Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands

Introduction:  There is a new surgical approach to removing the thyroid and/or parathyroid glands through the axilla, and it is designated robotic assisted transaxillary surgery (RATS).  It is anatomically directed to neck via an approach that starts in the axilla. Thus, RATS eliminates a visible scar in the front of the neck while also giving high-definition optics of the deep cervical anatomy.  This study reports on an initial series of single access RATS in the United States.

Methods:  The study used the prospective endocrine surgery database at a tertiary care center, finding all patients who had RATS between October 2009 and March 2010.  All procedures were done with a single transaxillary incision.

Results:  There were 13 patients, and they had 14 operations.  Indications for using RATS included indeterminate thyroid nodules (11 patients), primary hyperparathyroidism (2 patients), and the need for completion thyroidectomy (1 patient).

The patients who had robot-assisted thyroid lobectomy had a median thyroid nodule size of 2.1 cm (range, 0.8-2.8 cm).  The median body mass index was 25.33 (range, 21.3-34.4).  The mean and median total operative times were 142 minutes and 137 minutes, respectively (range, 113-192).

For the 2 patients who had robot-assisted parathyroidectomy, the mean and median total operative times were 115 minutes and 102 minutes, respectively.

There were minor complications in 4 patients (28.5%), but there was no significant perioperative morbidity or mortality.

Conclusion:  Robot-assisted thyroid surgery is feasible.  The authors suggest further study of the RATS technique for removing the thyroid and parathyroid glands.  Before RATS can be implemented into routine clinical practice in the US, more careful investigation is needed.

Commentary by Kresimira (Mira) Milas MD

Patients and physicians are becoming more aware of – and asking about - new techniques using robotic surgery to treat a number of medical conditions. Robot assisted-surgery has been used in the treatment of prostate cancer and to assist various gynecologic procedures for the last decade, but only relatively recently for thyroid and parathyroid diseases. The technique of robot-assisted thyroid removal via the axilla (armpit) was pioneered in Korea, where experience with this surgery has accrued to >1,000 patients. The above report from an experienced robotic surgery and endocrine surgery center in the United States represents an initial experience with 13 patients. It also represents the first reported series in the U.S. where thyroid and parathyroid surgery was performed via a single, small incision in the axilla.

Physicians, particularly surgeons, can turn to the details of this publication to learn about the patient selection criteria and expectations during surgery and post-operative recovery. All specialists who treat patients with thyroid and parathyroid disease will benefit from becoming familiar with the findings of this initial experience with RATS in U.S. patients. While the authors conclude that the procedure is feasible, they also highlight the fact that there is definite complexity to this approach. They reserve its use for patients who require unilateral resection of suspected benign primary thyroid lesions or benign endocrine tumors such as parathyroid adenomas. The largest thyroid nodule in this series was slightly smaller than 3 cm. RATS should not be performed for biopsy-proven thyroid cancer. The obvious benefit to the patient is cosmetic  - there is no visible scar in the front of the neck. Other potential benefits of this technology and its value of innovation and medical progress still need to be weighed against the concerns of cost, higher complication rates than traditional neck surgery, and the need to be performed by a skilled team. Additional guidance for safe and effective implementation of RATS can be found in the recent multidisciplinary review by Perrier et al (Thyroid 2010; 20:1327-1332).