Clinical Application Of Robot-assisted Bilateral Axillo-breast Approach Thyroidectomy

Part Ⅰ: Assessment of the feasibility and efficacy of bilateral axillobreast approach robotic thyroidectomyObjective: to assess the feasibility and efficacy of bilateral axillobreast approach robotic thyroidectomy(BABA RT).Methods: between March 2020 and June 2021,134 patients receiving bilateral axillo-breast approach robotic thyroidectomy were enrolled and analyzed in this retrospective analysis.An exact 1:1matching analysis was performed to compare the technical safety and oncologic outcomes between robotic thyroidectomy and conventional open surgery.Additionally,learning curves were assessed using cumulative summation(CUSUM)analysis.Results: There was no significant difference in general characteristics,short-time outcomes(including transient hypoparathyroidism,transient postoperative hoarseness,hematoma/seroma,mean postoperative hospital stay,and other complications),number of retrieved central lymph nodes and recurrence rates between robotic BABA and conventional groups.The mean number of retrieved lateral LNs in the robotic group was significantly less than those in the conventional group.The learning curve for working space making,robotic lobectomy and total thyroidectomy are approximately 20,30,and20 cases,respectively.No differences except for operation time were found between the learning group and the proficient group.Conclusions: Robotic thyroidectomy and neck dissection via BABA approach are feasible in terms of surgical completeness,surgical safety and oncological safety.Our results provide a criterion for judging whether the surgeon has entered the stable stage of robotic thyroidectomy via BABA in terms of operative time.Part Ⅱ:Application of carbon nanoparticles in bilateral axillobreast approach robotic thyroidectomy for papillary thyroid cancerObjective: to assess the safety and feasibility of preoperative injection of carbon nanoparticles in papillary thyroid cancer patients undergoing bilateral axillo-breast approach robotic thyroidectomy(BABA RT).Methods: In this retrospective cohort study,114 papillary thyroid cancer patients(PTC)undergoing BABA RT were enrolled from March2020 to March 2021.In the CNs group(n=64),0.15 ml of CNs was injected into the thyroid lobules with malignant nodules the day before surgery.Medical records were reviewed and analyzed,including complications of CNs usage,surgical outcomes,central lymph node(CLN)retrieval,and parathyroid glands(PGs)-related parameters.Results: No significant differences were found between the CNs and the control groups in terms of general characteristics and surgical parameters.Complications of CNs were rare in the CNs group.The mean number of retrieved CLN was significantly higher in the CNs group than in the control group(9.48±4.88 vs.5.40±2.67,P<0.001),as was the mean number of metastatic CLN(2.00±2.56 vs.1.04±1.70,P=0.018).There were no differences in PGs preserved in situ,PGs autotransplantation,and postoperative PTH levels on the first day and first month(all P>0.05).Conclusion: In patients with PTC undergoing BABA RT,preoperative application of CNs is a safe and feasible method to facilitate central neck detection.However,the value of the preoperative application of CNs in robotic thyroidectomy needs to be further studied because it has no significant benefit for parathyroid protection.Part Ⅲ:Application of indocyanine green angiography in bilateral axillo-breast approach robotic thyroidectomy for papillary thyroid cancerObjective: The efficacy of IGCA remains to be evaluated in PTC patients undergoing bilateral axillo-breast approach robotic thyroidectomy(BABA RT)and central neck dissection(CND).Methods: From March 2020 to August 2021,81 papillary thyroid cancer(PTC)patients receiving total thyroidectomy and CND were enrolled in this retrospective analysis.An intravenous bolus of 7.5 mg ICG was administrated three times in the ICGA group(n=34).Medical records were reviewed and analyzed,including the baseline characteristics,surgical parameters,PGs-related parameters,and perioperative PTH and calcium levels.Results: The mean number of total identified PGs and preserved PGs were significantly more in the ICG group than in the control group(3.74±0.45 vs.3.15±0.55,P<0.001;3.12±0.64 vs.2.74±0.57,P=0.007,respectively),as were PTH and calcium levels on POD 1(23.16±18.32 vs.6.06±7.74,P=0.039;2.13±0.11 vs.2.08±0.08,P=0.024,respectively).While there were no differences in PTH levels on POD 30.Additionally,patients with at least one well vascular PG had higher io PTH 3 and PTH on POD 1,which highly suggested the absence of postoperative hypocalcemia.Although not statistically significant,ICGA seemed superior to relative io PTH decline and io PTH 3 in predicting postoperative hypocalcemia.Conclusion: In PTC patients undergoing BABA RT and CND,ICGA is a simple,safe and effective tool in better identification and preservation of PGs as well as evaluation of PGs viability and function,with the potential to preserve more PGs,guide more appropriate autotransplantation,and accurately predict postoperative hypocalcemia.