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Robot-Assisted Thyroidectomy With Novel Camera-Port Retractor

Ishikawa, Norihiko MD, PhD; Kawaguchi, Masahiko MD, PhD; Moriyama, Hideki MD; Shimada, Masanari MD; Watanabe, Go MD, PhD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: September/October 2013 - Volume 8 - Issue 5 - p 384–388
doi: 10.1097/IMI.0000000000000025
How-to-do-it Article

Abstract: We performed gasless transaxillary robot-assisted thyroidectomy with a novel camera-port retractor (CP retractor). Herein, we describe the new instrument and its efficacy, which was evaluated by performing robot-assisted thyroidectomy. From October 2009 to August 2012, a total of 12 patients underwent robot-assisted thyroidectomy using the da Vinci Surgical System. The CP retractor was used in all cases, and we use the Maryland bipolar forceps and the microbipolar forceps on both arms for dissection of the surrounding tissues as well as for cutting and coagulation to avoid injury to the vessels and the nerves. The CP retractor provided excellent visualization without robotic arm instrument interference. The novel retractor is useful and safe, and the use of bipolar instruments is an effective option for robotic dissection around the nerves in the robot-assisted thyroidectomy.

From the Department of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan.

Accepted for publication September 29, 2013.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Norihiko Ishikawa, MD, PhD, Department of General and Cardiothoracic Surgery, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan. E-mail:

Conventional thyroidectomy requires a collar incision on the anterior neck to facilitate exposure of the thyroid gland. To avoid a neck scar, several minimally invasive procedures, such as the minimal cervical access approach and endoscopic technique, have been developed.1–5 Chung reported a large number of robot-assisted thyroidectomies via a transaxillary approach as an emerging surgical technique.6 Chung’s innovative procedure is based on the use of the da Vinci Surgical System (da Vinci; Intuitive Surgical Inc, Sunnyvale, CA USA),6 and several other robotic procedures have been developed worldwide to reduce the need for the anterior neck incision7–9 and the risk for postoperative complications, such as laryngeal nerve palsy or hypocalcemia. Herein, we describe a newly developed robotic instrument and its use in our first series of patients in performing robot-assisted thyroidectomy.

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This study was approved by the Ethics Review Board of Kanazawa University. A single surgeon (N.I.) performed all of the procedures at a single institution. Candidate patients were informed of the innovative features of the technique and of the subsequent risks, and they all provided informed consent. The following data were collected retrospectively for each patient: age, sex, preoperative diagnosis, size of thyroid gland and nodules based on both preoperative imaging and final pathology, laterality of the surgery, operative time, blood loss, use of drain, final pathologic diagnosis, intraoperative complications, and postoperative complications. Although criteria for robot-assisted thyroid surgery have been described by some authors,10 standard and well-accepted selection criteria have not been established yet.11 Because robot-assisted thyroidectomy is not approved by the Japanese Ministry of Health, Labor and Welfare, we planned hemithyroidectomy in all patients, and our criteria were follicular adenoma or benign thyroid nodule for definitive diagnosis and papillary carcinoma 2 cm or less without abnormal cervical lymph nodes by ultrasonography and without distant metastasis by positron emission tomography.

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Description of Camera-Port Retractor

The retractor system consists of two parts: a designed pipe (12 mm in diameter) and a detachable handle (Fig. 1A). The pipe can be atraumatically inserted through a skin incision using the detachable handle (Fig. 1B) and immobilized by means of the da Vinci camera arm. The novel camera-port retractor (CP retractor) is attached to the da Vinci camera arm; thus, the two will move in unison. When the surgeon controls the da Vinci camera at the console, the CP retractor maintains the operative exposure. The detachable handle is helpful to insert the pipe into the neck manually before being connected to the da Vinci camera arm. This unique retractor-mounted da Vinci camera arm that functions as a camera port and a retractor enhances the visualization of the thyroid gland and surrounding tissue (Fig. 2).

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Operative Procedure

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.

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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).

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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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Robotic thyroidectomy; Endoscopic thyroidectomy; Retractor; Axillary approach

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery