Advances in Robotic Transaxillary Thyroidectomy in Europe

Abstract

Purpose of reviewThe robotic surgical approach for minimally invasive thyroid surgery has been well described from the Korean surgeons and shows a wide spread diffusion in Asian area. This paper gives a systematic review aiming to pointed out the interest and the way of behaving of the European surgeons about the role of the robotic thyroidectomy (RT).Recent findingsA literature search was performed using Pubmed, MEDLINE, Cochrane and ClinicalTrials.gov databases, including only papers wrote from european surgeons enrolling patients operated in Europe. Outcomes of interest included patients characteristics, patients position, surgical devices, surgical technique, surgical outcomes, and complications. Eighteen studies have been included in the analysis, published from 2011 to 2017. An overall number of 1108 patients were treated in studies included. In the 44.4% of studies (eight trials), the Kuppersmith position was chosen, whereas in the 22.2% (four trials), the Chung position was selected, with a mean length on axilla skin incision of 5.8 ± 1.5 cm. Considering the characteristics of the surgical technique, the mean total surgical time was 166.8 ± 36.6 min (including total thyroidectomy and loboisthmectomy together), divided three consecutive phases, such as mean working space was 50.7 ± 21.8 min, mean docking time 16.0 ± 11.9 min and mean console time 102.87 ± 38.8 min. Considering the complications, only 50% of studies included reported data about acute complications. In particular, the most frequent was hypocalcemia, occurring in 32 cases (2.9%). RLN palsy occurred in 29 patients (2.6%), definitive in 13.8% of these cases and transient in 86.2%. Only nine studies reported the discharge time, with a mean of 2.4 ± 1.2 days after surgery.SummaryDespite the papers included in the study show a different way of collecting data, the transaxillary approach for robotic thyroidectomy for European patients is both feasible and safe. This procedure has to be carried out by surgeons expert in thyroid surgery with knowledge in robotic procedure. In the future, the incoming of dedicated instruments could improve and developed this technique.

Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform

“…Conversion from robotic to open surgery has been noted to occur in very large plunging goitres [43].The mean size of the nodule in our resected specimens ranged from 10 to 40 mm. Within these boundaries, all surgical procedures were successfully completed without need of converting to the open approach.…”

“…Nodule volume superior to 5 cm was contraindicated, to ease handling and visualization of structures in the context of the anatomy as presented during the first cases of the robotic approach. However with an ever increasing experience, relative contraindications are no longer regarded as such by proficient surgeons [42]: expert Groups routinely perform RATS on patients with Hashimoto's thyroiditis and Graves' disease or breast implants [43]. RATS has also been considered to be equally safe irrespective of the presence of BMI > 30 [44], although morbidly obese patients may pose significant challenges regarding positioning, dissection, and placement of the retractor needed to keep the working space open .…”

Die transaxilläre roboterassistierte Thyreoidektomie – Ergebnisse und Akzeptanz einer neuen Operationsmethode

“…Erwähnt werden müssen neue, bis dato in der traditionellen Schilddrüsenchirurgie nicht bekannte Komplikationen wie passagere Armplexusparesen bedingt durch die teilweise extreme Lagerung [19,24,25] und Dysästhesien der Haut über dem Zugangsweg bei Patienten mit wenig subkutanem Fettgewebe [19]. Nach der Ansicht der Autoren sollte eine Abduktion über 120°un- bedingt vermieden werden [15] (▶ Abb.…”

“…Chung-Position) wurde bereits durch Kuppersmith et al [26] nach Auftreten von Armplexusschäden modifiziert, wir plädieren für eine noch moderatere Armabduktion. Die europäischen Erfahrungen ermittelten immerhin eine Rate von passageren Paresen des Plexus brachialis von 2,4 % [19]. Bei sehr schlanken Patienten sollte vor allem über der Klavikula peinlich auf Brennschäden der Haut geachtet werden.…”

“…Zeitweilig bestehende Parästhesien über dem Zugangsweg treten relativ häufig auf, in unseren Patientengut bei 13,8 %, bilden sich aber nahezu immer nach längstens wenigen Wochen vollständig zurück. Es existieren zudem Berichte über Ösophagus-oder Trachealverletzungen und Verletzungen im Bereich der Gefäßnervenscheide mit hohem Blutverlust, deren Inzidenz im Promillebereich liegt [19,26,27] und die in unserem Patientengut glücklicherweise nicht vorkamen.…”