Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform

Abstract

Background: Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy.

Methods: We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter).

Results: Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy.

Conclusions: Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial.

Trial registration: Retrospectively registered on 20 july 2018 .

Trial registration number: researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

Keywords: Da Vinci Xi; Remote access surgery; Robotic-assisted; Thyroidectomy; Trans-axillary approach.

Fig. 1

Instrumentation set for preparation of working space (scalpel with blade n. 15, long Klemmer tissue forceps, short and Long DeBakey forceps, short and Long Metzenbaum scissors, Farabeuf and Langenbeck wound retractors, Modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany), 30° Endoscopic camera, 5 mm Johann and bipolar forceps, monopolar electrocautery with long tip extension, vessel sealing device, endoscopic suction/irrigation device)

Fig. 2

Da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA): a Patient cart; b Da Vinci Surgical System Xi: Video cart; c Da Vinci Surgical System Xi: Surgeon console

Fig. 3

a Patient positioning: the ipsilateral arm, padded, extended cephalad and flexed over the head is placed on a dedicated arm rest; b Patient positioning: extended ipsilateral arm secured in position

Fig. 4

a Landmarks: two dots mark the sternal notch and the cricoid cartilage, the mark at the inferior end of the future axillary incision is connected to the sternal dot by an imaginary transverse line; the mark at the upper end of the future axillary incision is connected to the cricoid dot by an imaginary line forming an angle of approximately 60° with the neck midline; b Landmarks: detail of the markings for the axillary incision (cephalad and middle dot) and for an accessory trocar (caudal dot) for retraction

Fig. 5

a Creation of working space: dissection of the subcutaneous tissue under direct view; b Creation of working space: moving deeper with stable retraction. The Modena retractor in place with suction tube mounted, preparing for dissection under endoscopic camera assistance; c Creation of working space: dissection under camera assistance can help limit the extension of the axillary incision; d Creation of working space: endoscopic view of dissection along the greater pectoralis fascia

Fig. 6

Docking: Da Vinci Xi docked in position with four arms engaged

Fig. 7

Detail of dissection using three robotic arms through the axillary incision (camera and instruments are ideally located at the three sides of an equilateral pyramid)

Fig. 8

a End of procedure. Detail of the sutured 5 cm incision, concealed in the axilla; b Cosmetic outcome at the level of the neck on 1st postoperative day