Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Abstract

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Keywords: da Vinci robot; efficacy; thyroidectomy; unilateral axilla-bilateral areola approach.

Figure 1

The incision sites were marked on the right axilla and in the medial margin of the bilateral areolae, and the line from each incision site to the superior border of the inner clavicle and right and left sternoclavicular joints, respectively, were used to guide the trajectory of the trocars.

Figure 2

The robot column was docked along the midline in a cephalad direction, with trocars in the right axilla and left areola connected to Arms 2 and 1 of the robot, and a trocar in the right areola connected to Arm 3 equipped with a 3D lens.

Figure 3

A thyroid retractor was inserted at the intersection between the upper edge of the clavicle and the exterior edge of the sternocleidomastoid muscle to retract the strap muscle laterally and expose the right thyroid (the retractor is indicated below).

Figure 4

A unipolar cautery dedicated for robotic surgery. Left: original, with tip diameter of 1.2 mm; right: modified, with tip diameter of 0.6 mm.

Figure 5

After right thyroidectomy and central lymph node dissection, the right superior and inferior parathyroid glands and recurrent laryngeal nerve are well-preserved.

Figure 6

Upper: an 8 mm-diameter trocar for robotic surgery; middle: a 20 mm-diameter trocar for specimen collection; Lower: inner core of a 20 mm-diameter trocar for robotic surgery.

Figure 7

Anteroposterior and lateral views of the neck and breasts six months after robotic thyroidectomy. The surgical scars on the right axilla and left and right areola are occult or insignificant.