Robotic-Assisted Transaxillary Thyroid and Parathyroid Surgery

Fig. 26.1

Lighted breast retractor

Fig. 26.2

Modified robotic thyroidectomy retractor (Marina Medical, Sunrise, FL, USA)

For the robotic dissection portion of the procedure, the da Vinci S, Si, or Xi system (Intuitive, Inc., Sunnyvale, CA, USA) can be used along with a 30-degree down looking scope, 5 mm Maryland dissector (Intuitive, Inc.), and 8 mm Prograsp forceps (Intuitive, Inc.). A 5 mm harmonic curved shear (Intuitive, Inc.) is used as the robotic vessel-sealing device. Four trocars can be inserted through the single axillary incision: two 5 mm trocars, one 8 mm trocar, and one 12 mm trocar. During the procedure a 5 mm laparoscopic suction and irrigation can be used by the assisting surgeon to retract structures such as sternocleidomastoid (SCM) muscle or trachea. Rolled gauze can be used for hemostasis during the procedure.

Instruments and surgical equipment
Flap creation and maintenance of working space
2 Army-navy retractors
2 Lighted breast retractors
Long Vascular Debakey forceps
Monopolar electrocautery (short and long tips)
Vessel sealing device
Special modified robotic thyroidectomy retractor (Marina Medical, Sunrise, FL, USA)
Robotic instruments
DaVinci Si or Xi robot system
Two 5-mm trocars
8-mm trocar
12-mm trocar
5-mm Maryland dissector
8-mm Prograsp forceps
5-mm Harmonic curved shear
30 degree endoscope
Laparoscopic suction/irrigation

Surgical Technique

Positioning

The patient is placed in the supine position and is intubated using one of the nerve integrity monitor endotracheal tubes to enable intraoperative monitoring of the recurrent laryngeal nerve. The neck is extended using a shoulder roll. The ipsilateral arm on the same side of the lesion is raised and flexed at the elbow with the forearm resting over the forehead, and secured in place with proper padding using soft pillows and foam (Fig. 26.3). By raising the arm, the distance between the incision and anterior neck will be shortened. The contralateral arm is tucked in on the side of the patient. Caution has to be taken not to overextend the shoulder in order to avoid traction injury of the brachial plexus. Nerve monitoring of the radial, median, and ulnar nerves using somatosensory evoked potential (SSEP) (Biotronic, Ann Arbor, MI) can be used to help avoid stretching of any of these nerves.

Fig. 26.3

Patient positioning in transaxillary approach; the arm is raised and flexed at the elbow resting comfortably over the patients face. Preoperative ultrasound is performed to assess the relation of the internal jugular vein and carotid to the thyroid

Intraoperative ultrasound is usually performed at the beginning of the procedure to assess the relation of the thyroid to the internal jugular vein and carotid artery. In cases of robotic-assisted parathyroidectomy, the location of the pathological parathyroid gland can be confirmed by performing intraoperative ultrasound.

Incision and Flap Creation

Incision

The neck, anterior chest, and the ipsilateral axilla are prepped and draped.
The incision location landmarks are the thyroid prominence, sternal notch, and the anterior axillary line. A 60° oblique line is drawn from the thyroid prominence to the axilla and a transverse line is drawn from the sternal notch to the axilla. Afterward, a 5–6 cm skin incision can be made between the two lines at the anterior axillary line along the lateral border of pectoralis major muscle. This will create a completely hidden incision in the axillary folds (Fig. 26.4).

Fig. 26.4

The skin incision landmarks, it is placed at the anterior axillary line between two lines, an oblique line from the thyroid prominence and a transverse line from the sternal notch

Flap Creation

1.

Using electrocautery, the subcutaneous flap is created superficial to the pectoralis major muscle fascia up to the clavicle. The army-navy and lighted breast retractors are used to facilitate this step (Fig. 26.5).

Fig. 26.5

Flap creation superficial to the pectoralis major muscle fascia
2.

Subplatysmal dissection is performed after crossing the clavicle until the two heads of (SCM) are identified. The flap dissection is continued medially to the medial border of the SCM.
3.

The avascular plane between the clavicular and sternal heads of the SCM is created. The omohyoid muscle is considered a great landmark of the superior pole of the thyroid gland. Great care should be taken to avoid injury to the internal and external jugular vein during this dissection (Fig. 26.6, 26.7, and 26.8).

Fig. 26.6

Opening of the avascular plane between the two heads of SCM

Fig. 26.7

The omohyoid muscle, which is a landmark of the upper pole, is identified after opening the plane between the two heads of SCM

Fig. 26.8

After dividing the omohyoid muscle the strap muscles, thyroid, and internal jugular vein are exposed
4.

The superior belly of omohyoid muscle is retracted or divided and then the thyroid is separated from the overlying strap muscles using the electrocautery or a vessel-sealing device until the contra lateral side of the thyroid gland is fully exposed.
5.

The blade of the special thyroid modified self-retaining retractor is placed through the axillary incision retracting the flap, the sternal head of SCM, and the strap muscles. It is mounted to the bed from the contralateral side of the operating table. Appropriate maintenance of the working space is an important aspect during the procedure. A suction tube should be attached to the suction channel of the retractor to remove the smoke during the procedure (Fig. 26.9).

Fig. 26.9

The external modified robotic thyroidectomy retractor is placed and connected to suction to eliminate the smoke during the procedure

Robot Docking

The robot is docked from the contralateral side of the table. A 30-degree down view endoscope and three robotic instruments are secured to the robotic arms and inserted through the single axillary incision. The 12 mm trocar is placed in the middle of the axillary incision on the lower edge and the camera is inserted in an upward direction (Fig. 26.10). The 8 mm trocar is placed at the upper edge of the incision, and the Prograsp forceps is inserted in downward direction. The two 5 or 8 mm trocars are placed as far apart as possible at the lateral ends of the incision, and the Maryland dissector is inserted at the non-dominant side of the surgeon in an upward direction and the Harmonic curved shear is inserted so it can be used by the dominant hand of the surgeon. Proper placement of the instruments and maintaining appropriate space between the arms is a crucial step of the procedure to avoid collision of the robotic arms (Fig. 26.11, 26.12, 26.13, and 26.14).