REVO

The 19th Korea-Japan Joint Meeting of Otorhinolaryngology - Head and Neck Surgery (KJJM 2024) / Thursday, March 21, 2024 / Lotte Hotel Seoul

Robotic/Endoscopic Thyroidectomy by Transaxillary approach (Dr. Myung-Chul Lee, Department of Otolaryngology at Korea Cancer Center Hospital)

 The 19th Korea-Japan Joint Meeting of Otorhinolaryngology - Head and Neck Surgery (KJJM 2024) was held from March 20 to 22 at Lotte Hotel Seoul. On the second day of the conference, the 21st, Dr. Myung-Chul Lee of the Department of Otolaryngology at Korea Cancer Center Hospital, gave a lecture entitled "Robotic and Endoscopic Thyroidectomy Using Transaxillary Approach". He introduced the use of endoscope and the Revo-i robot in thyroidectomy. This article summarizes and organizes his presentation.

Since the introduction of the concept of minimal invasive, thyroidectomy has evolved by leaps and bounds with the development of various approaches using endoscopic and robotic systems. In this presentation, I will show the history of the evolution of the thyroidectomy technique and the different approaches, followed by my recent thyroidectomy with the Revo-i robot.

•  History of robotic/endoscopic thyroidectomy

Endoscopic thyroidectomy from the Chest approach was first published by Shimizu in Japan in 1999 and Ohgami et al. in 2000. Around the same time, Ikeda et al. introduced the Axillary approach.

In 2006, Prof. Woong Youn Chung and others in Korea published the Gasless Axillary approach to overcome the limitations of existing methods. In 2007, the Bilateral Axillo-Breast approach (BABA) using gas was introduced by Prof. Yeo-kyu Youn and others in Korea.

In 2011, American otolaryngologists Terris et al. introduced the Retroauricular approach, which uses an incision behind the ear and robotic surgery to solve the problems with approaches through the chest (breast) and armpit.

In 2016, Anuwong et al. began to actively introduce it while publishing the Transoral approach, which uses an endoscope to access the oral cavity.

•  Personal experience with robotic/endoscopic thyroidectomy.

In 2011, the author developed and has been performing endoscopic thyroidectomy using the Unilateral Axillo-Breast approach with Gas insufflation (UABA) to overcome the disadvantages and improve the advantages of the traditional transaxillary approach and the Bilateral Axillo-Breast approach. After performing a large number of endoscopic surgeries, the Korea Cancer Center Hospital began performing robotic thyroidectomies in 2021 when it introduced Revo-i, a domestic surgical robot developed by South Korea's meerecompany. Revo-i's performance is comparable to those of existing foreign surgical robots. However, it boasts low costs in terms of the system, maintenance, and consumables, contrary to conventional surgical robots. As of today, we are actively performing gas-infused robotic UABA surgery with Revo-i.

The author shared diverse and extensive experience with these robotic/endoscopic robotic thyroidectomies in the international journal Clinical and Experimental Otorhinolaryngology (CEO) in 2022 under the title "Comparative Study of Gasless Transaxillary, Bilateral Axillo-Breast, Unilateral Axillo-Breast With Carbon Dioxide Insufflation, Retroauricular, and Transoral Vestibular Endoscopic Thyroidectomy Approaches at a Single Institution: A Retrospective Analysis and Lessons Learned". If you are interested in it, I highly recommend you read it. I am confident that it will prove to be beneficial to you.

•  A detailed review of each transaxillary approach

Finally, I'll conclude this presentation with a detailed description of each of the different approaches I've introduced.

The Axillary approach, first developed by Ikeda et al. in 2000, has the advantage of accessing the thyroid from the side, making it easier to expose important structures during surgery. Cosmetically, the scar is also minimized as it is hidden in the armpit. During the surgery, carbon dioxide gas was infused to create the surgical space, and the endoscope collided with the surgical tools, which made the procedure difficult.

The Gasless Axillary approach, introduced in 2006, does not use carbon dioxide gas and uses a retraction system to clear the space while performing the surgery, which has the advantage of providing a wider field of vision with less dust obstruction. There were also no complications from gas and fewer collisions between surgical instruments. However, this method has its limitations, as it requires a fairly wide flap elevation to access the thyroid from the armpit, which can cause chest dysesthesia, pain, and fibrosis.

The Unilateral Axillo-Breast approach without gas, which was introduced in 2009, is similar to the traditional gasless axillary approach, with many of the same advantages and disadvantages, but the ports drilled in the chest are relocated near the areola, making it cosmetically superior.

Advances in robotics led to the introduction of the Robotic Gasless TA approach in 2009, which utilizes the gasless axillary approach. It characterizes with utilizing surgical robots to see in three dimensions and multi-jointed instruments. It enables precise manipulation without hand tremors and reduces surgeon fatigue for more precise surgeries. The advantages of not using carbon dioxide gas include a wider field of view and no complications from the gas, but the limitations are similar to the traditional endoscopic approach, which can cause chest dysesthesia, pain, and fibrosis.

The Unilateral Axillo-Breast approach with Gas insufflation (UABA), published by the authors in 2011, has the advantages of no vertical armpit incision, which is cosmetically superior, and no flap elevation from the axillary to the thyroid, which minimizes complications such as chest pain and contractures. In addition, similar to the conventional axillary approach, it is easy to operate with good surgical vision and smooth instrument manipulation, and has the advantage of shorter operative time.

More recently, the Transaxillary Gas approach (TAGA) robotic thyroidectomy has been developed. Similar to the UABA developed by the author, the incision around the areola is moved to the lower armpit for better cosmetic results, which is made possible by using a robot rather than an endoscope. No vertical incision and no periareolar incision, resulting in cosmetically superior results and less discomfort such as chest dysesthesia.

The following is a description of the Robotic Unilateral Axillo-Breast approach with Gas (Robotic UABA), which the author has been performing since 2021. The Revo-i, which is made with Korean technology, has the advantages of robotic surgery described above, such as an enlarged view in three dimensions, multi-jointed instruments, hand tremor prevention, and reduced surgeon fatigue, allowing for more sophisticated surgery. It is less chest discomfort like endoscopic approaches, and cosmetically superior. 

The last is the recently introduced Single-port TA Robot Thyroidectomy (START), which utilizes a single-port robot. The vertical incision allows three surgical instruments and a camera to be used simultaneously, allowing for effective surgery, and the vertical incision is not long, which has cosmetic advantages.

This robotic/endoscopic axillary approach has continued to evolve to the present day, with the most dramatic change, in the author's opinion, being the transition from endoscopy to robotics. In particular, domestic surgical robots such as Revo-i have been developed in recent years and are making great progress. In the future, we will need to focus on creating more non-invasive, less complicated, and more efficient approaches, and this will require advances in surgical robotics to go hand-in-hand with research on how doctors operate.

Korean Article: https://www.whosaeng.com/152610