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 ¤  Abstract
 ¤ Introduction
 ¤  Materials and Me...
 ¤ Results
 ¤ Discussion
 ¤ Conclusion
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 Table of Contents     
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 4  |  Page : 280-285
 

Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience


1 Department of Surgical Oncology, Manipal Comprehensive Cancer Center, Bengaluru, Karnataka, India
2 Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, Karnataka, India

Date of Submission21-Feb-2016
Date of Acceptance02-Mar-2017
Date of Web Publication5-Sep-2017

Correspondence Address:
K R Ashwin
Consultant Surgical Oncologist, Department of Surgical Oncology, Manipal Hospital, #98, H A L Old Airport Road, Bengaluru - 560 017, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_42_16

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 ¤ Abstract 

Aim: Since last decades, more and more thyroidectomies have been performed by the minimally invasive method. Compared to conventional thyroidectomy, minimally invasive thyroidectomy has a superior cosmetic result. However, the outcome depends, in a large extent, on the skill of the operator and the learning curve is relatively long. Robotic thyroidectomy (RT) is a relatively new approach in treating thyroid lesions with improved ergonomics and surgical outcomes.
Purpose: We performed a prospective study of robotic-assisted transaxillary approach for thyroidectomy in Indian patients to examine the feasibility of the procedure.
Materials and Methods: A total of 35 patients underwent RT. Demographics, surgical indications, operative findings, postoperative functional outcome, local complications and pathological outcomes were recorded and analyzed.
Results: The median age of the cohort was 28.6 years and 31 of the patients were women. The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). Eighteen patients underwent less than total thyroidectomy and 17 patients underwent total thyroidectomy, with no conversion. The mean console time standard deviation was 115 min initially, and with experience, it reduced to 106 min for subsequent cases. The mean blood loss was 13 ml. Post-operative outcome was good with no serious complication noted in our series.
Conclusion: Robotic-assisted thyroidectomy using a gasless transaxillary approach is a feasible, safe and noninferior surgical alternative for selected patients. We believe with time RT will be widened and it will be performed more often.


Keywords: Minimally invasive thyroidectomy, robotic thyroidectomy, robotic surgery


How to cite this article:
Somashekhar S P, Ashwin K R. Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience. J Min Access Surg 2017;13:280-5

How to cite this URL:
Somashekhar S P, Ashwin K R. Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience. J Min Access Surg [serial online] 2017 [cited 2020 Jan 25];13:280-5. Available from: http://www.journalofmas.com/text.asp?2017/13/4/280/205878



 ¤ Introduction Top


Surgical management of thyroid diseases has changed considerably during the past 2 decades. There have been various modifications of an open approach and now progressing to multiple types of minimally invasive surgery, these evolving surgical approaches have resulted in better cosmetic results, shorter hospitalisations and faster patient recovery.[1],[2]

Since the use of endoscopy for neck surgery was first performed by Gagner in 1996, there has been a trend towards minimally invasive approaches for thyroidectomy across the world.[3],[4],[5],[6],[7],[8] These approaches range from videoscopic techniques through a small cervical midline incision all the way to removal of the thyroid gland through the axilla.[5],[6] Several approaches for endoscopic thyroidectomy have been described, including the anterior chest approach,[9] the breast approach [10] and the transaxillary approach.[11] Most of these surgical approaches require the use of gas insufflation in the neck.[12]

Research has demonstrated that endoscopic thyroidectomy is as an acceptable technique for the excision of benign thyroid tumours and for the treatment of thyroid cancer.[13],[14],[15] However, several instrumental and anatomic limitations have restricted the general adoption of these techniques.[5],[16]

The inherent limitations to this technique, including limited two-dimensional visualisation and use of nonflexible endoscopic instruments can make it difficult to visualise the surgical field adequately and to manipulate instruments. The da Vinci robotic surgical system was developed to address the limitations of endoscopic surgery and robots have been successfully applied to a number of disciplines. The da Vinci system allows for operational manipulations through a three-dimensional magnified field of view, multi-articulated instruments and an ergonomic workspace.[17],[18],[19]

Recent studies have reported that robotic thyroidectomy (RT) is a feasible, safe and effective method of performing such surgeries; although, most studies have been limited by small samples size and assessment at a single institution.[12],[20],[21]


 ¤ Materials and Methods Top


From August 2012 to December 2014, a prospective study was performed in Manipal Comprehensive Cancer centre. Thirty-five patients with thyroid nodule underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach. All patients were chosen using predetermined inclusion criteria after considering surgical risk, and all procedures were completed successfully using the da Vinci S surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Serum thyroid-stimulating hormone, ultrasound of the neck and fine-needle aspiration cytology was performed preoperatively for all patients.

The eligibility criteria applied were: (1) benign lesions or well-differentiated thyroid carcinoma; (2) a nodule size of 4 cm; the exclusion criteria applied were: (1) definite tumour invasion to an adjacent organ (recurrent laryngeal nerve [RLN], oesophagus, or trachea); (2) multiple bulky lateral neck node metastases or perinodal infiltration; (3) history of previous neck surgery.

Patient's clinicopathologic characteristics, operation types, operation times, postoperative hospital stays, complications, and short-term follow-up results were analysed. To the best of our knowledge, this is the first reported large series of use of this technique in India.

The operation time included docking time and console time. The docking time was defined as the time taken for correct alignment of all four robotic arms into the thyroid area, and console time was defined simply as the time spent at the robot console by the operating surgeon. In terms of postoperative management, for total thyroidectomy, serum calcium and phosphate were measured within 6 h and then every 12 h until the patient was stable.

Calcium supplements with a Vitamin D analogue were prescribed for symptomatic hypocalcaemia or if the serum parathyroid hormone (PTH) value was <10 IU/L and ionised calcium level were <7. Routine direct laryngoscopy was performed before surgery and within 1 week afterwards to assess vocal cord function. Vocal cord palsy, documented by direct laryngoscopy, lasting more than 6 months after surgery was considered as 'permanent.'

Procedure

With the patient in the supine position under general anaesthesia, the neck is slightly extended, and the lesion-side arm is abducted and fixed for the shortest distance from the axilla to the anterior neck. A 5–6-cm vertical skin incision is then made along the lateral border of the pectoralis major muscle in the axilla [Figure 1]. A subplatysmal skin flap from the axilla to the anterior neck area is then dissected over the anterior surface of the pectoralis major muscle and clavicle by electrical cautery under direct vision. After exposing the medial border of the sternocleidomastoid (SCM) muscle, the dissection is approached through the avascular space between the sternal and the clavicular heads of the SCM muscle and beneath the strap muscle until the lobe of the thyroid is exposed. An external Chung's retractor is then inserted through the skin incision in the axilla and increased to maintain a working field.
Figure 1: Incision

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After creating a working space, the robot arms are docked. The camera, Harmonic curved shears, Prograsp forceps and Maryland dissector are inserted through an axillary incision. The Camera is placed at the lower end of the wound with its tip directed upwards, 5 mm harmonic at the right edge, 5 mm Maryland at the left edge and the 8 mm prograsp forceps at upper end between harmonic and Maryland adjoining the retractor as close as possible to the retractor blade. The Maryland dissector and Harmonic curved shears should be as far apart as possible. Initially, in the first five cases, a second skin incision (0.8 cm in length) was made in the midline of the anterior chest wall, 5 cm inferior to suprasternal notch, to insert the fourth robot arm with prograsp forceps [Figure 2].
Figure 2: Port placement

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The Harmonic curved shears, which is used for all dissections and ligations of vessels, and the Maryland dissector are placed on both lateral sides of the camera, and a Prograsp forceps (Intuitive Inc.) is placed on the anterior chest arm.

The Lateral rotation of gland is performed with Prograsper and the upper pole of the thyroid is drawn downwards and medially. Superior pole dissection is performed; the superior thyroid vessels are identified and divided. After retracting the thyroid gland medially with the Prograsp forceps, careful dissection is continued to identify the inferior thyroid artery and the RLN in their usual anatomic relationship. Inferior pole dissection is completed after identifying, tracing the entire running course of the RLN and safeguarding it. The parathyroids and its supplying vessels are safely dissected and safeguarded. Then ligament of berry dissection is performed close to tubercle of Zuckerkandl and pre-tracheal dissection is completed with dissection of the gland from the trachea. No drains were placed at the end of the procedure. The skin was closed subcuticular sutures after checking for haemostasis [Figure 3].
Figure 3: Perioperative pictures

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 ¤ Results Top


[Table 1] shows a comparison of demographics, surgical indications, extent of resection, size of the dominant nodule and the final pathology.
Table 1: Demographics

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The median age of the cohort was 28.6 years (range, 16–47 years), and 31 (88.57%) of the patients were women. The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). Eighteen patients underwent less than total and 17 patients underwent total thyroidectomy with central compartment neck dissection in 11 patients. The mean number of dissected central lymph nodes was 4. No case was converted to conventional open surgery.

In an effort to evaluate the learning curve, the cases were divided into early and late experience groups. The early experience group was defined as the first 5 cases; the late experience group was composed of the next 30 cases. In the early experience group, the mean robot docking time was 18 min, compared with 11 min in the late group. The mean console time standard deviation was 115 min in the early experience group compared with 106 min in the late experience group.

The mean operating time for hemithyroidectomy was 96 min and for total thyroidectomy was 129 min. Mean total operation time was 133 min for initial five cases and 107 min for subsequent cases. The mean postoperative hospital stay was 2.5 days. The postoperative report revealed colloid goitre was the most common pathology and six patients had differentiated thyroid carcinoma.

The mean nodule size of the resected specimens in our patients ranged from 10 to 45 mm. Despite this, the surgical procedures were successfully carried out in all the cases without conversion to the open approach, implying that the size of the thyroid would not be a limiting factor to this approach. We were able to clearly view the RLN and the parathyroid glands on both sides, and there was no evidence of damage to either of these structures in any of the surgical procedures. Furthermore, the mean intraoperative blood loss in our series was 13 ml which is negligible compared to open surgery.

In terms of postoperative complications [Table 2], two cases had transient brachial nerve paralyses due to overstretching of the lesion side arm which resolved with conservative treatment. None of cases had hoarseness, confirmed with laryngoscopy.
Table 2: Post-operative outcomes

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The parathyroid glands were preserved. Clinical manifestations of hypocalcaemia were observed in 7 patients, confirmed by measurement of PTH values and serum calcium values. All patients with transient postoperative hypocalcaemia were discharged on a therapeutic regimen of oral calcium and Vitamin D. There were no cases of permanent hypocalcaemia. In all 7 patients, it resolved within 2 months. Permanent hypocalcaemia was not encountered in any patient.

Postoperative haematomas were encountered in two patients. The haematomas, which arose from tiny haemorrhagic foci in the subplatysmal flap, were evacuated and controlled without difficulty under local anaesthesia. Two patients developed postoperative seromas, which were resolved by repeated needle aspiration without compressive dressings. No inadvertent injury to adjacent structures, such as the trachea or oesophagus, occurred in our patients. All the patients had at least a 6-month follow-up period after surgery.

The postoperative cosmetic results were good. The small incision scar in the axilla was completely covered when the patient's arm in natural position. Most of the subjective parameters (hypoesthesia or paraesthesia in the neck or anterior chest wall and difficulty swallowing) improved within 6 months.


 ¤ Discussion Top


Technological advances have defined the pace of medical progress in the recent years, but the biggest challenge associated with them is assessing their safety, efficacy and value. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery has emerged as one of the most promising approaches.

Conventional thyroidectomy is a mature, safe and efficacious treatment and is considered gold standard approach for the past few decades, but the scar left in the anterior lower neck cannot be avoided. The scar results in a permanent cosmetic defect, which affects the aesthetic outcome and can prove very distressing for the patient cosmesis is particularly important to all persons as well as younger women, who constitute a large proportion of patients. While such a scar is well tolerated by many patients, local pain, paraesthesia, dysesthesias, numbness, contractures, hypertrophy of the scar and keloid formation have all been described as adverse sequelae of open thyroidectomy. Relocating the surgical scar to a less visible location is the goal of current endoscopic procedures. The impetus behind this expanding body of work is the desire to avoid a conspicuous cervical scar.

The noncervical, remote access approaches were originally developed primarily due to cosmetic considerations. The endoscopic cervical approach is surgically challenging since the neck is a very confined space and can be applied today to a small group of patients. Owing to the definite limitations of endoscopic procedures of the thyroid gland (no preexisting working space and a small and narrow operation field with close proximities of important motor nerves and major vessels to target organs), the endoscopic approach did not gain worldwide acceptance for thyroid surgery in the inception. During the early 21st century, the incorporation of cutting-edge robotic technology provided a safe and feasible approach for endoscopic thyroidectomy. Studies have serially demonstrated the surgical safety and feasibility of robotic techniques for thyroid surgery.[12],[13],[22],[23],[24],[25]

RT is an exciting new technology. The procedure requires a complete understanding of approaching routes, anatomy, and robotic instruments, and thus, sufficient training is absolutely necessary and requires careful observation of an expert's technique. The initial experiences of RT using transaxillary approach have been published, and have emphasised the importance of adequate training and patient selection before starting robotic thyroid surgery.[26],[27],[28],[29],[30],[31],[32] Many modifications have been made to devise optimal approaches. Nonetheless, these modifications present an on-going process, as is the development of more advanced robotic facilities.

Kang et al. have applied the da Vinci S surgical robot system to operations on thyroid cancer patients with low risk, using the unilateral axillary approach, and reported that adding the da Vinci S surgical robot system to endoscopic thyroidectomies has resolved the difficulties of conventional endoscopic surgery and provided additional benefits, such as the straightforward identification and preservation of the RLN and parathyroid glands; complete and safe thyroid resection and lymph node dissection in the deep, narrow working space; independence from an assistant; and improved surgeon comfort.[13],[24]

The gasless method has no risk of complications, such as hypercapnia, respiratory acidosis, tachycardia, subcutaneous emphysema and air embolism as seen in gas insufflation approaches.[5]

Despite the longer operative time, higher cost and bulkiness of the robot, it offers advantages such as improved motion of the endoscopic endowrist articulating instruments, availability of an improved three-dimensional view, and ability to damp the physiologic tremors. Moreover, the postoperative pain is comparatively less severe in RT with faster return to daily activities. RT also provides alternative benefits of significantly reducing the incidence of hyperaesthesia or paresthesia, and discomfort while swallowing.

Since we adopted our novel approach, the surgeon's learning curve has gradually improved. We speculated that an expanded set of indications will make this procedure available to a broader patient population. The gradual and step-wise extension of surgical methods and indications after proper training and sufficient experience provide the best way of optimally applying robotic thyroid surgery. Our experience with the transaxillary gasless RT described herein suggests that patient satisfaction in the India will be high.


 ¤ Conclusion Top


With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery has emerged as one of the most promising approaches. Robotic-assisted approach is feasible and safe. It produces outcomes similar to those of open thyroidectomy. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, thereby increasing patient satisfaction, and improved visualisation, arms articulations and precision, resulting in fewer surgical complications. The main disadvantages are longer operative time, and increased cost compared to conventional thyroidectomy.

On the basis of our experience, we conclude that RT using a gasless transaxillary approach is a feasible, safe and noninferior surgical alternative for selected patients. The inclusion criteria of this technique could be gradually extended to advanced thyroid cancer with experience and future introductions of the advanced robotic system or instrumental developments. In skilled hands, RT is a safe alternative to open thyroidectomy and should be offered to patients with aesthetic concerns.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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