Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Abstract

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the “fourth generation” in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2–3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient’s body habitus (BMI < 30 kg/m²) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.

How to do depends on where it settles: Mediastinal parathyroid adenomas

“…The implementation of the minimally invasive surgery with high technology have surgical tools with the maneuver capacity of a human wrist, filtration of the physiological tremor (6-Hz motion filter), good dissection capacity in hard-to-access fields, three-dimensional imaging possibility, and 10¥ magnification capacity. [5,12,13] The main advantage of RATS is that it provides access to deep and narrow areas through highly maneuverable instruments, where exploration and access are difficult even in open surgeries. Compared to other approaches, RATS is a superior method in the incisions of the highly narrow mediastinal lesions where vital organs, vena cava superior, brachiocephalic vein, phrenic nerves, and vagus nerve are located.…”

Surgical options in treating patients with primary hyperparathyroidism

“…Robotic-assisted parathyroidectomy is a modern technique and it represents the new generation in the evolution of minimally invasive parathyroidectomy techniques. 52 The beginnings of telerobotic surgical technology go back to the early 21 st century when a new established idea of robotic-assisted surgery offered solutions in overcoming the limitations associated with endoscopic techniques (twodimensional view of the operative filed, limited manipulation with surgical instruments, need for carbon dioxide insufflation and assistants during surgery). 52,53 In 2011, Tolley et al introduced and performed the first robotic-assisted parathyroidec-tomy without the scar in the neck (by infraclavicular incision), using the da Vinci ® surgical system.…”

“…52 The beginnings of telerobotic surgical technology go back to the early 21 st century when a new established idea of robotic-assisted surgery offered solutions in overcoming the limitations associated with endoscopic techniques (twodimensional view of the operative filed, limited manipulation with surgical instruments, need for carbon dioxide insufflation and assistants during surgery). 52,53 In 2011, Tolley et al introduced and performed the first robotic-assisted parathyroidec-tomy without the scar in the neck (by infraclavicular incision), using the da Vinci ® surgical system. 53 As for every other minimal invasive surgical approach, preoperative imaging studies that assist in the localization of lesions have been key elements in patients' selection for targeted robotic-assisted parathyroid surgeries.…”

“…Nowadays, only one small incision is necessary for RAS. 52 However, due to high prices of robotic systems and other equipment, robotic-assisted surgical technique in parathyroidectomy has been an alternative procedure only in selected medical centres in the USA and Great Britain. 53,54 There are only few known studies about RAS in parathyroidectomy, yet all the known data supports robotic-assisted parathyroidectomy as an equally successful and safe approach for treatment of PHPT as conventional open or endoscopic assisted parathyroidectomy (level 2 and 3 diagnostic evidence).…”

“…53,54 There are only few known studies about RAS in parathyroidectomy, yet all the known data supports robotic-assisted parathyroidectomy as an equally successful and safe approach for treatment of PHPT as conventional open or endoscopic assisted parathyroidectomy (level 2 and 3 diagnostic evidence). 52 Despite an excellent cosmetic outcome due to small incision and a safe approach to the surgery, high expenses, limited equipment, long duration of the procedure and technical difficulties represent limitations in choosing ideal candidates for RAS. [52][53][54]…”