15 Remote Access Thyroid Surgery
15.1 Introduction
Recent technological innovations have addressed growing patient interest in reducing the cosmetic impact of surgery, leading to the development of alternative approaches to thyroid surgery. These approaches have developed along two distinct pathways: minimally invasive techniques that create small anterior cervical incisions and remote access approaches that eliminate any anterior neck incision. Although minimally invasive techniques result in a small cervical scar that is well hidden in a natural skin crease, some patients regard the prospect of any publically visible scar as unacceptable. Remote-access techniques remove the incision from the visible portion of the neck and conceal it in a distant, hidden location. Endoscopic or robotic techniques are then used to access the thyroid compartment. For the appropriate patient who regards cosmesis as a priority, remote-access techniques can safely and effectively achieve both the surgical and the cosmetic goals. 1 , 2
15.2 Background
The “conventional” thyroidectomy technique was developed by Emil Theodor Kocher in the late 1800s. His methods, which used a 7 to 10 cm transverse cervical incision, 3 elevation of subplatysmal flaps, and meticulous dissection techniques, transformed thyroid surgery into a procedure that was so safe and universally accepted that, for more than 100 years, it was performed on all patients undergoing thyroid surgery, regardless of their gland size or disease.
The first endoscopic cervical surgery was described by the Gagner group 4 in 1996 to perform a subtotal parathyroidectomy. Although this procedure exposed many limitations of endoscopic neck surgery, including prolonged surgical time, mild hypercarbia and subcutaneous emphysema related to the CO2 insufflation, and a prolonged postoperative hospital stay, the cosmetic outcome was reported as excellent. 5 This experience attracted the interest of surgeons and patients and suggested the possibility of alternative approaches to thyroid surgery that could minimize the cosmetic impact of the procedure.
This growing interest resulted in the development of minimally invasive and remote access approaches. The minimally invasive approaches include both the minimally invasive video-assisted thyroidectomy (MIVAT) 6 , 7 and the minimally invasive nonendoscopic thyroidectomy (MINET). 8 These techniques employ incisions hidden in natural skin creases that are significantly smaller than those used for conventional thyroid surgery. The extent of dissection is reduced, and the procedure can be performed without a drain and on an outpatient basis. 9 Despite the limited incision length used in minimally invasive surgery and the predictably excellent cosmetic results achieved in the majority of patients, these procedures may result in a conspicuous anterior cervical scar that can be difficult to camouflage, an unacceptable possibility for some patients.
To further reduce the cosmetic impact of thyroid surgery, remote-access approaches were developed, which completely remove the scar from the visible portion of the neck and hide it in a concealed, distant location. These approaches primarily emerged in Asia, where poor wound healing and a cultural bias against visible neck scars are common. 10 , 11 It is important that patients realize that these approaches hide the scar but are not scarless. As a result of the remote access site, a longer and more extensive dissection is required, and structures that are not usually encountered during thyroid surgery may be at risk with these approaches.
Due to the heterogeneity of access sites and instrumentation that has been employed in remote access procedures, it is difficult to directly compare the overall degree of postoperative pain or duration of recovery for this group to that of conventional thyroid surgery. 12 , 13 , 14 Given the increased dissection extent and unconventional anatomical vantage point, the surgeon’s experience and comfort level can significantly impact operative times. 14 , 15 These approaches are generally more expensive than conventional or minimally invasive procedures. Currently, there are no reimbursement strategies in place in the United States to offset these increased costs. 16 , 17 Additionally, surgeon training and robotic equipment may not be widely available. Despite these challenges, remote access procedures are an attractive alternative for select patients who consider any visible cervical scar an undesirable result.
15.3 Remote Access Endoscopic Procedures
15.3.1 Chest/Breast Approaches
The first completely remote access thyroidectomy was performed by Ohgami et al 18 in 2000. The procedure used incisions at the parasternal border of one breast and along the superior margins of both areolas. Low-pressure CO2 insufflation and endoscopic equipment were also used to dissect across the chest and gain access to the thyroid compartment. Several variations of this technique have been described, including isolated anterior chest wall approaches 19 as well as bilateral 20 and unilateral 21 , 22 transareolar approaches. Use of chest/breast approaches are generally reserved for unilateral benign lesions < 3 cm and small papillary thyroid carcinomas in patients with no suspicious lymphadenopathy or prior neck surgery or irradiation. 19 , 20 , 21 , 22
These approaches avoid a visible neck scar but have a number of limitations. First, incisions on the anterior chest are prone to hypertrophic scarring. 23 Additionally, incisions on the breast may be an unappealing consideration for North American patients. 24 , 25 Due to the particular course of dissection, the operative field is narrow, restricting the range of movement of the rigid endoscopic instrumentation. 23
15.3.2 Axillary Approaches
Ikeda et al 26 , 27 described the endoscopic axillary approach as an alternative to the anterior chest and breast approaches. The incision is hidden in the axilla, and CO2 insufflation and endoscopic dissection are used to access the thyroid compartment. The cosmetic sequelae of this approach are less conspicuous as compared to those of conventional surgery; however, disadvantages include a significantly longer operating time, a narrow operative field, the need for endoscopic visualization, and potential morbidity associated with CO2 insufflation. 28 To avoid some of these limitations, “gasless” remote techniques were developed that used specialized retractor systems rather than CO2 insufflation. 29 The gasless approach has been described for thyroidectomy and central compartment node dissection in patients with low-risk papillary thyroid carcinoma, and postoperative thyroglobulin levels and iodine-131 scans reflect acceptable oncological outcomes. 29 , 30 Additional experience and longer follow-up periods will be needed to define the exact inclusion criteria for the treatment of malignant disease using this remote approach.
The axillo-bilateral-breast approach (ABBA) 23 and the bilateral axillo-breast approach (BABA) 31 are among several hybrid endoscopic procedures developed. These techniques combine axillary and areolar incisions for the cosmetic benefit of the axillary approaches while granting an additional anterior chest working port without necessitating a transverse parasternal scar. Several complications not typically linked to traditional thyroid surgery, including transient neuropraxia of the brachial plexus 32 and pneumothorax, 31 have been reported with these approaches. Although these endoscopic remote access approaches are still used in some Asian centers, they have failed to gain significant traction in Western practices.
15.4 Remote Access Robotic Procedures
To overcome the limitations of the endoscopic approaches, in 2009 a group of surgeons in South Korea introduced the concept of robotically assisted remote access thyroid surgery. 33 The introduction of the da Vinci Surgical System (Intuitive Surgical, Inc.) offers several critical advantages over endoscopic technology. The high-definition binocular camera system provides surgeons with a three-dimensional view of the operative field. Many of the robotic instruments are articulated in such a way that they offer as many or more degrees of freedom than the human wrist can achieve, allowing for improved mobility in tight operative spaces. The robot also faithfully reproduces the movements of the surgeon’s hands, permitting safe dissection around critical structures. These robotically assisted remote access procedures can be accomplished without the use of CO2 insufflation. Dual-incision axillary and chest wall, 33 single-incision axillary 34 and facelift 35 approaches have been developed. The technology also permits central and lateral neck dissections for malignant disease. 36
15.4.1 Robotic Axillary Thyroidectomy
The gasless robotic axillary thyroidectomy (RAT) was described in South Korea in 2009. 13 , 33 The initial cases were performed as dual-incision approaches using a second parasternal incision on the anterior chest wall. 13 , 30 Chung et al subsequently refined the approach, which is now most commonly accomplished through a single axillary incision. 33 , 34 , 37 In this technique, an axillary incision is performed, and a soft tissue pocket is developed across the anterior chest. A specially designed retractor (Chung retractor) maintains the pocket, and the thyroid compartment is accessed by separating the sternal and clavicular heads of the sternocleidomastoid (SCM) muscle. 30 The robot is introduced and the gland is removed. RAT has been used to treat benign thyroid nodules as well as small, well-differentiated thyroid cancers with outcomes comparable to treatment with conventional or endoscopically assisted approaches 13 , 15 , 30 , 38
Although this approach has remained popular in South Korea, the enthusiasm that RAT initially enjoyed in Western practices has waned. In the United States, where 2% of cases have required conversion to an anterior cervical approach, 39 , 40 , 41 there have been a number of significant complications not usually encountered in thyroid surgery, including brachial plexus injury, esophageal perforation, and significant blood loss from large-vessel injury. RAT also requires postoperative drainage and inpatient care—a step backward from many of the advances achieved with the minimally invasive anterior cervical approaches. 1 , 17 , 37 , 39 , 42 , 43 For these reasons, this procedure has been abandoned in many Western centers.
15.4.2 Robotic Facelift Thyroidectomy
The robotic facelift thyroidectomy (RFT) was developed to overcome the disadvantages associated with RAT (Table 15.1). 35 , 44 In this technique, robotic assistance is used to remove the thyroid gland through a postauricular modified facelift incision. 44
Recent assessment of more than 60 RFT procedures performed in our center found this technique to be safe and clinically feasible. 39 Though the first patient received a drain and overnight observation, every subsequent procedure has been performed on an outpatient basis without a drain. One incidence of transient vocal fold weakness and two seromas have been reported, all of which resolved without intervention. There were no cases of permanent recurrent laryngeal nerve injury or hypocalcemia. No conversions to an anterior cervical approach were required. This complication profile compares favorably to that reported for RAT. The initial mean operative time for a lobectomy was 157 minutes, which decreased to less than 2 hours with increasing surgeon experience. 35 , 39 The RFT approach has been replicated in at least four other centers with similar safety profiles. 2 , 35 , 44
Although no remote access procedure can be considered minimally invasive, the extent of dissection in RFT is approximately 38% less than that required for RAT (Fig. 15.1). 45 This translates into expedited recovery time, reduced postoperative discomfort, and drainless outpatient surgery. 1 , 2 , 45 The cervical course of dissection is more familiar to the head and neck surgeon than that of the transaxillary approach, 44 and the cephalad approach allows the recurrent laryngeal nerve (RLN) to be encountered early in dissection at its most constant location, which is advantageous in preventing nerve and parathyroid gland injury. 35 , 37 , 44 A disadvantage of RFT is transient hypesthesia in the great auricular nerve distribution even when the nerve is carefully preserved. 44
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