Robotic Facelift Thyroidectomy: II. Clinical Feasibility and Safety

Transcription

1 The Laryngoscope VC 2011 The American Laryngological, Rhinological and Otological Society, Inc. Robotic Facelift Thyroidectomy: II. Clinical Feasibility and Safety David J. Terris, MD; Michael C. Singer, MD; Melanie W. Seybt, MD Objectives: A number of remote access thyroidectomy techniques have been described in the last several years. These approaches are technically challenging, can be performed on only a limited patient population, and have been associated with significant complications. We describe a novel robotic facelift approach for thyroidectomy and report our initial clinical experience. Design: Planned analysis of a prospectively maintained database with institutional review board approval. Methods: Robotic facelift thyroidectomy (RFT) was performed on all patients. Demographic and surgical data were obtained and analyzed. Data collected included patient age, gender, body mass index (BMI), pathology, complications, and duration of surgery. Results: A total of 18 RFT procedures were undertaken in 14 patients. There were 13 females and 1 male, with a mean age of years (range: 12 70). The mean BMI was The procedures included 13 lobectomies, one bilateral thyroidectomy, and 3 completion thyroidectomies. All but the first procedure was performed on an outpatient basis without use of a drain. There were no conversions to open surgery, no permanent nerve injuries, and no cases of hypoparathyroidism. Operative times ranged from 97 to 193 minutes. Conclusions: RFT is a feasible remote access thyroidectomy approach. It appears from our initial experience that it may be performed in a safe and reproducible manner without a drain and on an outpatient basis. Additional clinical experience is warranted to further validate this technique. Key Words: Robotic, endoscopic, facelift, cosmetic, thyroidectomy, remote access. Level of Evidence: 2b. Laryngoscope, 121: , 2011 INTRODUCTION After more than a hundred years of performing thyroid surgery essentially the way it was described before the turn of the previous century, thyroidectomy has undergone transformative changes over the past 10 years. With the advent of technology such as advanced energy devices, 1 high-resolution endoscopy, 2 and laryngeal nerve monitoring, 3 thyroidectomies are being performed as minimally invasive, sutureless, drainless, outpatient procedures. 4 A spectrum of access in thyroid surgery has simultaneously emerged, spanning from conventional methods utilizing a Kocher incision through minimal access options 5 and now culminating in remote access techniques. 6 Remote access thyroid surgery has been particularly favored in Asian societies because of both a cultural aversion to neck scars as well as the predominance of a skin type that predisposes to hypertrophic scarring. Although a variety of sophisticated endoscopic Additional Supporting Information may be found in the online version of this article. From the Department of Otolaryngology Head and Neck Surgery, Georgia Health Sciences University, Augusta, Georgia, U.S.A. Editor s Note: This Manuscript was accepted for publication March 22, The authors have no financial disclosures for this article. Dr. Terris has directed a series of thyroid courses sponsored by J&J. Drs. Singer and Seybt have no conflicts of interest. Send correspondence to Dr. David J. Terris, Surgical Director, Georgia Health Thyroid Center, Department of Otolaryngology, Georgia Health Sciences University, 1120 Fifteenth Street, BP-4109, Augusta, GA dterris@georgiahealth.edu DOI: /lary remote access techniques characterized by presternal, 7 periareolar, 8 and axillary 9 portals have been described since the 1990s, the elimination of a neck scar has so far failed in the United States to justify the substantial surgical burden associated with these lengthy operations and wide dissection fields. In 2009, however, Chung and his team 10 described the marriage between a gasless axillary technique and robotic assistance that has generated considerable interest in North America. Consequently, a number of centers have attempted to duplicate these outcomes. For a number of reasons, likely including substantial differences in the size of Korean patients and the minimal burden of disease often managed surgically in that country, attempts to apply the Chung technique to the American population have resulted in the introduction of a number of new and dramatic complications, including multiple episodes of brachial plexopathy, 11 esophageal perforations and even transection (personal communications), excessive blood loss (exceeding 1,000 cc), 11 and inability to completely remove the thyroid gland. 11 We were among the first surgeons in the United States to apply this technique, 12 and although we did not encounter these complications, our enthusiasm was dampened by the negative experiences at other centers. We recognized that some of the challenges might relate to the distance between the access site (axilla) and the thyroid gland and the unfamiliar vector of approach to the thyroid compartment. Because of these challenges, we sought to develop an easier and safer approach that relies on more

2 familiar dissection planes and easier positioning. The foundation for a new robotic facelift approach originated in work we published in the 1990s demonstrating that a facelift incision for parotidectomy was feasible. 13 Subsequent investigations of endoscopic thyroidectomy in our laboratory revealed that a superior to inferior approach to the thyroid gland was optimal when compared to a series of transaxillary methods. 14 Others have embraced this original work and built upon these concepts, 15 including a recent description by Lee et al. 16 in which a postauricular portal combined with an axillary approach using an insufflation technique was utilized to remove the thyroid gland. We therefore pursued a series of preclinical and anatomic investigations 17 of a hybrid technique that combines a cosmetically satisfying postauricular facelift incision with the benefits provided by the gasless and fixed retractor principles promoted by Chung and a superior to inferior dissection of the thyroid gland. The feasibility and potential advantages of this approach relative to the transaxillary technique were confirmed. On the basis of those findings, we pursued a pilot study of a robotic facelift thyroidectomy technique. METHODS AND MATERIALS Institutional Review Board approval was sought and obtained to evaluate the outcomes from thyroid surgical interventions. This investigation focused on patients who underwent robotic facelift thyroidectomy from July 2010 through February of Surgeon, patient and disease criteria were defined and met prior to robotic surgery. Surgeon Selection Criteria Requisite robotic credentialing was pursued and included the following systematic training and exposure: 1. Extensive prior experience with the robotic da Vinci surgical system Additional certified console and assistant surgeon dry laboratory training. 3. Wet laboratory training comprised of both animal and cadaver robotic dissections. 4. Visiting preceptorship in Korea consisting of didactic presentations and observation of four robotic (transaxillary) thyroidectomy procedures. 5. Personal clinical experience with five robotic transaxillary thyroidectomy procedures. 6. Successful cadaveric simulation of robotic facelift thyroidectomy. 17 Patient Selection Criteria Patients who met indications for thyroidectomy and satisfied the following criteria were offered robotic facelift thyroidectomy: 1. Appropriate body morphology (not morbidly obese, with body mass index [BMI] <40). 2. Absence of substantial medical comorbidities (which would mandate a short anesthetic encounter). 3. No previous neck surgery. 4. Normal laryngeal function on preoperative laryngoscopy. Fig. 1. The incision is placed in the postauricular crease, crosses over to the occipital hairline under cover of the ear, and descends within the occipital hairline, which is shaved for approximately 1-cm to completely conceal the incision. 5. Ability to understand surgical options and provide informed consent, and acceptance of the possible need for conversion to open surgery. The optimal candidates for this approach include those with follicular neoplasms of unclear malignant potential or growing nodules of concern to the patient. Patients with small multinodular goiters were also eligible. Absolute contraindications to remote access surgery include substernal extension, presence of lymphadenopathy, or extrathyroidal extension of malignancy. Surgical Procedure The technical details of the robotic facelift thyroidectomy are summarized below. The patient is positioned supine on the operating table with the head turned slightly (30 ) away from the side of the procedure and supported to prevent excessive rotation. Laryngeal nerve monitoring is preferred, and therefore the patient is intubated with a laryngeal EMG tube (NIM-2, Medtronic Inc., Jacksonville, FL). Approximately 1 cm of hair is shaved along the occipital hairline. The patient is rotated 180 away from the anesthesiologist, injected with epinephrine-containing quarter percent marcaine solution, and sterilely prepped and draped. An incision is made in the postauricular crease and continued within the occipital hairline (Fig. 1). A musculocutaneous flap is raised superficial to the greater auricular nerve and external jugular vein and deep to the platysma muscle (Fig. 2), and extended inferiorly ventral to the sternocleidomastoid muscle down to the clavicle. The triangle defined by the omohyoid muscle, the sternocleidomastoid muscle, and the sternohyoid muscle is delineated, and the omohyoid muscle is retracted ventrally. The sternohyoid and sternothyroid muscles are reflected anteriorly and medially exposing the thyroid gland (Fig. 3). A fixed retractor system (modified from the Chung retractor device, Marina Medical, Tampa, FL) is introduced to retract the strap muscles ventrally and anteriorly, and to maintain a working space. The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) is deployed (Fig. 4) and is characterized by the placement of a 30 camera facing downward in the center of the surgical field, followed by a Maryland grasper in the second 1637

3 Fig. 2. A right-sided view of the open dissection necessary to expose the thyroid compartment. Easily seen are the greater auricular nerve (GAN), external jugular vein (EJV), sternocleidomastoid muscle (SCM), and the omohyoid muscle. Fig. 4. The robot is deployed after a fixed retractor is properly positioned for a right thyroid lobectomy. 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. A patient-side assistant can exchange instruments or provide suctioning as needed. arm and a Harmonic CS14C device (Ethicon Endosurgery, Inc., Cincinnati, OH) in the third arm. A Singer retractor (Augusta, GA) is placed on the sternocleidomastoid muscle to retract it laterally and posteriorly. The superior pole is mobilized away from the inferior constrictor muscle, the superior laryngeal nerve is identified, and the vascular pedicle is ligated as a single bundle with the Harmonic device (Fig. 5). The superior pole is then reflected ventrally and inferiorly and the superior parathyroid gland identified and dissected posterolaterally. The recurrent laryngeal nerve is identified just proximal to its entrance beneath the inferior constrictor muscle (Fig. 6) and dissected in a retrograde fashion until a safe distance between the nerve and the thyroid gland is achieved. The Prass nerve-stimulating probe (Medtronic, Inc.) may be utilized to confirm the identity and integrity of the nerve. The ligament of Berry is divided with the nerve under direct vision and then the isthmus is transected. The middle thyroid vein is ligated using the Harmonic device, and the inferior pole is fully mobilized using blunt dissection. The inferior parathyroid gland is identified and dissected inferiorly. The inferior thyroid artery and vein are ligated using the Harmonic device, the remaining attachments of the gland are divided, and the thyroid lobe is delivered through the incision. The wound is closed in layers after placing a large sheet of Surgicel in the thyroid compartment. Dermabond glue (Ethicon, Inc., Somerville, NJ) is used to seal the skin. After extubation, the patient is observed in the recovery room for a period of 60 to 90 minutes, flexible laryngoscopy is performed to confirm normal laryngeal function, and then the patient is discharged to home from the same day surgery center. Fig. 3. Once the omohyoid, sternohyoid, and sternothyroid muscles are retracted ventrally, the superior pole of the right thyroid lobe becomes visible. Fig. 5. Robotic view of a left superior thyroid pedicle just prior to ligation. 1638

4 substantial challenge with the facelift approach. Representative photographs of a patient with a remote history of a facelift who underwent a left robotic facelift thyroidectomy (Fig. 7) are depicted. Fig. 6. Robotic view of a left recurrent laryngeal nerve identification and electrical stimulation. Procedural times were carefully recorded and included the time for set up, the time required for development of the surgical pocket, the robot docking time, the time on the robotic console, and the time for skin closure. The total surgical time was reflected by the interval between the skin incision (the start of surgical pocket development) and the skin closure. RESULTS Fourteen consecutive patients met the criteria for robotic facelift thyroidectomy (RFT) and were offered this clinical approach. There were 13 females and 1 male, with a mean age of years (range: 12 70) who underwent 18 RFT procedures. There were nine right thyroidectomies, seven left thyroidectomies, and one total thyroidectomy (achieved by bilateral RFT through two separate incisions). The pathology revealed three malignancies (two papillary cancers and one follicular cancer); the remainder were benign (four follicular adenomas, one Hurthle cell adonenoma, and nine cases of nodular hyperplasia, and one normal contralateral lobe). Three of the procedures represented completion surgery to address the malignancies. The procedural times are reflected in Table I. The surgical complications consisted of two seromas and one episode of transient vocal fold dysfunction, each of which resolved promptly and without treatment. There were no cases of permanent nerve palsy, and no cases of temporary or permanent hypoparathyroidism (in the four patients who underwent staged or simultaneous total thyroidectomy). None of the procedures required conversion to open surgery. All patients described temporary periauricular hypesthesia in the distribution of the greater auricular nerve, which resolved within several weeks. All but the first RFT procedure were performed without drains and on an outpatient basis, and there were no readmissions. A Foley urinary drainage catheter was inserted for the first three cases, after which its use was discontinued. The only time it was used subsequent to that was for the bilateral thyroidectomy. Body habitus did not pose a DISCUSSION Thyroid surgery has evolved considerably to the point where most patients can anticipate a thorough removal of their gland without major complications, and with the presumption that their laryngeal nerves and parathyroid glands will be preserved. An increasingly sophisticated public has therefore driven a shift in the focus toward improving cosmetic outcomes. Consequently, the past 10 years have witnessed reductions in incision length, promotion of new technologies to facilitate minimal access techniques and eventually even remote access approaches to the thyroid compartment. Because even a long thyroidectomy scar usually heals satisfactorily and may be virtually unnoticeable, some have questioned the efforts to improve cosmetic outcomes with thyroid surgery. Nevertheless, in an increasingly patient-centered medical environment, the question are you satisfied with your thyroid scar? has been replaced by the question would you be more satisfied with a smaller scar, a query that has been indirectly but unequivocally answered in developed countries by the vast proliferation and implementation of minimally invasive procedures. However, a poor cosmetic outcome is occasionally associated with even minimally invasive techniques. Therefore, the compelling question that has now emerged is would you be even more satisfied with no neck scar? Because of this possibility, remote access techniques have therefore gained traction, even in the United States. A number of surgical portals have been described including presternal, circumareolar, axillary, retroauricular, and even intraoral sites. The obvious benefit of the elimination of a neck scar must be balanced against the costs (physiologic and economic) associated with the more invasive and costly remote access techniques. Although the risk-benefit ratio has not deterred the implementation of robotic axillary thyroidectomy in some centers, there has been widespread concern over compromise of some of the gains obtained in thyroid surgery over the past decade, particularly the achievement of an outpatient, drainless, sutureless procedure. We endeavored to develop a remote access technique that is as safe and effective as conventional thyroidectomy so that patients who desire the cosmetic TABLE I. Robotic Facelift Thyroidectomy Operative Times. Minimum Maximum Mean 6 SD Pocket dissection Docking Console Total Time in minutes; SD ¼ standard deviation. 1639

5 Fig. 7. Six-week postoperative photographs of a 62-year-old woman with a remote history of a facelift who had undergone a left robotic facelift thyroidectomy. benefits need not weigh aesthetic considerations against additional risks. After confirming feasibility in cadavers, we have therefore cautiously pursued a clinical study in order to assess the safety and feasibility of a straightforward technique that represents a hybrid of previously described principles. It combines elements from a facelift parotidectomy, 13 the Chung gasless robotic thyroidectomy, 10 the Lee retroauricular insufflation technique, 16 and the implementation of laryngeal nerve monitoring. 3 It is built upon our own experiments with totally endoscopic thyroidectomy options 14 and was stimulated by our disappointing experience with robotic axillary thyroidectomy. It is reflective of a natural progression from conventional techniques to minimally invasive and endoscopically assisted techniques that we have employed for more than 5 years, now culminating with a cosmetic remote access robotic thyroidectomy that may be accomplished in a safe and reproducible fashion with a low complication rate. Although it will be difficult to demonstrate differences between our technique and the axillary approach without large, randomized prospective trials, a series of advantages is apparent. The principal benefits of RFT are easier positioning and shorter distance to the thyroid, and a more natural approach for head and neck surgeons. 13 By simply placing patients supine on the operating table, the risk of brachial plexopathy is completely eliminated, and the positioning therefore takes no longer than would be required for a conventional thyroidectomy. The distance between the hairline incision and the superior pole of the thyroid is approximately 6 cm, and substantially less than that associated with axillary thyroidectomy. This has a number of benefits including the facilitation of nerve monitoring; reduced dissection also likely results in more rapid wound healing and less pain, although this will likely remain unproven. Drains are not required with the RFT, and 1640 therefore outpatient management can be pursued. Overall, fewer compromises in the progress that has been made in thyroid surgery must be accepted in order to move the incision to this remote location. A final very important advantage is that this procedure is actually easier in slightly obese patients because of the ease of raising the flap in preparation for robotic resection of the gland. Therefore, the proportion of patients eligible for this technique is greatly widened. A disadvantage of the RFT is that the path of dissection requires that the greater auricular nerve be identified and protected. Despite preservation of this nerve, most patients will experience temporary hypesthesia in the area corresponding to this nerve distribution. The sensation returns over time, and has not proven to be bothersome to any patients. A number of questions remain to be answered regarding the RFT or any remote access technique, especially when robotic technology is incorporated. It is not clear how many patients will favor a procedure that is longer and more invasive in order to obtain the sole advantage of elimination of a neck scar. Furthermore, additional costs associated with the approach (principally the longer anesthesia time) will need to be justified. An expanded patient population and multicenter application of this technique will be necessary in order to gain even greater confidence in its safety and feasibility. This expanded application would appear to be justified on the basis of the excellent early clinical results achieved thus far. CONCLUSIONS Robotic facelift thyroidectomy is a feasible remote access thyroid surgery approach. It appears from our initial experience that it may be performed in a safe and

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