Technique, Pearls, and Pitfalls of the Transaxillary Approach for Robotic Thyroidectomy (With Video)

摘要

Thyroidectomy using transaxillary robotic surgery (TARS) was first developed in 2007 using the Da Vinci robot (Intuitive Surgical, Sunnyvale, California). It is used as a safe and efficient alternative to conventional cervicotomy to remove from small thyroid nodules to Graves' disease goiters and cervical lymph nodes, in different populations.1, 2 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 of the procedure and duration of the procedure.1-4 Another important hurdle is the learning curve,3, 4 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. All consecutive transaxillary approaches for robotic thyroidectomy between 2010 and 2018, performed by the same head and neck surgeon (PA), were retrospectively analyzed (duration and complications), for the analysis of the learning curve. All patients had been given a choice between conventional cervicotomy and transaxillary robotic approach. Procedures took place in either an adult or a pediatric tertiary center and a Da Vinci Robot (Intuitive Surgical, Sunnyvale, California) was used for the subsequent thyroidectomy. Video of a transaxillary approach for a right hemithyroidectomy was edited according to IVORY guidelines (Video 1).5 Written consent was obtained from the patient and the study was approved by our Institutional Review Board. Trans-axillary approach for robotic thyroidectomy. Incision is made in the axillary fossa and a surgical corridor is made to reach the thyroid gland. EJV External jugular vein; SCM sternocleidomastoid muscle; SN Sternal notch; TC Thyroid cartilage. Video content can be viewed at https://doi.org/10.1002/lary.29753 The positioning of the patient is detailed in Figure 1. 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. The assistant is on the opposite side of the patient to hold the retractors without hindering the surgeon. Farabeuf and vaginal-valve retractors are required and should include a canal for smoke suction. Long instruments (30 cm) are necessary to reach the neck midline from the axillary incision. The procedure is best performed using a headlamp and surgical loupes, especially to aid precise hemostasis of perforating arteries during muscle dissection. The Da Vinci robot endoscope may also be used to increase visibility and for teaching (as for the video in this article) but requires a second assistant to manipulate it. The view from the endoscope may also help the assistant holding the retractors to obtain the best exposure possible by giving direct feedback. A 4- to 6-cm skin incision is performed immediately posterior to the anterior axillary fold, following the axi