Robotic Total Parathyroidectomy by the Axillo-Bilateral-Breast Approach for Secondary Hyperparathyroidism: A Feasibility Study

Workspace creation

Patients, under general anesthesia with endotracheal intubation, were placed on the operating table in the supine position with the neck extended slightly. After draping, instrument arm trajectory lines and the working area were drawn onto the patient's chest and neck area for reference (Fig. 1). Bilateral skin incisions (8 mm) were made on the margin of the areola. A 12-mm incision on the right side of the sternum beside and the 8-mm incision on the right or left the axillary crease outside the lateral border of the pectoralis major muscle were then made. After incisions, blunt dissection was carefully performed with a vascular tunneler through the port incisions to develop space in the trajectory lines and working area, as well as laterally to the medial border of the sternocleidomastoid muscle. The camera port first was placed on the right of the sternum (the drawing of the eye), using a disposable 12-mm trocar. Ports 1, 2, and 3 for the instrument arms were placed in the superomedial edge of the breast areola and the fold of the axilla (Fig. 1).

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FIG. 1.

The four-trocar axillo-bilateral-breast approach.

Patient cart positioning

The patient cart was rolled into position over the patient's head with the center column in line with the camera port, slightly angled to the operation table and the patient's head. The Mayo stand was placed toward the foot of the table for instrumentation, if desired.

Docking of the surgical robot system

Each of the four ports was docked with a robotic arm (Fig. 2). The da Vinci instrument ports were pointed toward the center of the cricoid cartilage using set-up joint release or port-clutch maneuvers.

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FIG. 2.

The four-arm da Vinci Surgical System, docked.

Console stages

The general principle of operation proceeding for robotic total parathyroidectomy was in the same manner as conventional open parathyroidectomy. The working space was further cleared with a Harmonic^® scalpel (Ethicon Endo-surgery, Inc., Cincinnati, OH) and maintained by CO₂ insufflation at 6–7 mm Hg. The thyroid gland was then grasped by the grasp forceps and rotated medially. Next, the middle thyroid vein was dissected with the dissector and divided using the Harmonic scalpel. The recurrent laryngeal nerve was dissected in the tracheoesophageal groove, and the recurrent laryngeal nerve was located. The thyroid lobe was at that point rotated medially, and with cautious dissection the parathyroid was identified. Because of its visual perspective of surgical anatomy, the parathyroid was then circumferentially dissected and excised en bloc with the thyroid lobe. By the combination of preoperative ultrasonography, ^99mTc-MIBI-SPECT/CT, and intraoperative exploration, each of the parathyroid glands was carefully discovered and removed (Fig. 3). The dissected parathyroid was taken out by a specimen pouch. The estimated weight of the autograft parathyroid tissue is 30 mg. ² The intraoperative parathyroid hormone level should be 50–110 ng/L, which was monitored throughout the procedure to ensure a successful operation. ³

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FIG. 3.

Identification and excision of the inferior parathyroid gland.

After discharge, the follow-up time was 7–10 months. Follow-up biochemical markers included serum phosphate, calcium, and parathyroid hormone. A scoring system was used by patients' self-assessment to grade the cosmetic outcome between 0 and 10.