Scarless Surgery: The benefits and drawbacks of robotic thryroidectomy

Surgeons in the U.S. are starting to adopt the procedure. Perhaps the most experienced is Ron Kuppersmith, MD, FACS, a clinical faculty member of the Texas A&M Health Science Center and an otolaryngologist with Texas ENT and Allergy. Last spring, he and a colleague, Andrew L. de Jong, MD, went to Korea and observed as Dr. Chung performed robotic surgery on the thyroid. Since returning, Dr. Kuppersmith has performed nearly two dozen such procedures (Otolaryngol Head Neck Surg. 2009;141(3):340-342). “Most cases I do are not robotic,” he said. “We’re very early in the experience, but the patients are excited about it. They’re asking about it. I had a patient call from Poland who wants to come and have the procedure, and we had one from Israel.”

The axillary approach is not for everyone, Dr. Kuppersmith said. “If the patient is obese, for example, it’s difficult. If the patient has trouble with range of motion in their shoulder, or if they have a large thyroid, or if the thyroid extends into the chest, or if they have a short neck, the procedure may not be appropriate. The anatomy has to be favorable,” he said.

Dr. Kuppersmith has found that some surgeons remain skeptical of the procedure because of the cost of the robotic system and the use of disposables. “That adds to the cost of a procedure that’s very good already,” Dr. Kuppersmith said. “In this health care environment, where everyone is being conscious of costs, does it make sense to use this really expensive tool to avoid having a neck incision? That’s a tough equation to work out.”

Simon K. Wright, MD, who co-authored the 2005 paper with Dr. Lobe on the use of the da Vinci robotic arms for head and neck surgery, also occasionally encounters a fellow physician with a negative opinion of robotic surgery, “but once a surgeon reviews the literature, understands the technique, and actually sees a case, the value of this option is more apparent,” he said. “Some patients are poor candidates for this type of surgery. I think everyone agrees, for example, that aggressive cancers of the thyroid gland shouldn’t be done this way at this time. Only a subset of patients undergoing thyroid surgery can be expected to benefit from this surgical approach, so the challenge at this point is to sort out who is an appropriate candidate.”

Emad Kandil, MD, FACS, chief of the Endocrine Surgery Section and assistant professor of surgery at Tulane University School of Medicine in New Orleans, is a recent convert to robotic thyroidectomy, in part because of the technique’s potential for avoiding complications. “This technique is not only about avoiding an incision and a permanent scar on the neck,” he said. “With the excellent 10-times magnification, the danger of injuring nearby structures, including nerves and parathyroid glands, is reduced.”