Fig. 10.1
Positioning of the patient for RFT is straightforward. While lying supine on the operating table, the head is turned 30° away from the side of surgery. A cushion is then used to prevent excessive rotation of the head
Selection Criteria
As with all surgical procedures, careful patient selection is fundamental for successful outcomes with RFT. Both disease and patient characteristics determine eligibility for the procedure.
Patients with presumed benign disease, with nodules not exceeding 4 cm in greatest dimension and with no substernal extension, are candidates for RFT. In order to ease the dissection during the procedure, the absence of thyroiditis is preferred. At this time, RFT should be limited to unilateral surgery. Due to anatomical constraints and the current state of robotic technology, visualization and dissection of the contralateral recurrent laryngeal nerve cannot be adequately achieved in order to perform a true total thyroidectomy.
Patient criteria must also be considered when assessing suitability for RFT. Patients should not be morbidly obese. Additionally, patients should be sufficiently healthy to tolerate a longer anesthetic exposure than is required for conventional thyroid surgery. Perhaps the most important factor is that the patient should be motivated to completely eliminate a neck scar, as this represents the principal advantage of remote access surgery. The patient should be fully informed of the risks of the procedure, including the expectation of hypesthesia in the region of the greater auricular nerve.
Procedural Details
Preoperative
Safe and successful performance of RFT requires contributions from the entire surgical team—nurses, anesthesiologists, and surgeons. All members of the robotic team should be well versed in the principle steps of the procedure. This will ensure efficiency of the operation.
The anesthesiologist should use circuit extenders to facilitate a 180° turn of the operative table. Laryngeal nerve monitoring is typically utilized, and intubation using a video laryngoscope device helps to ensure proper positioning of the laryngeal electromyographic endotracheal tube. Given the nerve monitoring, paralytic agents should be avoided.
Preoperatively, the surgeon should mark the incision both for RFT and for a cervical approach (Fig. 10.2). This would be used only in the rare case in which conversion to an open approach is needed. Both of these marks should be placed with the patient in the upright position in the holding area, in order to identify the most cosmetically pleasing sites. The postauricular incision begins just behind the ear lobule and runs in the postauricular crease. It crosses into the occipital hairline at a point above where the incision will be hidden by the auricle, and then extends down within the occipital hairline (this hair is clipped after intubation and positioning).
Fig. 10.2
The incision is placed in the postauricular crease and then crosses into the occipital hairline
Intraoperative
One of the benefits of RFT is that positioning of the patient is straightforward. The patient is placed on the operating table in the supine position. After intubation, the endotracheal tube is secured in position and the table is turned 180° away from the anesthesia cart. The patient’s head is turned 30° away from the side of the surgery. In order to prevent excessive rotation of the neck during the procedure, a cushion is placed next to the head on the side contralateral to the side of surgery. No urinary catheter is needed.
Approximately 1 cm of hair is clipped along the descending limb of the incision. Quarter percent bupivacaine with 1:200,000 of epinephrine is then injected along the length of the incision. After sterile prepping and draping, the table is placed in reverse Trendelenburg position and airplaned away from the side of surgery to improve ergonomics for the operative surgeon.
After the incision is made, dissection is performed down to the level of the sternocleidomastoid muscle. Flap elevation is achieved first in the subcutaneous and then the subplatysmal plane. Particularly in thinner patients with less subcutaneous fat, care must be taken to avoid creating a buttonhole through the flap and skin. After identifying the sternocleidomastoid muscle, the great auricular nerve and then the external jugular vein are encountered. Dissection should be maintained ventral to these structures. The entire length of the sternocleidomastoid muscle is then exposed, with particular attention paid to releasing the anterior border of the muscle.
Identification of the omohyoid muscle is the next critical step. By dissecting and then retracting this muscle ventrally, the sternohyoid and sternothyroid muscles are exposed (Fig. 10.3). These muscles are then reflected from lateral to medial, exposing the upper pole of the thyroid gland.
Fig. 10.3
A view of a right-sided operative pocket, with critical landmarks highlighted. The great auricular nerve (GAN), external jugular vein (EJV), sternocleidomastoid muscle (SCM), and the omohyoid muscle are indicated
The omohyoid muscle is most readily seen by rolling the anterior border of the sternocleidomastoid muscle laterally, a maneuver performed well with a malleable retractor. Cadaver dissections and intraoperative assessments have revealed that the omohyoid muscle can be consistently identified just inferior to an axial line drawn through the inferior aspect of the thyroid notch (Singer MC, 2012). The sternohyoid and sternothyroid muscles are elevated off the underlying thyroid gland down to the level of the sternum and then retracted ventrally with a modified version of the Chung retractor blade (Marina Medical, Sunrise, Florida) (Fig. 10.4). This maintains the operative pocket. Additional exposure is achieved by retracting the sternocleidomastoid muscle laterally using a retractor fixed to the operating table.
