Introduction

Recent technological advances and increasing patient interest have driven the development of alternative approaches to conventional thyroidectomy. These approaches have progressed along two divergent pathways: minimally invasive anterior cervical approaches and remote access approaches. Remote-access thyroidectomy approaches completely remove the incision from the visible portion of the neck by concealing it in a hidden distant location. These approaches may be attractive for patients who are highly motivated to avoid a publicly visible thyroidectomy scar. ¹ , ²

Background

The first remote-access techniques were described over a decade ago and involved chest and breast incisions for access and CO₂ insufflation to maintain the operative space. ³ More recently, with the aid of robotic technology, Chung et al developed a gasless transaxillary remote-access approach that could be accomplished via a single axillary incision. ⁴ , ⁵ , ⁶ The application of remote-access robotic axillary thyroidectomy (RAT) in the United States yielded a number of significant complications not previously encountered in thyroid surgery, including brachial plexus injury, esophageal perforation, and high-volume blood loss from damage to the great vessels. The rate of conversion to an anterior cervical approach is reported to be up to 2%. ⁷ , ⁸ , ⁹ Additionally, remote-access RAT requires a surgical drain and postoperative hospital admission, which represents a step backward from the advances achieved with the minimally invasive anterior cervical approaches. ¹ , ⁶ , ⁷ , ¹⁰ , ¹¹ , ¹²

Remote-access robotic facelift thyroidectomy (RFT) was developed to overcome some of the limitations associated with RAT. ¹³ , ¹⁴ RFT incorporates a single postauricular modified facelift incision as the access site, a fixed retractor system, and utilization of the surgical robot. ¹⁴ This technique, while not “minimally invasive,” reduces the extent of dissection by approximately 38% as compared to RAT, shortening the recovery time, reducing postoperative discomfort, and permitting drainless outpatient surgery. ¹ , ² , ¹⁵ , ¹⁶ One disadvantage of RFT is transient hypesthesia in the distribution of the great auricular nerve (GAN). ¹⁴

RFT also employs a more familiar dissection route to the thyroid compartment than the transaxillary method, though the approach is still from a nonconventional perspective. ¹⁴ , ¹⁶ In accessing the thyroid compartment from a cephalad to caudad trajectory, the axis of visualization is parallel to much of the relevant anatomy rather than from a traditional ventral point of view. From this viewpoint, familiar anatomical structures may be less readily identifiable. ⁶ During this course of dissection, the recurrent laryngeal nerve (RLN) is encountered early in its most constant location, which has been shown to be advantageous in avoiding nerve and parathyroid gland injury. ¹³ , ¹⁴ , ¹⁶

A recent assessment of our experience with RFT, evaluating 57 procedures on 50 patients, found RFT to be safe and clinically feasible. ⁷ There were no conversions to an anterior cervical approach. All but the first patient was discharged on the day of the procedure and without a drain. The initial mean operative time for a lobectomy was 157 minutes; however, with increased experience, most cases are now less than 2 hours. Complications included seroma, one case of transient accessory nerve weakness, and three cases of transient vocal cord paresis. There were no cases of permanent hypocalcemia or RLN injury. This profile compares favorably to that reported for RAT. ⁷ , ¹³

Indications

RFT may be an option for patients who value cosmesis as a priority. The purely cosmetic benefits of the procedure should be discussed. ¹⁴ The patient should also be counseled regarding the unlikely event that conversion to an open procedure via an anterior cervical incision may be necessary. Careful consideration of patient and disease characteristics should also be made to ensure the appropriateness of RFT ( Table 8.1 ).

Selection criteria for patients ¹ , ⁷ , ¹³ , ¹⁴ under consideration for the robotic facelift thyroidectomy include:

1. 
   

   A motivated patient who is committed to eliminating a scar of the visible neck and who is willing to accept a lengthier surgical time, increased extent of dissection, and transient auricular hypoesthesia

   
   
2. 
   

   A body mass index of less than 40

   
   
3. 
   

   The absence of substantial medical comorbidities with an American Society of Anesthesiologists class of 1 or 2

   
   
4. 
   

   Absence of previous neck surgery

   
   
5. 
   

   The ability to understand the alternative surgical options, accept the possibility of conversion to an open anterior cervical approach, and capability to provide informed consent

Selection criteria pertaining to disease characteristics ¹ , ⁷ , ¹³ , ¹⁴ are as follows:

1. 
   

   Anticipation of unilateral surgery for benign disease (for bilateral disease, patients may be candidates for staged bilateral RFT)

   
   
2. 
   

   Dominant nodule size less than 4 cm in greatest dimension

   
   
3. 
   

   Absence of clinically apparent thyroiditis

   
   
4. 
   

   Absence of lymphadenopathy, extrathyroidal extension, or substernal extension

Nerve Monitoring and Anesthetic Considerations

Under Glidescope video laryngoscope (Verathon, Seattle, WA) visualization for confirmation of appropriate placement, the patient is intubated with an electromyographic endotracheal tube for laryngeal nerve monitoring (NIM, Medtronic, Jacksonville, FL). A short-acting muscle relaxant is used if necessary for induction, with no muscle relaxation employed during the actual dissection. A propofol drip is preferred for maintenance of anesthesia. The operating table is turned 180° from the anesthesia team, necessitating extension tubing for the anesthesia circuit. At the conclusion of the procedure, deep extubation is preferred to minimize coughing and bucking on emergence that could predispose to bleeding and seroma formation. ¹ , ⁷

Procedure and Anatomical Landmarks

Marking

The patient is marked preoperatively while sitting upright. The modified facelift incision is drawn in a position that will be concealed by the ear, beginning adjacent to the postauricular crease and extending into the occipital hairline. The incision is continued inferiorly, approximately 1 cm within the occipital hairline, to ensure it will be obscured by hair postoperatively ( Fig. 8.1 ). ¹ , ¹³ , ¹⁴ No preauricular limb is used. ² A proposed anterior cervical incision is also marked in the unlikely possibility that conversion to open surgery is required.

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