Robotic Thyroid Surgery

Transcription

1 Curr Surg Rep (2013) 1:16 25 DOI /s MINIMALLY INVASIVE ENDOCRINE SURGERY (H CHEN, SECTION EDITOR) Robotic Thyroid Surgery Laura I. Wharry Michael T. Stang Published online: 22 December 2012 Ó Springer Science + Business Media New York 2012 Abstract While thyroid surgery has been performed safely for nearly a century, the societal desire for a smaller and less visible surgical incision and consequent neck wound have become increasingly important for some patients. Within the last 5 years, thyroid surgical methods have been adapted by several groups to utilize robotic platform technology with the goal of achieving safe resection of the thyroid gland without a visible neck blemish. We review the currently published data regarding the use of surgical robotic platforms to perform remote access thyroid surgery. In particular, the currently described approaches, outcomes, complication profile, learning curve, and cost are examined. We also discuss the utility of the approach in populations of special interest to the endocrine surgeon, and a rational framework for adoption of the technology among surgeons interested in adding this technique to their armamentarium. Keywords Robotic thyroidectomy Transaxillary thyroidectomy Minimally invasive thyroid surgery Robotic thyroid surgery Gasless transaxillary approach Bilateral axillary breast approach Central compartment nodal disease Lateral cervical compartment nodal disease Introduction: Historical Perspective The standard cervical approach to thyroid surgery was originally described by Kocher in 1883 and, along with the adoption of antiseptic techniques, revolutionized the nature L. I. Wharry M. T. Stang (&) Division of Endocrine Surgery, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Kaufmann Building Suite 101, Pittsburgh, PA 15213, USA stangmt@upmc.edu of thyroid surgery [1]. Mortality rates decreased from nearly 40 % to less than 1 % and his methodology has been successfully used throughout the world and refined since the early 1900s [1]. The approach utilizes a transverse cervicotomy and direct dissection on the thyroid capsule, thereby avoiding the recurrent laryngeal nerves (RLNs) and closely approximated parathyroid glands. For this and other important advances in the treatment of thyroid disease, he was awarded the Nobel Prize in 1908 [1]. Many variations of the cervical neck incision have been used ranging from vertical incisions to circular, T, V or Y shaped flaps. However, the predominant final iteration adopted was the wide transverse cervical collar incision. Historically, the cervicotomy used to approach the thyroid was wide and placed low on the neck near the sternal notch. Over the last several decades, the incision used in this approach has become less than two inches in many expert endocrine surgeon s hands and is often placed higher in the neck closer to the cricoid cartilage, typically following a natural cervical skin crease. Advances in related fields have improved the modalities available to effectively diagnose and treat those with thyroid disease. High-resolution ultrasound has been used to identify imaging characteristics which are more suspicious for malignancy and to reliably follow changes in nodules over time. Using ultrasound to guide FNA has also improved diagnostic accuracy and cytologic yields. Advancements in thyroid cytology have improved the utility of fine needle aspiration (FNA) biopsy, thereby decreasing the number of surgical biopsies needed or the need for diagnostic thyroid surgery. The more contemporary addition of molecular DNA analysis and RNA expression profiles to FNA specimens have further assisted physicians in determining need for surgical biopsy or resection when routine cytology does not provide a definitive answer.

2 Curr Surg Rep (2013) 1: Advanced instrumentation such as ultrasonic dissectors, bipolar energy vessel sealing devices and nerve monitoring have been developed in the attempt to improve safety, efficacy and efficiency. Retrospective and randomized studies have shown at best modest improvement in outcomes with the use of these adjuncts over time. As such, the standard approach developed by Kocher over a century ago has essentially remained unchanged. Development For some patients, even the small neck incision currently used by most endocrine surgeons is not considered aesthetically pleasing. This discernment may be due to cultural biases, patient-specific risk of hypertrophic scarring or keloid formation, or a personal perception of beauty. As such, a variety of procedures via remote access points have been described to achieve a less conspicuous cervical neck incision as first described with endoscopic parathyroid surgery in 1996 by Gagner [2] and followed by endoscopic thyroid lobectomy in 1997 by Hüscher [3]. The approaches described have ranged from a minimally invasive videoassisted thyroidectomy as championed by Miccoli and colleagues [4, 5] with a direct approach utilizing a traditionally placed but smaller transverse cervicotomy and maintenance of the potential working space with conventional retractors to more remote techniques using axillary, posterior auricular, anterior chest wall, or circumareolar incisions with or without insufflation [6 14]. The procedures allow a safe approach to thyroid surgery with either minimal cervical neck incision(s) or completely extra-cervical openings. Widespread adoption of these minimally invasive endoscopic techniques has been limited for several reasons. There is not a true anatomic space to develop with insufflation, and the potential space that is created is ultimately restricted by the cervical strap musculature. Current endoscopic video platforms and instruments provide less-thanoptimal visualization and limited mechanical translation of refined movements and dissection technique. Appreciation of the anatomy from a remote access approach can be quite challenging to initially master, contributing to a steep learning curve introducing the risk of increased complication rate and prolonged operative time. The traditional approach to thyroidectomy is able to be performed through a small incision with very low complication rates and excellent patient outcomes. Taken together, justification of these endoscopic procedures has been met with skepticism in their utility. The development of contemporary robotic surgical systems have helped resolve many of these problems to an extent with improved three dimensional visualization and reticulating instrumentation with multiple degrees of freedom of motion. Tremor stabilization and stability of the platform have allowed for more refined and delicate dissection in the relatively restricted working space of the cervical neck. Ultimately, endoscopic techniques have been adapted to the robotic platform with the hope of allowing for a more cosmetic incision while maintaining a comparable risk profile and surgical efficacy. Robotic Thyroid Surgery Methodology The first robotic thyroid surgery described was performed by Lobe and colleagues in 2005 and included a 19-year-old female patient with uninodular thyroid disease [15]. Several trocars were placed within the axilla and minimal CO 2 insufflation was utilized to facilitate dissection and maintenance of a working space with the da Vinci surgical robotic platform (Intuitive Surgical, Sunnyvale, CA). The thyroid lobectomy took 4.5 h and the patient was discharged on the first post-operative day without complication [15]. It wasn t until several years later before more substantial clinical experience was published regarding the use of robotic technology in thyroid surgery. Gasless Transaxillary Approach The most widely described method involves a novel gasless transaxillary approach (GTA). The original description in 2009 by Dr. Chung and colleagues at Yonsei University in Seoul, Korea, utilized the da Vinci surgical robotic platform. The adaptation of robotic thyroid surgery was built upon their extensive experience in approaching gasless transaxillary surgery endoscopically with more conventional endoscopic instrumentation [16]. The initial published series included 100 consecutive patients limited to papillary malignancies less than 2 cm without evidence of extrathyroidal extension [17]. The majority of cases included subtotal or total thyroidectomy with an average operative time of 2.3 h [17]. The patient is placed supine with the neck extended. The ipsilateral arm is extended cephalad. Positioning of the arm varies among practitioners, and is either kept in a neutral superiorly extended position with internal rotation as described by Kang et al. [18], or maintained flexed at the elbow and suspended above the face as described by Dr. Ikeda [10]. A 4 6 cm incision is made in the axilla and a subcutaneous flap is developed elevating off of the pectoralis major muscle and clavipectoral fascia. The natural plane separating the clavicular and sternal insertions of the sternocleidomastoid muscle is developed, allowing for anterior elevation of the sternal head and identification of the lateral margins of the sternohyoid and sternothyroid muscles. The strap musculature is elevated off the jugular vein, carotid artery and the anterior surface of the thyroid gland to provide

3 18 Curr Surg Rep (2013) 1:16 25 for excellent exposure the thyroid from the sternal notch to the cephalad extent of the superior poles. A specialized external retractor is placed through the transaxillary incision, maintaining elevation of the subcutaneous flap and cervical strap muscles. Space is maintained for the robotic arms as well as improving visualization via continuous suction of aerosoled particulates created by ultrasonic dissection. The robotic platform is utilized for the actual thyroid resection and is brought into the field with all three working arms plus the endoscopic camera traversing the axillary incision. The dissection proceeds very much as in conventional surgery with sequential vessel ligation of the superior pole vessels followed by transection of the inferior pole vessels and middle vein. The gland is rotated in an anteromedial fashion, allowing for sequential ligation of the posterior attachments along the tracheoesophagel groove, exposing the inferior thyroid artery and the entire course of the RLN. The nerve is dissected away from the posterior suspensory ligament which is then transected with the endoscapel. This approach allows for thyroid lobectomy or a total thyroidectomy from a single side with also the possibility of a level-vi lymph node dissection. If a completion thyroidectomy is required based on final pathology, this can be performed via the contralateral axilla if the patient desires a robotic approach. Several groups have described modifications to this approach to improve the ease of total thyroidectomy. As with Dr. Chung s original description and series, a separate sternal incision and port site can be placed to assist with gland retraction or visualization during resection of the contralateral thyroid lobe [17, 19]. Tae et al. [20] described a unilateral approach to thyroidectomy using a circumareolar incision for an accessory port placement in addition to the axillary flap. At least one group has advocated performing a staged completion lobectomy via the contralateral axilla [21]. In our own experience, a second incision chest wall or breast incision is not needed. Rather, the patient can be slightly repositioned with rotation towards the robotic arms augmenting the degree of the camera scope angle and facilitate visualization of the contralateral tracheoesophageal groove and RLN. To date, the GTA published literature from Korea represents over 1,000 robotic thyroid surgeries with comparable outcomes to traditional thyroidectomy and transaxillary endoscopic thyroidectomy sans robotic platform utilization [22 ]. Graves thyroiditis has traditionally been considered a relative contraindication to this approach, and there remains some controversy as to whether or not these techniques are applicable to a n population due to differences in body habitus and average tumor size. Since the initial description of this approach, several groups have described a relatively limited n experience which in total represent approximately 200 robotic thyroid surgeries [23, 24, 25, 26 29]. Bilateral Axillary Breast Approach Lee et al. [30] described a bilateral axillary and breast approach (BABA) of endoscopic thyroid surgery with the da Vinci robotic platform in Patients were selected with low-risk thyroid cancer, nodules with benign cytology up to 8 cm, and Grave s disease. Patients requiring re-operative surgery were excluded. The patient is again placed supine with the neck extended. Saline is injected subcutaneously to hydrodissect a subcutaneous plane and improve the ease of flap development. The endoscopic camera and a working port are placed at both areolar margins, allowing development of the anterior chest working space endoscopically. Two additional working ports are placed in the axillary folds bilaterally. This approach does utilize 5 6 mm Hg low-pressure CO 2 insufflation to maintain an adequate working space. The dissection begins in the midline separating the median raphe with identification of the cricoid thyroid membrane, isthmus and trachea. The isthmus is divided and the thyroid gland is retracted medially as the strap muscles are dissected off the gland and the inferior pole vessels are ligated with the harmonic endoscalpel. The upper pole vessels are sequentially isolated and transected. The specimen removed through axillary incision utilizing an endocatch bag. This approach does allow for both thyroid lobectomy and total thyroidectomy with or without central compartment lymph node dissection. Posterior Auricular Approach/Robotic Facelift Thyroidectomy Robotic facelift thyroidectomy is a gasless technique described in 2011 using a cadaver simulation model and subsequent human trials [31 34]. The patient is positioned supine with the head rotated 30 away from the side of interest. A posteriorauricular incision is made superficial to the greater auricular nerve, and the external jugular and musculocutaneous flaps are raised until the triangle of sternohyoid, sternocleidomastoid, and omohyoid is defined. Strap muscles are reflected anteromedially as a specialized fixed retractor is placed similar to that utilized in the GTA technique. The camera and working ports are all placed to traverse the retroauricular incision. The superior pole is mobilized and the vascular pedicles are controlled with a harmonic endoscalpel. The superior pole is then reflected medially, allowing for identification of the RLN. The inferior pole vessels are ligated, as is the posterior suspensory ligament, and the isthmus transected. This procedural approach is limited to thyroid lobectomy and should allow for an ipsilateral level-vi lymph node dissection. However, total thyroidectomy is achieved by re-positioning and approaching the contralateral lobe via a second incision over the contralateral mastoid process.

4 Curr Surg Rep (2013) 1: Transoral An interesting natural orifice transoral approach has been proposed in a pre-clinical cadaver study [35]. Three gingival buccal incisions are utilized. The mental nerve is identified and dissected free for several centimeters to prevent undue tension. A submental and subplatysmal plane is developed and the working space is maintained with CO 2 insufflation. A thyroid lobectomy and ipsilateral central compartment dissection have been described, and it is the opinion of the authors that such an approach provides superior visualization of the central compartment and completely negates the need for skin incisions However, further refinements with animal models are necessary prior to the initiation of clinical trials in humans. Oncologic Utility Several studies have shown the efficacy of treating well-differentiated thyroid cancer with robotic-assisted thyroidectomy. Radioactive iodine uptake, suppressed thyroglobulin (Tg), stimulated Tg, and surveillance ultrasound have served as long-term follow-up endpoints to determine the adequacy of resection in the context of thyroid malignancy [22, 36 ]. In general, these published series have demonstrated non-inferiority to traditional open thyroidectomy. However, wholesale acceptance of this data and the applicability to all thyroid surgical disease is tempered with the understanding that the majority of oncologic data is generated in patient populations with aggressive population screening for thyroid disease and likely represents a bias towards very low stage disease at baseline. Dr. Chung and colleagues have been the most prolific in describing their GTA technique in multiple series, with the first review of outcomes published in 2009 [18]. This review included 200 selected patients with well-differentiated thyroid carcinoma. Initial selection criterion included tumor size B2 cm with no ultrasound evidence of extrathyroidal extension or lateral cervical compartment nodal metastases. Thirty-eight of the 45 patients who underwent total thyroidectomy had RAI ablation with RAI uptake scanning performed 48 h after ablation. No patients had abnormal uptake. Three of 45 (6.7 %) had abnormal thyroglobulin levels at 4 months. No structural evidence of local recurrence was present at 10 and 18 months by ultrasonography. More robust oncologic outcomes data was elucidated in a large retrospective review in 1,000 patients with thyroid carcinoma published in 2011 [38]. Compared to previous reported series, this work reflected a wider breadth of disease and tumor stages as the experience with the surgical approach advanced over time. Inclusion criteria were a preoperative diagnosis of thyroid carcinoma, primary tumor size B4 cm and at most minimal thyroid capsular invasion or extrathryoidal extension into the strap musculature. Patients with known RLN, esophageal or tracheal invasion or multiple lateral cervical compartment lymph node metastases were excluded. Of these 1,000 patients, 627 had less-than-total thyroidectomy and 373 had total thyroidectomy. Thirty-six patients also had a robotically assisted selective lateral compartment dissection concurrent with total thyroidectomy. Overall, 75 % of patients presented with papillary thyroid microcarcinoma with mean tumor size 0.79 ± 0.6 cm. Of the 209 patients undergoing total thyroidectomy and RAI ablation, none had radioactive iodine uptake on 4 month follow-up imaging. The majority (68 %) had undetectable thyroglobulin levels (\1.0 ng/ml) at 4 months post RAI, and none of the patients had evidence of structural recurrent disease by neck ultrasound at 12 and 24 months of follow up. Biochemical evidence of possible persistent disease was detectable in 32 % of patients with Tg levels[1 ng/ml (mean 4.06 ± 2.31 ng/ml) at 4 months. However, the presence of interfering Tg antibodies or the degree of long term resolution of thyroglobulinemia is unknown. The number of complications was low, and the complication rate improved over the course of the study [22 ]. The BABA approach has been evaluated in 760 patients with PTC. A comparative analysis using a matched cohort analysis design was used to compare the robotic (n = 327) and open (n = 423) approaches and showed no differences in RAI uptake rations, stimulated TG or the proportion of patient with undetectable stimulated TG after first ablation [36 ]. These groups did differ, with the robotic group being younger, more female, lower stage, and smaller BMI. These differences were negated on propensity score matching was performed on the matched cohorts. The tumor size, presence of nodal metastases, and presence of multifocality did not differ between the two groups [36 ]. The n literature has yet to provide any substantial data regarding the degree of oncologic surgical adequacy in the hands of relatively less experienced robotic thyroid surgeons. Lymph Node Involvement Central Compartment Nodal Disease Central compartment lymph node dissection (CCLND) is technically feasible in all approaches [22, 38, 30]. Initial experiences with a small group of differentiated thyroid carcinoma patients harvested an average of 6.1 ± 4.4 nodes per case [37]. In the largest report of 1,000 patient undergoing thyroidectomy for cancer, central compartment dissection was performed on all patients, with an average of 4.62 ± 3.14 nodes harvested robotically [22 ]. Authors

5 20 Curr Surg Rep (2013) 1:16 25 utilizing the BABA approach noted the feasibility of CCLND but have not published data regarding their outcomes for numbers of lymph nodes retrieved [30, 36 ]. Lateral Cervical Compartment Nodal Disease Given the high propensity for papillary thyroid carcinoma to metastasize, lateral node involvement is an important factor for consideration when proposing alteration to the current surgical approach. Several descriptions have been made of the technique for modified radical neck dissection. The procedure itself involved robotic positioning and flap development similar to the GTA approach, with the primary difference adding the division of the clavicular head of the SCM to access levels IIa, III, IV and Vb [22 ]. An initial feasibility study was performed in 2009 with 33 patients to prove the ability to perform a robotic assisted modified radical neck dissection for lateral metastases. Tumor sizes were quite small 1.1 ± 0.5 cm with 61 % having micro-carcinoma. No major complications were observed in this small study [37]. The largest series includes 56 robot assisted procedures, compared to 109 open procedures, with no difference in the complication rate of hematoma, seroma, hypocalcemia, or RLN injury. The groups were similar with respect to gender, hospital length of stay, multifocality of primary tumor, bilaterality, and number of retrieved lymph nodes both in central or lateral compartments. Patients in the robot assisted group were significantly younger, 35.8 vs 46.1 years and as such were more likely to have Stage I disease, 80.4 vs 46.3 %. Tumors were also smaller, 1.14 vs 1.49 cm. The robotic approach took significantly longer, 277 vs 218 min [38]. No recurrences were seen in follow-up surveillance ultrasound, and no differences were seen in postoperative suppressed thyroglobulin levels or abnormal uptake on RAI scans. Use in Specific Situations Goiter Currently published studies limit resection to goiters smaller than 8 cm in longitudinal dimension [20, 24, 25, 26, 27, 29, 33, 39]. No published reports of substernal goiter resection have been identified in the current literature. As such, it is not currently recommended to approach large goiters over 8 cm or substernal goiters via any of the described robotic approaches. Age Two reports exist discussing the use of the robotic technique in pediatric patients. One series included patient with a mean age of 12.7 years and describes endoscopic as well as robotic cases, with the surgeons discarding the robotic technique in favor of the endoscopic technique early in the series [40]. It is not well elucidated if the robotic technique resulted in higher complications; the authors cite expense as the primary reason for discarding the robotic technique. A second case report exists of a 13-year-old who successfully underwent total thyroidectomy for goiter without complication [41]. No specific data exists on the use of the robotic approach in the geriatric population. While not specifically described, the procedure time is slightly longer with the robotic approach and is generally done for cosmetic advantages. It is unclear if the risks of longer anesthetic times are justified for cosmetic benefit in a geriatric population. Thyroiditis No specific papers exist discussing the use of robotic technology in patients with chronic autoimmune thyroiditis. However, nearly all series published to date include patients with thyroiditis among their series. The utility of a robotic surgical approach to the management of Graves thyroiditis is less clear as it was considered a contraindication for surgery in several of the initial clinical studies. Kandil et al. [42] reported their findings on a group of five patients undergoing GTA with total thyroidectomy for Graves disease. They were successful in performing the procedure robotically and had no reported post-operative complications. Above-Normal Body Mass Index (BMI) While concerns have been voiced over performing this procedure in patients with higher-than-normal BMI, with some groups limiting performance to favorable body habitus (BMI \30) [28], our group as well as others have been successful in performing both lobectomy and thyroidectomy in patients with body mass indices up to 44. Kandil et al. [25 ] examined the effect of BMI in their 2012 study and found operative time higher in obese patients (BMI C30) at 137 ± 66.2 vs 99.7 ± 66.6 min in normal or overweight (BMI \30) patients. Extent of operation and gland size were similar between the two groups. Complications were not reported by BMI status. A separate group also examined the effect of BMI on operative times and found a non-significant difference of 204 vs 225 min in patients who were normal (BMI B25) versus overweight (BMI [25) respectively. Complication profile was not reported by BMI [37]. Complication Profile The initial description of the GTA approach included a complication profile including 41 % transient

6 Curr Surg Rep (2013) 1: hypocalcemia, 4 % of transient hoarseness, seroma 2 %, permanent RLN injury 1 %, hematoma, 1 %, Horner syndrome, 1 %, and ipsilateral arm paralysis 1 %. Later publications show similar rates [43]. See Table 1. Vocal Cord Paresis RLN injury is a challenge to all surgeons who perform thyroidectomy. The currently published series have a temporary RLN injury rate between 3 and 20 %, with permanent injury rates ranging between 0.7 and 1 % [25, 34, 20, 44, 45, 43, 29, 30, 23]. The permanent rates are similar to rates for open surgery, where it is generally agreed that rates of less than 2 % are acceptable. Voice changes without evidence of nerve injury have been studied. In one comparative study, 21.4 % of patients had some evidence of vocal dysfunction in the robotic group, with 19.5 % having dysfunction in the open group (p = 0.829) [46]. All patients with dysfunction without frank paralysis had resolution by 3 months [46]. Several groups, although not all, recommend RLN monitoring to identify the nerve and assist with identifying complications intraoperatively. Brachial Plexus Neuropraxia The GTA requires abduction of the upper extremity of the affected side, or the right in a total thyroidectomy. A newly reported complication with this approach occurs when the arm is not properly supported and the brachial plexus is stretched during the procedure which can result in a neuropraxia of the affected nerve branches. This has occurred in % of cases [25, 44, 45, 43, 23] and has resolved within 6 months in published reports. Care must be taken during positioning to properly internally rotate and support the abducted extremity. Somatosensory evoked potential testing has been used to identify loss of amplitude in both somatosensory evoked potentials and transcranial electric motor evoked potentials during an impending brachial plexus injury during the GTA approach [47]. The patient s amplitude changes reversed with re-positioning. Esophogeal/Tracheal Perforation Esophageal and tracheal injuries are fortunately rare among the robotic approach, with only three cases being reported in the published literature [25, 45]. The loss of tactile input may contribute to this; however, these injuries also occur, albeit rarely, in open surgery. It is unclear if the robotic approach has any increased risk of this type of injury over open procedures. Hypoparathyroidism Transient hypoparathyroidism appears quite common with the robotic approach, with rates between 10 and 41 % [25, 20, 23, 45, 43]. No patients who underwent thyroidectomy via the GTA in the series reviewed had permanent hypoparathyroidism. Of the patients undergoing thyroidectomy via the BABA approach, 21 patients of 704 (2.9 %) developed transient hypocalcemia with 2 (0.3 %) requiring permanent treatment [30]. Hematoma/Seroma Cervical hematoma was found in 1 12 % of patient undergoing robotic-assisted thyroidectomy in the series that reported [25, 44, 34, 45, 20, 43, 29, 23]. Seroma formation is relatively common, with some groups leaving drains specifically for this reason. Of the groups reporting rates for seroma, rates of occurrence were between 2 and 12 % [23, 25, 43, 45, 44, 20]. Techniques for Avoiding Injuries While the robotic platform has advanced visualization and provided more degrees of freedom and fine motion stabilization, it does not take the place of a thorough knowledge of surgical approach and areas of technical complexity or deviations from the expected course. A clear understanding of the anatomy and possible anatomic variability can allow the surgeon to anticipate and recognize injuries which can occur due to aberrant anatomy [48]. RLN monitoring, SSEP monitoring, hemostatic agents, and careful positioning are all tools which assist the surgeon in avoiding complications [47, 49]. A well trained, consistent team, including console and bedside surgeons, and operating room personnel who all understand the complexity of the operation are invaluable in ensuring patients have a successful outcome [49]. As with all complications, understanding the pathogenesis can allow the operating surgeon to take steps necessary to prevent the undesired consequences [50 ]. Dr. Perrier and colleagues have recently published a framework for safe adoption of this new surgical technology and operative technique [50 ]. While it is an approach which can be equivalent to open thyroidectomy as far as oncologic equivalency and risk profile, it has a challenging learning curve and certainly requires a teamwork approach as the procedure is quite complex. Surgeons interested in adopting this technique should have a good understanding of endoscopic surgery, the anatomy involved, and spend the time in a proctored environment prior to attempting these procedures on live patients.

7 22 Curr Surg Rep (2013) 1:16 25 Table 1 Robotic thyroidectomy: published perioperative and post-operative data for selected series First author/ journal Date Location N Approach Operative time (min) Temporary hypocalcemia Permanent hypocalcemia Temporary vocal cord paresis/ hoarseness Permanent vocal cord paresis Tracheal/ esophageal injury Neuropraxia Hematoma Seroma Lin/Otolaryngol Head Neck Surg Terris/ Otolaryngol Head Neck Surg Kandil/J Am Coll Surg Landry/Ann Surg Oncol Sep- 12 Jun- 12 Apr- 12 Nov- 11 Lee/Ann Surg Jun- 11 Lee/Surg Laparosc Endosc Percutan Tech Kuppersmith/ Laryngoscope Aug- 11 Mar- 11 Kang/Surgery Dec- 09 South Korea South Korea South Korea Tae/Head Neck 2012 South Korea Foley/Surg Endosc Stevenson/Ann Surg Oncol Feb- 12 Sep GTA (17 %) (6 %) 10 RFT GTA (4 %) 25 GTA (20 %) 0 2 (8 %) 3 (12 %) 3 (12 %) 580 GTA 51 (37.8 %) 0 19(3.3 % 4 (0.7 %) 2 1 (0.2 %) 3 (0.5 %) 17 (2.9 %) 704 BABA GTA (3 %) (3 %) GTA (41 %) 0 13 (4 %) 3 (1 %) 1 (1 %) 2 (1 %) 6 (2 %) 113 GTA /44 (25 %) 0 7 (6.2 %) 0 0 2/113 (1.8 %) 11 GTA GTA (7.1 %) N (%) if published. Indicates no mention of complication was made in study (Data from [20, 23, 25, 26, 28, 29, 34, 43 45, 54])

8 Curr Surg Rep (2013) 1: Learning Curve Lee et al. [51] examined the learning curve of the robotic cases in Three novice surgeons were compared to an experienced surgeon. Complication rates and operative times were major endpoints of the study. Novice surgeons had a higher rate of major complications, hematoma, permanent nerve injury, permanent hypocalcemia, or hematoma, requiring re-operation with 2.4 vs. 0 %, p \ than the experienced surgeon. Minor complications were not significantly different. Operative times were 132 vs 181 min for the novice versus experienced surgeon during early portions of the study. Complication rates and operative times were similar between the groups once the novice surgeons had performed 50 total thyroidectomies and 40 subtotal thyroidectomies. Cost The addition of robotic technology has increased the per procedure cost which is highly variable based on institution. The up-front costs of the robot are immense, and special equipment and draping are required to use the system. A group from Vanderbilt University in Nashville, TN, estimated the cost of robotic thyroidectomy at $5795 vs $2668 for open thyroidectomy, using operative times from published series [52]. A second group compared costs between conventional, endoscopic and robotic approaches to thyroidectomy, also using the published data from Yonsei University, and estimated costs for conventional surgery to be $9028 ± 891 for conventional approach versus $13670 ± Costs were higher for the robotic case even when robot depreciation was not included in the analysis [53]. Certainly in the era of cost containment, it will remain to be seen if the added expense both in increased operative time and consumables required for the robotic approach is justified, and who, payer or patient, will pay the difference. Conclusions While evaluating a new technology, there needs to be some compelling reason to adopt new technology. Robotic thyroidectomy is one such technique where the superiority has not been proven in the terms of surgical completeness, length of stay, complication profile, or cost. Indeed, the only clear reason for performing the robotic approach is to avoid a cervicotomy and the consequent neck blemish. While this has great value on a personal level for many patients with concerns regarding the perception of how a scar on the neck alters intrinsic esteem or extrinsic aesthetics, it remains to be seen if these robotically assisted surgical approaches are adaptable to a more anthropometrically diverse n population. Currently, many of the studies are not scientifically rigorous and are predominately observational or retrospective in nature. Certainly, the reader is encouraged to be responsible with the technology. This technique has an extended learning curve and requires a well trained consistent team to perform these robotic thyroid approaches safely. Disclosure No potential conflicts of interest relevant to this study were reported. References Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance 1. Tapscott WJ. A brief history of thyroid surgery. Curr Surg. 2001;58(5): Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83(6): Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc. 1997;11(8): Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C. Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest. 1999;22(11): Miccoli P, Berti P, Bendinelli C, Conte M, Fasolini F, Martino E. Minimally invasive video-assisted surgery of the thyroid: a preliminary report. 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