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Trans Oral Robotic Thyroidectomy – A Series

Jagadishwar Goud. G, Harika Tirunagari , M.Bala Vikas Kumar
Global Journal of Surgery. 2017, 5(1), 14-16. DOI: 10.12691/js-5-1-5
Published online: July 26, 2017

Abstract

Introduction: Thyroidectomy from age old days is done by conventional direct neck approach leaving a scar which is cosmetically unappealing. In this study we make use of a natural orifice, the oral cavity, for thyroidectomy using the Da Vinci Robotic system. Methods and Materials: This is study of 15 patients undergoing trans oral robotic thyroidectomy for benign diseases over a period of 7 months in a single institute, Yashoda super speciality hospital, secunderabad. Results: Out of 15 patients, 3 had lower lip edema in the immediate postoperative period which subsided without any intervention. No evidence of surgical emphysema in any patient. There were no other complications like mental nerve palsy or recurrent laryngeal nerve palsy noted. Oral feeds were allowed on the 2nd post operative day and all the patients were discharged on the 3rd post operative day. Conclusions: Robotic Trans-oral approach to thyroid is gaining demand due to superior cosmetic results. The flexibility of the endo-wrist of the robot comes into play for the dissection of the thyroid gland in the restricted space. Robot provides a 3D vision which gives an added advantage of identification and meticulous handling of the neuro vascular structures avoiding complications.

1. Introduction

Thyroidectomy from age old days is done by conventional direct neck approach leaving a scar which is cosmetically unappealing. Advances in laparoscopic and robotic surgeries have replaced the conventional approach to a greater extent keeping in view the cosmetic demand of the present generations. In this study we make use of a natural orifice, the oral cavity, for thyroidectomy using the Da Vinci Robotic system. As far as our knowledge, this is one of the biggest series of Robotic Trans oral thyroidectomies in India.

2. Methods and Materials

This is a prospective study done in 15 patients attending surgical out patient department of Yashoda super speciality hospital, secunderabad, over a period of 7 months, from Nov 2016 to May 2017.

This study includes middle aged patients with benign thyroid enlargements undergoing trans-oral robotic thyroidectomy (hemi/total). The patients with huge thyroid enlargement of more than 8cm, extremes of age and malignancies are excluded from the study. FNAC, USG neck and Thyroid profile are taken into account for diagnostic purposes. Confirming the euthyroid status and benign nature of the nodule we proceeded for surgery after attaining surgical fitness. Hygiene of the oral cavity was maintained in order to prevent post operative infections.

Patient in placed in supine position with extension at the neck, nasal intubation done and oral cavity is cleaned with saline and betadine. A 2cm curvi linear incision is given in the middle of the inferior vestibule, space widening is carried out in the submental and anterior neck space using a blunt instrument (Figure 1).

A 10mm camera port (Figure 2) is inserted and CO2 was insufflated into the working space maintaining the pressure at 6-8mm Hg. Other 2 working ports of the robot are docked (Figure 3) in the inferior vestibular line laterally respecting the mental nerve anatomy and avoiding its injury.

Dissection is carried out in the sub platyssmal plane, the strap muscles are separated cranio caudally. Superior, middle and inferior thyroid vessels are addressed in this order bilaterally (total thyroidectomy), unilaterally with isthmectomy (hemi thyroidectomy). Thyroid is separated from its bed and specimen is retrieved from the 10mm camera port. Superior and Recurrent laryngeal nerve preserved, haemostasis secured and drain placed through one of the port sites.

3. Results

Transoral robotic thyroidectomy is an emerging new technique. There are very few complications post operatively. Out of the 15 patients undergoing the procedure, 3 had lower lip edema in the immediate post operative period which subsided without any intervention. None of the patients had haematoma formation. No evidence of surgical emphysema in any patient. There was no evidence of any numbness of the chin suggesting preservation of the mental nerve and no hoarseness of voice preserving the recurrent laryngeal nerve in the post operative period.

All the patients were followed up, all maintained the preoperative appearance and voice without the disease and without the scar.

4. Discussion

Robotic approach to the thyroid gland through trans-oral route is an emerging new technique which is gaining demand due to the superior cosmetic advantage. It completely avoids the scars which occur in conventional thyroidectomy. Endoscopic thyroid surgeries via trans axillary, retro auricular and breast approaches are few well established techniques which are not scar free but the scars are hidden 1, 2, 3, 4, 5. Apart from this the disadvantages of trans axillary, retro auricular and breast approaches is the that the surgical access is made from a distant site which makes un necessary dissection inevitable, which may lead to increase in intra and post operative complications. The trans-oral approach is now replacing the other approaches due to absolute scar free results and the complications related to obstructing clavicle, great vessel injury, esophageal perforation and post operative edema which may occur in other approaches are also avoided. The transoral approach to the thyroid gland is obvious when knowledge of the embryological development of the thyroid is considered 6, 7.

Thyroidectomy through transoral approach by Witzel 8 et al on porcine models and cadavers was proved to be safe and easy to perform.

We have performed robotic thyroidectomy through transoral approach in 15 patients. Antibiotics and antiseptic mouth washes were recommended in order to prevent wound infection as oral cavity is not a sterile area. Operative time for the procedure ranged from 90 mins – 120 mins. CO2 was insufflated to create working space. Trans-Oral Video-Assisted Neck Surgery (TOVANS) was performed transorally by Nakajo et al 9, where they achieved gasless surgical field using Kirschner wires. In our study we insufflated CO2 in order to avoid the scars formed by the Kirschner wires. As the procedure follows the anatomical planes of dissection, the post operative complications are minimised. A slender drain was placed in all the cases. The muscle planes and the mucosal layers are closed with absorbable material. Ryle’s tube feeds were given on the 1st post operative day, orals allowed on the 2nd day along with drain removal. All the patients were discharged on 3rd day. Both mental nerve and recurrent laryngeal nerve were well preserved without any evidence of nerve palsies. Though the study sample is small, we had successful results with very minimal complications. This surgery is gaining popularity due the scar free results and has a progressive outcome.

5. Conclusions

Robotic Trans-oral approach to thyroid is gaining demand due to superior cosmetic results. The flexibility of the endo-wrist of the robot comes into play for the dissection of the thyroid gland in the restricted space. Robot provides a 3D vision and magnified view which gives an added advantage of identification and meticulous handling of the neuro vascular structures avoiding complications. The learning curve can be extended in the scenarios like huge goitres, malignancies, neck dissections addressing lymph nodes and other swellings which are excluded in our study.

References

[1]  Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by axillary approach. J Am Coll Surg 2000; 191: 336-340.
In article      View Article
 
[2]  Barlehner E, Benhidjeb T. Cervical scarless endoscopic thyroidectomy: Axillo-bilateral-breast approach (ABBA). Surg Endosc 2008; 22: 154-157.
In article      View Article  PubMed
 
[3]  Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: Breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000; 10: 1-4.
In article      View Article  PubMed
 
[4]  Park YL, Han WK, Bae WG.100 cases of endoscopic thyroidectomy: Breast approach. Surg Laprosc Endosc Percutan Tech 2003; 13: 20-25.
In article      View Article
 
[5]  Sasaki A, Nakajima J, Ikeda K, Otsuka K, Koeda K, Wakabayashi G. Endoscopic thyroidectomy by the breast approach: A single institution’s 9-year experience. World J Surg 2008; 32: 381-385.
In article      View Article  PubMed
 
[6]  Karakas E, Steinfeldt T, Gockel A, et al. Transoral thyroid and parathyroid surgery-Development of a new transoral technique. Surgery 2011; 150: 108-115.
In article      View Article  PubMed
 
[7]  Karakas E. Steinfeldt T, Gockel A, Westermann R, Kiefer A, Bartsch DK. Transoral thyroid and parathyroid surgery. Surg Endosc 2010; 24: 1261-1267.
In article      View Article  PubMed
 
[8]  Witzel K, von Rahden B.H.A, Kaminski C, Stein H.J. Transoral access for endoscopic thyroid resection. Surg. Endosc. 2008; 22: 1871-1875.
In article      View Article  PubMed
 
[9]  Akihiro N,Hideo A, Munetsugu H. Trans-Oral-Video-Assisted Neck Surgery(TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandibular approach. Surg. Endosc. 2013; 27: 1105-1110.
In article      View Article  PubMed
 

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Cite this article:

Normal Style
Jagadishwar Goud. G, Harika Tirunagari, M.Bala Vikas Kumar. Trans Oral Robotic Thyroidectomy – A Series. Global Journal of Surgery. Vol. 5, No. 1, 2017, pp 14-16. http://pubs.sciepub.com/js/5/1/5
MLA Style
G, Jagadishwar Goud., Harika Tirunagari, and M.Bala Vikas Kumar. "Trans Oral Robotic Thyroidectomy – A Series." Global Journal of Surgery 5.1 (2017): 14-16.
APA Style
G, J. G. , Tirunagari, H. , & Kumar, M. V. (2017). Trans Oral Robotic Thyroidectomy – A Series. Global Journal of Surgery, 5(1), 14-16.
Chicago Style
G, Jagadishwar Goud., Harika Tirunagari, and M.Bala Vikas Kumar. "Trans Oral Robotic Thyroidectomy – A Series." Global Journal of Surgery 5, no. 1 (2017): 14-16.
Share
[1]  Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by axillary approach. J Am Coll Surg 2000; 191: 336-340.
In article      View Article
 
[2]  Barlehner E, Benhidjeb T. Cervical scarless endoscopic thyroidectomy: Axillo-bilateral-breast approach (ABBA). Surg Endosc 2008; 22: 154-157.
In article      View Article  PubMed
 
[3]  Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: Breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000; 10: 1-4.
In article      View Article  PubMed
 
[4]  Park YL, Han WK, Bae WG.100 cases of endoscopic thyroidectomy: Breast approach. Surg Laprosc Endosc Percutan Tech 2003; 13: 20-25.
In article      View Article
 
[5]  Sasaki A, Nakajima J, Ikeda K, Otsuka K, Koeda K, Wakabayashi G. Endoscopic thyroidectomy by the breast approach: A single institution’s 9-year experience. World J Surg 2008; 32: 381-385.
In article      View Article  PubMed
 
[6]  Karakas E, Steinfeldt T, Gockel A, et al. Transoral thyroid and parathyroid surgery-Development of a new transoral technique. Surgery 2011; 150: 108-115.
In article      View Article  PubMed
 
[7]  Karakas E. Steinfeldt T, Gockel A, Westermann R, Kiefer A, Bartsch DK. Transoral thyroid and parathyroid surgery. Surg Endosc 2010; 24: 1261-1267.
In article      View Article  PubMed
 
[8]  Witzel K, von Rahden B.H.A, Kaminski C, Stein H.J. Transoral access for endoscopic thyroid resection. Surg. Endosc. 2008; 22: 1871-1875.
In article      View Article  PubMed
 
[9]  Akihiro N,Hideo A, Munetsugu H. Trans-Oral-Video-Assisted Neck Surgery(TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandibular approach. Surg. Endosc. 2013; 27: 1105-1110.
In article      View Article  PubMed