Zaloguj się

Aby wyświetlić tę treść, wymagana jest subskrypcja JoVE. Zaloguj się lub rozpocznij bezpłatny okres próbny.

W tym Artykule

  • Podsumowanie
  • Streszczenie
  • Wprowadzenie
  • Protokół
  • Wyniki
  • Dyskusje
  • Ujawnienia
  • Podziękowania
  • Materiały
  • Odniesienia
  • Przedruki i uprawnienia

Podsumowanie

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.

Streszczenie

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.

Wprowadzenie

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'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.

Protokół

This study follows the guidelines of the Army Medical University's Human Research Ethics Committee. All patients mentioned in the study signed informed consent forms.

1. Preoperative preparation

  1. After successful nasotracheal intubation, place the patient supine with the head and neck into hyperextension.
  2. 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 or surgical patch to prevent disinfectant, blood, and other fluids from flowing into the eyes.
  3. Fill both external ear canals with cotton balls to prevent disinfectant and blood from entering the ear canals and cover the face with a cotton pad folded in half lest the face be crushed by the tracheal intubation.
  4. Cover the surface of the cotton pad with a non-woven surgical cap up to the nostrils. Apply surgical lamination externally, down to the level of the upper lip, while leaving the area at the foot of the horizontal line of the corners of the mouth uncovered, the lateral sides of the lamination reaching the edge of the sideburns while its upper side flush with the hairline.
  5. Use a robot surgical system. Place the patient in the supine position. Administer general anesthesia via nasotracheal intubation as per the anesthetist's recommendations.

2. Surgical procedure

  1. Inject Lidocaine (10 mL) + Ropivacaine (10 mL) + Adrenaline hydrochloride (10 drops) under the oral mucosa.
  2. Make an incision of approximately 8 mm above the lower lip ligament. Ensure that the incisions on both sides are approximately 8 mm long, between the sharp teeth and the first molar (Figure 5).
  3. Maintain the CO2 gas pressure at 6 mmHg and the gas flow rate in the 20 mL/min range.
  4. Dock the robot arm.
  5. Place Maryland bipolar coagulator into the left trocar, and ultrasonic scalpel into the right trocar, completing the flap freeing.
    1. Using an ultrasonic scalpel, separate the flap downward to the clavicle and bilaterally to the anterior border of the Sternocleidomastoid muscle.
    2. Use unipolar curved scissors to separate the white cervical line and part of the banded muscle to expose a portion of the thyroid gland (Figure 6) and use a 25 G syringe to inject approximately 0.1 mL of carbon nanoparticle suspension injection from the neck to the thyroid parenchyma under surgical observation to complete a negative image to illustrate the parathyroid gland (Figure 7).
    3. Use an ultrasound knife to release the striated muscle and use 4-0 absorbable sutures to suspend the striated muscle sutures, facilitating surgical visualization.
    4. Inject 1 mL of 2.5 mg/mL indocyanine green intravenously for better visualization and protection of the parathyroid glands. Switch to automatic fluorescence imaging mode for clear visualization of fluorescent parathyroid glands and comparison with non-fluorescent lymph nodes.
    5. Use an ultrasound knife to disconnect the blood vessels at the upper pole of the thyroid gland while searching for and protecting the parathyroid gland at the upper pole (Figure 8). Use curved bipolar forceps to complete the delicate operation of in situ parathyroid preservation (Figure 9).
    6. Reveal the laryngeal entry of the recurrent laryngeal nerve (Figure 10). Usually, the recurrent laryngeal nerve can be found more quickly within the triangular area formed by the medial parathyroid gland, thyroid gland, and laryngeal muscles. This area is rich in blood supply. Deal with bleeding and exudate at the entry larynx promptly to secure a straight field of view operation and reduce the difficulty of robotic thyroid surgery.
    7. Use the smoke evacuation device (mastoid suction device12; Figure 11) to remove the exudate and blood during the mass resection, maintaining the cleanness of the lens and the definition of the image of the local surgical area, ensuring accurate exposure and protection of recurrent laryngeal nerve during the surgery. Then, conduct the prophylactic unilateral central neck dissection.
    8. Perform a contralateral hemithyroidectomy with ipsilateral central lymph node prophylactic dissection in the same manner.
  6. Place all excised tissues in a specimen bag and remove them. Rinse the wound with saline.
  7. Place a negative pressure drainage tube into the thyroid bed through the cervical puncture hole. Use 4-0 absorbable barbed sutures to continuously suture the strap muscles. Use absorbable threads for the suturing of the oral incisions.

Wyniki

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. The clinical data of 4 pat...

Dyskusje

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 ...

Ujawnienia

The authors declare that there is no conflict of interest.

Podziękowania

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

Materiały

NameCompanyCatalog NumberComments
4-0 absorbable suturesCovidienVLOCM0023Suture the linea alba cervicalis 
5-0 Polyglactin braided absorbable sutureJohnson & JohnsonVCP433HOral mucosa suture
8 mm Cadiere forceps Intuitive Surgical, IncLOT N10210823Clamp tissue
8 mm Harmonic ACE scalpel Intuitive Surgical, IncREF 480275Coagulation, expand operating space
8 mm Maryland bipolar forceps Intuitive Surgical, IncLOT K10210830 REF 470172Expose the recurrent laryngeal nerve
8 mm Monopolar curved scissorsIntuitive Surgical, IncLOT K10211108 REF 470179Fine capsular anatomy
Carbon Nanoparticles Suspension InjectionChongqing Laimei Pharmaceutical Co., LtdN/A1 mL/50 mg; used for tracing regional drainage lymph nodes.
Da Vinci Xi Surgical SystemIntuitive Surgical, IncXiSurgical system
Endoscopy surgical specimen setrieval bagHangzhou Kangji Medical Equipment Co.Ltd.LOT 22021921 REF 104Y.111Remove specimens from air cavity
Medical pressure garmentFoshan qiaoke bio technology Co.Ltd.20200149Pressure dressing of the anterior neck area of the mandible

Odniesienia

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

Przedruki i uprawnienia

Zapytaj o uprawnienia na użycie tekstu lub obrazów z tego artykułu JoVE

Zapytaj o uprawnienia

Przeglądaj więcej artyków

Transoral Robotic ThyroidectomyPapillary Thyroid CarcinomaBilateral Central Lymph Node DissectionRobotic Surgical SystemUltrasonic ScalpelThyroid ParenchymaCarbon Nano Particle SuspensionIndocyanine GreenFluorescence ImagingRecurrent Laryngeal NerveProphylactic Neck DissectionCervical Puncture HoleNegative Pressure DrainageContinuous Suturing

This article has been published

Video Coming Soon

JoVE Logo

Prywatność

Warunki Korzystania

Zasady

Badania

Edukacja

O JoVE

Copyright © 2025 MyJoVE Corporation. Wszelkie prawa zastrzeżone