Robotic thyroidectomy

Robotic thyroidectomy is a relatively new application of the surgical robot and allows completion of a total thyroidectomy and central compartment node dissection. Although the robotic approach is not minimally invasive and is not the current standard of care, this approach has a cosmetic advantage — no neck scars.

Robotic thyroidectomy was pioneered in Asia. The need to avoid scars in a population with a high incidence of keloid formation and social stigma associated with neck scars provided the impetus for this approach. And this work forms a benchmark for early adopters in the United States and elsewhere.

According to surgeons in the Department of Otorhinolaryngology at Mayo Clinic in Rochester, Minn., robotic thyroidectomy is possible because of the excellent visualization provided by a high-resolution camera, wristed instrumentation promoting delicate and complex motions, and application of the harmonic scalpel to divide and seal vessels without ligature.

Although most applications of the surgical robot can be considered minimally invasive, its application to thyroidectomy should not be considered minimally invasive because the incisions are more distant and, therefore, a greater dissection length is required for access.

Surgeon workstation

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Surgical robot working platform

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Patient position and incision

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The surgical robot consists of a surgeon workstation and a separate working platform, with articulated arms in contact with the patient.

Access for the camera and instruments to reach the thyroid and central neck is acquired by an incision of approximately 6 cm in the anterior axillary fold and a separate small skin incision adjacent to the sternum. Elevation of skin and subcutaneous tissues off the pectoralis fascia and lower neck muscles provides working space.

The camera and two working arms are placed through the anterior axillary fold incision and a separate working arm is placed through the separate skin incision adjacent to the sternum. The 30° camera angle and harmonic scalpel allow the surgeon to perform a near-total thyroidectomy and central compartment node dissection if indicated.

Ideal candidates

Ideal surgical candidates have indeterminate thyroid lesions less than 4 cm in diameter or confirmed papillary thyroid cancers less than 2 cm in diameter that do not extend to the posterior portion of the gland. Patient body habitus must be taken into consideration, and obese patients are not candidates.

Current contraindications to the robotic approach include:

• Thyroid cancer spread to lateral neck nodes
• Papillary cancers larger than 2 cm in diameter or located in the posterior portion of the gland
• Indeterminate lesions greater than 4 cm in diameter

As with most procedures, gradual expansion of indications will occur as experience builds. Open-collar incision, which in experienced hands is very safe, effective and well accepted for access to the thyroid gland, is the standard with which outcomes should be compared. Until researchers learn more, robotic thyroidectomy should be reserved for patients who, for cosmetic reasons, wish to avoid a neck scar in exchange for an incision and scar in the anterior axillary fold.

To determine the safety, applicability and outcomes associated with robotic thyroid surgery, Mayo Clinic surgeons have established a prospective study. Early experience with partial and near-total thyroidectomy has been rewarding without complications of permanent hypocalcemia or vocal cord paralysis.

Points to remember

• Robotic thyroidectomy is a relatively new application of the surgical robot and allows completion of a total thyroidectomy with no surgical scar in the patient's neck.
• Ideal surgical candidates have either indeterminate thyroid lesions less than 4 cm in diameter or confirmed papillary thyroid cancers less than 2 cm in diameter that do not extend to the posterior portion of the gland.
• Mayo Clinic surgeons have established a prospective study to determine the safety, applicability and outcomes associated with robotic thyroid surgery.