American Thyroid Association Statement on Remote-Access Thyroid Surgery

Abstract

Background: Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption. Methods: A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery. Results: Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillobreast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision. Conclusions: Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.

The current status of robotic transaxillary thyroidectomy in the United States: an experience from two centers

“…A recent consensus statement from American Thyroid Association reiterated the findings of this study by accepting the presence of a niche group of patients favoring remote access thyroid surgery over the conventional approach either because of cosmetic or wound healing issues. The panel recommended the wishes of these patients to be respected, as long as the procedure was done by experienced surgeons under strict selection criteria (14).…”

Report of a Track Seeding of Thyroid Papillary Carcinoma During Robot- Assisted Transaxillary Thyroidectomy

“…The RT can be carried out by four main approaches: breast, bilateral axillo-breast, axillary and facelift approaches [2]. The advantages of this procedure are a magnified 3D sharp and zoomed view, a freedom of motion of the articulated instruments, a decreased tremor, and better ergonomics.…”

“…However, the RT implies: -a significantly increased operative time (mean difference=56 minutes), which is known to be a risk factor of surgical-site infections in the thyroid surgery [14], -a significantly longer mean hospital stay, according to a metaanalysis by Lang et al [7], -an increased global cost ($13,087 vs. $9,028) related to the consumables, the maintenance, the duration of the hospital stay and of the operating room occupation [2,15]. Some unusual risks of the RT must be quoted [16]: flap perforation (0.1%), paresthesia and fibrosis along the flap, brachial plexus traction injury (0.1%), great vessels injury at the thoracic outlet (0.03%), tracheal (0.2%) or carotid injury (0.03%), more frequent due to the absence of force feedback, or even disturbance of the interpretation of future mammograms [17].…”

“…According to the American Thyroid Association [2], the surgical indications should be the same as for the conventional OT, limited to patients having a particular cosmetic interest or a history of bad wound healing, and a preferentially thin body habitus, without excessive body fat along the flap trajectory. They recommend to use this technique with caution, by experimented surgeons in high-volume centers, on well-circumscribed nodules not larger than 3 cm, in a thyroid lobe smaller than 5-6 cm in the largest dimensions.…”

Preoperative information for thyroid surgery

“…A recent position statement reviews some but not all of these approaches and potential risks (14). The obvious advantage of any minimally invasive or remote access approach is the minimization or absence of a cutaneous incision.…”