Patient Preparation. With the patient in the supine positions and under general anesthesia, the neck is extended slightly by inserting a soft pillow under the shoulder and the face is turned away from the lesion. The lesion-side arm is abducted by 80° from body to expose axilla and lateral neck, and the head is tilted and rotated to face the non-lesion side (Fig. 24.8) [4, 5, 34]. The landmarks for flap dissection are bounded by the sternal notch and the midline of the anterior neck medially, the anterior border of the trapezius muscle laterally, and the submandibular gland superiorly.

Creation of Working Space. A 7–8 cm vertical skin incision is made in the axilla along the anterior axillary fold and the lateral border of the pectoralis major muscle. The subcutaneous flap from the axilla to the midline of the anterior neck is dissected over the anterior surface of the pectoralis major muscle and clavicle by electrical cautery under direct vision. After exposing the clavicle, subplatysmal flap dissection proceeds to the midline of the anterior neck medially, to the upper point where the external jugular vein and greater auricular nerve cross the lateral border of the SCM muscle superiorly. The external jugular vein is ligated at the crossing point of the SCM muscle. Laterally the trapezius muscle is identified and dissected upward along its anterior border. During the flap dissection in the posterior neck area, the spinal accessory nerve is identified and exposed along its course. After subplatysmal flap dissection, the clavicular head of the SCM is divided at the level of its attachment to the clavicle to expose the junction area between the IJV and the subclavian vein, and the dissection proceeds upward along with the posterior surface of the SCM to expose the submandibular gland and the posterior belly of the digastric muscle. The proximal external jugular vein is then clipped and divided at the crossing point of the SCM lateral border, and soft tissue detachment from the posterior surface of the SCM is continued lateral to medial until the IJV and CCA are exposed. After flap dissection, the patient’s head is returned to the neutral position. A spatula-shaped wide external retractor (Chung’s retractor) is then used to raise and tent the skin flap at the anterior chest wall, the SCM, and the strap muscles to create a working space. The entire neck levels (level IIa, III, IV, Vb, and VI areas) are fully exposed by elevating the SCM muscle and the strap muscles. A second skin incision (0.6–0.8 cm long) is then made on the medial side of the anterior chest wall to allow the fourth robotic arm to be inserted (2 cm superiorly and 6–8 cm medially from the nipple).

Robot Positioning and Docking Stage. The robotic column is placed on the lateral side of the patient contralateral to the main lesion, and the operative table is positioned slightly obliquely with respect to the direction of the robotic column to allow direct alignment between the axis of the robotic camera arm and the operative approach. Proper introduction angles are important to prevent collisions between robotic arms. Four robotic arms are used during the operation. Three arms are inserted through the axillary incision. A 30° dual-channel camera is placed on the camera arm through a 12-mm cannula which should be placed in the center of the axillary skin incision. In particular, the camera arm has to be inserted to face upward which means the external third joint should be placed in the lower portion (floor) of the incision entrance, and the camera tip should be directed upward. The 5-mm Maryland dissector is installed on the left side of the camera and the Harmonic curved shears on the right side through 8-mm cannula. A ProGrasp forceps is placed on the fourth arm and inserted through the 8-mm anterior chest cannula. The Harmonic curved shear and the Maryland dissector arms should be inserted in the opposite manner to the camera arm (to face downward). Finally, the external three joints of the robotic arms should form an inverted triangle. These proper positioning of angles are important to prevent collisions between robotic arms.

Console Stage. Actually, the robotic modified radical neck dissection procedure is similar to conventional open technique. Lateral neck dissection is initiated from the level III and IV area around the IJV. The IJV is handled medially using the ProGrasp forceps, and soft tissues and LNs are pulled laterally using a Maryland dissector. Careful dissection is needed during the detachment of the LNs from the posterior aspect of the IJV to avoid injury to the CCA and the vagus nerve. Smooth, sweeping, lateral movements of a Harmonic curved shears can establish a proper plane and allow vascular structures to be differentiated from specimen tissues. The dissection of the IJV is progressed upward from level IV to the upper level III area. During this procedure, the superior belly of the omohyoid muscle is cut at the thyroid cartilage level. Bundle of LNs are then drawn superiorly using the ProGrasp forceps, and the LNs are meticulously detached from the junction of the IJV and subclavian vein. In general, the transverse cervical artery as a branch of the thyrocervical trunk courses laterally across the anterior scalene muscle, anterior to the phrenic nerve. Using this anatomic landmark, the phrenic nerve and transverse cervical artery can be preserved without injury or ligation. Further dissection is followed along the subclavian vein laterally. The inferior belly of omohyoid muscle is cut where it meets the trapezius muscle. The distal external jugular vein is then clipped and divided at its connection with the subclavian vein. Level VB dissection in the posterior neck area proceeds along the spinal accessory nerve in the superomedial direction, and is followed by level IV dissection, while preserving the brachial nerve plexus, the phrenic nerve, and the thoracic duct. The dissection proceeds by making turns at levels VB, IV, and III and then by proceeding upward to the level IIA area. The individual nerves of the cervical plexus are sensory nerves, and when encountered during dissection, some of them might be sacrificed to ensure complete node dissection, while preserving the phrenic nerve and ansa cervicalis.

After performing the level III, IV, and VB node dissection, re-docking is needed for a better operating view to dissect the level II LN. The external retractor is then reinserted through the axillary incision and directed toward the submandibular gland. The operating table should also be repositioned more obliquely with respect to the direction of the robotic column to allow the same alignment between the axis of the robotic camera arm and the direction of retractor blade insertion. Drawing the specimen tissue inferolaterally, soft tissues and LNs are detached from the lateral border of the sternohyoid muscle, the submandibular gland, and the anterior surfaces of the carotid artery and the IJV. Level IIA dissection is advanced until the posterior belly of the digastric muscle is exposed superiorly. After removing the specimen, fibrin glue is sprayed around the area of the thoracic duct and minor lymphatics, and a 3-mm closed suction drain is inserted just under the axillary skin incision. Wounds are closed cosmetically. The incision scar in the axilla is completely covered when the arm is in its neutral position (Fig. 24.9a, b) [5, 35].

Over the past decade, robotic thyroidectomy has gained considerable traction in thyroid surgery, both locally in South Korea and abroad. Perioperative results, including operation time, volume of blood loss, length of hospital stay, occurrence of perioperative complications, and recurrence rates following robotic thyroidectomy, are summarized in Table 24.1 [9, 11–14, 16, 17, 21, 28–30, 34–45]. The operative safety and feasibility of robotic thyroidectomy were demonstrated in studies of 100, 200, 338, and 1,000 procedures performed by a single surgeon [9, 28, 29, 38] and of 1,043 procedures performed at several centers [40]. The major complication rate following 1,000 consecutive robotic thyroidectomies performed by a single surgeon was 0.8 %, whereas the rate following robotic thyroidectomy in 1,043 consecutive patients in several centers was 1.0 % [38, 40]. These complication rates are comparable to those following open thyroidectomy performed in experienced centers of excellence. However, these results come from centers with the largest worldwide experience with robotic thyroidectomy and may not be generalizable to less experienced centers, especially during their early adoption of this technique.