How To: Technique, Pitfalls of the Transaxillary Approach for Robotic Thyroidectomy

INTRODUCTION

Thyroidectomy using transaxillary robotic surgery (TARS) was first developed in 2007 using the da Vinci robot. It is used as a safe and efficient alternative to conventional cervicotomy to remove anything from small thyroid nodules to Graves’ disease goiters and cervical lymph nodes in different populations (World J Surg. 2018;42:393-401; Laryngoscope. 2011;121:521-526). Advantages of the technique are cosmetic, a high-definition view of structures, and a reduced risk of compressive cervical hematoma (due to a large surgical space); the main drawbacks are the cost and duration of the procedure (World J Surg. 2018;42:393-401; Laryngoscope. 2011;121:521-526; Ann Surg Oncol. 2011;18:226-232; Head Neck. 2015;37:1705-1711). Another important hurdle is the learning curve (Ann Surg Oncol. 2011;18:226-232; Head Neck. 2015;37:1705- 1711), as robotic surgery requires a new set of skills; training is required before the first operation can be performed. Furthermore, the transaxillary approach has its own learning curve, as it is uncommon for head and neck surgeons to laterally approach the neck midline.

In this article, we wish to help reduce the learning curve of the transaxillary approach for robotic thyroidectomy by providing a step-by- step description of the procedure, highlighting tips and pitfalls.

METHOD

All consecutive transaxillary approaches for robotic thyroidectomy between 2010 and 2018, performed by the same head and neck surgeon, were retrospectively analyzed (duration and complications), for the analysis of the learning curve. All patients had been given a choice between conventional cervicotomy and the transaxillary robotic approach. Procedures took place in either an adult or a pediatric tertiary center, and a da Vinci robot was used for the subsequent thyroidectomy.

Surgical Technique

Preparation and positioning. Under general anesthesia, the patient’s axilla is exposed by fixing the arm over the head with a 90° to 100° flexion of the elbow. The arm should rest in a natural fashion, over the forehead, so as to limit the risk of brachial plexus injury. The head is slightly turned toward the contralateral side of the incision and neck extended. Anatomical landmarks are drawn on the patient’s skin and may include the sternal notch, cricoid and thyroid cartilage, mandible angle, and sternocleidomastoid (SCM) muscle. The skin incision 1 cm posterior to the anterior axillary fold and the surgical corridor are also drawn. The arm can be moved back to its natural position to check that the scar will be well hidden. These landmarks must remain visible when draping the patient to be able to check for skin integrity during the procedure and allow conversion to cervicotomy if necessary.