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Feasibility and Safety of a New Robotic Thyroidectomy Through a Gasless, Transaxillary Single-Incision Approach
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Feasibility and Safety of a New Robotic Thyroidectomy Through a Gasless, Transaxillary Single-Incision Approach Sudhi Agarwal, MS, Mayiluaganan Sabaretnam, MS, Agarwal Ritesh, MS, Gyan Chand, MS Lucknow, India We have read with interest the article by Dr Ryu and colleagues,1 and would like to congratulate the authors for their innovative ideas, highly prudent in the development of robotic head and neck surgery. This group has adopted and mastered this technique for many years; all the other institutes have gained experience only recently.2 We have some queries for the authors: 1. Because the authors included patients with welldifferentiated thyroid carcinoma ⱕ2 cm and excluded those with definite extrathyroidal tumor invasion, how did they include T3 and T4a lesions? 2. Similarly, they excluded patients with lateral neck node metastasis, so how did they include N1b lesions? 3. Why did they exclude the distant metastasis, since a well-differentiated intrathyroidal follicular thyroid cancer with a distant solitary focus can be removed as safely as one without any distant metastasis? 4. The authors followed the American Thyroid Association recommendations for thyroidectomy. However, the 2009 American Thyroid Association guidelines (Recommendation 26) recommend total or near total thyroidectomy for tumors ⬎1 cm and lobectomy for low risk tumors ⱕ1 cm, and do not recommend subtotal thyroidectomy.3
REFERENCES 1. Ryu HR, Kang SW, Lee SH, et al. Feasibility and safety of a new robotic thyroidectomy through a gasless, transaxillary single incision approach. J Am Coll Surg 2010;211:e13–19. 2. Landry CS, Grubbs EG, Morris GS, et al. Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery 2010 Oct 12. [Epub ahead of print] 3. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. The American Thyroid Association (ATA) Guidelines Taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid 2009:19;1167–1214.
Disclosure Information: Nothing to disclose.
© 2011 by the American College of Surgeons Published by Elsevier Inc.
Reply Haeng Rang Ryu, MD, Sang-Wook Kang, MD, Woong Youn Chung, MD Seoul, Republic of Korea We appreciate Dr Sudhi Agarwal’s interest and excellent comments on our article about robotic thyroidectomy using a transaxillary single incision.1 Dr Agarwal raised several questions about patient selection. Initial patient selection and surgical strategy is very important. Clear patient selection criteria for the new technique of robotic thyroidectomy would clearly contribute to the expansion of this procedure worldwide. Answers to specific questions Dr. Agarwal has raised are as follows: 1. All patients with thyroid carcinoma underwent preoperative high-resolution staging ultrasonography. Using ultrasonography, we evaluated extrathyroidal invasion of the tumor, tumor infiltration of adjacent structures, and nodal involvement precisely.2 We excluded the patients with definite extrathyroidal tumor invasion preoperatively. However, if the cancer had minimal thyroidal extension, the patients were enrolled for robotic thyroidectomy. Most of the T3 lesions in this article represented patients with minimal thyroid capsule invasion of the tumor. Despite our careful preoperative staging and exclusion of patients with extrathyroidal invasion, unexpected T4a cases were occasionally encountered. We had 4 cases of unexpected, recurrent laryngeal nerve invasion; the tumor invasions were shallow and confined to the perineurium. We could shave off the tumor using endoscopic scissors and robotic monopolar scissors without damage to the nerves. All of the cases were successfully managed with endoscopic or robotic procedures without any severe perioperative morbidity or open conversion. All of these patients with advanced disease received postoperative radioactive iodine therapy (high dose, 150 mCi) and survived without any evidence of recurrence at the last follow-up. 2. While creating working space for robotic thyroidectomy, we sometimes noted several lymph nodes around the internal jugular vein that were not detected preoperatively with ultrasonography and CT. We usually remove these lymph nodes, and if the nodes are grossly suspicious for metastasis, we check the nodes with frozen section. If the lymph nodes are confirmed as metastatic nodes, we usually perform an additional robotic-modified radical neck dissection. However, if the lymph nodes are grossly thought
1097
ISSN 1072-7515/11/$36.00 doi:10.1016/j.jamcollsurg.2011.02.026
Feasibility and Safety of a New Robotic Thyroidectomy Through a Gasless, Transaxillary Single-Incision Approach Sudhi Agarwal, MS, Mayiluaganan Sabaretnam, MS, Agarwal Ritesh, MS, Gyan Chand, MS Lucknow, India We have read with interest the article by Dr Ryu and colleagues,1 and would like to congratulate the authors for their innovative ideas, highly prudent in the development of robotic head and neck surgery. This group has adopted and mastered this technique for many years; all the other institutes have gained experience only recently.2 We have some queries for the authors: 1. Because the authors included patients with welldifferentiated thyroid carcinoma ⱕ2 cm and excluded those with definite extrathyroidal tumor invasion, how did they include T3 and T4a lesions? 2. Similarly, they excluded patients with lateral neck node metastasis, so how did they include N1b lesions? 3. Why did they exclude the distant metastasis, since a well-differentiated intrathyroidal follicular thyroid cancer with a distant solitary focus can be removed as safely as one without any distant metastasis? 4. The authors followed the American Thyroid Association recommendations for thyroidectomy. However, the 2009 American Thyroid Association guidelines (Recommendation 26) recommend total or near total thyroidectomy for tumors ⬎1 cm and lobectomy for low risk tumors ⱕ1 cm, and do not recommend subtotal thyroidectomy.3
REFERENCES 1. Ryu HR, Kang SW, Lee SH, et al. Feasibility and safety of a new robotic thyroidectomy through a gasless, transaxillary single incision approach. J Am Coll Surg 2010;211:e13–19. 2. Landry CS, Grubbs EG, Morris GS, et al. Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery 2010 Oct 12. [Epub ahead of print] 3. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. The American Thyroid Association (ATA) Guidelines Taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid 2009:19;1167–1214.
Disclosure Information: Nothing to disclose.
© 2011 by the American College of Surgeons Published by Elsevier Inc.
Reply Haeng Rang Ryu, MD, Sang-Wook Kang, MD, Woong Youn Chung, MD Seoul, Republic of Korea We appreciate Dr Sudhi Agarwal’s interest and excellent comments on our article about robotic thyroidectomy using a transaxillary single incision.1 Dr Agarwal raised several questions about patient selection. Initial patient selection and surgical strategy is very important. Clear patient selection criteria for the new technique of robotic thyroidectomy would clearly contribute to the expansion of this procedure worldwide. Answers to specific questions Dr. Agarwal has raised are as follows: 1. All patients with thyroid carcinoma underwent preoperative high-resolution staging ultrasonography. Using ultrasonography, we evaluated extrathyroidal invasion of the tumor, tumor infiltration of adjacent structures, and nodal involvement precisely.2 We excluded the patients with definite extrathyroidal tumor invasion preoperatively. However, if the cancer had minimal thyroidal extension, the patients were enrolled for robotic thyroidectomy. Most of the T3 lesions in this article represented patients with minimal thyroid capsule invasion of the tumor. Despite our careful preoperative staging and exclusion of patients with extrathyroidal invasion, unexpected T4a cases were occasionally encountered. We had 4 cases of unexpected, recurrent laryngeal nerve invasion; the tumor invasions were shallow and confined to the perineurium. We could shave off the tumor using endoscopic scissors and robotic monopolar scissors without damage to the nerves. All of the cases were successfully managed with endoscopic or robotic procedures without any severe perioperative morbidity or open conversion. All of these patients with advanced disease received postoperative radioactive iodine therapy (high dose, 150 mCi) and survived without any evidence of recurrence at the last follow-up. 2. While creating working space for robotic thyroidectomy, we sometimes noted several lymph nodes around the internal jugular vein that were not detected preoperatively with ultrasonography and CT. We usually remove these lymph nodes, and if the nodes are grossly suspicious for metastasis, we check the nodes with frozen section. If the lymph nodes are confirmed as metastatic nodes, we usually perform an additional robotic-modified radical neck dissection. However, if the lymph nodes are grossly thought
1097
ISSN 1072-7515/11/$36.00 doi:10.1016/j.jamcollsurg.2011.02.026