This is a retrospective observational single institution-based study comprising 19 patients who underwent robotic thyroid surgery for thyroid carcinoma between October 2018 till January 2022 at Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India.
The preoperative diagnosis of patients with thyroid nodules was determined by ultrasound examination, and all patients underwent fine-needle aspiration cytology (FNAC) preoperatively. Only two patients had incidentally detected thyroid nodules on the Whole body [18 F] Positron Emission Tomography Scan. All patients underwent either indirect laryngoscopy or fiberoptic direct laryngoscopy to assess the vocal cords preoperatively.
All robotic thyroidectomies were performed using the Xi DaVinci Surgical system (Intuitive Surgical, Sunnyvale, California). The approach used was selected based on the extent of the disease, the patient’s preference and the criteria mentioned below. Informed consent was obtained from all patients for robotic surgery.
The indications for robotic thyroidectomy were differentiated thyroid carcinoma of size less than 4 cm in diameter without/with minimal extrathyroidal extension (ETE) and sub cm to cm-sized lymph node metastases in the central compartment or lateral compartment of the neck. Contraindications included large differentiated thyroid carcinoma with gross extra thyroid extension, bulky neck nodes with infiltration of adjacent neck structures and a previous history of neck surgery. In our institution, either Modified BABA (Bilateral AxilloBreast Approach) or Retroauricular approach for robotic thyroidectomy was used.
Selection criteria of various approaches :
1) Patients with nodules in both thyroid lobes and each nodule size between 3-4 cm with bilateral central compartment nodes generally underwent a Modified BABA approach. In patients with a previous history of radiation therapy - Modified BABA was preferred.
2) Patients with nodules between 3 and 4 cm in the thyroid lobe and nodes in the lateral compartment of the neck generally underwent a Retroauricular (facelift) approach.
3) For Patients who required total thyroidectomy with bilateral lateral compartment nodal clearance - A bilateral Retroauricular approach was used.
4) Patients with thyroid microcarcinoma requiring hemithyroidectomy were asked about personal preference for the approach after explaining both approaches.
A) Modified BABA approach:
In this approach, we utilised five port incision sites, i.e. two breast (areola) ports, two axillary ports and one assistant port. The assistant port was always made on the right side between the breast and axillary port in the anterior axillary line, which the assistant used for suctioning, ligaclips application and retraction of structures during surgery. All ports were 8 mm in length except the assistant port, which was 12 mm. The patient's position was supine, with the neck extended and arms slightly abducted. Initially, laparoscopic guided flap elevation in a plane above the pectoralis muscle was done, and it took approximately 45 minutes. Docking of the robot was done next, and robotic surgery commenced. The working space was maintained using CO2 insufflation at a pressure of 5–6 mm of Hg. The midline fascia between the strap muscles was divided, and the isthmus was dissected and cut to aid in mobilising the thyroid gland. The thyroid gland was dissected, with the parathyroid glands preserved, as well as the external branch of the Superior Laryngeal Nerve and Recurrent Laryngeal Nerve (RLN). The resected specimen was removed in a retrieval bag through the 12-mm assistant port. Suction drains were placed, and the port incisions were closed.
Advantages :
1) Provides a symmetrical view similar to conventional surgery.
2) Gives the most significant operating angle to prevent instrument collision.
3) Both thyroid and central compartment lobes can be easily approached.
4) The assistant port helps in retraction, suctioning, ligature clip application and better handling of the gland.
5) Excellent cosmesis due to tiny separate and hidden incisions.
Disadvantages :
1) Requires a longer operative time.
2) Specimen retrieval of larger thyroid nodules is complex.
3) Difficulty in accessing lateral neck nodes, especially level II.
B) Retroauricular (facelift) approach.
This approach utilised the postauricular and occipital hairline incision. The flap was raised in the subplatysmal plane over the SCM muscle under direct vision and using a headlight. Limits of raising the flap were the posterior border of the SCM muscle, superiorly to the lower border of the mandible, inferiorly up to the sternal notch and anteriorly to the anterior of the contralateral SCM. The flap was raised to the anterior border of the trapezius posteriorly if lateral neck dissection was also to be done. The Chung retractor was applied, and the robot was docked. The superior belly of omohyoid, sternohyoid and sternothyroid muscles were dissected and retracted to expose the thyroid gland. The parathyroid glands were identified and preserved. RLN was identified in the tracheoesophageal groove and preserved. The Berry’s ligament and thyroid isthmus were dissected, and thyroidectomy was then completed. A suction drain was placed, and the incision was closed in layers.
Advantages :
1) Closest approach to the thyroid; thus, operative time is less.
2) Good cosmesis, as the scar is hidden behind the auricle and hairline.
3) Approaching the lateral compartment neck nodes on the ipsilateral side is more accessible.
4) Larger thyroid nodules can be retrieved easily due to a longer incision.
Disadvantages :
1) It does not provide a symmetrical view of thyroid surgery compared to the conventional approach.
2) Narrow working space leads to cluttering and collision of instruments.
3) Difficulty in accessing the contralateral lobe.
C) Bilateral Retroauricular approach
This approach is similar to the ipsilateral Retroauricular approach, with the only addition of a contralateral postauricular incision for contralateral lobectomy/contralateral neck dissection when the exposure using the ipsilateral incision was inadequate.
Data Collection
In this retrospective review, data collection was done, which included patient and tumour characteristics, operative time, post-operative Parathyroid hormone and ionised serum calcium levels, post-operative stay, histopathological results, number of retrieved lymph nodes, postoperative scar and Pre-Adjuvant radioiodine therapy Thyroglobulin levels. Total operative time was defined as the time from the first incision to the completion of skin closure, and it also included docking and undocking of the robot. Continuous variables were expressed as the median with range, and categorical variables as the number with percentage.