Pros of Robotic Transaxillary Thyroid Surgery: Its Impact on Cancer Control and Surgical Quality

R obots are increasingly being used in surgery because of their greater visualization, precision, and articulation. Robotic surgery has been found to eliminate many problems encountered with conventional endoscopic techniques. Since conventional open thyroidectomy is a safe, effective, and time-honored approach in thyroid surgery, however, some surgeons may doubt the value of using robots for thyroid surgery. Although the same doubts were expressed during the introduction of robotic prostatectomy only 5 years ago, 70% to 80% of radical prostatectomies in the United States are now performed using the da Vinci Surgical System (1). Similarly, the effectiveness and safety of laparoscopic cholecystectomy were questioned when the procedure was initially introduced in the United States; since that time, however, laparoscopic cholecystectomy has been shown to be superior and has become the gold standard for treatment of gallbladder diseases (2). Analogous to the introduction of laparoscopic cholecystectomy and robotic prostatectomy, we submit that robotic thyroidectomy will in time become the standard technique for thyroid surgery.

Open thyroidectomy is performed through a midline cervical incision, which can result in paresthesia, hyperesthesia, and unsightly scarring. Additionally, voice changes and dysphagia without discrete clinical findings have been found to affect patients postoperatively (3). Initially described in 2007, robotic thyroidectomy using a gasless transaxillary approach eliminates the need for any cervical incisions, increasing patient satisfaction relative even to the small incisions used in minimally invasive video-assisted techniques. Another apparent benefit of robotic surgery is improved dexterity and visualization, resulting in better cancer control following complete thyroidectomy plus radical cervical lymph node dissection. Robotic thyroidectomy also results in better functional outcomes, including reduced rates of voice changes, swallowing difficulty, and postoperative pain and sensory changes, when compared with conventional open thyroidectomy (4).

From 2009 to the present, there have been more than 30 clinical reports, including three multicenter trials and one review article, on robotic thyroid surgery via a gasless transaxillary approach. Most of these clinical reports showed that robotic surgery resulted in identical or superior levels of surgical radicality and oncologic safety, when compared with conventional open or endoscopic surgery, in patients with thyroid carcinomas. Operative safety and short-term oncologic outcomes following robotic thyroidectomy, including operation time, amount of blood loss, length of hospital stay, rate of perioperative complications, and recurrence rates, have been extensively reviewed, both in single and multicenter trials (5 –9). These studies showed that robotic thyroidectomy yielded excellent postoperative outcomes, including minimal complication rates and a high degree of oncological safety. Moreover, we recently reported on our initial experience with robotic modified radical neck dissection (MRND) using a gasless transaxillary approach, including details of operative techniques and short-term outcomes (10). We found that the short-term operative outcomes of robotic MRND were satisfactory, with no serious postoperative complications, and that the use of axillary incisions yielded a maximal esthetic effect.

From the patient's perspective, the gasless transaxillary approach eliminates the need to make a neck incision and improves cosmetic outcomes. Although this is not an important consideration for some patients, cosmetic outcomes are of great importance in a subset of patients, who experience considerable distress if the outcome is not esthetically acceptable. Accordingly, in comparing the degree of surgical quality in patients undergoing robotic and open thyroidectomy, we evaluated not only postoperative pain, sensory changes, voice changes, and swallowing discomfort, but also patient satisfaction. Robotic thyroidectomy was found to yield better patient outcomes, including reduced pain and increased cosmetic satisfaction (7 –9), as well as better functional outcomes, as shown by lower rates of hyperesthesia, paresthesia, postoperative voice change, and swallowing discomfort (7,8). From these results, I believe that the process for the working space creation in robotic surgery is more invasive than in open surgery; however, the actual thyroidectomy and lymph node dissection procedure might be more precise and less invasive in robotic surgery.

Learning new surgical skills can be demanding, and robotic systems have often been regarded as requiring sophisticated techniques with a long learning curve. However, the use of robotics has been shown to improve learning curves in surgeons attempting to learn advanced laparoscopic techniques. Studies comparing robotic and endoscopic thyroidectomy (4) have found that robotic thyroidectomy resulted in the retrieval of a greater number of cervical lymph nodes, required a shorter operation time, and was associated with a more rapid learning curve than conventional endoscopic thyroidectomy (11,12). For example, the learning curve for robotic thyroidectomy was only 35–40 operations, compared with 55–60 operations for conventional endoscopic thyroidectomy (12,13), suggesting that the robotic system can enable surgeons to be become more proficient in endoscopic thyroidectomy at a more rapid rate.

In our update of a critical review on robotic thyroidectomy, we analyzed the results of studies of robotic surgery and discussed the impact of the robotic technique on thyroid cancer management, from oncological, functional, and surgical viewpoints (4). For patients, the clinical benefits of robotic thyroidectomy include excellent cosmetic results, reduced pain, improvements in swallowing function, and low morbidity rates, as well as oncologic safety. For surgeons, the use of a robot, controlled via a master–slave interface, may improve visualization and surgical ergonomics, resulting in reduced musculoskeletal discomfort compared with open or endoscopic surgery (6).

Although many studies have described the success of robotic thyroidectomy in Korean patients, the efficacy of robotic thyroidectomy may differ in patients from the United States and other countries. Compared with Korean patients, American patients generally have a higher body mass index (BMI) and a larger body habitus, specifically the distance from the axilla to the sternum, making robotic thyroidectomy more difficult. Moreover, robotic thyroidectomy may introduce new potential risks, such as stretch injury to the brachial plexus, perforation of the trachea, or injury to the carotid artery or internal jugular vein (14). These potential risks are related to a new approach to the surrounding anatomy and are also associated with the learning curve. However, we have rarely experienced these severe complications, even in patients with a high BMI or large body habitus. Therefore, patient selection is critical for surgeons first learning to use the robotic technique, and indications for robotic thyroidectomy will likely extend as surgeons gain more experience. I also believe that a team approach is important in using a robot for thyroid surgery; this may maximize safety and efficiency and may shorten the learning curve.

In summary, robotic thyroidectomy and MRND using a gasless transaxillary approach were both safe and feasible in thyroid cancer patients, yielding excellent cosmetic effects, a reduction in pain, and decreased rates of postoperative voice changes and swallowing discomfort. This technique has also been associated with minimal complication rates, and with a high degree of oncologic safety. For surgeons, robotic thyroidectomy offers a shorter operation time and a shorter learning curve, along with ergonomic benefits, compared with conventional endoscopic thyroidectomy. I expect that surgeons, in the near future, can do less invasive robotic surgery for thyroid diseases and provide more benefits to the patients with the advance of robotic technology.