Surgical Outcomes of Robotic Thyroidectomy for Thyroid Tumors over 4 cm via the Bilateral Axillo-Breast Approach

doi:10.21203/rs.3.rs-3476387/v1

Download PDF

Article

Surgical Outcomes of Robotic Thyroidectomy for Thyroid Tumors over 4 cm via the Bilateral Axillo-Breast Approach

https://doi.org/10.21203/rs.3.rs-3476387/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 20 May, 2024

Read the published version in Scientific Reports →

You are reading this latest preprint version

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, 74 patients underwent robotic BABA thyroidectomy. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (45.9%), atypia of undetermined significance (20.3%), follicular neoplasm (27.0%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 minutes for lobectomy and 207.3 minutes for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (3.5%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Biological sciences/Cancer/Head and neck cancer

Biological sciences/Cancer/Endocrine cancer/Thyroid cancer

minimally invasive surgery

robotic surgery

bilateral axillo-breast approach

thyroidectomy

large goiter

Thyroid nodules are a common thyroid disease worldwide. Mu et al.'s recent review and meta-analysis showed an incidence rate of one in four individuals and a growing prevalence over the past decade ¹ In parallel, remote access surgeries for thyroidectomies have developed and are increasingly used in the last two decades. In previous studies, remote-access surgeries have shown comparable results to conventional open thyroidectomy in terms of oncologic outcomes and surgical complications. This is particularly relevant as the majority of remote-access surgeries are performed for either benign conditions or small-sized differentiated thyroid cancer, for which there is an excellent prognosis.

There are several remote-access thyroid surgeries. The axillary-bilateral breast approach (ABBA) was first described in Japan in 2003 ². This was followed by the development of the bilateral axillo-breast approach (BABA) in 2004 using endoscopic instruments ³. The robotic platform was applied to this approach in 2008, and currently, robotic BABA thyroidectomy is one of the most popular remote-access techniques used in thyroid surgery ⁴. In its early application, robotic BABA thyroidectomy was used for patients with small subcentimeter tumors. However, with increasing experience and expertise, the indications for this approach are expanding, including thyroid cancer (2-4 cm), differentiated thyroid cancer with lateral node metastasis, Graves’ disease, completion thyroidectomy and large thyroid tumors ⁵. Nonetheless, there is a lack of data regarding the use of robotic BABA thyroidectomy for large thyroid nodules.

In this study, we aimed to analyze the clinicopathologic features and surgical outcomes of patients with nodules larger than 4 cm who underwent robotic BABA thyroidectomy. To our knowledge, this is the first study focusing on the feasibility and surgical outcomes of robotic BABA surgery for large nodules (>4 cm).

2.1 Patient Demographics and Clinicopathological Characteristics

A total of 74 patients were included in the study, and the demographics and clinicopathological characteristics are shown in Table 1. Our study included 68 women (91.9%) and 6 men (8.1%), with a mean age of 40.3 ± 12.9 years. Thyroid nodules were diagnosed by FNA as benign (34, 45.9%), atypia of undetermined significance (15, 20.3%), follicular neoplasm (20, 27.0%), malignancy (4, 5.4%) and lymphoma (1, 1.4%). The dominant mean size of the thyroid nodule was 4.9 ± 0.8 cm (range, 4.0-8.5 cm) by preoperative ultrasonography. Thyroid lobectomy was performed in 63 patients (85.1%), while total thyroidectomy was performed in 11 (14.9%) patients. The mean operation time was 182 ± 0.03 minutes, and the mean length of hospital stay was 2.9 ± 0.7 days.

The final histopathologic results are shown in Table 2. The most common type of tumor was benign (n=40, 54.1%), followed by high-risk neoplasms (n=28, 37.8%) and low-risk neoplasms (n=4, 5.4%). Among the patients with high-risk neoplasms, 13 patients underwent completion thyroidectomy according to ATA 2015 guideline risk stratification. All completion thyroidectomy cases were performed by robotic BABA thyroidectomy within 6 months from the first operation. The mean follow-up period was 64.9 29.2 months.

2.2 Surgical Outcomes

The operation time for each step is shown in Table 3. The mean total operation time was 178.4 ± 39.6 minutes for lobectomy and 207.3 ± 48.4 minutes for total thyroidectomy (Table 3). The mean total operation time and console time were significantly shorter in the robotic BABA lobectomy group than in the robotic BABA total thyroidectomy group (p=0.033, p=0.048). There were no significant differences between lobectomy and total thyroidectomy in each step mentioned as follows: robot setting & draping, flap dissection and closure time.

To assess the correlation between tumor size and operation time, we conducted a correlation analysis of the duration of each step involved in the surgical procedure (Table 4). As shown in Table 4, the tumor size had no effect on the total operation time or each operation step. In the case of lobectomy, no statistically significant correlations were found between the total procedure time and flap dissection time, with coefficients of 0.06 and 0.065 (p=0.641, p=0.673). As for total thyroidectomy, the study only identified a marginal positive correlation between the total operation time and tumor size, which was not statistically significant (coefficient value = 0.013, p=0.970).

There were no cases of open conversion, tumor spillage, bleeding, seroma, wound infection, flap injury or tracheal injury. Three patients (3/85, 3.5%) showed transient vocal cord palsy, and all of them recovered within 6 months. In robotic BABA total thyroidectomy, there were 3 cases (3/11, 27.2%) of transient hypoparathyroidism and 1 case (1/11, 9.1%) of permanent hypoparathyroidism (Table 5). There was no tumor recurrence during the follow-up period.

Since its introduction in 2008, robotic BABA thyroidectomy has become one of the most remarkable remote-access approaches globally, particularly in Korea ⁴. While scholars in previous studies have reported favorable outcomes of robotic BABA surgery ^6-8, there is limited research on robotic BABA thyroidectomy for large tumors.

The present study was designed to analyze the clinical pathological characteristics and surgical outcomes of robotic BABA thyroidectomy in tumors larger than 4 cm. In addition, we revealed that robotic BABA thyroidectomy showed acceptable operation times and complication rates compared to previous studies.

There are various approaches that lead to a “scarless” neck in thyroid surgery: transaxillary approaches, retroauricular approaches, trans-oral approaches and so on. Among them, BABA has the following advantages. It utilizes 4 small incisions at the bilateral breast and axillary areas that allow a symmetrical “bottom-up” view of the neck that mimics that of conventional open thyroid surgery. This facilitates the identification of the recurrent laryngeal nerves and parathyroid glands on either side of the neck, allowing the use of working ports on both sides of the patient. With the combination of robotic-assisted surgery (da Vinci robotic surgical system), the efficacy of robotic BABA thyroidectomy increased due to the advantages of multirotational wrist articulation and a three-dimensional high-resolution view.

Over time, many surgeons have demonstrated the safety of robotic BABA thyroidectomy and have tried to overcome existing surgical criteria ⁹. A recent study also suggested that surgical indications might extend up to 4 cm for malignant tumors and up to 8 cm for benign nodules ¹⁰. Nonetheless, the available evidence that inspects large tumors in detail is still insufficient.

In one recent study, Chai et al. ⁸ examined the stability of robotic BABA thyroidectomy in 21 thyroid cancers larger than 2 cm by analyzing the operation time and complications compared with conventional open surgery. Additionally, they analyzed follow-up data such as thyroglobulin levels, and radioactive iodine uptake to demonstrate the oncological outcomes in patients. However, as the study focused on malignant nodules larger than 2 cm, the average nodule size was relatively smaller than that in our study (2.8 ± 0.3 cm vs. 4.9 ± 0.8 cm), which could be associated with a shorter operation time (165.1 ± 43.9 min vs. 182.7 ± 41.9 min).

Another study, conducted by Johri et al. ¹¹ in India, involved analyzing patients who underwent BABA for large goiters based on a size of 6 cm. While our study solely focused on robotic BABA thyroidectomy, that study included endoscopic BABA or unilateral axillo-breast approach procedures. In addition, we analyzed the time according to the surgical steps, while in the prior study, the time analysis was based on the surgical extents, such as those of lobectomy, total thyroidectomy and completion thyroidectomy (Supplementary table 1). Regarding lobectomy, our study had longer operation times than the previous study, which could be attributed to the time required for robot docking (size < 6.0 cm; 152.0 ± 38.6 vs. 175.6 ± 39.4, size ≥ 6.0 cm; 184.3 ± 85.5 vs. 195.6 ± 38.2). Upon analysis for total thyroidectomy, however, both studies showed a similar operation time below 6 cm (206.4 ± 62.0 vs. 207.3 ± 48.4). In terms of complications, the present study demonstrated low rates of complications except for one case of permanent hypoparathyroidism. Whereas four cases of open conversion were reported in the prior study, we did not encounter any cases of open conversion (4.0% vs. 0.0%). The results might indicate that the robotic approach could exhibit more stability than the endoscopic approach when conducting surgery for large-sized nodule, despite a potential increase in operation time.

In this study, the mean operation time for robotic BABA lobectomy in other studies ranged from 160.9 to 236.3 minutes, while the mean operation time for robotic BABA total thyroidectomy was longer, ranging from 189.6 to 310.1 minutes ^12-14. Our mean operation time of lobectomy was 178.4 ± 39.6 minutes, and the mean operation time of total thyroidectomy was 207.3 ± 48.4. Considering that the mean size of the tumor ranged from 0.8 to 1.1 cm in the other studies, the operation times of the study were comparable. The total operation time, and console time were significant longer in robotic BABA total thyroidectomy compared to robotic BABA lobectomy. There was no significant differences were observed in the time taken for setting and draping, flap dissection, and closure steps.

There were no longer hospital stays or increased complication rates. Previous studies showed that the mean hospital stay was 3.1-4.5 days for all surgical techniques, even including the open method ^15,16. Despite the tumor size and high surgical difficulty, the length of stay did not increase compared to other studies. Our incidence of transient VCP (2.47%) was also comparable to reported rates of 0-6% for conventional thyroidectomy ¹⁷ and represented an improvement compared to 20.3% in an early series of endoscopic BABA surgery ³. The incidence of transient and permanent hypocalcemia for conventional thyroidectomy has been reported to be from 0.3% to 49% and 0% to 13%, respectively ¹⁷. In some studies on endoscopic/robotic thyroidectomies, incidences of 0-30% and 0-4% have been reported for transient and permanent hypocalcemia, respectively ^18-20. Our results for patients with large thyroid nodules showed comparable complication rates of transient hypoparathyroidism (27.2%). Although the rate of permanent hypoparathyroidism was 9.1% (1 out of 11 patients), the result has to account for the small sample size. We did not observe any other complications, such as postoperative hematoma, seroma formation, or tracheal injury. There were no skin flap-related complications, such as bruising, burns, or perforation. Additionally, no open conversions were required in our series.

A meta-analysis by Shan et al. ¹⁵ indicated that robotic BABA thyroidectomy required longer operative times than open thyroidectomy, mainly due to additional time for flap creation and robot docking. Conversely, with the optimal flap dissection procedure, robotic BABA thyroidectomy is able to secure a wider working space, which allows for better dissection of larger tumors. An issue of concern in minimally invasive surgery for large tumors is the potential for tumor spillage. However, among the remote-access techniques, robotic BABA surgery offers several advantages in managing larger-sized thyroid tumors. The use of 3 working ports excluding the camera port makes it easier to achieve good retraction for larger glands as well. The Endo-wrist exhibits a wide range of motion, which facilitates easy retraction of the gland medially and laterally and reduces operator fatigue. Furthermore, the axillary skin is easily stretched to accommodate specimen extraction and, if needed, can be extended more with little compromise to cosmetic results ^21,22. These findings explain why BABA can be a safe approach even for Graves' disease ²³. Consequently, we had no case of spillage in the operation bed or tract during thyroidectomy. When followed for an average of 64.9 months, all the patients had no recurrence.

Despite the comparable results, our study has several limitations. First, the restricted number of cases included in this study makes it challenging to assess the complications in comparison to other research. Second, as a retrospective study, the results led to selection biases and missing data. Third, the final pathology includes a wide variety of both benign and malignant conditions, with benign conditions being the majority. Hence, it is also difficult to analyze the adequacy of oncological clearance for larger malignant tumors in patients undergoing robotic BABA thyroidectomy. To our knowledge, however, this is the first study focused on evaluating the surgical safety and outcomes of robotic BABA thyroidectomy for larger tumors that includes an analysis of the time taken for each operative step and postoperative complications.

In conclusion, the study revealed that patients with larger thyroid tumors can also benefit from having a “scarless in the neck” surgery. Robotic BABA surgery is a safe technique that can be extended to such patients with no significant increase in complications, provided there is a sufficient level of surgical experience and expertise.

4.1 Patients

We retrospectively reviewed the electronic medical charts of patients who underwent robotic BABA thyroidectomy for thyroid nodules over 4 cm with preoperative neck ultrasonography in Seoul National University Hospital between January 2008 and August 2022. Robotic thyroidectomies were performed using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA). The extent of thyroidectomy was determined by fine needle aspiration (FNA) results, tumor size, tumor location, multifocality and underlying thyroid disease (Hashimoto’s thyroiditis or Graves’ disease).

All patients who underwent the operation were evaluated by preoperative sonography and CT (Figure 1). The study was approved by the Institutional Review Board of Seoul National University Hospital (H-2212-056-1384). Informed consent was waived due to the retrospective nature of this study.

4.2 Surgical Procedure

The process of robotic BABA thyroidectomy involved the following steps: i) setting & draping; ii) flap dissection; iii) thyroidectomy; and iv) closure ⁵. i) The setting and draping was defined as the induction of general anesthesia and the completion of surgical drape. Under general anesthesia, patients lay in the supine position with neck extension over the thyroid pillow, and surgeons draped from the neck to the breast area. ii) Flap dissection was defined as the step from hydrodissection to completion of the skin flap. We drew the surgical marking over the chest for incision line and flap dissection. A diluted epinephrine solution (1:200,000) was injected along the surgical marking for hydrodissection. Four incisions were made for robotic BABA thyroidectomy in bilateral axillae and bilateral supra-areolas. In flap dissection, the operator made a working space from 2 cm below the clavicle to the thyroid cartilage and beyond the medial border of the sternocleidomastoid muscle. When creating the initial working space, blunt dissection was performed with a tunneler. After sufficient working space was made, the flap was extended by using an energy device. When flap dissection was complete, the position was modulated to 30 degrees of Trendelenburg, and robot docking started. iii) In a routine robotic BABA thyroidectomy procedure, the midline was separated, and thyroidectomy was performed in console. In selected cases, lymph node dissection was conducted during the surgical procedure based on the results of FNA, imaging studies and the surgeon's clinical judgment. Throughout the surgical procedures, we attempted to locate and preserve the parathyroid glands. In all cases, an intraoperative neuro-monitoring system was used to identify and preserve recurrent laryngeal nerves (Figure 2). iv) The closure was executed by suturing the strap muscle and then closing the skin.

4.3 Postoperative Follow-Up

The vocal cords of all subjects were evaluated using laryngoscopy or laryngeal ultrasonography preoperatively and postoperatively. Vocal cord palsy (VCP) was diagnosed as fixation or hypomobility on laryngoscopy or sonography. For patients with vocal cord hypomobility or palsy, repeated examinations were conducted during the follow-up visits. Transient VCP was defined as an injury that recovered within 6 months, while permanent VCP was the status that did not recover beyond 6 months. In the case of total thyroidectomy patients, serum levels of total calcium, ionized calcium, phosphorus and parathyroid hormone were added to evaluate postoperative hypoparathyroidism. Hypoparathyroidism was defined by laboratory findings of parathyroid hormone (PTH) under 15.0 pg/ml or the need for calcium medication for symptom relief, such as numbness and tingling sensations. Transient hypoparathyroidism was perceived as a recovery within 6 months, while permanent hypoparathyroidism was defined as still requiring calcium supplementation 6 months after the operation.

4.4 Statistical Analysis

Statistical analysis was performed using Statistic Package for Social Science (SPSS 25.0). Continuous variables are reported as the mean with standard deviation (SD), and categorical variables are reported as frequencies and percentages. While linear regression analysis was used to compare continuous variables, a paired T test was used to compare the categorical variables. Pearson’s correlation coefficients between tumor size and operation time were calculated.

ABBA, axillary-bilateral breast approach; BABA, bilateral axillo-breast approach; FNA, fine needle aspiration; VCP, Vocal cord palsy: PTH, parathyroid hormone

Ethics Statement

The study was carried out in accordance with the principles laid out in the World Medical Association’s Declaration of Helsinki. This study was approved by the Institutional Review Board of Seoul National University Hospital. As data were obtained retrospectively, patient identities remained undisclosed. Informed consent is not mandatory for retrospective studies in Korea, and the institutional review board waived the need for informed consent.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author Contributions

HL B, JH W, and SK contributed to the conception and design of the study. JK, HWY, JYC, YJC and LKE organized the database. YJ and JC performed the statistical analyses. HL B and JH W wrote the first draft of the manuscript and wrote sections of the manuscript. All authors contributed to manuscript revision and read and approved the submitted version. All authors contributed to the article and approved the submitted version.

Funding

This research was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIP) (grant numbers: 2021R1F1A1055710).

Acknowledgments

We would like to thank the patients who provided us information.

Data Availability Statement

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Mu, C. et al. Mapping global epidemiology of thyroid nodules among general population: a systematic review and meta-analysis. Front Oncol 12, 1029926 (2022). https://doi.org:10.3389/fonc.2022.1029926
Shimazu, K. et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13, 196-201 (2003). https://doi.org:10.1097/00129689-200306000-00011
Choe, J. H. et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31, 601-606 (2007). https://doi.org:10.1007/s00268-006-0481-y
Lee, K. E., Rao, J. & Youn, Y. K. Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique: our initial experience. Surg Laparosc Endosc Percutan Tech 19, e71-75 (2009). https://doi.org:10.1097/SLE.0b013e3181a4ccae
Kwak, J. et al. Robotic completion thyroidectomy via the bilateral axillo-breast approach. J Clin Med 10, 1707 (2021). https://doi.org:10.3390/jcm10081707
Choi, Y. S., Shin, W. Y. & Yi, J. W. Single surgeon experience with 500 cases of the robotic bilateral axillary breast approach (BABA) for thyroid surgery using the Da-Vinci Xi system. J Clin Med 10, 4048 (2021). https://doi.org:10.3390/jcm10184048
Lee, K. E. et al. Robotic thyroidectomy by bilateral axillo-breast approach: review of 1,026 cases and surgical completeness. Surg Endosc 27, 2955-2962 (2013). https://doi.org:10.1007/s00464-013-2863-1
Chai, Y. J. et al. Surgical safety and oncological completeness of robotic thyroidectomy for thyroid carcinoma larger than 2 cm. Surg Endosc 31, 1235-1240 (2017). https://doi.org:10.1007/s00464-016-5097-1
Kim, W. et al. Advancements in bilateral axillo-breast approach (BABA) robot surgery: a review. Ann Robot Innov Surg 3, 34-40 (2022). https://doi.org:10.37007/aris.2022.3.2.35
Kwak, J., Yu, H. W. & Lee, K. E. Bilateral axillo-breast approach robotic thyroid surgery. Ann Robot Innov Surg 1, 69-80 (2020). https://doi.org:10.37007/aris.2020.1.e10
Johri, G. et al. Feasibility of endoscopic thyroidectomy via axilla and breast approaches for larger goiters: widening the horizons. J Thyroid Res 2018, 4057542 (2018). https://doi.org:10.1155/2018/4057542
Kim, W. W., Jung, J. H. & Park, H. Y. A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach. J Surg Oncol 111, 135-140 (2015). https://doi.org:10.1002/jso.23793
Kim, E. B. et al. Postsurgical outcomes and surgical completeness of robotic thyroid surgery: a single surgeon's experience on 700 cases. J Laparoendosc Adv Surg Tech A 28, 540-545 (2018). https://doi.org:10.1089/lap.2017.0597
Cho, J. N., Park, W. S., Min, S. Y., Han, S. A. & Song, J. Y. Surgical outcomes of robotic thyroidectomy vs. conventional open thyroidectomy for papillary thyroid carcinoma. World J Surg Oncol 14, 181 (2016). https://doi.org:10.1186/s12957-016-0929-y
Shan, L. & Liu, J. Meta-analysis Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy and Conventional Thyroidectomy. Surg Innov 26, 112-123 (2019). https://doi.org:10.1177/1553350618817145
de Vries, L. H. et al. Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 12, 719397 (2021). https://doi.org:10.3389/fendo.2021.719397
Randolph, G. & Randolph, G. Surgery of the Thyroid and Parathyroid Glands. (Saunders, 2003).
Choi, J. Y. et al. Endoscopic thyroidectomy via bilateral axillo-breast approach (BABA): review of 512 cases in a single institute. Surg Endosc 26, 948-955 (2012). https://doi.org:10.1007/s00464-011-1973-x
Chai, Y. J. et al. A comparative study of postoperative pain for open thyroidectomy versus bilateral axillo-breast approach robotic thyroidectomy using a self-reporting application for iPad. Ann Surg Treat Res 90, 239-245 (2016). https://doi.org:10.4174/astr.2016.90.5.239
Rao, R. S. & Duncan, T. D. Endoscopic total thyroidectomy. JSLS 13, 522-527 (2009). https://doi.org:10.4293/108680809X12589998404209
Anuwong, A. et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc 32, 456-465 (2018). https://doi.org:10.1007/s00464-017-5705-8
Duncan, T. D., Rashid, Q. N. & Speights, F. Surgical excision of large multinodular goiter using an endoscopic transaxillary approach: a case report. Surg Laparosc Endosc Percutan Tech 18, 530-535 (2008). https://doi.org:10.1097/SLE.0b013e31817fd99f
Kwon, H. et al. Comparison of bilateral axillo-breast approach robotic thyroidectomy with open thyroidectomy for graves' disease. World J Surg 40, 498-504 (2016). https://doi.org:10.1007/s00268-016-3403-7

Table 1. Patient demographic characteristics.

*Patient demographic* *characteristics*	*Total (n=74)*
Sex (n, %) Female Male	68 (91.9%) 6 (8.1%)
Age (years, mean SD)	40.3 12.9 [15-67]
BMI (mean SD)	22.9 3.7 [16.7-35.5)
Thyroid nodule main location (n, %) Right Left	35 (47.3%) 39 (52.7%)
Preoperative nodule size (cm, mean SD)	4.9 0.8 [4.0-8.5]
Preoperative FNA (n, %) Benign AUS FN PTC/ suspicious PTC Lymphoma	34 (45.9%) 15 (20.3%) 20 (27.0%) 4 (5.4%) 1 (1.4%)
Extent of thyroidectomy (n, %) Lobectomy Total thyroidectomy	63 (85.1%) 11 (14.9%)
Central lymph dissection (n, %) No Yes	65 (87.8%) 9 (12.2%)
Length of hospital stay (days)	3.9 ± 0.7 [2-5]
Operation time (min)	182.7 ± 41.9 [90-310]

BMI, body mass index; FNA, fine needle aspiration; AG, adenomatous goiter, AUS, atypia of undetermined significance; FN, follicular neoplasm, PTC, papillary thyroid carcinoma,

Table 2. Final histopathological results.

*Histopathological results*		*Total (n=74)*
Benign tumor (n=40, 54.1%)	Follicular nodular disease	24 (32.4%)
	Follicular adenoma	13 (16.2%)
	Oncocytic adenoma	3 (4.1%)
Low-risk neoplasm (n=4, 5.4%)	FT-UMP NIFTP	2 (2.7%) 1 (1.4%)
Low-risk neoplasm (n=4, 5.4%)	Hyalinizing trabecular tumor	1 (1.4%)
High-risk neoplasm (n=28, 37.8%)	Follicular thyroid carcinoma	14 (18.9%)
	FVPTC	10 (13.5%)
	PTC	2 (2.8%)
	Oncocytic carcinoma	2 (2.8%)
ETC (n=2, 2.8%)	Dyshormonogenetic goiters	1 (1.4%)
ETC (n=2, 2.8%)	Lymphoma	1 (1.4%)

FT-UMP, follicular tumor of uncertain malignant potential; FVPTC, follicular variant papillary thyroid carcinoma; PTC, papillary thyroid carcinoma

Table 3. Analysis of operation times between lobectomy and total thyroidectomy.

*Operation step*	*Lobectomy*	*Total thyroidectomy*	*p value*
Total operation	178.4 ± 39.6 (min)	207.3 ± 48.4 (min)	0.034
Robot setting & draping	23.3 ± 10.1 (min)	25.0 ± 8.5 (min)	0.613
Flap dissection	46.4 ± 15.0 (min)	45.0 ± 21.8 (min)	0.832
Console time	60.4 ± 27.6 (min)	94.0 ± 30.1 (min)	0.017
Closure	20.9 ± 7.8 (min)	20.0 ± 4.5 (min)	0.785

Table 4. The correlation coefficient values between operation times and tumor size.

*Operation step*	*Lobectomy*	*p value*	*Total thyroidectomy*	*p value*
Total operation	0.060	0.641	0.013	0.970
Robot setting & draping	-0.096	0.476	-0.310	0.384
Flap dissection	0.065	0.673	-0.206	0.657
Console time	-0.003	0.986	-0.122	0.845
Closure	-0.061	0.714	-0.278	0.594

Table 5. Postoperative complications.

Postoperative complication

n, %

Vocal cord palsy

Transient

Permanent

3 (3.5%)

0 (0%)

Hypoparathyroidism

Transient

Permanent

3 (27.2%)

1 (9.1%)

Other complications (n, %)

Bleeding

Seroma

Wound Infection

Flap injury

Tracheal injury

0 (0%)

No competing interests reported.

SuppleTable231020BABAthyroidnoduleover4cm.docx

Download PDF

Journal Publication

published 20 May, 2024

Read the published version in Scientific Reports →

Editorial decision: Revision requested
09 Feb, 2024
Reviews received at journal
26 Jan, 2024
Reviewers agreed at journal
24 Jan, 2024
Reviews received at journal
09 Jan, 2024
Reviewers agreed at journal
31 Dec, 2023
Reviews received at journal
08 Dec, 2023
Reviewers agreed at journal
05 Nov, 2023
Reviewers invited by journal
28 Oct, 2023
Editor assigned by journal
25 Oct, 2023
Editor invited by journal
25 Oct, 2023
Submission checks completed at journal
25 Oct, 2023
First submitted to journal
22 Oct, 2023

You are reading this latest preprint version

Surgical Outcomes of Robotic Thyroidectomy for Thyroid Tumors over 4 cm via the Bilateral Axillo-Breast Approach

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Results

2.1 Patient Demographics and Clinicopathological Characteristics

2.2 Surgical Outcomes

Discussion

Methods

4.1 Patients

4.2 Surgical Procedure

4.3 Postoperative Follow-Up

4.4 Statistical Analysis

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1