Key points

Introduction

The performance of thyroid surgery has changed greatly over the last decade. Incorporating principles and techniques from other surgical fields, a range of minimally invasive and minimal incision thyroidectomy procedures have been developed. The most widely adopted of these is the minimally invasive video-assisted thyroidectomy, described and refined by Miccoli and colleagues. These minimally invasive thyroidectomy techniques are designed to minimize dissection and tissue trauma, leading to decreased postoperative pain and faster recovery times. At the same time, incisions as small as 2 cm can now be used to perform thyroid surgery. When properly placed in the neck, this type of incision typically heals with excellent cosmetic results. Nonetheless, for some patients, any cervical scar is undesirable, including patients with a predisposition to the development of keloids or hypertrophic scars. As a result, surgeons have sought to develop remote access thyroidectomy techniques in which the thyroid compartment is approached from an incision not in the cervical region. These operations result in less conspicuous, noncervical scars.

Many remote access techniques, some endoscopic and others robot assisted, have been described. The most popular of these use the axilla as the access point to the thyroid compartment. Robotic facelift thyroidectomy (RFT), uses a facelift incision in the postauricular area to provide entry to the thyroid compartment. This technique was developed based on the notion that this approach would be less invasive, easier to learn, and perhaps safer than the axillary-based approaches. RFT consequently is a hybrid approach that integrates important components of traditional thyroid surgery with several innovative principles, including use of the modified facelift incision, the integration of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA), and the use of a fixed retractor system as described by Chung . RFT has now been shown to be feasible and safe and an increasing number of institutions have begun to offer it to select patients. This article describes the indications, technical details, outcomes, and potential complications of RFT.

Introduction

The performance of thyroid surgery has changed greatly over the last decade. Incorporating principles and techniques from other surgical fields, a range of minimally invasive and minimal incision thyroidectomy procedures have been developed. The most widely adopted of these is the minimally invasive video-assisted thyroidectomy, described and refined by Miccoli and colleagues. These minimally invasive thyroidectomy techniques are designed to minimize dissection and tissue trauma, leading to decreased postoperative pain and faster recovery times. At the same time, incisions as small as 2 cm can now be used to perform thyroid surgery. When properly placed in the neck, this type of incision typically heals with excellent cosmetic results. Nonetheless, for some patients, any cervical scar is undesirable, including patients with a predisposition to the development of keloids or hypertrophic scars. As a result, surgeons have sought to develop remote access thyroidectomy techniques in which the thyroid compartment is approached from an incision not in the cervical region. These operations result in less conspicuous, noncervical scars.

Many remote access techniques, some endoscopic and others robot assisted, have been described. The most popular of these use the axilla as the access point to the thyroid compartment. Robotic facelift thyroidectomy (RFT), uses a facelift incision in the postauricular area to provide entry to the thyroid compartment. This technique was developed based on the notion that this approach would be less invasive, easier to learn, and perhaps safer than the axillary-based approaches. RFT consequently is a hybrid approach that integrates important components of traditional thyroid surgery with several innovative principles, including use of the modified facelift incision, the integration of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA), and the use of a fixed retractor system as described by Chung . RFT has now been shown to be feasible and safe and an increasing number of institutions have begun to offer it to select patients. This article describes the indications, technical details, outcomes, and potential complications of RFT.

Treatment goals

RFT is designed to avoid a cervical incision and achieve thyroidectomy results (both complication rates and completeness of resection) that match those of conventional and minimally invasive thyroidectomy approaches. Although some investigators suggest that the use of the robot in remote access procedures makes them minimally invasive and safer, these claims are difficult to justify. Patients undergoing RFT should understand that this technique offers cosmetic benefits in the context of safely performed thyroid surgery. The goal of RFT (or any remote access procedure) is not to be minimally invasive.

Preoperative planning and special equipment

In order to achieve excellent results with RFT proper patient selection is critical. Appropriate indications and contraindications are shown in Table 1 .

In RFT, the first phase of the surgery, creating the operative pocket, is completed under direct vision. The surgical robot is then docked and the thyroidectomy begun. To complete the initial phase of the surgery a standard tray of head and neck instruments is needed. In addition, a series of progressively longer retractors and forceps is necessary to facilitate dissection as the pocket is developed inferiorly. An extralong tip electrocautery tip is also helpful during this step of RFT.

Once the operative pocket is created it is maintained by a fixed retractor system that elevates the myocutaneous flap. A second retractor is needed to laterally retract the sternocleidomastoid muscle (SCM). The da Vinci S or Si robot (Intuitive Surgical Inc, Sunnyvale, CA) is used to complete the excision.