How To: Technique, Pitfalls of the Transaxillary Approach for Robotic Thyroidectomy

The assistant is on the opposite side of the patient to hold the retractors without hindering the surgeon. Farabeuf and vaginal- valve retractors are required and should include a canal for smoke suction. Long instruments (30 cm) are necessary to reach the neck midline from the axillary incision.

The procedure is best performed using a headlamp and surgical loupes, especially to aid precise hemostasis of perforating arteries during muscle dissection. The da Vinci robot endoscope may also be used to increase visibility and for teaching (see supporting video) but requires a second assistant to manipulate it. The view from the endoscope may also help the assistant holding the retractors to obtain the best exposure possible by giving direct feedback.

Incision and approach to neck midline. A 4- to 6-cm skin incision is performed immediately posterior to the anterior axillary fold, following the axillary hairline (thus the scar is hidden in the axilla), and the lateral border of the pectoralis major is exposed. Using monopolar electrocautery, dissection is performed above the pectoral fascia toward the clavicle and the SCM. A thin layer of fat tissue may be left on the pectoral muscle fascia so as not to expose perforating arteries, which can retract into the muscle and cause delayed bleeding.

Before opening the SCM muscle, the surgical corridor is widened superiorly and inferiorly to maximize exposure and visibility. The dissection should remain in a subplatysmal plane above the clavicle by following the lateral border of the clavicular head of the SCM. Thus, originating from the SCM, the dissection should proceed laterally until two fingers can comfortably be inserted in the workspace. Great care must be taken, as the skin and muscle covering the clavicle are very thin and the external jugular vein is superficial immediately beneath the platysma.

Neck midline and exposure of thyroid gland. Once the sternal and clavicular heads of the SCM have been identified, the neck midline is approached by dissecting between both branches. Electrocautery dissection should remain close to the sternal head of the SCM to prevent any injury of the internal jugular vein (IJV), which lies at the same depth and is immediately medial to the clavicular head.

The sternal head is elevated, exposing the strap muscles. The omohyoid muscle is an important landmark that must be identified, as it is immediately superior to the IJV and usually indicates the upper pole of the thyroid gland. As with the SCM, dissection must remain close to the omohyoid to prevent IJV injury. The omohyoid muscle can be sectioned if a larger workspace is required (lymph node dissection or large gland).