Obesity (BMI >30 kgm−2)
Large ipsilateral goiter
Previous surgery to the neck
Previous radiotherapy to the neck
Important co-comorbidity (ASA>2)
Suspicion of parathyroid carcinoma
Ipsilateral acromioclavicular osteoarthritis
The ideal RP patient would be slim with a preoperatively localized parathyroid adenoma. Individuals with a predisposition to hypertrophic scarring and keloid formation are ideal candidates as the avoidance of a neck scar is particularly desirable [8].
11.2 Informed Consent
Informed consent is undertaken by the attending surgeon. RP may be offered as an alternative to the conventional cervical approach, and both options should be discussed with the patient.
The risks associated with RP are the same as for conventional parathyroidectomy with regard to the recurrent laryngeal nerve (RLN), infection, hematoma, seroma, persistent hyperparathyroidism, and need for revision surgery. The literature does not support an increased infection rate with RP compared to cervical parathyroidectomy [9].
Additional points that should be explained to the patient include the fact that there will still be a scar though this will be concealed in the axilla. Moreover, it is very likely that they will experience dysesthesia on the chest over the area that the subcutaneous flap has been raised. This almost always resolves though may take several months. Pain is not a particular problem with RP [9, 10]. The patient should also be made aware of the risk of brachial plexus neurapraxia. This is rare and becomes almost a “theoretical” risk when the ipsilateral arm is placed in the “extended salute” position (see Sect. 3, “Patient Positioning”).
With regard to the latter risks (axillary scar, dysesthesia on chest, and potential for brachial plexus neurapraxia) and the prolonged operative time, it should be made clear to the patient that these are specific to RP and not associated with conventional parathyroidectomy so that they can subsequently make an informed decision. The inpatient stay and time off work are similar to the conventional open technique [9, 11].
11.3 Patient Positioning
It is important to position the patient’s ipsilateral arm when they are awake in order to ensure comfort and thus minimize the risk of traction on the brachial plexus (and associated neurapraxia) [12]. The ipsilateral arm must be free of identification bracelets, lines, blood pressure cuffs, or EKG leads. Arm positioning involves the back of the patient’s hand touching the central portion of the forehead, in an “extended salute” position (Fig. 11.1). This has been shown to minimize the risk of brachial plexus neurapraxia [13].
Fig. 11.1
The “extended salute” position for single-port transaxillary robotic parathyroidectomy. By adjusting the position of the ipsilateral arm with the patient awake to assess for comfort, the risk of traction injury to the brachial plexus is minimized. Doing so and marking the incision immediately prior to surgery constitute vital components of preoperative planning. The laterality is pre-marked with an arrow as is the external jugular vein, sternal head of sternocleidomastoid muscle, parathyroid adenoma location, and the 5–6 cm axillary incision. This is rechecked once the patient is positioned on the operating table as in our experience this is the optimal way to plan where to place the incision to prevent subsequent migration. Note extensive scaring on the chest from chickenpox (anteriorly) and right lateral minithoracotomy hypertrophic scar from previous bullectomy to treat pneumothorax. This is a patient who had valid reasons for wanting to avoid a visible neck scar and seeking a transaxillary approach for his parathyroidectomy
A 5–6 cm axillary incision is also marked at this point as in our experience this is the optimal way to plan where to place the incision to prevent subsequent migration. The incision may need to be extended superiorly in a curvilinear fashion so that it sits in a natural skin crease. This reduces tension and a tendency toward hypertrophic and pigmented scarring. Laterality (side of surgery) is indicated by a skin marker (arrow).
Following this, the anesthesiologist intubates the patient and ventilates them via a transoral endotracheal tube with electrodes (NIM EMG Endotracheal Tube, Medtronic, Inc., Jacksonville, FL). The correct positioning of the NIM EMG endotracheal tube with the electrodes at the level of the glottis is confirmed by direct laryngoscopy. Visualization of the electromyographic waveform on the nerve integrity monitor (NIM) following insertion of the stimulator and earth leads serves as additional confirmation. An extended tip of the NIM must be available due to the long distance between the axillary incision and neck. At induction, the patient is routinely administered intravenously 1.2 g co-amoxiclav and 4 mg dexamethasone.
Contrary to conventional parathyroid surgery, a shoulder roll is not placed under the shoulders as this leads to neck extension moving the parathyroid adenoma away from the robotic instruments. Instead, a pillow is placed under the patient’s head and shoulders to provide adequate and comfortable support in a subtle “sniffing the morning air” position. The head of the table is then dropped to about 20° to widen the angle between the arm and chest.
11.4 Surgical Equipment
The surgical equipment consists of the non-robotic trays (used for the single-port transaxillary access) and the robotic instruments. These are illustrated in Figs. 11.2, 11.3, 11.4, 11.5, 11.6, and 11.7.
Fig. 11.2
Non-robotic instruments used for establishing the single-port transaxillary access. These include a Bovie (monopolar electrocautery) with a long extension and insulated tip, Harmonic scalpel (Ethicon Endo-Surgery, Inc., Johnson & Johnson, Cincinnati, OH), pledgets (Teleflex® Inc., NC), and Langenbeck retractors
Fig. 11.3
Self-illuminating retractor used for raising the subcutaneous flap for single-port transaxillary access to the neck
Fig. 11.4
The Modena surgical modular retractor (CEATEC® Medizintechnik) is introduced once the flap has been raised and prior to docking the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). It incorporates a suction tube to its blade to prevent fogging of the robotic dual-channel endoscope intraoperatively
Fig. 11.5
The three robotic arms used: Harmonic ACE curved shears, DeBakey forceps, and Maryland dissector used in single-port transaxillary robotic parathyroidectomy. The fourth assistant arm holds the 8 mm ProGrasp which serves mainly for retraction of the ipsilateral thyroid lobe (see Fig. 11.17). Following insertion into their trochars, all robotic arms and camera are inserted through the axillary incision
Fig. 11.6
A 30° down, 12 mm dual-channel endoscope is used. The endoscope and all robotic arms are inserted through the axillary incision
Fig. 11.7
The extended tip of the nerve integrity monitor required during robotic dissection for stimulation of the recurrent laryngeal nerve due to the long distance between the axillary incision and neck
11.5 Transaxillary Access to the Neck
This follows patient positioning (Fig. 11.8), sterilization, and draping. It provides access to the operative field and precedes the robotic part of the operation. A step-by-step narrative is provided in Figs. 11.9, 11.10, 11.11, 11.12, 11.13, 11.14, and 11.15.
Fig. 11.8
The “extended salute” position for right single-port transaxillary robotic parathyroidectomy (laterality pre-marked with arrow). This position shortens the distance between the incision site and parathyroid adenoma by elevating and externally rotating the clavicle while protecting the brachial plexus from traction. This is a modification to Chung’s method for transaxillary robotic thyroidectomy where the arm is fully extended over the head [14]. We advise against the fully extended arm position as this puts the brachial plexus at risk through traction. We have had no such problems since modifying Chung’s method of arm positioning. Adjusting the position of the ipsilateral arm with the patient awake to assess for comfort and marking the incision immediately prior to surgery constitute vital components of preoperative planning. The 5–6 cm axillary incision has been pre-marked and rechecked once the patient is positioned on the operating table as in our experience this is the optimal way to plan where to place the incision to prevent subsequent migration. Note the NIM EMG endotracheal tube, eye protection, and special arm rest to support the arm which is abducted and flexed with the forearm being pronated so that the back of the hand rests on the central portion of the forehead. A Velcro coin is attached to the hand and forehead to maintain the position
Fig. 11.9
The axillary incision. Note the sterile field includes the neck, anterior thorax, and ipsilateral axilla. EKG leads are placed on the back so as not to interfere with the sterile field
Fig. 11.10
Following the axillary incision, a subcutaneous flap is raised superficial to the clavipectoral fascia. The superior and inferior points of the axillary incision are extended to the thyroid cartilage and sternal notch, respectively. The resulting shape of the flap is that of a trapezoid. In taller patients, if the distance from the axilla to the sternal notch exceeds the limit of the instruments, the robot can be docked in earlier to perform the last (most distal) part of the subcutaneous flap raising. The technique for entering the neck is identical to the one described below but is performed robotically. This modification expands the range of patients to whom single-port transaxillary robotic parathyroidectomy can be offered [15]
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