Robotic retro-auricular thyroidectomy: Indications and Technique

Krishnakumar Thankappan

doi:10.4103/jhnps.jhnps_20_19

REVIEW ARTICLE

Year : 2019 | Volume : 7 | Issue : 1 | Page : 6-10

Robotic retro-auricular thyroidectomy: Indications and Technique

Krishnakumar Thankappan
Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Web Publication

26-Jul-2019

Correspondence Address:
Krishnakumar Thankappan
Amrita Institute of Medical Sciences, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_20_19

Abstract

Conventional approach results in a conspicuous anterior neck scar, which is difficult to camouflage. Remote-access surgical approaches are being developed with the aid of technological advancements with an intention to hide the scar. Robotic thyroidectomy is getting accepted worldwide. Advantages of the robotic approach include better visualization, dexterity, and precision. Surgeon ergonomics is also better. The purpose of this article is to review the technique and report the early experiences with robotic retro-auricular thyroidectomy from India.

Keywords: Carcinoma thyroid, remote access approach, retro-auricular approach, robotic thyroidectomy, thyroidectomy

How to cite this article:
Thankappan K. Robotic retro-auricular thyroidectomy: Indications and Technique. J Head Neck Physicians Surg 2019;7:6-10

How to cite this URL:
Thankappan K. Robotic retro-auricular thyroidectomy: Indications and Technique. J Head Neck Physicians Surg [serial online] 2019 [cited 2023 Jun 4];7:6-10. Available from: https://www.jhnps.org/text.asp?2019/7/1/6/263513

Introduction

Conventionally, thyroidectomy is performed through a transverse lower neck crease incision. Conventional approach results in a conspicuous anterior neck scar, which is difficult to camouflage. Remote-access surgical approaches are being developed with the aid of technological advancements with an intention to hide the scar. These approaches can be endoscopic or robotic. Robotic thyroidectomy is getting accepted worldwide, but majority of the literature is from South Korea.^{[1],[2],[3],[4],[5]} A widely acknowledged approach is the transaxillary (TA) route. Robotic facelift or retro-auricular (RA) approach was initially reported by Terris et al.,^[6],[7] and is popularized by Byeon et al.^[1] The purpose of this article is to review the technique and report the early experiences with robotic RA thyroidectomy from India.

Why Robotic Surgery

Thyroidectomy is a procedure which is commonly done in females and mostly in their younger ages. It is evident that a fraction of these patients is unhappy about the scar. It is prudent to develop and improve upon a technique which can avoid the scar. Endoscopic techniques were developed and are still popular. Endoscopic surgery in the neck has many limitations such as two-dimensional vision, the need for an assistant to hold the camera, restriction in the number of instruments that can be used together, and the relatively difficult learning curve.^{[8],[9],[10],[11]} Robotic surgery has many advantages.^[12],[13]

Advantages of Robotic Thyroidectomy

Visualization

Robotic surgery gives three-dimensional stereoscopic vision with a high magnification (×10 greater than the human eye) and high definition.

Dexterity

It offers improved dexterity with wristed instruments.

Precision

Surgeon's tremor is eliminated. In addition, the visualization, retraction, and dexterity aid to perform precise surgery.

Enhanced retraction

In robotic thyroidectomy, there is a fourth arm with a forceps to retract, compared to endoscopic surgery. In addition, the bedside assistants also help in retraction.

Surgeon ergonomics

After docking the robot, the surgeon is seated in a separate console to control the robotic arms.

Limitations of Robotic Thyroidectomy

Cost

Cost is the main limitation. It includes the initial establishment cost, annual maintenance cost, disposable instrument cost, and the cost involved in the prolonged anesthesia and operative time. Studies on TA approach have shown that increased operating time coupled with the capital expense of the robotic system and specialized equipment will increase the cost significantly.^[14],[15] Cost can be curtailed by the multidisciplinary use, especially in an institutional practice.

Learning curve

Robotic thyroidectomy is reported to have a learning curve of 35–40 cases. However, this is less (55–60 cases), compared to endoscopic thyroidectomy.^[9],[10] Proper case selection is important to overcome the learning curve.

Instrument size

The Xi system now has 8-mm instruments. Even the 5-mm instruments in the Si model are large. The reduction in size of the instruments and technological developments, like single flexible arm surgery, may solve these issues.

Lack of haptic feedback

New surgeons may find the absence of haptic feedback inconvenient. The visual clues should be relied on to assess the surgical field.

Advantages of Retro-Auricular Approach

It is like the modified facelift (MFL) approach used for parotidectomy. The difference is the absence of a preauricular limb in the MFL incision. The advantages of the RA approach are that it offers better cosmesis when compared to the standard thyroidectomy and TA incisions, the anatomy and the vector of dissection is familiar to head-and-neck surgeons, brachial plexus is not at risk, and the short area of dissection is relative to the TA approach.

Patient Selection

An ideal patient for any remote-access approach would be a small or an average-sized (body mass index <30) young patient who is concerned about the neck scarring or a history or hypertrophic scar. The thyroid pathology will have an influence on selecting the approach. Presence of thyroiditis is a relative contraindication, due to associated fibrosis and adhesions. Malignancy as such is not a contraindication. Neck dissection can be done with RA approach.

Relative contraindications

Well-differentiated thyroid cancers >T2
Thyroid nodules >4 cm
Larger goiters
Severe Grave's disease with enlarged glands
Advanced thyroiditis
Morbid obesity.

Absolute contraindications

Thyroid cancer with evidence of gross invasion
Previous neck surgery or irradiation
A substernal or retrosternal goiter.

Case Selection during the Learning Curve

To tide over the learning curve, in the initial phases, it is best to select the patients who are:

Young, are nonobese, are requesting for robotic thyroidectomy
Nodule size <3 cm
A benign or malignant nodule may be included, malignant nodules of a differentiated carcinoma
No clinical or radiological evidence of nodal involvement
In suspected malignant cases, it is best to select patients indicated for total thyroidectomy, as the completion thyroidectomy may be difficult initially
It is best to choose a bilateral approach initially (each lobe approached from the ipsilateral RA area). Approaching the contralateral lobe from the ipsilateral lobe RA area may be technically challenging in the initial phases.

Anesthesia

The procedure is done under general anesthesia. The endotracheal tube can be placed orally or nasally. If orally placed, the tubing should be placed in a sterile plastic cover and taken toward the leg side of the patient. If placed nasally, the tubing can be taken in the head drape and then below the table toward the leg side. The anesthesiologist is positioned at the patient's feet and the surgeon and the assistant at the patient's head. Usual deep-vein thrombosis-preventive prophylaxis should be taken. The patient should be catheterized prior to the procedure, and routine single-dose antibiotic prophylaxis is recommended.

Surgical Equipment

Skin flap retractors

Skin hooks
Army navy retractors
Langenbach's retractors of different sizes
Self-retaining retractor (L & C Bio, South Korea) [Figure 1]a and [Figure 1]b.

Instruments for gross dissection

Monopolar cautery with tips of three different sizes: small, medium, and long
Debakey forceps
Yankauer suction tips (plastic and longer metal type).

Surgical robot. The authors use da Vinci Xi system (Intuitive Surgical Systems, Sunnyvale, CA, USA). Si version is also available. Three components of the system are (1) the patient cart, (2) vision cart, and (3) the surgeon console [Figure 2]a, [Figure 2]b,[Figure 2]c.

Figure 1: (a) Self-retaining skin retractor (b) retractor blades

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Figure 2: (a) daVinci Xi robot components, patient cart (b) vision cart (c) surgeon console

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12 mm, 30° facedown endoscope
5-mm Maryland forceps
5-mm harmonic curved scissors
5-mm monopolar cautery
8-mm prograsp forceps.

For Xi model:

8-mm 30° facedown endoscope
8-mm bipolar Maryland forceps
8-mm monopolar curved scissors
8-mm monopolar spatula tip
8-mm prograsp forceps.

Vessel ligation clip system.

Surgical Technique

Position

The patient is placed in the supine position with head rotated to the contralateral side. The neck is placed in the natural relaxed position without extension. Ipsilateral ear lobule can be deflected away with the help of a Tegaderm dressing.

Working space creation

Retro-auricular approach is an open surgery. No gas insufflation is involved. The incision is placed postaurally, behind the ear lobule; goes cranially and turns posteriorly at the level of the external auditory canal; and runs horizontally up to 5 mm inside the hairline. The incision is then turned inferiorly and posteriorly staying 5 mm inside the hairline up to about 5–6 cm. The skin flaps are raised at a subplatysmal plane, initially staying over the sternomastoid muscle, keeping a layer of fascia intact over the muscle. There is a high chance of buttonholing the flap, and special attention needs to be given to prevent this. Care is taken not to injure the great auricular nerve and the external jugular vein. The dissection proceeds inferiorly to reach the suprasternal notch in the midline and the clavicular level laterally. Too much of lateral dissection is not necessary in a thyroidectomy without neck dissection. The flap must be raised beyond the midline to expose the contralateral platysma. Once the working space is created, the self-retaining retractor is introduced and placed to maintain the height of the space for robotic docking.

Robotic docking

The robot is docked with the 30° scope face down and centrally along the retractor blade. The authors prefer to place the scope in the second or the third arm of the Xi system. The Maryland forceps is placed to the left of the scope and curved monopolar scissors to the right. The prograsp forceps can be on the remaining extreme arm, either 1 or 4 depending on the side of the surgery.

Thyroidectomy

The investing layer of the deep cervical fascia is initially separated from the anterior border of the sternomastoid muscle. The Prograsp forceps can be used to hold and retract the tissue, whereas the Maryland forceps and the curved scissors are together used to dissect and cut the tissue. All the vessels encountered including the superior thyroid pedicle can be cauterized and cut
Omohyoid, sternohyoid, and sternothyroid muscles are sequentially delineated and retracted to visualize the anterior surface, the isthmus, and the inferior border of the thyroid gland
Superior pole vessels are dissected and delineated, coagulated, and cut
The dissection proceeds medially, and the external branch of the superior laryngeal nerve is visualized entering the cricothyroid muscle. Further, medial dissection is done to divide the isthmus
Attention is then turned laterally and inferiorly retracting the superior pole medially. The dissection is maintained close to the capsule of the gland without breaching it. The middle thyroid vein is identified, coagulated, and cut. The inferior thyroid artery is identified, coagulated close to the gland, and cut. The dissection in the loose areolar tissue laterally will identify the recurrent laryngeal nerve entry point. The nerve may be followed and preserved. It is not always necessary to dissect the nerve fully
Dissection is further done to release the inferior pole. The vessels are coagulated and cut to complete the hemithyroidectomy
Contralateral lobectomy can be done through the same side, but the authors preferred to do it through a contralateral postauricular route in the initial few cases. Contralateral lobectomy from the ipsilateral side requires identification of the recurrent laryngeal nerve in the opposite trachea-esophageal groove inferiorly
The contralateral superior pole is identified, coagulated, and cut. The lobe is then released from the trachea by medial dissection, preserving the recurrent laryngeal nerve and parathyroids to complete the thyroidectomy
Hemostasis is checked meticulously; suction drains are inserted and taken out behind the hairline. The postauricular skin is closed in layers.

Postoperative Care

The postoperative care is not different from that of the conventional thyroid surgery. Calcium levels must be monitored. The suction drain is removed when the drainage amount decreases to <20 ml/day. The patient is usually discharged the following day.

Complications

Complications seen in the conventional thyroidectomy can occur in robotic thyroidectomy too. Literature review showed that the rates of recurrent laryngeal nerve palsy, temporary and permanent hypocalcemia, hematoma, and seroma are similar. Unusual complications specific to the robotic postauricular thyroidectomy are rare but reported.^[9] They include:

Increased postoperative pain and paresthesia around the neck and postaural area
Tracheal, esophageal, vessel injury
Nerve injury: Great auricular nerve and marginal mandibular nerve (both may be injured during flap raising, but preventable with appropriate precautions)
Skin discoloration, ischemia, and necrosis of the postauricular part. This can also be minimized with special care taken during raising the flap. The tip of the flap must be kept sufficiently broad, moistened, and not very thin
Hair loss along the incision line, hypertrophic scar, and keloid are rare
Periauricular paresthesia and numbness.

Our Early Experience

The authors' institution has done twenty cases over a period of 24 months. The patients included 19 females and one male. The mean age was 28.3 years (range, 23–45 years). The mean size of the nodule was 25.5 mm (range, 15–30 mm). Total thyroidectomy was done in 16 patients through a bilateral RA approach. Four patients underwent hemithyroidectomy. Each lobe was approached from the ipsilateral RA area. On the postoperative pathology, 16 patients had papillary carcinoma and 4 had benign pathology. Three patients had temporary hypocalcemia and two patients developed hypertrophic scar. One of the patients had vocal unilateral cord palsy, where the tumor was involving the nerve. One patient had bilateral vocal cord paresis, which improved subsequently. Overall, the outcomes were encouraging. A detailed analysis of the cases is not intended in this article and hence not reported. [Figure 3] depicts the cosmetic outcome in a patient.

Figure 3: (a) Preoperative anterior neck (b) postoperative anterior neck (c) retro-auricular hidden scar

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Conclusions

Among the remote-access approaches to the thyroid, robotic approaches score above the conventional endoscopic methods. RA approach may have some technical advantages. Adequate cadaver and preclinical training should be done. Standardized teaching for robotic surgical skill is necessary. Case selection is important, especially in the initial phases of the learning curve. Our early experience with robotic RA thyroidectomy was encouraging. Further prospective evaluation needs to be done to see the feasibility and efficacy, especially in India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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