The higher socioeconomic status enjoyed today has resulted in quality of life being viewed as a major issue. This trend has greatly influenced medical disciplines, and many medical and surgical therapies have been modified based on quality of life considerations. Accordingly, minimally invasive surgery in various surgical fields has rapidly developed and spread due to increased concerns about issues, such as incision scars, degree of pain, and time required to return to work after surgery.

In the head and neck area, well-differentiated thyroid carcinoma (WDTC) is the most common malignancy and, unlike other cancers of the head and neck, usually has a favorable prognosis. Furthermore, the incidence of early-stage cancer of the thyroid has markedly increased due to the institution of various health-screening programs, and the proportion of thyroid cancer in young women, who are particularly sensitive to cosmesis, is increasing. Accordingly, trials on endoscopic or minimally invasive techniques in thyroid surgery have been continuously conducted with a main aim of avoiding visible scars on the neck, and many early satisfactory results have already been reported for these techniques.

Papillary carcinoma of the thyroid (PTC)—the most common type of WDTC—usually has a mild biologic course, but nevertheless, it frequently metastasizes to the cervical lymph nodes (LNs). In cases of metastasis to the lateral neck nodes (LNM) from PTC, bilateral total thyroidectomy with modified radical neck dissection (MRND) for metastatic lateral cervical nodes is the treatment of choice. However, although conventional open MRND is the safest and most efficient type of surgical treatment, a desperately long incision scar on the neck is inevitable. In view of the favorable nature and high prevalence of PTC in women, the avoidance of unsightly scarring in the neck area necessitates minimally invasive and remote approaches to lateral neck dissection. Accordingly, I have applied endoscopic techniques to thyroidectomy and MRND procedures for PTC with LNM. Furthermore, the incorporation of dexterous robotic technology in surgery of the neck enables more precise and meticulous endoscopic movement during the complex procedure required for MRND. Recently, a robotic MRND technique for cancer of the thyroid with LNM was introduced and produces excellent cosmetic results. In addition, the technical feasibility and safety of robotic MRND have been reported, and the technique has been found to be capable of complete compartment-oriented dissection.

In the early 20th century, George Washington Crile first described a systematic surgical approach to en bloc neck dissection for cancers of the head and neck, and subsequently, Martin and his colleagues refined Crile’s original methods and substantially expanded the concept of radical neck dissection to its current format. Later many surgeons, including Suárez, Bocca, and Gavilán, attempted to modify, standardize, or establish the surgical extent of neck dissection. During the 1960s, surgeons at the MD Anderson Hospital (Jesse, Ballantyne, and Byers) began to selectively remove, based on location of the primary lesion, only the neck LN groups at highest risk of metastasis.

Recently, profound comprehension of the pathophysiology of cancers of the head and neck and intensive treatment experience resulted in alternative surgical options for cervical LN metastasis, such as selective or
superselective neck dissection in accordance with primary tumor biology to reduce surgical morbidity while preserving oncologic safety.

In carcinoma of the thyroid, MRND type III (actually, selective neck dissection [levels II-VI]) is the current treatment of choice for the management of WDTC with LNM. In this chapter, I will describe in detail robotic MRND methods for the management of WDTC with LMN.

A complete examination of the head and neck should be performed. The location of the enlarged nodes can often guide you to the primary cancer. It is important to check the thyroid gland for nodules.

The size, number, and mobility of the LNs are important. It is also critical to note fixation to the skin, or underlying structures which may be a contraindication to this procedure.

1. Life expectancy of <3 months

2. Uncontrollable cancer at the primary site

3. Fixed LNs unchanged by irradiation and/or chemotherapy

4. Surgeon who is inexperienced with robotic surgery and open MRND

WDTC should be diagnosed in all patients by preoperative fine-needle aspiration biopsy (FNAB). High-resolution staging ultrasonography (US) and computed tomography of the neck can be performed for preoperative staging of the disease. All patients with clinically palpable lateral neck nodes or a lateral LN with a suspicious ultrasound appearance by preoperative staging US should undergo US-guided FNAB.

The presence of metastasis to a lateral neck node can be determined by US-guided FNAB histology or by measuring thyroglobulin (Tg) levels in FNAB washout fluid (FNA-Tg > 10 ng/mL, >mean + 2 SD of FNA-Tg measured in node-negative patients, or >serum-Tg) from lateral neck LNs.