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Robotic Thyroidectomy

A new option for thyroid surgery that doesn’t leave a neck scar

There's a new treatment option for patients who need to have thyroid surgery: robotic thyroidectomy.

No, that doesn't mean that a robot is doing your surgery.

Robotic thyroidectomy does mean that you won't have a scar on your neck, and for many people, that's reason enough to try this recently-developed surgical technique.

In this article, you'll learn more about the details of robotic thyroidectomy and if it's a surgical option for your thyroid disorder. You'll also get more information from Eren Berber, MD, an endocrine surgeon at the Cleveland Clinic who is one of the first surgeons in America to use this technique. Dr. Berber is also on the EndocrineWeb Editorial Board.

Development of Robotic Thyroidectomy
Robotic thyroidectomy—a minimally invasive surgical technique to remove all or part of the thyroid—was developed by doctors in South Korea. It can also be called robot-assisted thyroid surgery, or robot-assisted endoscopic surgery.

Robotic thyroidectomy is, in fact, a logical next step in thyroid surgery. As Dr. Berber says, "This made sense that robotic thyroidectomy would be the next step in thyroid surgery, especially for those who don't want a neck scar."

Before its development, there were two main options for thyroid surgery: conventional open surgery or endoscopic surgery. Conventional open surgery involves a scar on the neck; endoscopic techniques might or might not involve a neck scar.

Open thyroid surgery, also known as standard or conventional open surgery, uses a 4-6cm long incision for most patients, although some surgeons do the operation through a 3cm incision. For many years, it was the only thyroidectomy technique available. The surgeon would expose the entire thyroid so that he or she could directly see the gland and what to remove.

Open surgery led to endoscopic surgery, which is a minimally invasive technique. The surgeon uses a small camera to see what he or she is working on while they do the surgery with special instruments. There are different approaches available, but most involve an incision in the neck, leaving a 2-3cm scar even in best cases.

Robot-assisted surgery has been done on other parts of the body; it's been used to do prostatectomies and hysterectomies, for example. However, robotic thyroidectomy is the first time robot-assisted surgery has been done in the head and neck. (You can learn more about how robotic thyroidectomy is done in the next section.)

One of the first studies about robotic thyroidectomy was published in March 2009—so as you can see, it really is a recent development. More studies are coming out now, as more doctors report their experience and success with this new technique.

How It Works
Robotic thyroidectomy eliminates the neck scar by accessing the thyroid gland through an incision under the arm. This is called an axillary approach. That incision is 5-7cm long, but it's hidden—not front and center, like neck scars from open or even most endoscopic thyroidectomies. There's another very small incision—5mm—in the chest.

Robotic thyroidectomy is done using the daVinci Surgical System, a system that's been used in many other robot-assisted surgeries with much success. The daVinci system has:

  • Four robotic hands: These are called EndoWrist instruments, and they do work just like hands. They can grab things, twist, and turn—and they're incredibly small. The robotic hands allow the surgeon to make very precise movements.
  • 3D camera: This is a high-definition camera that gives the surgeon a 3D image of the thyroid. He or she can zoom in and get an even more detailed look; the camera includes magnification of 10x.
  • Console: The surgeon sits at the console, where he or she controls the four robotic hands and sees images from the 3D camera.

The four robotic hands and the 3D camera are inserted through the incisions. The surgeon can then accurately remove part or all of the thyroid, depending on what the patient needs.

As a reassurance, the daVinci robot is completely under the control of the surgeon. The robotic hands cannot move on their own; they must be told what to do by the surgeon. The daVinci Surgery System also cannot be programmed; the surgeon must be there giving input and making decisions during the surgery.

Advantages of Robotic Thyroidectomy
Dr. Berber, who was trained in robotic thyroidectomy by the surgeons who developed the technique in South Korea, explains the advantages of robotic thyroidectomy. "You have to compare the advantages to conventional [open] surgery and to laparoscopic [endoscopic] surgery," he says.

Dr. Berber highlights the following robotic thyroidectomy advantages in comparison to open surgery:

  • No incision in the neck
  • Better view: Dr. Berber elaborates, "With open surgery, you're looking at the thyroid from the top down, so it's a little difficult to see the deeper structures, such as the recurrent laryngeal nerve. The 3D camera gives you a magnified view in robotic thyroidectomy and enables you look at the thyroid directly."
  • Better identification of critical structures: Due to the magnified 3D view, it is easier to identify critical structures, such as the recurrent laryngeal nerve (the nerve that goes to your voice box) and parathyroid glands.
  • Better dexterity in certain areas: The robotic instruments give the surgeon a 6º freedom of motion, which enables manipulation of certain portions of the thyroid more easily.

When comparing robotic thyroidectomy to endoscopic (laparoscopic) surgery, Dr. Berber mentions the following advantages:

  • No incision in the neck
  • Less cumbersome: Dr. Berber finds some minimally invasive techniques "cumbersome," especially those in the neck (such as thyroidectomies). He explains, "Some of these techniques use an insufflation of CO2, which may cause swelling of the neck after surgery. These techniques are quite awkward because the regular laparoscopic [endoscopic] instruments used for these techniques are straight and do not give the range of motion we get with open or robotic surgery." An insufflation is when the surgeon puts air—or in this case CO2—into a body cavity to expand it during surgery. For an endoscopic thyroidectomy, the surgeon needs to expand the neck region around the thyroid to allow better access.
  • Better view: Endoscopic surgery uses a camera, but it's just a 2D camera. It shows the surgeon flat images, while the 3D camera used in robotic thyroidectomies shows a much more accurate and true-to-life image.

The recovery time for robotic thyroidectomy is about the same as it is for open or endoscopic surgery—a patient usually spends one day in the hospital following the surgery.

Disadvantages of Robotic Thyroidectomy
The only disadvantages that Dr. Berber sees in robotic thyroidectomy right now is that it can't be used on every patient.

Who Can Have a Robotic Thyroidectomy?
Dr. Berber says that, unfortunately, robotic thyroidectomy isn't a viable treatment option for everyone, but as the techniques improve, more people may be able to have this surgery.

Right now, robotic thryoidectomies work best for patients who:

  • Are not overweight
  • Have a smaller thyroid gland (4cm at the largest)
  • Have smaller nodules (2cm at the largest)
  • Have nodules on just one side of the thyroid gland

If you need to have a thyroidectomy, talk to your doctor about a robotic thyroidectomy. Find out if it's a feasible option for you. No matter your treatment options, always make sure you fully understand the risks and benefits. Ask all questions that you need so that you know what's going to happen before, during, and after surgery.

Conclusion
Dr. Berber looks forward to doing more robotic thyroidectomies because he sees so many advantages to them.

The biggest benefit is, of course, the lack of a scar on the neck. Consider this: it's mainly women ages 20-40 who need thyroidectomies (we have an article on what thyroid disorders may require a thyroidectomy). That patient population is likely to be very excited by the lack of a scar on the neck. Cosmetically speaking, a robotic thyroidectomy is a huge step forward in thyroid surgery.

And beyond the cosmetic benefits, robotic thyroidectomy is a fascinating advance in how surgeons can treat thyroid patients. It enables surgeons to do endoscopic procedures with more precision because the robotic hands have dexterity similar to, if not better than, human hands.

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