Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America

Background: Since its introduction nine years ago, gasless transaxillary thyroidectomy with robotic assistance (RT) has achieved a relatively limited application in North America. This study aimed to assess the outcomes of RT in a recent large, diverse North American population. Methods: Consenting patients were selected for the RT approach from November 2010 to July 2015 based on patient preference, and their perioperative data were retrospectively reviewed. Results: Of 301 robotic thyroidectomies completed in 281 patients, 160 were total thyroidectomy and 141 were lobectomy. Women predominated (98.9%), with a mean age of 41 years (range 17–74 years) and a mean follow-up of 24 months (range 3–71 months). The mean body mass index (BMI) was 25.7 kg/m 2 (range 17–44 kg/m 2 ). However, 33.3% of patients had a BMI 25–29.9 kg/m 2 , 12.4% had a BMI 30–34.9 kg/m 2 , 3.5% had a BMI 35–39.9 kg/m 2 , and 0.7% had a BMI ≥40 kg/m 2 . Excluding 20 completion lobectomy, the indications for surgery were indeterminate cytology (53%), malignant cytology (10%), growth (18%), Graves' disease (12%), and other (5%). The mean size of the largest resected nodule was 2.5 cm (range 0.7–6.4 cm). Mean operating time for robotic lobectomy and total thyroidectomy was 81 and 109 minutes, respectively. One patient was converted to standard cervicotomy for failure to progress endoscopically. Complications included temporary dysphonia (6.0%), permanent recurrent laryngeal nerve deficit (1.3%), hypocalcemia (temporary 8.2%, permanent 1.1%), seroma (0.7%), and hematoma requiring reoperation (0.3%). Complications did not differ in patients with a BMI ≥25 kg/m 2 compared to those with a BMI 3 cm or surgery for Graves' thyroiditis. One patient developed grade II arm lymphedema ipsilateral to the axillary incision at two years, which resolved with conservative management. No patient had a surgical site infection or brachial plexopathy. Cancer was present histologically in 133 (48%) patients. Among 91 patients with cancer of the index nodule, 48.4% had papillary, 44.0% follicular variant papillary, 2.2% minimally invasive follicular carcinoma, and 5.5% minimally invasive Hürthle cell carcinoma. One patient had sclerosing variant thyroid paraganglioma. To date, all patients are without evidence of tumor recurrence. Conclusions: At a high-volume center, gasless transaxillary endoscopic thyroid surgery done with robotic assistance is a safe, efficient, and eff