Robotic-Assisted Thyroidectomy

Introduction

Open thyroidectomy incorporated a midline skin crease was first popularized by Kocher in 1906; since that time it has remained the standard surgical technique for thyroidectomy. This approach provides the most direct route to the thyroid bed and offers complete visualization of the surgical field. Therefore it results in excellent, predictable, and reproducible clinical outcomes with consistent preservation of the parathyroid glands and recurrent laryngeal nerves (RLN).

Gaining access to the thyroid bed from a remote site was made possible with the recent development of the da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, California). There are two approaches to the thyroid bed during robotic thyroidectomy. The first approach accesses the thyroid bed from the lateral direction by entering the bed between the anterior border of the sternocleidomastoid muscle and the sternothyroid muscle. This is accomplished either by way of the transaxillary (TA) or retroauricular (RA) approach. The former method was described first by Chung et al. and has been widely adopted as a single-incision gasless approach to the thyroid bed from the axilla. The RA, or modified facelift technique, was first described by Terris et al. and has become a popular remote access to the neck for robotic-assisted approaches. Byeon et al. recently demonstrated an acceptable cosmetic outcome with a good safety profile in their series of 87 patients undergoing RA thyroidectomy.

The second surgical access to the thyroid bed begins in the midline using the bilateral axillobreast (BABA) technique. This approach offers the surgeon the same midline approach as open thyroidectomy. The main benefit of remote access thyroidectomy is that it leaves no scar on the neck, which is obviously important to some patients. The robotic system also provides the surgeon with a magnified, three-dimensional view of the surgical field which enhances the ability to preserve the RLN, external branch of the superior laryngeal nerve (EBSLN), and the parathyroid glands. In this chapter, we describe the robotic thyroidectomy performed via the lateral approach from either the TA or RA incision.

Key Operating Learning Points

• 1.

  It is essential to gain exposure and create a wide working space before proceeding to the console to perform robotic thyroidectomy.

• 2.

  Make sure that the robotic working arms are docked between 30 and 45 degrees to the camera arm so as to increase the maneuverability of both working instruments.

• 3.

  Identify the omohyoid muscle first before proceeding to mobilize the thyroid gland; this is important in preventing inadvertent injury to the internal jugular vein (IJV).

• 4.

  Owing to the lack of haptic feedback to the console surgeon, proper identification of the trachea and cervical esophagus is crucial in avoiding accidental injury to these structures.

• 5.

  It is important to ensure a near bloodless field when the RLN is dissected at Berry’s ligament to prevent inadvertent injury to the nerve and postoperative hematoma.

• 6.

  Monitoring of the RLN is helpful to confirm both anatomic and functional preservation of the nerve during surgery and upon completion of the thyroidectomy.

Preoperative Period