The original operative procedure has been previously described in detail by Korean study groups12,13; our technique is a slightly modified version. The patients were placed in the supine position under general anesthesia. The neck was maintained slightly extended with a soft pillow placed under the patients’ shoulders, and the lesion-side arm was raised and fixed. After the patient was prepared and draped, a 4- to 5-cm vertical skin incision was made in the lesion-side axilla (Fig. 3A). A working space was then created by dissecting the subcutaneous tissues, and a subplatysmal skin flap to the anterior aspect of the neck was dissected over the anterior surface of the pectoralis major muscle and the clavicle. After the medial border of the sternocleidomastoid muscle (SCM) was exposed, the dissection was advanced through the avascular space between the sternal and clavicular heads of the SCM and beneath the strap muscle and the omohyoid to expose the lesion-side lobe of the thyroid and create a sufficient working space from the sternal notch to the superior pole of the thyroid. The da Vinci Surgical System was then introduced from the contralateral side of the lesion. To maintain adequate exposure, the CP retractor was inserted through the axillary incision in the anterior chest using the detachable handle and then attached to the da Vinci camera arm to elevate the skin flap. The hemithyroidectomy and three robotic arms were used for the surgery. The 30-degree down-angled endoscope and head-side robotic arm were inserted through the axillary incision, and the caudal-side robotic arm was inserted through an 8-mm port created on the lateral side of the chest wall (4 cm caudal to the axillary incision).
After docking the robotic system, the surgeon carried out the hemithyroidectomy and lymph node dissection. The EndoWrist Maryland Bipolar Forceps (Intuitive Surgical Inc., Sunnyvale, CA USA) were used to orient the thyroid tissue, and the EndoWrist Harmonic Curved Shears (Intuitive Surgical Inc., Sunnyvale, CA USA) were used to dissect surrounding tissues as well as to cut and seal the blood vessels. The recurrent laryngeal nerve (RLN) was systematically identified and preserved. The EndoWrist Maryland Bipolar Forceps mounted on the left arm were mainly used to orient the thyroid tissue. The EndoWrist Micro Bipolar Forceps mounted on the right arm were used for dissection of the surrounding tissues as well as for cutting and coagulation (double bipolar method) (Fig. 4). To avoid injury to the external branch of the superior laryngeal nerve, the inferior parathyroid gland, and the RLN, the EndoWrist Micro Bipolar Forceps connected to a VIO 300D electrosurgical unit (ERBE, Marietta, GA USA) were used after the third case. The “Dry cut” mode for the right microbipolar forceps was used to cut the surrounding tissue, and the “Faced coagulation” mode was used for cutting and hemostasis. For the left Maryland Bipolar Forceps, the “Soft coagulation” mode was used for hemostasis of oozing and bleeding from the vessel and the surface of the thyroid gland. For the ligation of vessels, including the superior and inferior thyroid arteries, and division of the thyroid gland between the lobe and the isthmus, we used the EndoWrist Harmonic Curved Shears (Intuitive Surgical Inc). After removal of the resected specimen, central compartment lymph node dissection was performed for thyroid cancer. A closed suction drain was inserted into the thyroid bed through the 8-mm port, and the wound was closed in two layers.
From October 2009 to August 2012, a total of 12 patients underwent robot-assisted thyroidectomy using the da Vinci Surgical System (Table 1). All patients were candidates for hemithyroidectomy. One patient was converted from the da Vinci procedure to open surgery because of intraoperative detection of direct invasion to the esophagus (patient 8). Other patients underwent robot-assisted hemithyroidectomy successfully using the CP retractor. The patients included 2 men and 10 women, with a mean age of 52.3 years (range, 31–68 years). The mean size of the thyroid nodules was 12.3 mm (range, 7–20 mm). Postoperative diagnoses were benign follicular adenoma in 2 patients and papillary carcinoma in 10 patients. The mean total operative time was 187 minutes (range, 118–244 minutes). The median blood loss was 30.1 g (range, 0–110 g). We observed postoperative complications in two patients. One patient developed transient RLN paralysis (patient 2). At first, we used the EndoWrist Harmonic Curved Shears for all dissections and separation of the tissue surrounding the thyroid, the vessels, and the nerves. Patient 2 developed transient RLN paralysis despite a good intraoperative visualization and anatomic preservation of the nerve. We inferred that this paralysis was probably caused by thermal injury from the Harmonic Curved Shears during the dissection, and the dissection maneuver around the nerves was changed from the use of the Harmonic Curved Shears to the EndoWrist Micro Bipolar Forceps. After switching to the bipolar instrument, there were no further incidents of nerve paralysis in any patient. One seroma under the anterior chest that needed puncture was identified postoperatively (patient 12). No esophageal or tracheal injury or neuropraxia was encountered. No case of postoperative hematoma, hypocalcemia, or infection was observed. All patients were satisfied with the surgical management and pleased with the well-hidden axillary incision. The retractor provided excellent handling and allowed easier access to the neck. It also optimally retracted the skin flap, which provided both an excellent operative field and adequate visualization without impinging on the robotic arms. The intraoperative and postoperative observation did not show any injury to the skin flap (Fig. 3B).
Successful robot-assisted thyroid operation depends on excellent and consistent exposure of the thyroid gland and the surrounding tissue and organs. This simple and easy-to-handle CP retractor provides exceptional and consistent exposure of the surgical field in robot-assisted thyroidectomy and prevents traumatic injury without impinging on the robot arms.
In the original procedure for robot-assisted thyroidectomy developed by Chung, the customized transaxillary retractor is used to expose the thyroid gland.14 This transaxillary retractor consisted of a lifter and a blade. After insertion of the blade, it was attached to the lifter, and the skin and the sternal heads of the SCM and the strap muscle are lifted. Nevertheless, the blade is large, and an axillary incision of at least 5 cm is required to insert it under the skin flap. It was evident that if a less cumbersome retractor could be inserted through a tiny incision, the robotic procedure could be performed using several ports rather than the need for a large skin incision. With these points in mind, we designed a CP retractor.
During robot-assisted thyroidectomy, large robotic arms are placed on the axilla and move freely, and avoiding the retractors and the robotic arms from interfering with their respective movements is exceedingly important for the safety of the operation. In this study, we successfully performed robot-assisted thyroidectomy without the retractor impinging on the robotic arms. The retractor is easy to handle and can reduce the time required for setting it up. The retractors can be removed when not required for the procedure.
According to the original methods of robot-assisted thyroidectomy that were reported by Chung, all dissection maneuvers used the EndoWrist Harmonic Curved Shears.14 Patient 2 developed temporary RLN paralysis, and we inferred that this was caused by thermal injury from the ultrasonic device. An ultrasonic surgical device is often used in open and endoscopic surgery for simultaneous cutting and coagulation. These instruments do not have wrist articulation because of their mechanical structure presenting some hindrance to their use. It is our preference that the articulation of the instruments is more important than the merits of the ultrasonic device, so we introduced the double bipolar methods. The original double bipolar methods use the Fenestrated Bipolar Forceps (Intuitive Surgical Inc) mounted on the left arm and the EndoWrist Maryland Bipolar Forceps mounted on the right arm, and we modified the instruments to the EndoWrist Maryland Bipolar Forceps on the left arm and the EndoWrist Micro Bipolar Forceps on the right arm because of the need for more precise dissection, cutting, and coagulation of tissue around the thyroid.
This study is a relatively small retrospective analysis. Our institute uses a three-arm standard da Vinci system for the hemithyroidectomy, but we could not use a fourth arm for grasping the forceps, enabling the surgeon to strongly grasp, tract, and maintain tissues during thyroid dissection. We hesitate to perform this technique for total thyroidectomy given that this is not an approved procedure for resecting the thyroid. The findings of our 12 cases demonstrate that postoperative complications for robot-assisted hemithyroidectomy are comparable with those of other reports. In this series, operative time was a little longer, but the surgeon’s lack of experience in thyroid robotic surgery may have been a relevant factor.
This report suggests that the novel CP retractor is useful and safe, and the use of bipolar instruments rather than ultrasonic devices is an effective option for robotic dissection around the nerves in robot-assisted thyroidectomy.
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Keywords:©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery
Robotic thyroidectomy; Endoscopic thyroidectomy; Retractor; Axillary approach