- Email: [email protected]
Robotic facelift thyroidectomy
Operative Techniques in Otolaryngology (2013) 24, 120–125
Robotic facelift thyroidectomy Lauren C. White, MD, Michael C. Singer, MD, David J. Terris, MD, FACS From the Department of Otolaryngology-Head and Neck Surgery, Georgia Regents University, Augusta, Georgia KEYWORDS Thyroid; Robotic; Remote access; Cosmetic
The field of thyroid surgery has evolved to the point where multiple access options are now available. These include conventional approaches, minimally invasive endoscopic and non-endoscopic methods, and even remote access techniques with or without robotic assistance. Remote access surgery is reserved for those individuals who are committed to completely eliminating a neck scar. The procedures require more extensive dissection and robotic technology facilitates their performance. While an axillary approach has been the most commonly pursued, we have developed an easier technique that puts fewer structures at risk and involves a reduced area of dissection. It uses as its access portal a modified facelift incision. r 2013 Elsevier Inc. All rights reserved.
Introduction Surgical approaches to thyroidectomy have progressively evolved over the past decade. Innovations, such as highresolution endoscopy, remote-access surgery, and robotic techniques, have transformed the procedure in many centers. The traditional Kocher incision followed by subplatysmal flap elevation and retraction of strap muscles has transitioned to minimally invasive techniques with reduced incision size, faster recovery, and more rapid wound healing. The video-assisted endoscopic minimally invasive technique, pioneered by Miccoli et al. in Pisa,1 has been adopted by numerous groups because of its small cervical incision, gasless technique, and reduced recovery time.2 This technique has matured into a commonly available approach,3 but still is associated with a cervical incision with sometimes unpredictable healing outcomes. Ikeda et al. in Tokyo were among the first to systematically explore remote-access alternatives that would obviate the need for a cervical incision.4 They described a transaxillary endoscopic approach requiring insufflation.
Address reprint requests and correspondence: David J. Terris, MD, FACS, Georgia Regents Thyroid Center, Department of Otolaryngology, Georgia Regents University, 1120 15th St, BP-4109, Augusta, Georgia 30912-4060. E-mail address: [email protected]. 1043-1810/$ - see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2013.04.007
Although this strategy achieves the worthy goal of avoiding the cervical scar associated with the conventional Kocher incision, the axillary approach involves the dissection of planes less familiar to thyroid surgeons and requires awkward arm positioning to rotate the clavicle downward and shorten the distance to the thyroid compartment. The procedure is lengthy and requires a prolonged hospital stay. The introduction of the da Vinci surgical robotic system offers the benefit of 3-dimensional optics in comparison to the 2-dimensional environment of traditional endoscopic surgery. With the implementation of the robotic technology, Woong Youn Chung and his group in Seoul refined the axillary thyroidectomy and developed a gasless technique that uses a novel retractor to maintain the optical cavity, avoiding the need for insufflation of the dissection field.5,6 He has built a large practice focusing on robotic axillary thyroidectomy (RAT) over the past 5 years during which more than 1,500 procedures have been performed with promising outcomes. When attempts were made to replicate the RAT in North America, however, a number of dramatic and severe complications have occurred at an alarming rate. These have included numerous brachial plexus injuries, esophageal perforations (and even transection), and excessive blood loss exceeding a liter,7–10 most of which have not been reported in peer-reviewed publications.
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Robotic Facelift Thyroidectomy
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These limitations prompted exploration of safer and easier remote-access alternatives. These investigations resulted in the development of a hybrid approach incorporating a modified facelift (postauricular and occipital hairline) incision,11,12 the established Chung fixed retractor system, and robotic technology. This robotic facelift thyroidectomy (RFT) avoids the less familiar territory of the axillary region and represents a shorter distance for dissection, which therefore allows for a drainless, outpatient procedure with faster recovery. The orientation of the RFT approach results in dissection of the thyroid gland in a superior to inferior direction, where the recurrent nerve is identified early in the procedure in its most constant location just prior to its entrance in the larynx.13 This robotic, gasless, single-access port has been shown to be safe and cosmetically satisfying,14 and avoids many of the previously mentioned pitfalls encountered with other remote-access thyroidectomy techniques.15 It is important to acknowledge that although we believe these are substantial advantages of RFT compared with RAT, neither of these techniques can be considered to be minimally invasive. On the contrary, more extensive dissection is required with either of these approaches than with cervical surgery. This and other principles related to the comparison of various techniques are reflected in Table 1.
Surgical indications for RFT When considering a RFT technique, the importance of patient selection and extent of disease cannot be over-emphasized. This technique remains a limited part of our practice because the only benefit is the absence of a neck scar; patients for whom this is not important are better served by a cervical approach. Among those who are concerned about the cosmetic elements of the procedure, the important disease characteristics include a thyroid condition that is unilateral, is not known to be cancerous, is not associated with thyroiditis, and does not exceed 4 cm in greatest dimension. These and additional parameters are enumerated in Table 2. Table 1
Comparison of thyroidectomy techniques Conv
Minimally invasive No Hidden incision No Nerve stimulation possible Yes Easy positioning Yes Drainless Yes Outpatient Yes Reduced dissection No Difficulty þ High BMI Yes Size of nodules þþþþ
MIVAT
Axillary
Facelift
Yes No Yes Yes Yes Yes Yes þþ No þ
No Yes No No No No No þþþþ No þþ
No Yes Yes Yes Yes Yes Yes þþþ Yes þþþ
þ, easiest or smallest;þþþþ, most difficult or largest; BMI, body mass index; conv, conventional surgery; MIVAT, minimally invasive videoassisted thyroidectomy. Adapted from Terris et al.14
Table 2
Selection criteria
1. Motivated patient (who is committed to completely
eliminating a cervical neck scar) Nonmorbidly obese American Society of Anesthesiology class 1 or 2 Absence of previous neck surgery Anticipated unilateral surgery (enlarging benign thyroid nodule or follicular neoplasm of undetermined malignant potential) 6. Dominant nodule size o4 cm 7. Absence of clinically apparent thyroiditis 8. Absence of lymphadenopathy, substernal extension, or extrathyroidal extension 2. 3. 4. 5.
Surgical technique There are several discrete components involved in the undertaking of RFT, and these are described later in the article. The anesthesiologists are an integral part of the robotic surgery team, and the first consideration is the positioning and optimal anesthesia technique. A surgical checklist (Table A1) has proven to be useful.
Positioning and anesthesia After informed consent is obtained, the patient is marked in the preoperative area while sitting upright. Both the facelift and a standard cervical incision are outlined, in the unlikely event that a transition to open surgery is needed. As nerve monitoring is utilized, a GlideScope videolaryngoscope is preferred for intubation to ensure proper positioning of the laryngeal EMG endotracheal tube (NIM, Medtronic-ENT, Jacksonville, FL). A 6-0 tube is used for all patients. Circuit extension tubing is added to accommodate the footprint of the robot when turned. We prefer no relaxation and a propofol drip to allow better titration of the anesthesia. The bed is rotated 1801 from anesthesia and the patient is maintained supine with the head turned 301 from the side of surgery. No shoulder roll is used. Excessive rotation of the head is prevented by supporting it with a bulky towel roll. The head is positioned close to the corner of the bed for improved ergonomics during the initial dissection. The patient is placed in reverse Trendelenburg and airplaned away from surgeon to facilitate the open dissection. The occipital hairline is shaved along the anticipated incision for a width of approximately 1 cm, and the incision line is injected with 0.25% Marcaine with epinephrine (1:200,000). The patient is prepped and draped in a sterile fashion from the postauricular region to anterior chest.
Development of surgical pocket The previously marked modified facelift incision is made from the postauricular crease to the occipital hairline (Figure 1). A musculocutaneous flap is developed, which is superficial to the greater auricular nerve and usually
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superficial to the external jugular vein. The flap remains deep to the platysma muscle and ventral to the sternocleidomastoid muscle throughout dissection until the clavicle is reached. The next step is to identify a triangle demarcated by the superior omohyoid, anterior border of sternocleidomastoid, and posterior sternohyoid muscle. The omohyoid is retracted ventrally, and the remaining strap muscles are reflected anteromedially, thoroughly exposing the thyroid gland. Additional mobilization of the thyroid posterolaterally may be accomplished. Once an ample pocket is created, the modified Chung retractor is introduced (Marina Medical, Tampa, FL) and care is taken to capture the omohyoid, the sternothyroid, and the sternohyoid muscles. A Singer retractor is used to retract the sternocleidomastoid muscle posterolaterally.
Robotic docking The da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA) is deployed with the pedestal angled at approximately 301 to the table and the long axis oriented parallel to the Chung retractor (Figure 2). Three arms of the robot are arranged coaxially to the retractor and with adequate spacing to minimize interference between the arms. The 301down dual-channel endoscope is positioned in the surgical field first; the Maryland forceps (nondominant hand) and Harmonic ACE (Ethicon Endosurgery, Cincinnati, OH) device (dominant hand) are positioned on either side. A field surgeon sits on a short stool at the patient side to provide suction (Terris malleable suction, Medtronic-ENT, Jacksonville, FL) and to change instruments as needed.
Figure 1 The robotic facelift thyroidectomy is accomplished through a modified facelift incision, which is a combination of a postauricular and occipital hairline incision.
extubation is undertaken to minimize increased pressures resulting from coughing and bucking. The patient is observed for 60–90 minutes in the recovery room, and is discharged on the same day from the surgery unit. Prior to discharge, flexible laryngoscopy is performed to confirm normal laryngeal function.
Clinical experience Forty-four robotic facelift thyroidectomies have been performed at our institution over a two-year period in 38
Robotic resection The superior pole is mobilized away from the inferior constrictor muscle (Figure 3), the superior laryngeal nerve is visualized and protected, and the upper pedicle is ligated with the Harmonic ACE device (Figure 4A). The superior parathyroid gland is identified and dissected posterolaterally (Figure 4B). The recurrent laryngeal nerve is then sought as it enters the larynx just beneath the inferior constrictor muscle (Figure 5A). The Prass probe (Medtronic-ENT, Jacksonville, FL) may be used to confirm the identity of this nerve. With the nerve now identified, and coursing inferolaterally, the ligament of Berry and isthmus may be safely divided (Figure 5B). The middle thyroid vein is ligated with the Harmonic ACE device, and the inferior pole is fully mobilized by dissecting the inferior parathyroid gland away from the thyroid, and then ligating the inferior thyroid vessels with the Harmonic ACE device. The thyroid gland is dissected from the anterior trachea. The specimen is removed from the field, and the pocket is irrigated copiously. Hemostasis is assured, and SURGICEL (Ethicon, Somerville, NJ) is placed into the pocket. The incision is closed in layers, with interrupted 4-0 vicryl sutures for the subcutaneous layer and DERMABOND for the skin. Steri-strips are applied along the incision. Deep
Figure 2 The setup of the room for robotic facelift thyroidectomy is depicted. Additionally, the placement of the fixed Chung retractor and the three robotic arms is demonstrated.
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Robotic Facelift Thyroidectomy
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Figure 3 The superior pole is visualized after dissection is accomplished. The upper pedicle is divided as the first step in resection. SP = superior pole; CC = common carotid artery; IJV = internal jugular vein; EJV = external jugular vein; GAN = greater auricular nerve; SH = sternohyoid muscle; ST = sternothyroid muscle; OM = omohyoid muscle; SCM = sternocleidomastoid muscle.
Figure 4 The upper pedicle of the thyroid gland is divided using a Harmonic device (A). The superior parathyroid gland is dissected posterolaterally (B). SLN = superior laryngeal nerve; SP = superior pole; SPG = superior parathyroid gland.
patients (six had staged bilateral procedures; one patient had a total thyroidectomy performed through separate bilateral incisions and was considered as one procedure). There were 37 females and 1 male with a mean age of 42.4 ± 14.8 years (range 12 to 70 years) and mean body mass index of 28.4 ± 7.4 (range 18.7 to 52.0). There were twenty-six right-sided surgeries and nineteen left-sided surgeries (the sum is 45 because of the single total thyroidectomy). The mean total operative time was 151.4 minutes (excluding the total thyroidectomy). The pathology
was benign in 35 cases (80%) and malignant in 9 (20%); these included 22 with nodular hyperplasia, 11 follicular or oncocytic adenomas, 3 benign parenchymal tissue, 6 papillary carcinomas, 2 follicular carcinomas, and 1 sclerosing mucoepidermoid carcinoma with eosinophilia. All but the first case were completed as a drainless, outpatient procedure. Complications included two nonoperative seromas and two temporary recurrent laryngeal nerve pareses; there were no cases of permanent vocal cord paralysis or hypoparathyroidism.
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Figure 5 The recurrent laryngeal nerve is identified just proximal to its entrance in the larynx underneath the inferior constrictor muscle, and may be stimulated with a Prass probe (A). With the nerve visualized and protected, the ligament of Berry, the inferior pole, and the isthmus may be divided and the remaining attachments of the thyroid to the trachea are released (B). RLN = recurrent laryngeal nerve; MTV = middle thyroid vein; IPG = inferior parathyroid gland.
Conclusions RFT is a feasible, cosmetically desirable approach to thyroidectomy using familiar dissection planes, which can be performed safely as an outpatient, drainless procedure.
References 1. Miccoli P, Berti P, Materazzi G, et al: Minimally invasive videoassisted thyroidectomy: Five years of experience. J Am Coll Surg 199:243-248, 2004 2. Terris DJ, Bonnet A, Gourin CG, et al: Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope 115(6): 1104-1108, 2005 3. Seybt MW, Terris DJ: Minimally invasive thyroid and parathyroid surgery—Where are we now and where are we going? Otolaryngol Clin North Am 43(2):375-380, 2010 4. Ikeda Y, Takami H, Sasaki Y, et al: Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 196:189-195, 2003 5. Kang SW, Lee SC, Lee SH, et al: Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: The operative outcomes of 338 consecutive patients. Surgery 146:1048-1055, 2009 6. 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 211:e13-e19, 2010
7. Kuppersmith RB, Holsinger FC: Robotic thyroid surgery: An initial experience with North American patients. Laryngoscope 121(3): 521-526, 2011 8. Landry CS, Grubbs EG, Morris GS, et al: Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery 149(4):549-555, 2011 9. Luginbuhl A, Schwartz DM, Sestokas AK, et al: Detection of evolving injury to the brachial plexus during transaxillary robotic thyroidectomy. Laryngoscope 122(1):110-115, 2012 10. Kandil E, Abdelghani S, Noureldine SI, et al: Transaxillary gasless robotic thyroidectomy: A single surgeon’s experience in North America. Arch Otolaryngol Head Neck Surg 138(2):113-117, 2012 11. Terris DJ, Tuffo KM, Fee WE Jr: Modified facelift incision for parotidectomy. J Laryngol Otol 108(7):574-578, 1994 12. Lee KE, Kim HY, Park WS, et al: Postauricular and axillary approach endoscopic neck surgery: A new technique. World J Surg 33(4): 767-772, 2009 13. Veyseller B, Aksoy F, Yildirim YS, et al: Effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. Arch Otolarygol Head Neck Surg 137(9):897-900, 2011 14. Terris DJ, Singer MC, Seybt MW: Robotic facelift thyroidectomy: Patient selection and technical considerations. Surg Laparosc Endosc Percutan Tech 21(4):237-242, 2011 15. Terris DJ, Singer MC: Qualitative and quantitative differences between two robotic thyroidectomy techniques. Otolaryngol Head Neck Surg 147(1):20-25, 2012
White et al Table A1
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Surgical checklist for robotic facelift thyroidectomy
Pre-operation
Positioning
Intra-operation
Nursing − Equipment − Long nerve stimulator − Ultrasound − Head roll—2 white towels − Shaver − Skin stapler − Instruments and supplies − Bovie extender − Chung system − SCM hooks with protectors − 3-O proline suture—in room − 2-O silk suture—open − Renal vein 2 − Modified Chung blade − SCM retractor system − 3-O Vicryl suture 2—open
Nursing-Anesthesia-Surgery − Turn 1801 − Head placed at top of bed − Head/body in corner of bed ipsilateral to side of surgery − Right Left
Nursing − Bovie setting: 25 cutting (blend), 20 coagulation − Turn on nerve monitor − Start recording for robotic dissection − Record times
− − − − − − −
No straps across bed Tape across draw sheet only Bis and LNM boxes placed at foot of bed Head turned away from side of surgery Head supported by head roll Head wrap with single towel Tape across head wrap and roll
Anesthesia − EMG tube − Extralong circuit
Anesthesia − OR table airplaned away or reverse Trendelenburg − Propofol drip − Deep extubation
Surgery
Surgery − Shave hairline − Injection − 2-O silk through lobe for ear retraction
− Mark postauricular and neck incision − Overhead lights or monitors moved to
periphery
Robotic facelift thyroidectomy Lauren C. White, MD, Michael C. Singer, MD, David J. Terris, MD, FACS From the Department of Otolaryngology-Head and Neck Surgery, Georgia Regents University, Augusta, Georgia KEYWORDS Thyroid; Robotic; Remote access; Cosmetic
The field of thyroid surgery has evolved to the point where multiple access options are now available. These include conventional approaches, minimally invasive endoscopic and non-endoscopic methods, and even remote access techniques with or without robotic assistance. Remote access surgery is reserved for those individuals who are committed to completely eliminating a neck scar. The procedures require more extensive dissection and robotic technology facilitates their performance. While an axillary approach has been the most commonly pursued, we have developed an easier technique that puts fewer structures at risk and involves a reduced area of dissection. It uses as its access portal a modified facelift incision. r 2013 Elsevier Inc. All rights reserved.
Introduction Surgical approaches to thyroidectomy have progressively evolved over the past decade. Innovations, such as highresolution endoscopy, remote-access surgery, and robotic techniques, have transformed the procedure in many centers. The traditional Kocher incision followed by subplatysmal flap elevation and retraction of strap muscles has transitioned to minimally invasive techniques with reduced incision size, faster recovery, and more rapid wound healing. The video-assisted endoscopic minimally invasive technique, pioneered by Miccoli et al. in Pisa,1 has been adopted by numerous groups because of its small cervical incision, gasless technique, and reduced recovery time.2 This technique has matured into a commonly available approach,3 but still is associated with a cervical incision with sometimes unpredictable healing outcomes. Ikeda et al. in Tokyo were among the first to systematically explore remote-access alternatives that would obviate the need for a cervical incision.4 They described a transaxillary endoscopic approach requiring insufflation.
Address reprint requests and correspondence: David J. Terris, MD, FACS, Georgia Regents Thyroid Center, Department of Otolaryngology, Georgia Regents University, 1120 15th St, BP-4109, Augusta, Georgia 30912-4060. E-mail address: [email protected]. 1043-1810/$ - see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2013.04.007
Although this strategy achieves the worthy goal of avoiding the cervical scar associated with the conventional Kocher incision, the axillary approach involves the dissection of planes less familiar to thyroid surgeons and requires awkward arm positioning to rotate the clavicle downward and shorten the distance to the thyroid compartment. The procedure is lengthy and requires a prolonged hospital stay. The introduction of the da Vinci surgical robotic system offers the benefit of 3-dimensional optics in comparison to the 2-dimensional environment of traditional endoscopic surgery. With the implementation of the robotic technology, Woong Youn Chung and his group in Seoul refined the axillary thyroidectomy and developed a gasless technique that uses a novel retractor to maintain the optical cavity, avoiding the need for insufflation of the dissection field.5,6 He has built a large practice focusing on robotic axillary thyroidectomy (RAT) over the past 5 years during which more than 1,500 procedures have been performed with promising outcomes. When attempts were made to replicate the RAT in North America, however, a number of dramatic and severe complications have occurred at an alarming rate. These have included numerous brachial plexus injuries, esophageal perforations (and even transection), and excessive blood loss exceeding a liter,7–10 most of which have not been reported in peer-reviewed publications.
White et al
Robotic Facelift Thyroidectomy
121
These limitations prompted exploration of safer and easier remote-access alternatives. These investigations resulted in the development of a hybrid approach incorporating a modified facelift (postauricular and occipital hairline) incision,11,12 the established Chung fixed retractor system, and robotic technology. This robotic facelift thyroidectomy (RFT) avoids the less familiar territory of the axillary region and represents a shorter distance for dissection, which therefore allows for a drainless, outpatient procedure with faster recovery. The orientation of the RFT approach results in dissection of the thyroid gland in a superior to inferior direction, where the recurrent nerve is identified early in the procedure in its most constant location just prior to its entrance in the larynx.13 This robotic, gasless, single-access port has been shown to be safe and cosmetically satisfying,14 and avoids many of the previously mentioned pitfalls encountered with other remote-access thyroidectomy techniques.15 It is important to acknowledge that although we believe these are substantial advantages of RFT compared with RAT, neither of these techniques can be considered to be minimally invasive. On the contrary, more extensive dissection is required with either of these approaches than with cervical surgery. This and other principles related to the comparison of various techniques are reflected in Table 1.
Surgical indications for RFT When considering a RFT technique, the importance of patient selection and extent of disease cannot be over-emphasized. This technique remains a limited part of our practice because the only benefit is the absence of a neck scar; patients for whom this is not important are better served by a cervical approach. Among those who are concerned about the cosmetic elements of the procedure, the important disease characteristics include a thyroid condition that is unilateral, is not known to be cancerous, is not associated with thyroiditis, and does not exceed 4 cm in greatest dimension. These and additional parameters are enumerated in Table 2. Table 1
Comparison of thyroidectomy techniques Conv
Minimally invasive No Hidden incision No Nerve stimulation possible Yes Easy positioning Yes Drainless Yes Outpatient Yes Reduced dissection No Difficulty þ High BMI Yes Size of nodules þþþþ
MIVAT
Axillary
Facelift
Yes No Yes Yes Yes Yes Yes þþ No þ
No Yes No No No No No þþþþ No þþ
No Yes Yes Yes Yes Yes Yes þþþ Yes þþþ
þ, easiest or smallest;þþþþ, most difficult or largest; BMI, body mass index; conv, conventional surgery; MIVAT, minimally invasive videoassisted thyroidectomy. Adapted from Terris et al.14
Table 2
Selection criteria
1. Motivated patient (who is committed to completely
eliminating a cervical neck scar) Nonmorbidly obese American Society of Anesthesiology class 1 or 2 Absence of previous neck surgery Anticipated unilateral surgery (enlarging benign thyroid nodule or follicular neoplasm of undetermined malignant potential) 6. Dominant nodule size o4 cm 7. Absence of clinically apparent thyroiditis 8. Absence of lymphadenopathy, substernal extension, or extrathyroidal extension 2. 3. 4. 5.
Surgical technique There are several discrete components involved in the undertaking of RFT, and these are described later in the article. The anesthesiologists are an integral part of the robotic surgery team, and the first consideration is the positioning and optimal anesthesia technique. A surgical checklist (Table A1) has proven to be useful.
Positioning and anesthesia After informed consent is obtained, the patient is marked in the preoperative area while sitting upright. Both the facelift and a standard cervical incision are outlined, in the unlikely event that a transition to open surgery is needed. As nerve monitoring is utilized, a GlideScope videolaryngoscope is preferred for intubation to ensure proper positioning of the laryngeal EMG endotracheal tube (NIM, Medtronic-ENT, Jacksonville, FL). A 6-0 tube is used for all patients. Circuit extension tubing is added to accommodate the footprint of the robot when turned. We prefer no relaxation and a propofol drip to allow better titration of the anesthesia. The bed is rotated 1801 from anesthesia and the patient is maintained supine with the head turned 301 from the side of surgery. No shoulder roll is used. Excessive rotation of the head is prevented by supporting it with a bulky towel roll. The head is positioned close to the corner of the bed for improved ergonomics during the initial dissection. The patient is placed in reverse Trendelenburg and airplaned away from surgeon to facilitate the open dissection. The occipital hairline is shaved along the anticipated incision for a width of approximately 1 cm, and the incision line is injected with 0.25% Marcaine with epinephrine (1:200,000). The patient is prepped and draped in a sterile fashion from the postauricular region to anterior chest.
Development of surgical pocket The previously marked modified facelift incision is made from the postauricular crease to the occipital hairline (Figure 1). A musculocutaneous flap is developed, which is superficial to the greater auricular nerve and usually
122
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superficial to the external jugular vein. The flap remains deep to the platysma muscle and ventral to the sternocleidomastoid muscle throughout dissection until the clavicle is reached. The next step is to identify a triangle demarcated by the superior omohyoid, anterior border of sternocleidomastoid, and posterior sternohyoid muscle. The omohyoid is retracted ventrally, and the remaining strap muscles are reflected anteromedially, thoroughly exposing the thyroid gland. Additional mobilization of the thyroid posterolaterally may be accomplished. Once an ample pocket is created, the modified Chung retractor is introduced (Marina Medical, Tampa, FL) and care is taken to capture the omohyoid, the sternothyroid, and the sternohyoid muscles. A Singer retractor is used to retract the sternocleidomastoid muscle posterolaterally.
Robotic docking The da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA) is deployed with the pedestal angled at approximately 301 to the table and the long axis oriented parallel to the Chung retractor (Figure 2). Three arms of the robot are arranged coaxially to the retractor and with adequate spacing to minimize interference between the arms. The 301down dual-channel endoscope is positioned in the surgical field first; the Maryland forceps (nondominant hand) and Harmonic ACE (Ethicon Endosurgery, Cincinnati, OH) device (dominant hand) are positioned on either side. A field surgeon sits on a short stool at the patient side to provide suction (Terris malleable suction, Medtronic-ENT, Jacksonville, FL) and to change instruments as needed.
Figure 1 The robotic facelift thyroidectomy is accomplished through a modified facelift incision, which is a combination of a postauricular and occipital hairline incision.
extubation is undertaken to minimize increased pressures resulting from coughing and bucking. The patient is observed for 60–90 minutes in the recovery room, and is discharged on the same day from the surgery unit. Prior to discharge, flexible laryngoscopy is performed to confirm normal laryngeal function.
Clinical experience Forty-four robotic facelift thyroidectomies have been performed at our institution over a two-year period in 38
Robotic resection The superior pole is mobilized away from the inferior constrictor muscle (Figure 3), the superior laryngeal nerve is visualized and protected, and the upper pedicle is ligated with the Harmonic ACE device (Figure 4A). The superior parathyroid gland is identified and dissected posterolaterally (Figure 4B). The recurrent laryngeal nerve is then sought as it enters the larynx just beneath the inferior constrictor muscle (Figure 5A). The Prass probe (Medtronic-ENT, Jacksonville, FL) may be used to confirm the identity of this nerve. With the nerve now identified, and coursing inferolaterally, the ligament of Berry and isthmus may be safely divided (Figure 5B). The middle thyroid vein is ligated with the Harmonic ACE device, and the inferior pole is fully mobilized by dissecting the inferior parathyroid gland away from the thyroid, and then ligating the inferior thyroid vessels with the Harmonic ACE device. The thyroid gland is dissected from the anterior trachea. The specimen is removed from the field, and the pocket is irrigated copiously. Hemostasis is assured, and SURGICEL (Ethicon, Somerville, NJ) is placed into the pocket. The incision is closed in layers, with interrupted 4-0 vicryl sutures for the subcutaneous layer and DERMABOND for the skin. Steri-strips are applied along the incision. Deep
Figure 2 The setup of the room for robotic facelift thyroidectomy is depicted. Additionally, the placement of the fixed Chung retractor and the three robotic arms is demonstrated.
White et al
Robotic Facelift Thyroidectomy
123
Figure 3 The superior pole is visualized after dissection is accomplished. The upper pedicle is divided as the first step in resection. SP = superior pole; CC = common carotid artery; IJV = internal jugular vein; EJV = external jugular vein; GAN = greater auricular nerve; SH = sternohyoid muscle; ST = sternothyroid muscle; OM = omohyoid muscle; SCM = sternocleidomastoid muscle.
Figure 4 The upper pedicle of the thyroid gland is divided using a Harmonic device (A). The superior parathyroid gland is dissected posterolaterally (B). SLN = superior laryngeal nerve; SP = superior pole; SPG = superior parathyroid gland.
patients (six had staged bilateral procedures; one patient had a total thyroidectomy performed through separate bilateral incisions and was considered as one procedure). There were 37 females and 1 male with a mean age of 42.4 ± 14.8 years (range 12 to 70 years) and mean body mass index of 28.4 ± 7.4 (range 18.7 to 52.0). There were twenty-six right-sided surgeries and nineteen left-sided surgeries (the sum is 45 because of the single total thyroidectomy). The mean total operative time was 151.4 minutes (excluding the total thyroidectomy). The pathology
was benign in 35 cases (80%) and malignant in 9 (20%); these included 22 with nodular hyperplasia, 11 follicular or oncocytic adenomas, 3 benign parenchymal tissue, 6 papillary carcinomas, 2 follicular carcinomas, and 1 sclerosing mucoepidermoid carcinoma with eosinophilia. All but the first case were completed as a drainless, outpatient procedure. Complications included two nonoperative seromas and two temporary recurrent laryngeal nerve pareses; there were no cases of permanent vocal cord paralysis or hypoparathyroidism.
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Figure 5 The recurrent laryngeal nerve is identified just proximal to its entrance in the larynx underneath the inferior constrictor muscle, and may be stimulated with a Prass probe (A). With the nerve visualized and protected, the ligament of Berry, the inferior pole, and the isthmus may be divided and the remaining attachments of the thyroid to the trachea are released (B). RLN = recurrent laryngeal nerve; MTV = middle thyroid vein; IPG = inferior parathyroid gland.
Conclusions RFT is a feasible, cosmetically desirable approach to thyroidectomy using familiar dissection planes, which can be performed safely as an outpatient, drainless procedure.
References 1. Miccoli P, Berti P, Materazzi G, et al: Minimally invasive videoassisted thyroidectomy: Five years of experience. J Am Coll Surg 199:243-248, 2004 2. Terris DJ, Bonnet A, Gourin CG, et al: Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope 115(6): 1104-1108, 2005 3. Seybt MW, Terris DJ: Minimally invasive thyroid and parathyroid surgery—Where are we now and where are we going? Otolaryngol Clin North Am 43(2):375-380, 2010 4. Ikeda Y, Takami H, Sasaki Y, et al: Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 196:189-195, 2003 5. Kang SW, Lee SC, Lee SH, et al: Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: The operative outcomes of 338 consecutive patients. Surgery 146:1048-1055, 2009 6. 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 211:e13-e19, 2010
7. Kuppersmith RB, Holsinger FC: Robotic thyroid surgery: An initial experience with North American patients. Laryngoscope 121(3): 521-526, 2011 8. Landry CS, Grubbs EG, Morris GS, et al: Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery 149(4):549-555, 2011 9. Luginbuhl A, Schwartz DM, Sestokas AK, et al: Detection of evolving injury to the brachial plexus during transaxillary robotic thyroidectomy. Laryngoscope 122(1):110-115, 2012 10. Kandil E, Abdelghani S, Noureldine SI, et al: Transaxillary gasless robotic thyroidectomy: A single surgeon’s experience in North America. Arch Otolaryngol Head Neck Surg 138(2):113-117, 2012 11. Terris DJ, Tuffo KM, Fee WE Jr: Modified facelift incision for parotidectomy. J Laryngol Otol 108(7):574-578, 1994 12. Lee KE, Kim HY, Park WS, et al: Postauricular and axillary approach endoscopic neck surgery: A new technique. World J Surg 33(4): 767-772, 2009 13. Veyseller B, Aksoy F, Yildirim YS, et al: Effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. Arch Otolarygol Head Neck Surg 137(9):897-900, 2011 14. Terris DJ, Singer MC, Seybt MW: Robotic facelift thyroidectomy: Patient selection and technical considerations. Surg Laparosc Endosc Percutan Tech 21(4):237-242, 2011 15. Terris DJ, Singer MC: Qualitative and quantitative differences between two robotic thyroidectomy techniques. Otolaryngol Head Neck Surg 147(1):20-25, 2012
White et al Table A1
Robotic Facelift Thyroidectomy
125
Surgical checklist for robotic facelift thyroidectomy
Pre-operation
Positioning
Intra-operation
Nursing − Equipment − Long nerve stimulator − Ultrasound − Head roll—2 white towels − Shaver − Skin stapler − Instruments and supplies − Bovie extender − Chung system − SCM hooks with protectors − 3-O proline suture—in room − 2-O silk suture—open − Renal vein 2 − Modified Chung blade − SCM retractor system − 3-O Vicryl suture 2—open
Nursing-Anesthesia-Surgery − Turn 1801 − Head placed at top of bed − Head/body in corner of bed ipsilateral to side of surgery − Right Left
Nursing − Bovie setting: 25 cutting (blend), 20 coagulation − Turn on nerve monitor − Start recording for robotic dissection − Record times
− − − − − − −
No straps across bed Tape across draw sheet only Bis and LNM boxes placed at foot of bed Head turned away from side of surgery Head supported by head roll Head wrap with single towel Tape across head wrap and roll
Anesthesia − EMG tube − Extralong circuit
Anesthesia − OR table airplaned away or reverse Trendelenburg − Propofol drip − Deep extubation
Surgery
Surgery − Shave hairline − Injection − 2-O silk through lobe for ear retraction
− Mark postauricular and neck incision − Overhead lights or monitors moved to
periphery