The evolution of thyroidectomy operation approaches has been catalyzed by the introduction of the Da Vinci surgical robotic system, which can offer the surgeon improved visualization and ability for tissue dissection using wristed instrumentation (Head Neck. 2011. doi:10.1002/HED.21454). While the gasless transaxillary robotic thyroidectomy has become popular in Korea (Surgery. 2009. doi:10.1016/J.SURG.2009.09.007), it has had limited adoption in the United States.
Explore This IssueDecember 2023
In response to the challenges of the transaxillary approach, Terris et al. described the robotic facelift (RF) thyroidectomy, which uses a retroauricular facelift incision for insertion of the Da Vinci robotic camera and arms (Laryngoscope. 2011. doi:10.1002/LARY.21832), and has been reported in the Western population using the Da Vinci Si and Xi systems. In 2019, the new Da Vinci single port (Sp) surgical system received clearance from the U.S. Food and Drug Administration for transoral otolaryngology procedures. Compared with the older multiarm Da Vinci Si and Xi systems in which the RF thyroidectomy was initially described, the Sp system offers the potential advantage of increased access and flexibility through a smaller incision and working tunnel (Head Neck. 2020. doi:10.1002/HED.26436). Here we report our initial experience using the Sp system for robotic thyroidectomy via posterior neck approach (RT-PNA).
A retrospective chart review was performed for all patients undergoing RT-PNA by the senior author at Massachusetts Eye and Ear from 2022 to 2023.
Patients with thyroid nodules requiring hemithyroidectomy wishing to avoid an anterior neck scar were offered RT-PNA. One exception was a patient with a 5.8-cm thymic cyst who was motivated to avoid an anterior neck scar. Patients requiring total thyroidectomy were offered transoral robotic or traditional open approaches.
Surgical Technique: Setup and Positioning
The patient was intubated with a Nerve Integrity Monitoring (NIM) endotracheal tube and positioning is verified with GlideScope video laryngoscopy. The patient was positioned supine with a thyroid bag or shoulder roll positioned for moderate neck extension. The chin was turned to the contralateral side and braced against a shoulder roll or stack of blue towels. Over-rotation can tighten the neck skin envelope and limit operating space. A 6–8 cm vertical incision was planned 1 cm behind the posterior border of the sternocleidomastoid muscle (SCM). The hairline would be shaved if needed. This positioning allows for a shorter distance to the thyroid bed and a more favorable instrument angle to engage the inferior pole vessels, yet is well concealed when viewed from the front. A more posterior incision can be made within the hairline, but this increases the distance to the operative field and the amount of muscle retraction needed, which can increase postoperative pain.
Access and Approach