Robot-Assisted Transaxillary Thyroid Surgery: As Safe as Conventional-Access Thyroid Surgery?

Abstract

From a medical point of view, transaxillary thyroid surgery, the most popular approach in order to avoid scarring, needs not only to be feasible but also as safe as conventional-access thyroidectomy. From the patient perspective, the greater exposure of the thyroid facilitated by the transaxillary route is not as important as the potential of this new surgical approach for less damage in the short and long term. These considerations clinically trump the issue of cost and reimbursement policies [2–4] because most endoscopic procedures are less cost-effective than conventional open surgeries. Is transaxillary, more specifically robot-assisted transaxillary surgery (RATS), as it stands today [5–7] , as safe as conventional open-access thyroid surgery (CATS)? That is to say, is it safe enough for patients with uncomplicated, small, nonretrosternal goiter, or low-risk localized thyroid cancer to serve as an alternative to Miccoli’s minimally invasive video-assisted technique [1, 8] ? At present, this is not at all clear. Kang et al. [9] , from the Yonsei University College of Medicine in Seoul (South Korea), were the first to describe RATS in 2009. Within a 5-year period, a total of 10,000 RATS procedures (without being able to avoid double counting of procedures reported by the same group in more than 1 publication) have been described in about 31 publications [4, 10–39] . Thirteen publications performed a head-to-head comparison of RATS and CATS [4, 9, 11, 12, 16, 18, 19, 23, 29, With the advent of minimally invasive techniques in thyroid surgery, conventional open-access surgery for bilateral multinodular goiter was extended to encompass total thyroidectomy. At the same time, the surgical approach to the thyroid gland was reduced to a minimum. Totally endoscopic and video-assisted procedures through a minimal neck incision were shown to be better tolerated by the patient, resulting in improved cosmesis with no increase in surgical morbidity [1] . In terms of perioperative and cosmetic benefit, minimally invasive procedures are superior to conventional open surgery when the surgical trauma inflicted to gain access to a fairly small target organ is substantial (e.g. in laparoscopic cholecystectomy or adrenalectomy). Owing to the short distance to the target organ, the thyroid and parathyroid glands stand least to gain from the use of minimally invasive surgery. Keeping the neck incision as short as possible was a first step towards achieving a better cosmetic result in the neck. Unfortunately, only some 15% of thyroid patients were suitable candidates for this type of surgery. Some other patients were dissatisfied because their expectations of having no visible neck scar were not met. Nowadays, more and more people from all walks of life, whatever their physical build or ethnic, geographic or cultural background, yearn for better surgical cosmesis after thyroidectomy – why should they not opt straightaway for a neck without a scar? Published online: May 3, 2013