Thyroidectomy is a relatively new application of the surgical robot and allows completion of a total thyroidectomy and central compartment node dissection while avoiding neck incisions.
Jan L. Kasperbauer, M.D., of the Department of Otorhinolaryngology at Mayo Clinic, says: "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."
The surgical robot consists of a surgeon workstation and a separate working platform with articulated arms in contact with the patient.
Application of the gasless technique of robotic thyroidectomy was pioneered by Dr. Woong Youn Chung of Yonsei University College of Medicine, Seoul, South Korea. The need to avoid scars in a population with a high incidence of keloid formation and negative social stigma associated with neck scars provided the impetus for this approach. Dr. Chung's work forms a benchmark for early adapters in the United States and elsewhere.
Dr. Kasperbauer explains: "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 2 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 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.
Dr. Kasperbauer notes: "Patient body habitus must be taken into consideration, and obese patients are not candidates. As with most procedures, gradual expansion of indications will occur as experience builds. Current contraindications to the robotic approach include lateral neck nodes, papillary cancers larger than 2 cm in diameter or located in the posterior portion of the gland, and indeterminate lesions greater than 4 cm in diameter."
To determine the safety, applicability, and outcomes associated with robotic thyroid surgery, Dr. Kasperbauer and colleagues have established a prospective study at Mayo Clinic in Rochester, Minnesota. This investigation was initiated after performing procedures on cadavers and observing robotic thyroid surgery performed by Dr. Chung in South Korea.
Dr. Kasperbauer comments: "Early experience with lobectomy and near-total thyroidectomy with central compartment dissection in our patients has been rewarding without permanent hypocalcemia or vocal cord paralysis."
John C. Morris, M.D., of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic, says: "It is important for patients and endocrinologists to understand that robotic thyroidectomy is not minimally invasive and is not the standard of care. The main advantage of robotic thyroidectomy is cosmetic—no neck surgical scar. The standard with which we need to compare outcomes is the open-collar incision for access to the thyroid gland, which in experienced hands is very safe, effective, and well accepted.
"Until we 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."