Development of the working space
• Electrocautery with a short, regular, and long tip
• Vascular DeBakey
• Army–navy retractors
• Right-angled retractors
• Breast lighted retractorsa
Table devices
• Chung’s retractor, or Marina retractor (Marina Medical, Sunrise, FL, USA)
• Laparoscopic suction irrigation
• Laparoscopic clip appliers for hemostasis
• Endo Peanut 5-mm device
Robotic instrumentation
• 5-mm Maryland dissector
• 8-mm ProGrasp forceps
• 5-mm Harmonic curved shears
• 30° endoscope (used in the rotated down position)
Robotic arrangement
• Arm 1- Maryland dissector
• Arm 2- Harmonic shears
• Arm 3- ProGrasp forceps
• Endoscope
It is important for the surgeon to determine the best way to organize the operating room prior to the procedure. The operating table should be positioned where the anesthesiologist has access to the patient’s airway. The patient cart is covered with sterile drapes and positioned on the contralateral side of the operating table. The patient cart is initially kept away from the operating table during the development of the working space to allow space for the surgical assistant to work across the table and retract the thyroid gland. Dr. Kandil routinely performs continuous nerve monitoring of the ulnar, radial, and median nerves to avoid neuropraxia when using the transaxillary approach. We also use intraoperative nerve stimulation to definitively identify motor nerve structures during the procedure.
Robotic Transaxillary Parathyroidectomy
Step 1—Patients are placed in a supine position while under general anesthesia, and then intubated with a NIM transoral endotracheal tube (Medtronic Xomed, Jacksonville, FL, USA) to allow intraoperative monitoring of the recurrent laryngeal nerve function.
Step 2—Appropriate placement of the NIM endotracheal tube is confirmed by direct laryngoscopy and by visualization of the electromyographic waveform on the NIMS monitor.
Step 3—The neck is slightly extended, and the arm ipsilateral to the lesion is placed cephalad and flexed above the head (Fig. 26.1). This optimizes exposure of the axilla and creates a short distance from the axillary skin to the thyroid gland, through which dissection would be performed.
Fig. 26.1
Incision marking for robotic transaxillary parathyroidectomy
Step 4—Blood is drawn for a baseline rapid PTH serum level prior to prepping the neck or palpating the neck.
Step 5—The thyroid is identified by palpation and a vertical line is drawn from the midline of the thyroid to the sternal notch, demarcating the medical boundary of dissection. The inferior limit of dissection is drawn from the sternal notch to the ipsilateral axilla in a transverse manner. The superior limit of dissection is drawn in an oblique manner from the thyrohyoid membrane to the axilla (Fig. 26.1).
Step 6—Following infiltration with 10 mL of 1 % lidocaine with 1 in 200,000 adrenaline, a two-inch (5 cm) incision is then made with a scalpel from the intersection of the oblique line and the anterior axillary line as the superior limit and the intersection of the transverse line with the anterior axillary line as the inferior limit. Attention to detail in incising and handling the skin reduces cicatrix hypertrophy.
Step 7— Monopolar electrocautery under direct vision is then used to dissect to the pectoralis fascia. A subcutaneous flap is raised in the direction of the thyroid until the sternal and clavicular heads of the sternocleidomastoid muscle are visualized and opened.
Step 8—A retractor is used to elevate and retract the sternal head exposing the strap muscles. The natural dehiscence between the sternal and clavicular heads is entered using the Harmonic Scalpel (Ethicon, Somerville, NJ, USA), allowing identification of the carotid sheath and ipsilateral omohyoid and sternohyoid muscles.
Step 9—The strap muscles are then elevated off the thyroid gland providing exposure from the sternal notch to the superior pole and across the midline.
Step 10—A wound protector is placed to protect the axillary wound edges from any heat generated by the electrocautery or the harmonic scalpel.
Step 11—A specially designed retractor (Marina Medical, Sunrise, FL, USA) is placed under the strap muscles and secured to the table mount lift to maintain an adequate working space without gas insufflation. This facilitates access to the posterolateral thyroid lobe.
Step 12—The da Vinci Si robot system is docked from the side of the bed contralateral to the operative field. The robotic instruments used are the ProGrasp forceps (Intuitive Surgical, Sunnyvale, CA, USA), Maryland Dissector (Intuitive Surgical, Sunnyvale, CA, USA) and Harmonic scalpel (Ethicon, Somerville, NJ, USA). The 30° endoscope is used in a downward facing orientation. The robotic arms are equipped with the Maryland dissector, the ProGrasp forceps , and the Harmonic scalpel. The Maryland dissector and Harmonic scalpel should be as far apart as possible. This is important in minimizing the risk of collision of the arms during the procedure.
Step 13—The thyroid gland is turned medially and with cautious dissection the pathological parathyroid gland is identified.
Step 14—The middle thyroid vein is divided using the Harmonic scalpel.
Step 15—Identification of the inferior thyroid pedicle with dissection RLN in tracheoesophageal groove is then undertaken to minimize the risk of injury to either structure.
Step 16—A nerve stimulator is routinely used by the assistant surgeon to confirm correct identification of the RLN.
Step 17—Once the pedicle has been delineated, the Harmonic scalpel is used to hemostatically seal and divide the small branches of the inferior thyroid artery close to the capsule of the adenoma.
Step 18—The parathyroid lesion is then dissected, excised, and delivered through the axillary incision (Video Clip 26.1).
Step 19—After gland removal, a serum sample is drawn for rapid PTH analysis. A 50 % or greater drop in PTH level and within normal range predicts a successful single gland surgery. The patient is kept sedated and surgical field maintained until the laboratory results are received. Those patients with no change in PTH level or inadequate reduction of the PTH likely have a secondary adenoma (or less likely an unappreciated MEN patient).
Step 20—The wound is irrigated and inspected for hemostasis. A Jackson-Pratt drain is coursed through the axilla and sutured to the skin.
Step 21—Meticulous closure of subcutaneous tissues and skin is performed using subdermal and subcuticular closure with fine attention to detail.
Robotic Retroauricular (Facelift) Parathyroidectomy
Step1—Patients are placed supine on the operating room table. The head is turned to the side contralateral to the side of the diseased gland. Patients are intubated using a NIM endotracheal tube size 6.0 (Medtronic Xomed, Jacksonville, FL, USA) to allow intraoperative monitoring of RLN function.
Step 2—A small portion of postauricular hair is shaved for the extension of the planned incision lines into the hair-bearing skin.
Step 3—The retroauricular incision is then marked out just posterior to the earlobe, extending into the postauricular crease and adjacent to the occipital hairline at a position that will be covered completely by the ear and hair at rest (Fig. 26.2).
Fig. 26.2
Incision marking for robotic retroauricular parathyroidectomy
Step 4—Blood is drawn for a baseline rapid PTH serum level prior to prepping the neck or palpating the neck.
Step 5—The flap is created superficial to the platysma using a Metzenbaum scissor. Care is taken to preserve the greater auricular nerve. Dissection in the plane superficial to the platysma is performed until the head of the sternocleidomastoid muscle is visualized.
Step 6—The space between the strap muscles and the SCM is created with electrocautery or Harmonic scalpel (Ethicon, Somerville, NJ, USA). The working space is created all the way to just above the omohyoid muscle, which correlates with the superior pole of the thyroid lobe.
Step 7—A specially designated retractor (Marina Medical, Sunrise, FL, USA) is then secured to the table mount lift and placed under the strap muscles to allow continuous exposure of the surgical field, maximizing access to the parathyroid gland.
Step 8—The da Vinci Si system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is then docked using the 30° scope, Maryland dissector, and a Harmonic scalpel (The camera is positioned in the center of the field, a Maryland grasper is placed in the nondominant hand, and the Harmonic is placed in the dominant hand). The robot is docked from the contralateral side of the operative field, with the 30° down looking endoscope, Harmonic scalpel, and Maryland forceps entering via the retroauricular incision.
Step 9—The thyroid gland is turned medially and with cautious dissection the pathological parathyroid gland is identified.
Step 10—The middle thyroid vein is divided using the Harmonic scalpel.
Step 11—Identification of the inferior thyroid pedicle with dissection RLN in tracheoesophageal groove is then undertaken to minimize the risk of injury to either structure.
Step 12—A nerve stimulator is routinely used by the assistant surgeon to confirm correct identification of the RLN.
Step 13—Once the pedicle has been delineated, the Harmonic scalpel is used to hemostatically seal and divide the small branches of the inferior thyroid artery close to the capsule of the adenoma.
Step 14—The parathyroid lesion is then dissected, excised, and delivered through the incision.
Step 15—After gland removal, a serum sample is drawn for rapid PTH analysis. A 50 % or greater drop in PTH level and within normal range predicts a successful single gland surgery. The patient is kept sedated and surgical field maintained until the laboratory results are received.
Step 16—The wound is irrigated and inspected for hemostasis.
Step 17—Meticulous closure of subcutaneous tissues and skin is then performed.
Robotic Thoracoscopic Mediastinal Parathyroidectomy
The presence of a thoracic surgeon is usually required for this procedure. This surgery is not done on an outpatient basis and requires a chest tube to be placed. This approach is utilized to avoid open thoracotomy or median sternotomy.
Step1—A left or right sided approach is chosen according to the location of the ectopic parathyroid gland. The patient is placed in a lateral decubitus position (depending on adenoma localization) with contralateral single-lung ventilation.
Step 2—A 10-mm port for the robotic endoscope is positioned in the 6th intercostal space in the anterior axillary line, and two 8-mm robotic operating ports are placed in the 4th intercostal space, a handbreadth right and left of the first incision.
Step 3—An accessory port is placed in the midclavicular line through the 6th intercostal space, through which a flexible retractor (US Surgical, Norwalk, Conn) is inserted to hold the lung away.
Step 3—A second accessory port through the posterior axillary line in the 6th intercostal space is provided for eventual suction.
Step 4—Resection of the parathyroid adenoma is performed by the thoracic surgeon at the console. This is done by incising either the parietal pleura covering the aortopulmonary window or pericardium depending on the location. The identification of the vagal and recurrent laryngeal nerves are encouraged, but are not considered to be an essential part of the procedure.
Step 5—The vascular pedicle is controlled with the harmonic scalpel or clips and once freed, the adenoma is removed. Compared to conventional thoracoscopic surgery, the robotic operating system provides better visualization of the operating field and facilitates the movement of the instruments. Radioguided surgery can be used but usually there is significant background activity from the heart.
Robotic parathyroidectomy is usually performed as an outpatient procedure. The patients are discharged on anti-inflammatory pain medication with narcotics only for breakthrough discomfort. Patients are supplemented with calcitriol 0.25 mcg twice daily and elemental calcium 1 g twice daily unless signs or symptoms of hypocalcemia present. No laboratory studies are required following intraoperative verification of serum PTH normalization. The patient’s first outpatient follow-up is at 1 week for pathology review, wound inspection and further instruction on wound care. Duration and extent of vitamin D and calcium supplementation are based on preoperative bone mineral density determination and interdisciplinary management with an endocrinologist.
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