Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients.

Various robotic surgical procedures have been performed in recent years, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. This study aimed to introduce the authors’ technique of robot-assisted endoscopic thyroid surgery and to demonstrate its applicability in the surgical management of thyroid cancer. From 4 October 2007 through 14 March 2008, 100 patients with papillary thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach. This novel robotic surgical approach allowed adequate endoscopic access for thyroid surgeries. All the procedures were completed successfully using the da Vinci S surgical robot system. Four robotic arms were used with this system: a 12-mm telescope and three 8-mm instruments. The three-dimensional magnified visualization obtained by the dual-channel endoscope and the tremor-free instruments controlled by the robotic systems allowed surgeons to perform sharp and precise endoscopic dissections. Ipsilateral central compartment node dissection was used for 84 less-than-total and 16 total thyroidectomies. The mean operation time was 136.5 min (range, 79–267 min). The actual time for thyroidectomy with lymphadenectomy (console time) was 60 min (range, 25–157 min). The average number of lymph nodes resected was 5.3 (range, 1–28). No serious complications occurred. Most of the patients could return home within 3 days after surgery. The technique of robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach is a feasible, safe, and effective method for selected patients with thyroid cancer. The authors suggest that application of robotic technology for endoscopic thyroid surgeries could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid cancer.

Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients

Endoscopic techniques have recently been applied in thyroid surgery using cervical, axillary, and breast approaches. We modified the axillo-bilateral breast approach (ABBA) and developed the bilateral axillo-breast approach (BABA) to obtain optimal visualization for total thyroidectomy. We used two 12-mm ports through bilateral circumareolar incisions for flexible videoscopy and Harmonic scalpel and two 5-mm ports through both axillae for graspers and dissectors. Thyroidectomy was performed under full visualization of the superior and inferior thyroidal arteries, parathyroid glands, and recurrent laryngeal nerves. After performing 25 ABBA endoscopic thyroid surgeries, we developed BABA and performed 110 operations using this method. The BABA operations included 52 total thyroidectomies, 2 near-total thyroidectomies, 8 subtotal thyroidectomies, 43 lobectomies, and 3 subtotal lobectomies. Pathology revealed 41 benign lesions and 69 cancers. Mean operation time was 165.3 ± 43.5 minutes. There were 2 cases of conversion to open surgery, 1 due to cancer with capsular invasion and the other due to tracheal injury. Nine postoperative complications developed: transient unilateral vocal cord palsy in 4 cases, transient hypocalcemia in 4 cases, and postoperative infection in 1 case. The 2-month postoperative thyroglobulin level was less than 1 ng/ml in all examined cases of total thyroidectomy. Cosmetic results were excellent. The BABA technique for endoscopic thyroid surgery is a feasible method of total thyroidectomy with a low rate of postoperative complications and, additionally, excellent cosmetic results. Therefore, in selected cases of thyroid cancer, the BABA endoscopic total thyroidectomy should be considered as a valid surgical option.

Endoscopic thyroidectomy using a new bilateral axillo-breast approach.

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study.

We developed a new endoscopic thyroid surgery by the axillo-bilateral-breast approach (ABBA) method, which is different from the previously described breast approach (BA) in that the port sites are modified to obtain a better view and to prevent the interference of surgical instruments. This modification also improves cosmetic results by eliminating the parasternal incision, which results in hypertrophic scar in a significant number of cases treated with BA. Twelve patients with benign thyroid tumors successfully underwent endoscopic thyroid surgery by ABBA, and their clinical outcomes were compared with those of four patients treated with BA. The mean operation time was significantly shorter in the ABBA group than in the BA group (188 minutes vs. 270 minutes; P < 0.01). Furthermore, the mean blood loss in the ABBA group (53 mL) was half of that in the BA group (108 mL). Neither conversion to open surgery nor significant intraoperative complications were experienced. The operative scars by ABBA became inconspicuous in a few weeks. These results seem to indicate that ABBA is a better method than BA and can be a feasible option, particularly for young patients who opt for the better cosmetic outcome.

Endoscopic thyroid surgery through the axillo-bilateral-breast approach.

An original technique for performing endoscopic thyroidectomy using a breast approach to avoid an operative scar in the neck was developed. The subcutaneous space in the breast area and the subplatysmal space in the neck were bluntly dissected through a 15-mm incision between the nipples, and CO2 was insufflated at 6 mm Hg to create the operative space. Three trocars were inserted at the breast, and dissection of the thyroid and division of the thyroid vessels and parenchyma were performed endoscopically using an ultrasonically activated scalpel. Four hemithyroidectomies and one partial resection of the thyroid for five female patients with thyroid adenomas 5 to 7 cm in diameter were successfully performed using this procedure. There were no conversions to open surgery or complications. No scars were apparent in the neck, and all patients were fully satisfied with the cosmetic results. Endoscopic thyroidectomy using a breast approach and low-pressure subcutaneous CO2 insufflation is a feasible and safe procedure, which results in satisfactory cosmetic results.

Scarless Endoscopic Thyroidectomy: Breast Approach for Better Cosmesis

We report a case of spontaneous rupture of a giant cavernous hemangioma of the liver arising from the caudate lobe, with extrahepatic growth, in a 67-year-old man. At emergency laparotomy, partial resection of the caudate lobe was performed and the hemangioma was found to measure 13 ×12×8 cm. The patient had a 10-year history of severe asthma requiring steroid therapy. To investigate the risk factors for spontaneous rupture of hepatic hemangioma, we compared the characteristics of patients with ruptured and non-ruptured lesions showing extrahepatic growth reported in the Japanese literature. Lesions with a diameter ≥4 cm located on the surface of the liver or showing extrahepatic growth appear to have a high risk of spontaneous rupture if the patient receives steroid therapy for a coexisting disorder. Even in patients who have not received steroid therapy, hemangiomas≥7–8 cm in diameter located in the left lobe with extrahepatic growth may also have a high risk of rupture. The treatment of hepatic hemangioma should be decided on the basis of the size and the location, and on the requirement for steroid therapy.

Spontaneous rupture of liver hemangioma: Risk factors for rupture

A case of cecum cancer metastasizing to the spleen ten months after a radical operation which was detected by elevated serum CEA is reported. A 56-year-old woman developed a cecum carcinoma with high serum level of CEA. Although serum CEA level had been almost normalized after right hemicolectomy, it elevated again during the follow-up period. Splenic tumor suggestive of recurrent cecum cancer was pointed out by CT scan and angiogram. Splenectomy, sampling of lymph nodes, and resection of peritoneal nodules were performed at the 2nd operation. In histology, they were moderately differentiated adenocarcinoma consistent with the primary tumor. Tumor thrombus was observed in the splenic sinus. Detection of splenic metastasis from colonic carcinoma is extremely rare during clinical course, since most splenic metastasis is found as a part of wide-spreaded metastasis in autopsy studies. Although prognosis of the patient with splenic metastasis is very poor, solitary metastasis will be indication for splenectomy. In this case hematogenous metastatic pattern was suggested.

https://www.jstage.jst.go.jp/article/ringe1963/56/7/56_7_1431/_pdf

A case of cecum cancer metastasizing to the spleen after right hemicolectomy

Percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous transhepatic choledochoscopy (PTCS) can be employed as preoperative diagnosis of bile duct cancer, when caution should be exercised to posibble complications including intrahepatic hemangioma, choleperitonitis, peritonitis carcinomatosa, and implantation of cancer cells. This time we experienced a case of mucus producing bile duct carcinoma recurred in the PTCD fistula. A 51-year-old woman underwent preoperative PTCD with a diagnosis of intrahepatic bile duct cancer. On the 34th day after hepatectomy or 49th day after a PTCD tube was inserted, an induration was felt in subcutaneous tissue at the fistula which was the same site as the PTCD tube was inserted. With a diagnosis of recurrence to the subcutaneous tissue at the PTCD fistula, the tumor was excised. Histopathological findings of the site was the same as those of intrahepatic bile duce carcinoma. However, on the 150th day after the PTCD tube was inserted, another induration was felt at the same site. It was diagnosed as re-recurrence, and an excision of the tumor and associated resection of the 7 and 8th libs and diaphragm were performed. In a review of the literature, recurrence of bile duct cancer to the PTCD fistula is rare, but there may arise some future problem in the management of PTCD.

https://www.jstage.jst.go.jp/article/ringe1963/57/11/57_11_2766/_pdf

Mucus producing intrahepatic bile duct carcinoma recurred in the ptcd fistula -report of a case-

A 58-year-old woman was urgently admitted to the hospital because of a swelling and severe pain of the right calf. There was a previous history of undergoing a mitral valve replacement 11 years before, and thereafter she was controlled with an oral anticoagulant agent (Warfarin). She was also taking antidepressive agents for recent 2 years. Phlebography revealed a thrombotic occlusion localized in the right calf. After anticoagulant and thrombolytic therapies, the recanalization of the occlusive region was obtained. However, the patient was reluctant to walking, and developed the foot drop and steppage gait on the 19th after admission. The deep venous thrombosis complicated by peroneal nerve palsy like our experience is very rare. It is suggested that the compartment syndrome might be related to the cause, which developed the peroneal nerve palsy. In addition, this case emphasizes the inportance that we should improve the swelling of the calf by walking as soon as possible, and avoid the long-term leg abduction position on bed, in order to prevent this complication.

Katsuhiko Noga

Papers

Scarless Endoscopic Thyroidectomy: Breast Approach for Better Cosmesis

Spontaneous rupture of liver hemangioma: Risk factors for rupture

A case of cecum cancer metastasizing to the spleen after right hemicolectomy

Mucus producing intrahepatic bile duct carcinoma recurred in the ptcd fistula -report of a case-

A case report of deep venous thrombosis complicated by peroneal nerve palsy