Abstract
Over the last two decades, technology and innovation have entered the medical world at an extraordinary pace, particularly in the field of surgery. Instantaneous access to information via the internet, high-definition endoscopes, recurrent laryngeal nerve monitoring, minimally invasive surgical platforms, and surgery simulation to name a few have revolutionized the field of surgery. Some advances, such as Natural Orifice Translumenal Endoscopic Surgery (NOTES), have begun to loose their luster, but there is little disagreement that the spin-off technology from waning initiatives like NOTES can lead to other advances that could not have been anticipated at the outset. The ability to now perform an endoscopic Heller's myotomy without any incisions is truly amazing and potentially a great advance for achalasia patients.
Endoscopic approaches to the parathyroid and thyroid glands were first developed in the mid-1990s (1,2). The endoscopic endocrine surgery pioneers initially developed a variety of endoscopic cervical approaches that required one or more small incisions in the neck. Recognized advantages of an endoscopic approach included enhanced lighting of the operative field, a magnified view of pertinent thyroid anatomy, and an improved cosmetic outcome. Despite these advantages, endoscopic endocrine neck procedures have not gained wide acceptance in many regions of the world, including the United States.
Innovative surgeons mostly from the Asian corridor embraced the early principles of endoscopic neck surgery and began to develop a variety of remote endoscopic techniques, among them the endoscopic transaxillary thyroidectomy (ETT) and the bilateral axillary and breast approach (BABA) (3,4). With remote endoscopic thyroid procedures, the incision is placed in a site remote from the neck, permitting endoscopic thyroid excision without a scar on the neck. Conventional laparoscopic instruments and energy devices are used to perform endoscopic thyroidectomy. Even though the thyroid surgery is performed without a scar on the neck, many authorities consider these approaches to be “maximally invasive” because of the wide dissection plane and the long duration of surgery compared to conventional thyroidectomy. Because these approaches are technically demanding and require advanced training in both laparoscopic surgery and endocrine surgery, remote endoscopic thyroid surgery has been slow to catch on except at a select few high-volume thyroid surgery programs.
The arrival of robotic technology on the scene has led to renewed enthusiasm for remote endoscopic thyroid techniques by the current generation of thyroid surgeons. Introduced and perfected by the endocrine surgery team at Yonsei Medical Center in Seoul, South Korea, robotic transaxillary thyroidectomy is an approach that is identical to ETT with one small difference: a robotic platform and instruments are used to perform the procedure rather than conventional laparoscopic instruments (5). Though many clinicians equate robotic thyroidectomy with the transaxillary approach, it is worth noting that that both ETT and BABA can be performed with or without the use of the robotic system. Proponents of the robotic approaches report many advantages of robotic thyroidectomy including enhanced three-dimensional visualization, extended freedom of motion of the robotic instruments, the availability of a fourth arm to retract the thyroid gland medially, team building, education and comfortable surgeon ergonomics. This reviewer can attest to these advantages of robotic thyroidectomy. The remainder of this review will focus on the many disadvantages of robotic thyroidectomy and why robotic thyroidectomy will likely be performed at only a few niche centers around the world.
One of the greatest disadvantages of robotic thyroidectomy is the increased cost. About 18% of the gross domestic product in the United States is spent on healthcare, accounting for a massive component of the world's largest economy (6). In the United States, the Affordable Care Act is changing the health care landscape in which we practice. To prepare for the insurance coverage expansion mandated by the Affordable Care Act, third party payers are decreasing reimbursement at the national, regional, institutional, and provider level. These changes are increasing pressure on an already strained health care system. Robotic thyroidectomy costs more than conventional and endoscopic thyroidectomy as demonstrated by two recent presentations at the 2012 meeting of the American Association of Endocrine Surgeons (7,8). The increased costs of robotic thyroidectomy are derived from numerous sources, including the capital expense of the robotic system ($1.5–$1.75 million), the annual service contract (>$50,000/year), the increased use of disposable instruments, and the prolonged anesthesia and operative times. Although these expenses may decrease with increased competition in the market place and with enhanced surgeon experience (thus lowering the duration of surgery), the increased costs invariably contribute to the overall expense of delivering health care irrespective of the country of origin.
Another reason for not embracing robotic thyroidectomy is that both conventional and nonrobotic endoscopic thyroidectomy can be performed safely with an excellent cosmetic outcome. With conventional thyroidectomy, the incision is often placed in a natural skin crease so that the scar is not visible over time. Since conventional thyroid surgery can be performed with minimal morbidity, especially when performed by experienced thyroid surgeons, it will be hard to improve upon the excellent outcome. Moreover, endoscopic thyroid surgery itself can be performed safely without the robot. Our colleagues at Yonsei Medical Center performed hundreds of endoscopic thyroid procedures before introducing robotic techniques. Studies that compare robotic and endoscopic thyroidectomy demonstrate that there is no significant difference in the outcomes of these two techniques (9). Thyroid surgeons must not forget that the robotic thyroid surgery pioneers gained invaluable experience with endoscopic techniques prior to introducing the robotic approach. Commencing one's endoscopic thyroid experience directly with a robotic approach, without any prior endoscopic thyroid surgery experience, is a cause for great concern.
Another major disadvantage of robotic thyroidectomy revolves around how surgeons are trained to perform robotic thyroidectomy. Who should be doing this training and how should the training be conducted? In the United States, more than 70% of all thyroid procedures are performed by surgeons who perform less than 15 thyroid operations per year (10). It is well known that the complication rate of thyroid surgery is inversely proportional to the experience of the operating surgeon. Introducing an unfamiliar approach to the thyroid gland (endoscopic approach) that mandates the use of a complex piece of equipment (the robot) to inexperienced thyroid surgeons is a recipe for disaster. The likelihood of low-volume thyroid surgeons marketing a “new standard approach” to thyroid gland removal in order to increase their thyroid surgery volume is a sad reality. Moreover, training the current generation of general surgery and otolaryngology residents in the fundamentals of safe thyroid surgery is already a real challenge for a variety of factors such as the 80-hour work week and the increased competition for thyroid cases among these specialties. Adding robotic techniques to the training pathway of our residents does have some potential benefits, such as the clear demonstration of thyroid anatomy, team-building, and the advancement of technology, but this reviewer is concerned that the thyroid surgery training pathway will be further diluted if robotic techniques penetrate the field of thyroid surgery.
Finally, one of the major disadvantages of robotic thyroidectomy is the involvement of a third party—the company that fabricates the robotic equipment—in the field of thyroid surgery. Companies that make robotic surgery equipment have an obligation to ensure that surgeons know how to use their equipment and generally the robotic training pathways are comprehensive. But promoting an entirely new approach to the thyroid gland with robotic equipment without any prior endoscopic thyroid surgery experience is a major fault in the current training pathway in the opinion of this reviewer. The work force of robotic companies is highly incentivized to promote their product and in the absence of competition in the robotic space, the costs remain high. Starting in July 2009, robotic thyroidectomy was heavily promoted in the United States by one company; however, it was soon discovered that the company had not obtained proper U.S. Food and Drug Administration (FDA) approval to market its product for robotic thyroidectomy. In October 2011, the company abruptly withdrew all support in the United States for the training and proctoring of robotic thyroidectomy, pending approval of a new FDA application. This unanticipated development left many robotic thyroid surgeons in a quandary and has dampened the enthusiasm for robotic thyroidectomy at many institutions in the United States.
The Yonsei team and others are to be commended for advancing the art of thyroid surgery by developing these novel techniques for robotic and nonrobotic endoscopic thyroidectomy. The Endocrine Surgery team at Mount Sinai has largely abandoned robotic thyroidectomy in favor of endoscopic (nonrobotic) transaxillary thyroidectomy in properly selected patients. Yet our group and others have found that only a small percentage of thyroid patients are eligible for an endoscopic approach. No one can predict to what extent robotic thyroidectomy will influence or change the field of thyroid surgery. But thyroid surgeons must ask the real-life question “Should we embrace a technique (robotic thyroidectomy) when safer, less complicated, and cheaper alternatives exist?” In the opinion of this reviewer, the answer is no.