Surg Endosc (2011) 25:221228 DOI 10.

1007/s00464-010-1163-2

Robotic thyroidectomy by a gasless unilateral axillo-breast or axillary approach: our early experiences
Kyung Tae Yong Bae Ji Jin Hyeok Jeong Seung Hwan Lee Mi Ae Jeong Chul Won Park

Received: 6 February 2010 / Accepted: 23 May 2010 / Published online: 22 June 2010 Springer Science+Business Media, LLC 2010

Abstract Background Various endoscopic thyroidectomy procedures have been designed to minimize visible scarring. However, endoscopic thyroidectomies have some limitations in obtaining adequate surgical views and in the precise manipulations of the endoscopic instrument. Recently, robotic technology has been applied to thyroid surgery. The aim of this study was to determine the technical feasibility, intraoperative safety, and efcacy of robotic thyroidectomy. Methods We analyzed 41 patients with thyroid nodules who underwent robot-assisted endoscopic thyroidectomy from October 2008 to August 2009 using a gasless unilateral axillo-breast or axillary approach with a da Vinci S Surgical System robot at Hanyang University Hospital, Seoul, Korea. We also compared the early surgical outcomes of robotic thyroidectomies with those of 167 patients who underwent conventional open thyroidectomies during the same period. Results In the robotic group, there were more female patients (P = 0.001) and the mean age was younger than that of the open thyroidectomy group (P \ 0.001). The robotic thyroidectomy surgical procedure was completed successfully in all patients. Unilateral lobectomy was performed in 29 patients and total thyroidectomy was
K. Tae Y. B. Ji J. H. Jeong S. H. Lee C. W. Park (&) Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul 133-792, Korea e-mail: cwpark@hanyang.ac.kr K. Tae e-mail: kytae@hanyang.ac.kr M. A. Jeong Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea

performed in 10 patients. The rate of central compartment neck dissection (CCND) for thyroid cancer was not different between the two groups (P = 0.127). The operative time was longer and the amount of drainage was higher in the robotic group than the open group (P \ 0.001 and P = 0.002, respectively). The complication rate was not different between the two groups. The postoperative pain score of the neck and anterior chest was not different between the two groups except the anterior chest pain score at postoperative week 1. The cosmetic satisfaction was greater in the robotic group (P \ 0.001). Conclusion Robot-assisted endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach using a da Vinci S Surgical System robot is a safe, feasible, and cosmetically excellent procedure. It can be a promising alternative to endoscopic thyroidectomy or conventional open thyroidectomy. Keywords Robot Endoscopic thyroidectomy da Vinci Surgical System Axillo-breast approach Axillary approach

Conventional open thyroidectomy provides direct exposure to perform safe and quick operations with minimal morbidity and almost no mortality. However, the procedure leaves a scar on the anterior neck. Some scars heal well and blend with skin creases, while others may heal with hypertrophy. Sometimes these healing and scarring processes become major concerns, especially to young women. Thyroid nodules are common in young women, who are interested not only in treatment of the disease but also in aesthetic results. As a result, a variety of minimally invasive techniques to minimize neck scars and surgical morbidity have been developed. The minimally invasive

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thyroidectomy technique includes mini-open-incision thyroidectomy, video-assisted thyroidectomy, and pure endoscopic thyroidectomy [110]. Endoscopic thyroidectomy was rst performed by Huscher et al. in 1997 via a cervical approach [1]. The advantages of endoscopic thyroidectomy over conventional open thyroidectomy include better aesthetic results and better surgical views with magnication. Also, the direct approach, such as a cervical approach, is less invasive than an open thyroidectomy. Endoscopic thyroidectomy is appropriate in certain patients. However, there are some limitations to endoscopic thyroidectomy in obtaining adequate surgical viewing angles, precisely manipulating endoscopic instruments, and meticulously dissecting tissues. These limitations result from the narrow working space, two-dimensional operative views, and the use of inadequate endoscopic instruments. Recently, robotic technology using the da Vinci Surgical System robot has been applied to minimally invasive thyroid surgery to overcome the limitations of endoscopic thyroidectomy [11 14]. The da Vinci S Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA) provides a three-dimensional 10129 magnied view of the surgical area. It also provides hand-tremor ltration, ne-motion scaling, and precise and multiarticulated hand-like motions. Since 2005 we have been performing endoscopic thyroidectomy using a unilateral axillary or axillo-breast approach without CO2 gas insufation for benign and malignant tumors of the thyroid [9]. We have used the da Vinci S Surgical System robot for our endoscopic thyroidectomies since 2008 and have developed a new surgical procedure, robot-assisted endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach. Here we report on our initial experiences to assess the technical feasibility, intraoperative safety, and efcacy of robotassisted endoscopic thyroidectomy using the da Vinci S Surgical System robot.

thyroid carcinoma with denitive extrathyroidal extensions, multiple cervical lymph node metastases in the lateral neck or central compartment, or distant metastases. We also excluded cases with a history of previous neck, thyroid, or breast surgery and irradiation. Informed consent was obtained from each patient for robot-assisted endoscopic thyroidectomy and for the possibility of conversion to open thyroidectomy. For each patient, we analyzed the clinical characteristics, tumor size, pathologic type, operative time, type of operation, amount of drainage, duration of hospital stay, postoperative complications, postoperative neck and anterior chest pain, and cosmetic satisfaction. Flexible laryngoscopy was performed preoperatively and postoperatively in all patients to evaluate vocal cord mobility. Postoperative neck and anterior chest pain and cosmetic satisfaction were evaluated with questionnaires. Postoperative pain was rated on a scale of 1 (no pain), 2 (mild), 3 (moderate), 4 (severe), to 5 (very severe) at 1 week, 1 month, and 3 months after surgery. Postoperative cosmetic satisfaction was rated on a scale of 1 (very satised), 2 (satised), 3 (average), 4 (dissatised), to 5 (very dissatised). We compared the early surgical outcomes of robotic thyroidectomy with the surgical outcomes of 167 patients who underwent conventional open thyroidectomy with/without central compartment neck dissection (CCND) at our institution during the same period. We excluded cases of papillary thyroid carcinoma that underwent lateral neck lymph node dissection in conventional open thyroidectomy group. The v2 test was used for statistical analysis. All statistical data were obtained using SPSS v15.0 (SPSS, Inc., Chicago, IL, USA). Differences were considered statistically signicant when P \ 0.05. Operative procedure All robot-assisted endoscopic thyroidectomies were performed by one surgeon (KT) with the patient under general anesthesia. The surgical procedure included ap elevation under direct vision to make a working space, docking the robot system, and console work. Patients were placed in the supine position. The neck was slightly extended, and the lesion-side arm was raised to expose the axillary fossa. After preparation and draping of the operative eld, a 56cm skin incision was made in the axillary fossa (Fig. 1A). The skin ap was elevated under direct vision in the plane of the subplatysmal layer over the pectoralis major muscle from the axilla to the anterior central neck area. When the dissection reached the sternocleidomastoid (SCM) muscle, it was continued through the space between the sternal and clavicular heads of the SCM. With great care not to injure the internal jugular vein, we next dissected underneath the sternothyroid muscle to expose the thyroid gland. After

Materials and methods Patients We performed 41 robot-assisted endoscopic thyroidectomies by a gasless unilateral axillo-breast or axillary approach using the da Vinci S Surgical System robot at Hanyang University Hospital, Seoul, Korea, between October 2008 and August 2009. Preoperative diagnosis of thyroid nodules was determined by ultrasonography, neneedle aspiration cytology, and computed tomography. Indications for robot-assisted endoscopic thyroidectomy included follicular adenoma or benign thyroid nodules \5 cm in diameter and papillary thyroid carcinoma\2 cm at its largest diameter. We excluded cases of papillary

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Surg Endosc (2011) 25:221228 Fig. 1 Robotic thyroidectomy by a gasless unilateral axillobreast approach. A A 56-cm skin incision was made in the axillary fossa and a 0.8-cm incision was made on the circumareolar margin. B An external retractor was used to maintain the working space without CO2 gas insufation. In the axillary port, an endoscope was placed in the center and two robotic arms were placed on either side of the endoscope. The fourth arm of the da Vinci S robot was placed through the breast port for retraction of the thyroid gland with Prograsp. C The view after placement of the four robotic arms

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exposure of the thyroid gland, we used an external retractor (Meditech Inframed, Seoul, Korea) to maintain an adequate working space without CO2 gas insufation (Fig. 1B). For the axillo-breast approach, a second skin incision 0.8 cm long was made on the circumareolar margin of the breast for placement of an 8-mm trocar used for insertion of a fourth robotic arm. After making working space, the robotic arms were docked (Fig. 1C). Three arms were inserted through the axillary incision port. The dual-channel 30 endoscope was placed at the center of the axillary port, and Harmonic curved shears and Maryland forceps were placed on either side of the endoscope. For the axillo-breast approach, a fourth robotic arm with Prograsp forceps was inserted through the breast port. In the axillary approach, we did not make a circumareolar incision for better aesthetic results, and thus used only three robotic arms (one endoscope and two robotic instruments) through the axillary incision port without the fourth robotic arm. After completion of the docking of the robotic arms, the console work began (Fig. 2A). We usually started the dissection at the lower pole of the thyroid gland. Pretracheal and paratracheal lymph nodes and brofatty soft tissue were dissected from the trachea using Harmonic curved shears (Fig. 2B). The identication of the trachea is important as it can be used as a surgical landmark. After the dissection of the lower pole, we moved to the upper pole of the thyroid gland. The superior thyroid vessels were divided individually, close to the thyroid gland, to preserve the external branch of the superior laryngeal nerve using Harmonic curved shears (Fig. 2C). The superior parathyroid gland was identied and carefully preserved with an intact blood supply (Fig. 2D). The thyroid gland was then

retracted medially and the paratracheal lymph nodes and perithyroidal soft tissue were dissected while tracing the whole course of the recurrent laryngeal nerve (RLN) with great care to preserve it (Fig. 2E). The isthmus was divided and ipsilateral total lobectomy with CCND was completed (Fig. 2F). The resected specimen was extracted through the axillary incision port (Fig. 2G). In cases of total thyroidectomy, contralateral lobectomy was performed after completion of ipsilateral lobectomy. The contralateral lobe was dissected in a similar manner with multidirectional retraction of the thyroid lobe. A suction drain was inserted nearby the axillary incision, and the wound was closed.

Results The clinicopathologic characteristics of robotic thyroidectomy and conventional open thyroidectomy are summarized in Table 1. There were 39 females and two males in the robotic group. The mean age was 39.2 10 years (range = 1951 years). Postoperative pathology of the robotic thyroidectomy group showed 27 patients with papillary carcinoma, 10 with nodular hyperplasia, and 4 with follicular adenoma. The mean tumor size was 1.63 1.05 cm (range = 537 mm). The robotic group had more female patients (P = 0.001) and the mean age was younger than that of the open thyroidectomy group (P \ 0.001). There were no signicant differences in tumor size or pathologic type between the two groups. The entire surgical procedure of robot-assisted endoscopic thyroidectomy was completed successfully in all patients. No cases were converted to open thyroidectomy.

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224 Fig. 2 Surgical procedure for robotic thyroidectomy by a gasless unilateral axillo-breast approach. A The left thyroid lobe was exposed with placement of an external retractor. B Dissection of pretracheal lymph nodes and identication of the trachea. C Superior thyroid vessels were divided using Harmonic curved shears. D The superior parathyroid gland should be preserved with careful dissection. E Identication and preservation of the RLN. F Surgical view after completion of left lobectomy and ipsilateral CCND. G Surgical specimen showing left total lobectomy and ipsilateral CCND

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The axillo-breast approach was used in 39 patients and the axillary approach without breast port was performed in two cases. Ipsilateral lobectomy with isthmusectomy was performed in 29 patients, subtotal thyroidectomy (ipsilateral

total lobectomy and contralateral partial lobectomy) was performed in two cases, and total thyroidectomy was performed in 10 patients. The rate of total thyroidectomy for thyroid cancer was higher in the open thyroidectomy group

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Surg Endosc (2011) 25:221228 Table 1 Clinicopathologic characteristics of patients treated with robotic and conventional open thyroidectomy Characteristics Robotic thyroidectomy (n = 41) Open thyroidectomy (n = 163) P value

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Gender Male Female Age Size of tumor (cm) Pathologic type Benign tumor Malignant tumor 14 (34.1%) 27 (65.9%) 42 (25.8%) 121 (74.2%) 2 (4.9%) 39 (95.1%) 39.2 10 1.63 1.05 45 (27.6%) 118 (72.4%) 51.7 12.4 1.98 1.53

0.001

\0.001 0.170 0.189

(P \ 0.001) (Table 2). In the robotic group, prophylactic ipsilateral CCND was performed in 24/27 (88.9%) patients with papillary carcinoma. Central compartment node metastasis occurred in 7/24 (33.3%) patients. The rate of CCND for thyroid cancer was not different between the two groups. The mean number of lymph nodes removed was 4.78 1.99 (range = 28) and 9.61 6.8 (range 131) in the robotic and open thyroidectomy groups, respectively, which represents a signicant difference between the two groups (P \ 0.01). In the robotic thyroidectomy group, the mean operative time was 179 12.5 min (range = 112295 min). The time for ap elevation was 46.2 12.5 min, docking time was 12.2 9.1 min, console time was 85.8 34.6 min, and closure time was 40.8 18.1 min. The operative time was signicantly shorter in the open thyroidectomy group (131 47 min, range of 85290 min) compared with that

for the robotic thyroidectomy group (P \ 0.001) (Table 2). The preparation and draping time was also shorter in the open thyroidectomy group compared with that for the robotic thyroidectomy group (22.89 8.48 vs. 33.5 10.01, P = 0.009). The average total amount of postoperative drainage was 249 106 ml in the robotic group and 152 55 ml in the open group. The amount of drainage was signicantly higher in the robotic group than in the open group (P = 0.002). The length of postoperative hospital stay was not different between the two groups (Table 2). There was no signicant difference in postoperative complications between the two groups (Table 3). In the robotic thyroidectomy group, a transient RLN palsy occurred in one patient (2.4%) and she recovered 6 weeks after surgery. Among patients who underwent total thyroidectomy, transient hypoparathyroidism occurred in two of 10 (20%) and 34 of 113 (30.1%) in the robotic and open groups, respectively (P = 0.395). In the robotic thyroidectomy group, there was no postoperative hematoma or permanent RLN palsy or hypoparathyroidism. Seroma occurred in two patients. There were no inadvertent injuries to the trachea, esophagus, or larynx during any of the operations. There was also no injury to the brachial plexus or shoulder in the robotic thyroidectomy group. The postoperative neck and anterior chest pain score and cosmetic satisfaction score as scored by questionnaire are summarized in Table 4. The questionnaire was completed by 32 patients in the robotic group and 89 patients in the open group. There were no signicant differences in neck pain score at 1 week, 1 month, or 3 months postoperatively. At postoperative week 1, the anterior chest pain score was higher in the robotic group than in the open

Table 2 Comparison of surgical outcomes in robotic and conventional open thyroidectomy Robotic thyroidectomy (n = 41) Type of thyroidectomy Ipsilateral lobectomy with isthmusectomy Subtotal thyroidectomy Total thyroidectomy CCND in malignant tumor Number of removed lymph node Operative time (min) Draping time (not included in operation time) Flap elevation time Docking time Console time Closure time Amount of drainage (ml) Hospital stay (days) CCND central compartment neck dissection 29 (70.7%) 2 (4.9%) 10 (24.4%) 24/27 (88.9%) 4.78 1.99 (range = 28) 179 53 (range = 112295) 33.5 10.0 46.2 12.5 12.2 9.1 85.8 34.6 40.8 18.1 249 106 6.4 1.6 152 55 6.1 2.1 0.002 0.370 47 (28.8%) 3 (1.8%) 113 (69.4%) 93/121(76.9%) 9.61 6.8 (range = 131) 131 47 (range = 85290) 22.9 8.48 0.127 \0.01 \0.001 0.009 Open thyroidectomy (n = 163) P value \0.001

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226 Table 3 Comparison of postoperative complications in robotic and conventional open thyroidectomy Complications Robotic Open thyroidectomy thyroidectomy (n = 41) (n = 163) 1/41 (2.4%) 0 4/163 (2.5%) 1/163 (0.6%) P value 0.736 0.799

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Transient RLN palsy Permanent RLN palsy

Transient 2/10 (20%) hypoparathyroidism in TT Permanent 0 hypoparathyroidism in TT Postoperative hematoma Seroma Chyle leakage 0 2/41 (4.9%) 0

34/113 (30.1%) 0.395 5/113 (4.2%) 5/163 (3.1%) 6/163 (3.7%) 1/163 (0.6%) 0.650 0.322 0.504 0.799

RLN recurrent laryngeal nerve; TT total thyroidectomy

Table 4 Comparison of postoperative pain score and cosmetic satisfaction in robotic and conventional open thyroidectomy Robotic thyroidectomy (n = 32) Neck pain Postop 1 week Postop 1 month Postop 3 months Anterior chest pain Postop 1 week Postop 1 month Postop 3 months Cosmetic satisfaction Postop 1 week Postop 1 month Postop 3 months Postop postoperative 1.5 0.5 1.4 0.5 1.5 0.9 2.5 0.6 2.9 0.9 2.8 1.4 \0.001 \0.001 \0.001 2.0 0.8 1.6 0.7 1.5 1.0 1.2 0.5 1.3 0.5 1.3 0.8 \0.001 0.636 0.214 1.9 0.8 1.7 0.7 1.8 0.9 1.7 0.9 1.6 0.8 1.8 1.0 0.584 0.814 0.804 Open thyroidectomy (n = 89) p value

group (P \ 0.001). However, at 1 and 3 months after surgery, the anterior chest pain score was not different between the two groups. Cosmetic satisfaction was excellent in the robotic thyroidectomy group compared with the open thyroidectomy group at 1 week, 1 month, and 3 months after surgery (P \ 0.001). The incision scar in the axilla can be completely concealed when the arm is down in its natural position, and the circumareolar incision became almost as inconspicuous over time (Fig. 3). We also analyzed the data in the subgroups according to type of operation (lobectomy and total thyroidectomy). In either subgroup, the results of operative time, the amount of drainage, the neck and anterior chest pain score, and the cosmetic satisfaction score were similar to the results of the total group, which includes the lobectomy and total thyroidectomy subgroups (data not shown).

Fig. 3 A, B Postoperative photographs of a 29-year-old woman 3 months after robotic thyroidectomy. The axillary scar was concealed when the patients arm was by her side in the normal position and the circumareolar scar eventually became inconspicuous

Discussion Although endoscopic thyroidectomy has various advantages, it also has technical limitations and disadvantages. To overcome and minimize these limitations, the da Vinci Surgical System robot has been used for endoscopic thyroidectomies [13, 14]. Robotic thyroidectomy offers many advantages over traditional endoscopic thyroidectomy.

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It provides an excellent surgical view with three-dimensional magnication and precise and convenient manipulation of instruments without tremor. RLN and parathyroid glands can be safely preserved and complete CCND can be done easily. Another advantage is that assistants to hold the endoscope or retract the thyroid gland are not necessary. We have used the da Vinci S Surgical System robot to perform robotic thyroidectomy with a gasless unilateral axillo-breast or axillary approach since October 2008. Our axillo-breast or axillary approach used in endoscopic or robotic thyroidectomy has many advantages. This approach provides a lateral operative view, as in open surgery. Identication of the RLN and the parathyroid gland is relatively easy. The postsurgical aesthetic appearance is excellent; there are no scars on the anterior neck or the anterior chest wall. There are, however, some disadvantages to robotic thyroidectomy. It is more invasive because of the wide dissection needed, and it is more time consuming than conventional open thyroidectomy. Also, it is relatively difcult to approach the contralateral lobe using a unilateral approach method. However, such limitations can usually be overcome with greater experience. With the da Vinci S Surgical System robot, contralateral lobectomy can be done relatively easily compared to endoscopic thyroidectomy. Our robotic thyroidectomy is similar to the robot-assisted endoscopic thyroidectomy using a gasless transaxillary approach reported by Kang et al. [13]. However, we did not use the parasternal port for the fourth robotic arm. Because parasternal skin incisions usually leave a hypertrophic scar on the anterior chest, we designed a circumareolar incision for the fourth robotic arm. Furthermore, in the axillary approach, the axillary incision port was used for only one endoscopic robotic arm and two instrumental robotic arms for dissection of thyroid gland. This approach is cosmetically superior because there is no scar on the breast. However, in the axillary approach, the dissection was relatively difcult because there was no fourth robotic arm available to retract the thyroid gland. In our approach we did not cut the omohyoid muscle for improved exposure of the thyroid gland. We also performed precise dissection of the space between the strap muscles without cutting the SCM, sternothyroid, or sternohyoid muscle. With minimal dissection of strap muscles, postoperative brous band-like contracture in the neck and anterior chest did not occur. Our approach has some advantages compared with the bilateral axillary breast approach (BABA) using the da Vinci robot system as reported by Lee et al. [14]. The BABA approach used two breast and two axillary ports with CO2 gas insufation. Although recent reports have shown that there is no risk to patients if pressure levels of 46 mmHg are used, CO2 gas insufation methods can result in CO2 gas-related complications. Compared to CO2 gas insufation, our gasless method using an external

retractor has some advantages. Gasless methods enable surgeons to use conventional instruments that are used in open thyroidectomy for dissection of skin aps or bleeding control. Gasless methods also lack the disruption associated with smoke suction. Our approach also has a very important advantage over the BABA approach. In cases of postoperative hematoma, we can use the axillary incision site to evacuate the hematoma without additional skin incisions; in the BABA approach, additional cervical skin incisions can be necessary to control postoperative bleeding. We have compared the early surgical outcomes of our robot-assisted endoscopic thyroidectomies with data from conventional open thyroidectomies. We found that robotic thyroidectomy is more time-consuming. However, the operative time decreased as the surgeon became more familiar with the robotic surgical process. In latter half of patients who underwent robotic thyroidectomy in our study, the docking and console times were signicantly decreased (9.7 4.5 and 75.7 32.2, respectively) compared to those in the rst half of patients (15.9 11.4 and 98.5 34.8, respectively) (P = 0.035). To compare the surgical completeness of total thyroidectomy using the two surgical methods, we compared the serum thyroglobulin level of 7 patients in the robotic thyroidectomy group with that of 64 patients in the open thyroidectomy group who underwent postoperative radioactive iodine ablation. The postoperative thyroglobulin level after thyroxine withdrawal before radioactive iodine ablation was 9.81 11.46 ng/ml and 4.48 8.44 ng/ml for the robotic and open thyroidectomy groups, respectively. There was a trend toward a higher level of thyroglobulin in the robotic group; however, it was not signicantly different between the two groups (P = 0.273). In a few cases of robotic total thyroidectomy, a little thyroid tissue (\12 g) may be left at Berrys ligament or the upper-pole area of the contralateral side because of an insufcient surgical angle. The area dissected to expose the thyroid gland is wider in a robotic thyroidectomy than in an open thyroidectomy, and the amount of drainage is greater in a robotic thyroidectomy. Thus, it may appear that the robotic thyroidectomy is more invasive than a conventional open thyroidectomy. However, the postoperative anterior chest pain score was greater in robotic thyroidectomy only for the rst postoperative week. After 1 and 3 months, the anterior chest and neck area pain scores were not different between the two groups. The complication rate was not different between the two groups. There were no major complications in the robotic thyroidectomy group. Transient RLN palsy occurred in one patient in the robotic thyroidectomy group. We were able to preserve the RLN in this patient. The RLN palsy was likely caused by a thermal injury from the Harmonic curved shears. Satisfaction with the cosmetic results was signicantly higher in the robotic

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Surg Endosc (2011) 25:221228 2. Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, Kitajima M (2000) Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 10:14 3. Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G (2001) Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 130:10391043 4. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M (2000) Endoscopic neck surgery by the axillary approach. J Am Coll Surg 191:336340 5. Gagner M, Inabnet WB III (2001) Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 11:161163 6. Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E, Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillo-bilateral breast approach. Surg Laparosc Endosc 13:196201 7. Yoon JH, Park CH, Chung WY (2006) Gasless endoscopic thyroidectomy via an axillary approach: experience of 30 cases. Surg Laparosc Endosc Percutan Tech 16:226231 8. Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601606 9. Tae K, Kim SY, Lee YS, Lee HS (2007) Gasless endoscopic thyroidectomy by an axillary approach: preliminary report. Korean J Otolaryngol 50:252256 10. Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufation for unilateral benign thyroid lesions. Surg Endosc 23:20532060 11. Tanna N, Joshi AS, Glade RS, Zalkind D, Sadeghi N (2006) Da Vinci robot-assisted endocrine surgery: novel application in otolaryngology. Otolaryngol Head Neck Surg 135:633635 12. Miyano G, Lobe TE, Wright SK (2008) Bilateral transaxillary endoscopic total thyroidectomy. J Pediatr Surg 43:299303 13. Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, Nam KH, Chang HS, Chung WY, Park CS (2009) Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 146:10481055 14. Lee KE, Rao J, Youn YK (2009) Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique; our initial experience. Surg Laparosc Endosc Percutan Tech 19(3):e71e75 15. Chung YS, Choe JH, Kang KH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK (2007) Endoscopic thyroidectomy for thyroid malignancies: comparison with conventional open thyroidectomy. World J Surg 31:23022308 16. Miccoli P, Elisei R, Materazzi G, Capezzone M, Galleri D, Pacin F, Berti P, Pinchera A (2002) Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of it completeness. Surgery 132:10701074 17. Lombardi CP, Raffaelli M, De Crea C, Princi P, Castaldi P, Spaventa A, Salvatori M, Bellantone R (2007) Report on 8 years of experience with video-assisted thyroidectomy for papillary thyroid carcinoma. Surgery 142:944951 18. Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R (2007) Minimally invasive video-assisted functional lateral neck dissection for metastatic papillary thyroid carcinoma. Am J Surg 193:114118

group. We suggest that the most signicant advantage of our robotic thyroidectomy is the excellent postoperative cosmesis, although the easy identication and preservation of RLN and parathyroid gland is another advantage. Robotic thyroidectomy using the da Vinci S Surgical System robot has an important disadvantage. Robotic thyroidectomy is a new innovative technique so it is not covered by the national health insurance system in Korea. The patient has to pay the extra cost for robotic surgery. The expense of robotic surgery might be reduced by decreasing the cost of robot or by changing the Korean national health insurance system. Although robot-assisted endoscopic thyroidectomy is technically feasible and has been shown to be safe intraoperatively and have comparable early surgical outcomes, the oncologic safety of robotic surgery should be veried before applying robotic surgery for removal of thyroid cancer. Initially, endoscopic thyroidectomy was used to remove benign thyroid nodules but its use has been extended to resection of thyroid cancer, and the oncologic results of endoscopic thyroidectomy have been investigated [1518]. Some authors reported similar results when comparing robotic and open thyroidectomies. However, the oncologic safety of robotic thyroidectomy for thyroid cancer has not been determined because of the short follow-up period of the new technique. Further studies with a larger number of cases and long-term follow-up are necessary to evaluate the oncologic safety and efcacy of robotic thyroidectomy for thyroid cancer.

Conclusions Robot-assisted endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach using the da Vinci S Surgical System robot is a safe, feasible, and cosmetically excellent procedure. It can be a promising alternative to endoscopic thyroidectomy or conventional open thyroid surgery.
Acknowledgment This work was supported by a research fund from Hanyang University (HY-2006-C). Disclosures Dr. Chul Won Park received the research fund from Hanyang University (HY-2006-C). Drs. Tae, Ji, Jeong, Lee, and Jeong have no conicts of interest or nancial ties to disclose.

References
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