Robot

Thyroid gland surgery : The benefits of robotics.

When to operate?

 

  • Thyroid nodule (a single cyst on the gland) : Immediate decision to operate with a nodule measuring 3-4 cms for there is a 20 % risk of cancer in nodules over 4 cms. In this case, partial removal of the gland at the site of the nodule is made, specially if the patient is young or presents risk factors for thyroid cancer.
  • Endothoracic goiter (a large nodule in the lung) : compressive symptoms on the windpipe causing breathing and swallowing difficulties.
  • Multinodular goiter (several cysts on the gland : where cancer is suspected (5-10 % of cases), punction of the suspect nodule, tell-tale signs revealed by x-ray or ultrasound examination or an increase in nodule size.
  • Hyperthyroidism : When the patient cannot tolerate the antithyroid treatment or radioactive iodine or should a woman wish to become pregnant.
  • Cancer of the thyroid : total thyroidectomy is performed in the first place, followed by curetage in the event of recurrence.

 

 

Surgical techniques

 

‘Traditional’ surgery

 

Middle - of - the - neck incision .
This technique earned the Swiss surgeon Emil Theodor Kocher the Nobel Prize for Medecine in 1909 for his work on the physiology, the pathology and the surgery of the thyroid gland. Since then, very little has changed.....

The technique has been thoroughly mastered and is effective but can leave a visible scar at the base of the neck.
In traditional surgery, the surgeon’s visibility is restricted when it comes to the deep structures of the neck that contain the delicate nerves.

Risk of complications

  • Drop in blood calcium levels, temporary (20% of cases), permanent ( 5% )
  • A potential complication is temporary (5 %) or permanent (1 %) voice loss, voice change or hoarseness.

Robotic thyroid surgery is a less invasive procedure.

Numerous surgeons have perfected different techniques aiming at avoiding an ugly scar on the neck. Notably endoscopic thyroid surgery which still however leaves a small scar on the neck.

A Korean surgeon (Dr. WY Chung, Seoul) has perfected a technique that enables the thyroid to be reached through an incision in the axillary fold (under the arm). It would appear that a neck scar is unseemly in Korean culture. That is the reason why he has developed a ‘concealing’ technique that has been discussed in innumerable articles since 2006. It has now been thoroughly perfected and robotic thyroid surgery is now routinely carried out in many countries (South Korea, the USA, Brazil, Japan ….)

The most up-to-date technology : the da Vinci surgical system

First, access is gained through the axillary fold, and dissection, an incision of 5-6 cms, is only superficial until the neck muscles are reached allowing a retractor to be inserted under the skin so that the 4 arms of the robot can be introduce. 
Da Vinci

Da Vinci
The surgeon then directs the da Vinci system that converts his delicate and precise movements by means of the miniaturized instruments placed inside the patient’s body. The instruments have free movement in all directions in order to cut away those parts of the thyroid that need removing. Blood vessel coagulation is assured by the ultracision technique. At all times, the surgery is performed and monitored thanks to the perfect visualization your surgeon is afforded by the magnified high-resolution 3D image before him.
Da Vinci

Candidates for robotic –assisted thyroid surgery

Robotic-assisted surgery of the thyroid gland through an incision in the axillary fold is not suitable for every patient.

  • - Nodule size must be 5 cms or less.
  • Only malignant nodules between 2 – 4 cms are suitable. The technique is perfectly adapted to node dissection when indicated, the rate of complications being much lower than in traditional surgery.
  • Patient morphology also counts. Obese patients, as well as those who have already been operated on several times are not suitable as in these cases, approach through the axillary incision becomes too complex.

The many advantages in robotic thyroid surgery :

  • The surgeon has easier access and even more precision is added to his skill since robotic thyroid surgery is performed with a high-resolution 3D image of the surgical site.
  • Greater protection for the surrounding anatomical structures : the parathyroid glands (those with normal calcium rate) and the recurrent laryngeal nerves (those governing the vocal cords) with less than 0.5% voice change. Article to be published by Dr. WY Chung (International Thyroid Congress, Paris 11 – 16/09/2010
  • Improved aesthetic appearance thanks to the reduction in size of the scar and its concealed position under the arm.
  • Reduction of post-operative pain : As the incision is at a distance from the operation site, the patient no longer experiences the usual difficulties in swallowing associated with neck incision.
  • Reduction in length of hospitalization and speedier return to professional activity.

Who performs this surgery in France?

http://www.docteuraidan.fr/sites/default/files/image/SANY0225_0.JPGIn the specific field of thyroid surgery, Dr. Patrick Aidan was one of the first to develop this technique. To-day, he has already operated on more than 28 patients and the results of this state-of-the art technique are very promising. He completed his residency at French hospitals before serving as one of their Heads of Clinical Faculty prior to being invited to practice at the American Hospital in Paris. He’s certified surgeon in Intuitive Robotic Surgery.

Dr. Patrick Aidan has been called upon to address numerous specialist medical Congresses-among the most recent :

  • "Chirurgie Robotique thyroïdienne par voie transaxillaire" : Société Française d'endocrinologie (Deauville),  1er octobre 2010
  • "Faisabilité de thyroïdectomie par chirurgie Robotique assistée" : Congrès Français de  Chirurgie (Palais des congrès Paris), 6 octobre 2010
  • "Voie transaxillaire : intérêt du Robot da Vinci pour les thyroïdectomies" : Congrès Français d'ORL (Palais des congrès Paris), 16 octobre 2010

At present, more than 30 robots have been installed in France (300 in Europe and 1,300 in the USA). Annually, a total of more than 200,000 procedures using this technique are performed throughout the world in all medical specialities.

Disadvantages :

  • The robot’s price (2 M euros) but it can be used in several surgical specialities such as urology, gynaecology, digestive tract surgery etc.
  • Special training is required for the surgeon and his medical team.

 

Conclusion

Robotic surgery is particularly indicated in thyroid gland removal. The surgeon’s movements are even more precise and therefore post-operative complications will occur less often. 
Indications for its use are very exact and the absence of a scar on the neck is a considerable aesthetic advantage.