chest and in the sub-platysmal plane in the neck.
Fig. 10.8 Trans-axillary
incision
10 Robotic Thyroidectomy
Fig. 10.9 Trans-axillary
working space after the
ap is raised
137
Creating a working space
Identifying the sternomastoid insertion is essential, then entering the avascular space
between the sternal and clavicular heads of the sternomastoid muscle. Omohyoid
muscle is identied, retracted supercially and posterolaterally. Strap muscles are
identied and dissected off the thyroid to the lateral border of the contralateral thyroid lobe. Chung retractor is placed and xed to maintain working space.
Docking stage
Three robotic arms consisting of a camera, Maryland dissector and harmonic scalpel are docked in the working space. The camera is placed in the centre position,
dissector and harmonic scalpel placed on either side of the camera without any collision. The fourth robotic arm with Prograsp forceps can be inserted through a
0.8mm port in the anterior chest wall.
Console stage (surgical resection of the thyroid gland)
The superior pole of the thyroid is grasped with Prograsp forceps and retracted
medially, and blunt dissection is done to identify the superior laryngeal nerve’s
external branch. Superior thyroid vascular pedicle is ligated close to the gland with
a harmonic scalpel. The superior parathyroid gland is identied and preserved.
Blunt haemostatic is dissection done with the help of Maryland dissector and harmonic scalpel, recurrent laryngeal nerve identied at the entry point into the cricothyroid muscle and preserved. The inferior parathyroid gland is identied and
preserved. The thyroid lobe is detached from the berry ligament with sharp dissection and specimen delivered in a plastic bag. RLN integrity is tested and conrmed
with the nerve monitor. Robotic arms are retracted from the surgical eld. The surgical eld (Fig.10.10) is irrigated with warm saline, and haemostasis is conrmed
138
Fig. 10.10 Surgical
thyroidectomy bed after a
trans-axillary
thyroidectomy
K. Thankappan et al.
with Valsalva manoeuvre. The suction drain would be secured, and the wound
closed in layers.
Robot-assisted breast-axillo insufation thyroidectomy (RABIT) approach [26]
is a modication of the robotic BABA approach described by Lee etal. [28]
10.5.3 Robotic trans-oral thyroidectomy
Trans-oral thyroidectomy is becoming popular. A truly scarless approach is the
advantage. The operation is done through a median, central approach, allowing
bilateral exploration of the thyroid gland and central compartment. Endoscopic
approaches [29] and robotic approaches are described [30]. A summary of the
robotic approach is given below [30, 31]. An ideal patient for trans-oral thyroidectomy would be:
• Uncomplicated thyroid nodule up to 3cm
• No obesity, not too short neck
• Females
• Male patient is more challenging (laryngeal prominence/thyroid cartilage is
larger in adult men)
• Left lobectomy is more challenging for the right-hand surgeon
10.5.3.1 Preparation andProcedure
Patient positioning
Patient is in supine position with neck extended using a sandbag under the shoulder.
Oral mucosal incision
Three incisions are made. The rst one is a midline incision, about 2cm from the
frenulum in a horizontal fashion (Fig.10.11). The other two (Fig.10.12) are on
either side on the mucosal aspect of the angle of the mouth.
10 Robotic Thyroidectomy
Fig. 10.11 Trans-oral
midline incision
Fig. 10.12 Trans-oral
lateral incisions after the
ports are introduced
139
Creating a working space
A sub-platysmal ap is intended to be created using the three incisions. First, the
midline incision is addressed using a blunt dissection technique to reach the lower
border of the mandible. Following this, a sub-platysmal ap is raised in the midline
over the strap muscles up to the supra-sternal notch. This may be facilitated by inltration of normal saline mixed with adrenaline. A 30° endoscope is introduced through
this, and carbon-di-oxide insufation at 8–10 L/min is done through this port.
Similarly, sub-platysmal dissection is done through the other two incisions as well.
Docking stage
The robotic system is deployed (Fig.10.13). The cannulae are then introduced. The
central cannula is used to secure the endoscope. This is followed by the Maryland
dissector and Harmonic scalpel through the right and left angle of mouth ports,
respectively.
140
ab
Fig. 10.13 Trans-oral
docking
K. Thankappan et al.
Fig. 10.14 (a) Trans-oral thyroidectomy, midline and the straps are being separated; (b) Trans-
oral thyroidectomy bed after surgery
Console stage (surgical resection of the thyroid gland)
The dissection begins in the mid-line (Fig.10.14a). The strap muscles are separated
and then elevated off the thyroid gland to expose the thyroid lobe being addressed
rst. The pyramidal lobe is identied and dissected of the thyroid cartilage.
Isthmectomy is performed to free the thyroid lobe from the trachea in the midline.
Following this, the superior pole is identied, and each vessel is ligated individually. The superior parathyroid gland is identied and preserved. The superior pole is
retracted inferiorly, and the recurrent- laryngeal nerve is identied at its point of
entry into the larynx. The thyroid is dissected off the Berry’s ligament. The inferior
dissection is then continued, and the inferior parathyroid gland is identied and
preserved. Hemi thyroidectomy is thus completed (Fig.10.14b). The procedure is
repeated on the opposite side when indicated.
10 Robotic Thyroidectomy
141
10.6 Complications andOutcomes: AComparison
withOpen Thyroidectomy
10.6.1 Postoperative Pain
Post-operative pain in the immediate period and chronic pain over 3–6months have
been studied. Overall evidence suggested that RT and OT were comparable for postoperative pain and the requirement of analgesics. There is extensive ap elevation
in most of the approaches of RT; however, the retro- auricular approach reduces it by
38% [32, 33].
10.6.2 Recurrent Laryngeal Nerve Injury
In literature, there is no universal denition of transient and permanent RLN palsy.
However, their incidences in RT vary between 1 and 7% for transient injury and
0–2% for permanent injury. This is comparable with OT [32, 34–36].
10.6.3 Brachial Plexus Injury
The potential of a brachial plexus injury is a complication of the trans-axillary RT,
which is not encountered in a usual thyroidectomy. Although it has a low incidence
of 0.2%, it is a debilitating and worrying complication for the patient. This can be
avoided by other approaches [37].
10.6.4 Hypoparathyroidism
The denitions of postoperative, transient and permanent hypoparathyroidism differed among various studies. However, all available meta- analyses showed that the
current risk of transient and permanent hypothyroidism is not increased with
RT.The reported rates of transient and permanent hypoparathyroidism in RT ranged
from 0–53% and 0–3%, respectively [32, 35, 36, 38, 39].
10.6.5 Bleeding and Hematoma
These are known life-threatening complications of thyroidectomy. An incidence of
2–3% has been reported in patients undergoing RT, which is comparable with OT
[32, 35, 36, 38, 39].
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K. Thankappan et al.
10.6.6 Voice and Swallowing Function
The patient’s voice, irrespective of the RLN function status, has been studied, and
short-term and long-term outcomes suggest better results with RT than OT [32, 40].
Similar comparatively better outcomes have been noted in swallowing function
post RT.
10.6.7 Paraesthesia
Signicantly higher chest and neck paraesthesia has been reported in RT due to
more extensive skin ap elevation. However, these sensations over the chest wall
skin are regained considerably after 3months of surgery. Retroauricular thyroidectomy can result in an altered sensation of the pinna and behind the ear. Hypertrophic
scar in the post-auricular area is also common [32, 41].
10.6.8 Cosmetic Satisfaction
Cosmetic advantage is the most important outcome of RT and gains superiority over
OT in all studies. The degree of psychological distress is also shown to have reduced
with RT. [42]
10.6.9 Complications Specific to Trans-Oral Approaches
Mental nerve injury, skin burns, temporary chin numbness and oral commissure
tears. Neck infections can also rarely occur.
10.7 Economic Parameters
10.7.1 Peri-Operative Time
Liu etal. [43], in an evidence-based review of 19 comparative studies and seven
meta-analyses, showed that the operating time for robotic thyroidectomy is signicantly more than that of open thyroidectomy. But, on comparing robotic and endoscopic thyroidectomy, Lang et al. found no signicant difference in the total
operating time when a robot was used. Considering the extra steps of surgery
involved in RT compared to OT, in the form of docking and elevation of the skin
aps, it may hardly be ever possible to compare the time taken in RT to that of
OT.However, with the increased experience, the time taken for RT ought to reduce.
10 Robotic Thyroidectomy
143
10.7.2 Hospital Stay
The total duration of hospital stay is the same for robotic and open thyroidectomy.
However, there is an increasing trend to promote thyroidectomy as a day case procedure [32, 38, 43].
10.7.3 Cost
The robotic setup is expensive, and the cost gets added to the surgical cost. Duration
of surgery and operation theatre time also is an added disadvantage when the cost is
concerned. The cost includes the initial establishment cost, the maintenance cost
and the cost of instruments and disposables. The instruments have a cap on the
number of surgeries they can be used. The cost of RT is shown to be 2.1 times that
of OT [44, 45].
10.8 Oncological Outcomes
Considering RT is not a contra-indication for differentiated thyroid cancer, it is
prudent to look at the oncological outcomes [32, 43] of RT compared to OT.Central
compartment neck dissection is also being performed contentedly through the
robotic approach at the same time when indicated. The oncological outcomes can be
studied as lymph node retrieval, surgical completeness of resection, tumour recurrence, and survival outcomes. Considering good survival outcomes in general for
differentiated thyroid carcinomas compared to other head and neck malignancies,
survival outcomes need a long-term follow-up for thyroid cancer. While survival
outcomes have not extensively been compared between RT and OT, Lymph node
retrieval and completeness of resection have been studied in at least three published
meta-analyses [36, 39, 46].
10.8.1 Completeness of Resection
Post thyroidectomy, for differentiated thyroid cancer, the completeness of resection
is assessed by radioactive iodine (RAI) uptake on post-therapy whole body scan as
well as the thyrotropin (TSH)-stimulated serum thyroglobulin (sTg) level. Two
meta-analyses by Wang etal. and Son etal. did not nd any difference for stimulated thyroglobulin levels. However, Lang etal., in a meta-analysis including a large
number of single studies, showed a considerably high sTg level in RT as compared
to OT, indicating towards, like explained, an incompleteness of resection. Evidence
suggests that the amount of remnant thyroid tissue as reected by the sTg level may
be higher post RT than post OT.However, this is reported to be resolved after RAI
ablation [36, 39, 46].
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K. Thankappan et al.
10.8.2 Lymph Node Retrieval
Radical central compartment dissection is considered the hallmark of oncological
control. The number of lymph nodes retrieved in RT is lower than in OT in three
meta-analyses. However, the lymph node retrieval for lateral neck dissection is similar in both. RT may be inferior in the number of lymph nodes retrieved from the
central compartment [36, 39, 46, 47].
10.8.3 Survival and Recurrence
Short-term locoregional recurrence within the rst two postoperative years is comparable between RT and OT.In the only long-term follow- up study by Lee etal., the
rates of locoregional recurrence at 5years was 1.2% for both RT and OT.The survival outcomes between RT and OT were compared, and at 5-year follow-up, no
signicant difference between RT and OT for the disease- free survival was observed
(99.7% versus 98.7%, 𝑃 = 0.89). Considering the good survival outcomes of DTC,
a longer time may be needed to compare survival outcomes and recurrences between
robotic and open thyroidectomy [47, 48].
10.9 Advantages ofRobotic Thyroidectomy
The advantages [24] of robotic thyroidectomy are:
10.9.1 Visualisation
RT allows a three-dimensional view. A tenfold greater magnication and high denition are achieved as compared to the human eye. The vision is surgeon controlled
and, unlike endoscopic thyroidectomy, does not need an assistant to hold the camera.
10.9.2 Dexterity
An enhanced dexterity due to the wristed hand movements is possible. Seven
degrees of freedom on movements have been described, shoulder roll, wrist yaw,
arm yaw, wrist roll, wrist pinch, shoulder pinch, and elbow pinch.
10.9.3 Retraction
The fourth arm of the robot helps in retraction. A bedside assistant also helps with
suctioning and retraction. This helps in further better visualisation during surgery.