Name: transoral robotic total thyroidectomy and bilateral central regional lymph node dissection for papillary thyroid carcinoma
Uploaded: 2023-09-15T13:50:00
Description: Watch this Scientific Journal Video about Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma at JoVE.com

Supported by the General project of technology innovation and application development of Chongqing (Grant No. CSTC2019jscx-msxmX0196).

This study follows the guidelines of the Army Medical University&#39;s Human Research Ethics Committee. All patients mentioned in the study signed informed consent forms.
1. Preoperative preparation
<ol>
	<li>After successful nasotracheal intubation, place the patient supine with the head and neck into hyperextension.</li>
	<li>Let the eyes close naturally. Apply eye ointment and cover the area from the top of the brow bone to the nasal flanks with an appropriate eye patch o...

<ol>
	<li>Shimazu, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+thyroid+surgery+through+the+axillo-bilateral-breast+approach.">Endoscopic thyroid surgery through the axillo-bilateral-breast approach.</a> Surgical Laparoscopy, Endoscopy &amp; Percutaneous Techniques. 13 (3), 196-201 (2003).</li><li>Ikeda, Y., Takami, H., Niimi, M., Kan, S., Sasaki, Y., Takayama, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+thyroidectomy+by+the+axillary+approach.">Endoscopic thyroidectomy by the axillary approach.</a> Surgical Endoscopy. 15 (11), 1362-1364 (2001).</li><li>Alabbas, H., Bu Ali, D., Kandil, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+retroauricular+thyroid+surgery.">Robotic retroauricular thyroid surgery.</a> Gland Surgery. 5 (6), 603-606 (2016).</li><li>Witzel, K., von Rahden, B. H. A., Kaminski, C., Stein, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+access+for+endoscopic+thyroid+resection.">Transoral access for endoscopic thyroid resection.</a> Surgical Endoscopy. 22 (8), 1871-1875 (2008).</li><li>Benhidjeb, T., Wilhelm, T., Harlaar, J., Kleinrensink, G. -. J., Schneider, T. A. J., Stark, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Natural+orifice+surgery+on+thyroid+gland:+totally+transoral+video-assisted+thyroidectomy+(TOVAT):+report+of+first+experimental+results+of+a+new+surgical+method.">Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method.</a> Surgical Endoscopy. 23 (5), 1119-1120 (2009).</li><li>Wilhelm, T., Metzig, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video.+Endoscopic+minimally+invasive+thyroidectomy:+first+clinical+experience.">Video. Endoscopic minimally invasive thyroidectomy: first clinical experience.</a> Surgical Endoscopy. 24 (7), 1757-1758 (2010).</li><li>Park, J. O., Sun, D. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+endoscopic+thyroidectomy:+our+initial+experience+using+a+new+endoscopic+technique.">Transoral endoscopic thyroidectomy: our initial experience using a new endoscopic technique.</a> Surgical Endoscopy. 31 (12), 5436-5443 (2017).</li><li>Clark, J. H., Kim, H. Y., Richmon, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+robotic+thyroid+surgery.">Transoral robotic thyroid surgery.</a> Gland Surgery. 4 (5), 429-434 (2015).</li><li>Richmon, J. D., Pattani, K. M., Benhidjeb, T., Tufano, R. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+robotic-assisted+thyroidectomy:+a+preclinical+feasibility+study+in+2+cadavers.">Transoral robotic-assisted thyroidectomy: a preclinical feasibility study in 2 cadavers.</a> Head &amp; Neck. 33 (3), 330-333 (2011).</li><li>Wilhelm, T., Metzig, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+minimally+invasive+thyroidectomy+(eMIT):+a+prospective+proof-of-concept+study+in+humans.">Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans.</a> World Journal of Surgery. 35 (3), 543-551 (2011).</li><li>Nakajo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trans-oral+video-assisted+neck+surgery+(TOVANS).+A+new+transoral+technique+of+endoscopic+thyroidectomy+with+gasless+premandible+approach.">Trans-oral video-assisted neck surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach.</a> Surgical Endoscopy. 27 (4), 1105-1110 (2013).</li><li>Anuwong, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+endoscopic+thyroidectomy+vestibular+approach:+a+series+of+the+first+60+human+cases.">Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases.</a> World Journal of Surgery. 40 (3), 491-497 (2016).</li><li>Kim, H. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transoral+robotic+thyroidectomy:+lessons+learned+from+an+initial+consecutive+series+of+24+patients.">Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients.</a> Surgical Endoscopy. 32 (2), 688-694 (2018).</li><li>Kim, H. Y., Park, D., Bertelli, A. A. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+pros+and+cons+of+additional+axillary+arm+for+transoral+robotic+thyroidectomy.">The pros and cons of additional axillary arm for transoral robotic thyroidectomy.</a> World Journal of Otorhinolaryngology - Head and Neck Surgery. 6 (3), 161-164 (2020).</li><li>Park, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+versus+endoscopic+transoral+thyroidectomy+with+vestibular+approach:+A+literature+review+focusing+on+differential+patient+suitability.">Robotic versus endoscopic transoral thyroidectomy with vestibular approach: A literature review focusing on differential patient suitability.</a> Current Surgery Reports. 10, 133-139 (2022).</li><li>Park, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Institutional+experience+of+200+consecutive+papillary+thyroid+carcinoma+patients+in+transoral+robotic+thyroidectomy+surgeries.">Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries.</a> Head &amp; Neck. 42 (8), 2106-2114 (2020).</li></ol>

Some scholars have reported transoral robotic thyroid surgery. In Kim's series of TORT studies, the authors used four robotic arms on's automated platforms to perform the TORT procedure. A fourth arm was used via a transaxillary incision primarily for traction of the strap muscles, and this access was also used to extract specimens and place drains when needed13,14.
In this three-port robot approach, one transverse incision of about 8 ...

Thyroid surgeons use different surgical approaches (bilateral axillary breast approach1 [Figure 1], axillary approach2 [Figure 2], retroauricular approach3 [Figure 3], etc.) to conceal surgical incisions and achieve scarless thyroid surgery in the neck. However, none of these technologies can completely avoid scars on the patient&#39;s skin surface. In all methods, only the oral vestibule approach (Figure 4) can achieve the shortest distance of flap separation, leaving no scar on the whole body surface4,5,6. In recent years, natural mouth endoscopic surgery (NOTES)7has been introduced in oral thyroid surgery.
Thyroid surgery performed through this method can be completed through an endoscope or robotic surgical system. Compared with the endoscopic surgery system for thyroid surgery, this robot system has an enlarged three-dimensional high-definition field of view and a rotatable mechanical wrist capable of intuitive motion, making surgeons more flexible in performing satisfactory surgeries8,9. The benefits of this innovative technology include minimally invasive dissection and channels for both thyroid glands10,11,12. However, oral thyroidectomy often requires an axillary-assisted incision to complete the surgery. To achieve the ultimate cosmetic effect, our surgical team delves into the feasibility of an oral three-port robotic thyroidectomy without an axillary incision for the treatment of early papillary thyroid cancer.
This article introduces the application of a robotic surgical system to complete oral thyroidectomy and bilateral central lymph node dissection. Furthermore, the feasibility and safety of this approach have been demonstrated by successfully completing a three-port robotic thyroidectomy without axillary incision and central regional lymph node dissection.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>4-0 absorbable sutures</td>
			<td>Covidien</td>
			<td>VLOCM0023</td>
			<td>Suture the linea alba cervicalis&#160;</td>
		</tr>
		<tr>
			<td>5-0 Polyglactin braided absorbable suture</td>
			<td>Johnson &#38; Johnson</td>
			<td>VCP433H</td>
			<td>Oral mucosa suture</td>
		</tr>
		<tr>
			<td>8 mm Cadiere forceps&#160;</td>
			<td>Intuitive Surgical, Inc</td>
			<td>LOT N10210823</td>
			<td>Clamp tissue</td>
		</tr>
		<tr>
			<td>8 mm Harmonic ACE scalpel&#160;</td>
			<td>Intuitive Surgical, Inc</td>
			<td>REF 480275</td>
			<td>Coagulation, expand operating space</td>
		</tr>
		<tr>
			<td>8 mm Maryland bipolar forceps&#160;</td>
			<td>Intuitive Surgical, Inc</td>
			<td>LOT K10210830 REF 470172</td>
			<td>Expose the recurrent laryngeal nerve</td>
		</tr>
		<tr>
			<td>8 mm Monopolar curved scissors</td>
			<td>Intuitive Surgical, Inc</td>
			<td>LOT K10211108 REF 470179</td>
			<td>Fine capsular anatomy</td>
		</tr>
		<tr>
			<td>Carbon Nanoparticles Suspension Injection</td>
			<td>Chongqing Laimei Pharmaceutical Co., Ltd</td>
			<td>N/A</td>
			<td>1 mL/50 mg; used for tracing regional drainage lymph nodes.</td>
		</tr>
		<tr>
			<td>Da Vinci Xi Surgical System</td>
			<td>Intuitive Surgical, Inc</td>
			<td>Xi</td>
			<td>Surgical system</td>
		</tr>
		<tr>
			<td>Endoscopy surgical specimen setrieval bag</td>
			<td>Hangzhou Kangji Medical Equipment Co.Ltd.</td>
			<td>LOT 22021921 REF 104Y.111</td>
			<td>Remove specimens from air cavity</td>
		</tr>
		<tr>
			<td>Medical pressure garment</td>
			<td>Foshan qiaoke bio technology Co.Ltd.</td>
			<td>20200149</td>
			<td>Pressure dressing of the anterior neck area of the mandible</td>
		</tr>
	</tbody>
</table>

transoral robotic total thyroidectomy and bilateral central regional lymph node dissection for papillary thyroid carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The average operative time was ~253 min (minimum time: 205 min, maximum time: 300 min), with an average blood loss of ~20 mL (minimum blood loss: 10 mL, maximum blood loss: 50 mL). The drain was removed until the drainage fell to less than 30 mL/day, and the patients were discharged 2-3 days postoperatively. Figure 12 shows the follow-up images of the 4 patients 1-month post-surgery. The images show that there are no surgical scars on the body of the patients.&#160;The clinical data of 4 pat...

Watch this Scientific Journal Video about Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma at JoVE.com

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

This study describes a novel transoral vestibular robotic thyroidectomy without axillary opening for the treatment of papillary thyroid carcinoma. In this study, a robotic surgical system was used to perform total thyroidectomy and bilateral central lymph node dissection via an oral vestibular approach. To begin, use an ultrasonic scalpel and separate the flap downward towards the clavicle.Extending bilaterally to the anterior border of the sternal cleidomastoid muscle. Next, use unipolar curved scissors to separate the white cervical line and a portion of the banded muscle, resulting in an exposed section of the thyroid gland. Using a 25 gauge syringe, inject 0.1 milliliters of carbon nano particle suspension injection into the thyroid parenchyma to visualize the parathyroid gland.Then employ an ultrasound knife to release the striated muscle. Using 4-O absorbable sutures, suspend the striated muscle sutures for a clear surgical visualization. After injecting one milliliter of indocyanine green, switch to the automatic fluorescence imaging mode for a vivid representation of fluorescent parathyroid glands in contrast to nonfluorescent lymph nodes.Using an ultrasound knife, cut the blood vessels at the upper pole of the thyroid gland while protecting and locating the parathyroid gland. Then used curved bipolar forceps to carry out the intricate process of preserving the parathyroid in its natural location. Now locate the laryngeal nerve within the triangular region formed by the medial parathyroid gland, the thyroid gland, and the laryngeal muscles.Uncover the laryngeal entry of the recurrent laryngeal nerve. Activate the smoke evacuation device to clear any exudate and blood that emerges during the mass resection. Maintain cleanliness of the lens and surgical area to ensure accurate exposure and protection of the recurrent laryngeal nerve during the procedure.Initiate the prophylactic unilateral central neck dissection. Execute a contralateral hemi thyroidectomy and an ipsilateral central lymph node prophylactic dissection. Transfer all excised tissues to a specimen bag and proceed with removal.Next, rinse the wound with saline. Insert a negative pressure drainage tube into the thyroid bed via the cervical puncture hole. Employ 4-O absorbable barbed sutures for continuous suturing of the strap muscle.The follow-up images of the four patients one month post-surgery showed no surgical scars on the body of the patients. The use of the three hole method is a safe and reliable alternative to the four hole method for thyroid surgery via the oral vestibular approach.

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