We have come along way since Moorish physician Albucasisin about 952 AD had successfully removed goitre under sedation with opium with the use of simple ligatures along with hot cautery irons as the patient sat with a bag tied around his neck to collect the blood from the wound. However, Halsted in his ‘The operative history of goitre’ scrutinised procedures done before 1850 and analysed them to be associated with 40 % mortality. The French Academy of Medicine banned thyroid operations in 1850 due to the high mortality associated with them. Thyroid surgery started coming out of its doldrums in the middle of the nineteenth century. This was due to the concerted improvement in anaesthesia, infection prophylaxis and better haemostasis. Between 1877 to 1881, Billroth performed 48 thyroidectomies and was able to decrease the mortality to 8.3 %. Theodor Kocher, a pupil of Billroth, carried forward the baton of thyroid surgery from his teacher. From 1872-1882 brought down the mortality to 2.4 %. By 1895, the mortality rate improved to about 1 %.In 1909, Kocher was awarded the Nobel Prize for the work done by him on thyroid surgery.He laid down the principles of thyroidectomy performing more precise “extracapsular dissection”. Halsted and Evans in 1907 described the the blood supply of parathyroid glands and opined that ‘ultraligation’ of the thyroid arteries distal to the points of origin of the parathyroid artery branches or close to the thyroid capsule. They suggested avoiding inferior thyroid artery ligation. These principles were laid in the beginning of the century.
The incisions taken during the 1850s,were undertaken via longitudinal, oblique, or vertical neck incisions. Jules Boeckel of Strasbourg introduced the collar incision to thyroid surgery in 1880, and this approach was popularized by Theodore Kocher. Since then transverse cervical incision along the skin crease is used to perform thyroid surgery.Laparoscopic surgery was introduced and was widely been done for majority of abdominal surgeries with decreased hospital stay.
As thyroid nodule happens majorly in females which are usually young. The first endoscopic thyroidectomy was first performed in 1997, introducing the era of remote-access approaches for thyroidectomy (Endoscopic Thyroidectomy). Several remote-access approaches have been attempted to place the incision in a more favorable location, including breast, axillary, face-lift, and transoral approaches for hiding the scar. The prolonged learning curve necessary for remote access without wristed instrumentation has led to adoption of robotic instrumentation.
The Da Vinci robotic system (Intuitive Surgical, Sunnyvale, California) was first utilized for transaxillary thyroidectomy by Chung in 2007.
South Koreans have championed robotic thyroidectomy via transaxillary and facelift or retroauricular approach. Using a robotic system helped to overcome some of the limitations of the endoscopic procedures such as reduced range of motion, and impaired eye-hand coordination (while relying on an unstable 2-dimentional view). Because of this, robotic thyroidectomy has become increasingly popular around the world attracting both surgeons and patients, searching for new and innovative procedures and allowing for the removal of thyroid glands with a superior cosmetic result when compared to the conventional open thyroidectomy procedures. Many studies have described the safety of the remote-access robotic thyroidectomy procedures and have demonstrated comparable oncologic outcomes between the robotic and open conventional thyroidectomy.
Patent selection :In general, the best candidates are nonobese (body mass index <30) young patients, without extensive comorbidities or advanced disease, with a history of keloid or hypertrophic scar or otherwise motivated to avoid a cervical incision. The remote-access approaches are usually deferred in patients with a previous history of neck surgery or irradiation of the neck. The thyroid nodule size should be less than or equal to 4 cm with no extrathyroidal extension and no cervical lymph nodes.
We routinely perform robotic retroauricular thyroidectomy at our institution. We will share of our recent case, 20 year old euthyroid female with left thyroid nodule, ultrasound guided FNAC showed benign nodule but one outside report suggested suspicious ? papillary cancer . The ultrasound neck showed well defined left thyroid nodule of 3.5×4 cm with no cervical lymph nodes. As patient was young opted for robotic left hemithyroidectomy via retroauricular approach. The incision was placed behind the ear and 1cm inside the hairline(as shown with redline in fig 1), skin flap are raised in subplatysmal plane crossing midline and inferiorly upto the suprasternal notch. Chung’s self retaining retractors is placed to keep the skin flap retracted. Robotic 3 instruments (prograsp, Maryland and monopolar scissors)with 30 degree camera were docked with one assistant. Console phase was started with elevation of strap muscles and exposure of thyroid lobe. The superior pedicle was bipolar cauterized close to thyroid lobe,parathyroid preserved, recurrent laryngeal nerve identified at ligament of berry and preserved, thyroid isthmus cut with cautery after mobilization of thyroid from trachea. The specimen was sent for frozen section which showed benign nodule. Patient was kept in postoperative recovery room for few hours and shifted to ward. The patient was discharged on 2nd postoperative day. The patient achieved excellent cosmesis with this advanced robotic retroauricular thyroidectomy (as shown in fig2 & 3). The other head & neck procedures that can be performed are trans oral robotic surgery for oropharyngeal and supraglottic cancer and retroauricular robotic neck dissectionwith good cosmesis and much reduced morbidity.