Is It Possible to Completely Resect the Contralateral Lobe Using a Single Unilateral Axillary Incision During Robotic Total Thyroidectomy in an American Cohort?

Letter to the Editor

By Jandee Lee1 and Woong Youn Chung2

1EulJi University School of Medicine, Seoul, Korea and 2Yonsei University College of Medicine, Seoul, Korea

To the Editors:

We read with great interest the article by Landry et al,[1] entitled "Robot-assisted transaxillary thyroid surgery (RATS) in the United States: Is it comparable to open thyroid lobectomy?" This article reflects the widespread interest in comparing the results of RATS with those of open thyroidectomy, and represented the first comparative series in the U.S. Although this article contributes useful information, showing that RATS achieved its targeted outcomes, we have a few queries and suggestions.

  1. Are bilateral axillary incisions always necessary for total thyroidectomy (TT)? The authors of this article asserted that contralateral resection will not adequately remove all thyroid tissue during TT.

    Many studies of RATS in Korean[2] and a few in U.S.[3-5] have reported that a single incision is sufficient for safe completion thyroidectomy with reasonable visualization of the contralateral side. We agree that American patients generally have a higher body mass index (BMI) and a larger body habitus than Asian populations, making TT through a single incision more difficult in Americans. However, we have also encountered patients in Korea with a BMI and body habitus comparable to those of American patients. Following a learning period of about 40-50 operations, we found that experienced surgeons were successful in performing total RATS through a single incision in these more difficult patients (our unpublished results). Therefore, it is reasonable to conclude that patient selection is critical for surgeons learning to perform RATS with a single incision and that indications for RATS will likely extend as surgeons gain more experience.
  2. Recently, the technique of robotic TT through a single incision in the axilla was a little modified, making it easier to perform. We found that tilting the patient table to the side of the thyroid gland containing the lesion during the dissection of the contralateral side enhanced our ability to visualize the contralateral side. In addition, when we started to dissect the lower portion of the contralateral lobe and to expose the contralateral recurrent laryngeal nerve (RLN), we traced the exposed contralateral RLN laterally and dissected medially from the trachea to the contralateral RLN. After that dissection, the upper pole and contralateral Berry ligament area would be easier to dissect. These modifications made total resection during thyroidectomy easier compared with our previous method, in which the upper portion of the contralateral lobe was dissected first.
  3. In agreement with Landry et al, we have also found that good outcomes can be maximized if the entire group travels to observe a master surgical team and if the entire group implements the approach together. In our recent review of studies of RATS, we found that many of these studies reported that RATS resulted in similar or superior levels of cancer control and safety when compared with conventional open or endoscopic surgery in patients with thyroid carcinomas.[2] Therefore, with proper training and the use of proper tools, RATS represents the future of minimally invasive thyroid surgery, and indications for RATS may be safely extended by qualified surgeons with proper training and support.


1. Landry CS, Grubbs EG, Warneke CL, Ormond M, Chua C, Lee JE, Perrier ND. Robot-assisted transaxillary thyroid surgery in the United States: Is it comparable to open thyroid lobectomy? Ann Surg Oncol. doi 10.1245/s00434-011-2075-7. (Online November 8, 2011).

2. Lee J, Chung WY. Current status of robotic thyroidectomy and neck dissection via gasless transaxillary approach. Curr Opin Oncol. 2012;24:7-15.

3. Kandil EH, Noureldine SI, Yao L, Slakey DP. Robotic transaxillary thyroidectomy: An examination of the first one hundred cases. J Am Coll Surg. doi 10.1016/j.jamcollsurg.2012.01.002 (Online Feb 21, 2012)

4. Berber E, Siperstein A. Robotic transaxillary total thyroidectomy using a unilateral approach. Surg Laparosc Endosc Percutan Tech. 2011;21:207-210.

5. Kuppersmith RB, Holsinger FC. Robotic thyroid surgery: an initial experience with North American patients. Laryngoscope. 2011;121:521-526.

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