Supported by the General project of technology innovation and application development of Chongqing (Grant No. CSTC2019jscx-msxmX0196).

This study follows the guidelines of the Army Medical University&#39;s Human Research Ethics Committee. All patients mentioned in the study signed informed consent forms.
1. Preoperative preparation
<ol>
	<li>After successful nasotracheal intubation, place the patient supine with the head and neck into hyperextension.</li>
	<li>Let the eyes close naturally. Apply eye ointment and cover the area from the top of the brow bone to the nasal flanks with an appropriate eye patch or surgical patch to prevent disinfectant, blood, and other fluids from flowing into the eyes.</li>
	<li>Fill both external ear canals with cotton balls to prevent disinfectant and blood from entering the ear canals and cover the face with a cotton pad folded in half lest the face be crushed by the tracheal intubation.</li>
	<li>Cover the surface of the cotton pad with a non-woven surgical cap up to the nostrils. Apply surgical lamination externally, down to the level of the upper lip, while leaving the area at the foot of the horizontal line of the corners of the mouth uncovered, the lateral sides of the lamination reaching the edge of the sideburns while its upper side flush with the hairline.</li>
	<li>Use a robot surgical system. Place the patient in the supine position. Administer general anesthesia via nasotracheal intubation as per the anesthetist&#39;s recommendations.</li>
</ol>
2. Surgical procedure
<ol>
	<li>Inject Lidocaine (10 mL) + Ropivacaine (10 mL) + Adrenaline hydrochloride (10 drops) under the oral mucosa.</li>
	<li>Make an incision of approximately 8 mm above the lower lip ligament. Ensure that the incisions on both sides are approximately 8 mm long, between the sharp teeth and the first molar (Figure 5).</li>
	<li>Maintain the CO2 gas pressure at 6 mmHg and the gas flow rate in the 20 mL/min range.</li>
	<li>Dock the robot arm.</li>
	<li>Place Maryland bipolar coagulator into the left trocar, and ultrasonic scalpel into the right trocar, completing the flap freeing.
	<ol>
		<li>Using an ultrasonic scalpel, separate the flap downward to the clavicle and bilaterally to the anterior border of the Sternocleidomastoid muscle.</li>
		<li>Use unipolar curved scissors to separate the white cervical line and part of the banded muscle to expose a portion of the thyroid gland (Figure 6) and use a 25 G syringe to inject approximately 0.1 mL of carbon nanoparticle suspension injection from the neck to the thyroid parenchyma under surgical observation to complete a negative image to illustrate the parathyroid gland (Figure 7).</li>
		<li>Use an ultrasound knife to release the striated muscle and use 4-0 absorbable sutures to suspend the striated muscle sutures, facilitating surgical visualization.</li>
		<li>Inject 1 mL of 2.5 mg/mL indocyanine green intravenously for better visualization and protection of the parathyroid glands. Switch to automatic fluorescence imaging mode for clear visualization of fluorescent parathyroid glands and comparison with non-fluorescent lymph nodes.</li>
		<li>Use an ultrasound knife to disconnect the blood vessels at the upper pole of the thyroid gland while searching for and protecting the parathyroid gland at the upper pole (Figure 8). Use curved bipolar forceps to complete the delicate operation of in situ parathyroid preservation (Figure 9).</li>
		<li>Reveal the laryngeal entry of the recurrent laryngeal nerve (Figure 10). Usually, the recurrent laryngeal nerve can be found more quickly within the triangular area formed by the medial parathyroid gland, thyroid gland, and laryngeal muscles. This area is rich in blood supply. Deal with bleeding and exudate at the entry larynx promptly to secure a straight field of view operation and reduce the difficulty of robotic thyroid surgery.</li>
		<li>Use the smoke evacuation device (mastoid suction device12; Figure 11) to remove the exudate and blood during the mass resection, maintaining the cleanness of the lens and the definition of the image of the local surgical area, ensuring accurate exposure and protection of recurrent laryngeal nerve during the surgery. Then, conduct the prophylactic unilateral central neck dissection.</li>
		<li>Perform a contralateral hemithyroidectomy with ipsilateral central lymph node prophylactic dissection in the same manner.</li>
	</ol>
	</li>
	<li>Place all excised tissues in a specimen bag and remove them. Rinse the wound with saline.</li>
	<li>Place a negative pressure drainage tube into the thyroid bed through the cervical puncture hole. Use 4-0 absorbable barbed sutures to continuously suture the strap muscles. Use absorbable threads for the suturing of the oral incisions.</li>
</ol>

<ol><li>Shimazu, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+thyroid+surgery+through+the+axillo-bilateral-breast+approach%5BTitle%5D)+AND+%22Surgical+Laparoscopy%2C+Endoscopy+%26+Percutaneous+Techniques%22%5BJournal%5D)">Endoscopic thyroid surgery through the axillo-bilateral-breast approach.</a> Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 13 (3), 196-201 (2003).</li>
<li>Ikeda, Y., Takami, H., Niimi, M., Kan, S., Sasaki, Y., Takayama, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+thyroidectomy+by+the+axillary+approach%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Endoscopic thyroidectomy by the axillary approach.</a> Surgical Endoscopy. 15 (11), 1362-1364 (2001).</li>
<li>Alabbas, H., Bu Ali, D., Kandil, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+retroauricular+thyroid+surgery%5BTitle%5D)+AND+%22Gland+Surgery%22%5BJournal%5D)">Robotic retroauricular thyroid surgery.</a> Gland Surgery. 5 (6), 603-606 (2016).</li>
<li>Witzel, K., von Rahden, B. H. A., Kaminski, C., Stein, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+access+for+endoscopic+thyroid+resection%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Transoral access for endoscopic thyroid resection.</a> Surgical Endoscopy. 22 (8), 1871-1875 (2008).</li>
<li>Benhidjeb, T., Wilhelm, T., Harlaar, J., Kleinrensink, G. -J., Schneider, T. A. J., Stark, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Natural+orifice+surgery+on+thyroid+gland%3A+totally+transoral+video-assisted+thyroidectomy+%28TOVAT%29%3A+report+of+first+experimental+results+of+a+new+surgical+method%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method.</a> Surgical Endoscopy. 23 (5), 1119-1120 (2009).</li>
<li>Wilhelm, T., Metzig, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Video.+Endoscopic+minimally+invasive+thyroidectomy%3A+first+clinical+experience%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Video. Endoscopic minimally invasive thyroidectomy: first clinical experience.</a> Surgical Endoscopy. 24 (7), 1757-1758 (2010).</li>
<li>Park, J. O., Sun, D. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+endoscopic+thyroidectomy%3A+our+initial+experience+using+a+new+endoscopic+technique%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Transoral endoscopic thyroidectomy: our initial experience using a new endoscopic technique.</a> Surgical Endoscopy. 31 (12), 5436-5443 (2017).</li>
<li>Clark, J. H., Kim, H. Y., Richmon, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+robotic+thyroid+surgery%5BTitle%5D)+AND+%22Gland+Surgery%22%5BJournal%5D)">Transoral robotic thyroid surgery.</a> Gland Surgery. 4 (5), 429-434 (2015).</li>
<li>Richmon, J. D., Pattani, K. M., Benhidjeb, T., Tufano, R. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+robotic-assisted+thyroidectomy%3A+a+preclinical+feasibility+study+in+2+cadavers%5BTitle%5D)+AND+%22Head+%26+Neck%22%5BJournal%5D)">Transoral robotic-assisted thyroidectomy: a preclinical feasibility study in 2 cadavers.</a> Head & Neck. 33 (3), 330-333 (2011).</li>
<li>Wilhelm, T., Metzig, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+minimally+invasive+thyroidectomy+%28eMIT%29%3A+a+prospective+proof-of-concept+study+in+humans%5BTitle%5D)+AND+%22World+Journal+of+Surgery%22%5BJournal%5D)">Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans.</a> World Journal of Surgery. 35 (3), 543-551 (2011).</li>
<li>Nakajo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Trans-oral+video-assisted+neck+surgery+%28TOVANS%29.+A+new+transoral+technique+of+endoscopic+thyroidectomy+with+gasless+premandible+approach%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Trans-oral video-assisted neck surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach.</a> Surgical Endoscopy. 27 (4), 1105-1110 (2013).</li>
<li>Anuwong, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+endoscopic+thyroidectomy+vestibular+approach%3A+a+series+of+the+first+60+human+cases%5BTitle%5D)+AND+%22World+Journal+of+Surgery%22%5BJournal%5D)">Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases.</a> World Journal of Surgery. 40 (3), 491-497 (2016).</li>
<li>Kim, H. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transoral+robotic+thyroidectomy%3A+lessons+learned+from+an+initial+consecutive+series+of+24+patients%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients.</a> Surgical Endoscopy. 32 (2), 688-694 (2018).</li>
<li>Kim, H. Y., Park, D., Bertelli, A. A. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+pros+and+cons+of+additional+axillary+arm+for+transoral+robotic+thyroidectomy%5BTitle%5D)+AND+%22World+Journal+of+Otorhinolaryngology+-+Head+and+Neck+Surgery%22%5BJournal%5D)">The pros and cons of additional axillary arm for transoral robotic thyroidectomy.</a> World Journal of Otorhinolaryngology - Head and Neck Surgery. 6 (3), 161-164 (2020).</li>
<li>Park, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+versus+endoscopic+transoral+thyroidectomy+with+vestibular+approach%3A+A+literature+review+focusing+on+differential+patient+suitability%5BTitle%5D)+AND+%22Current+Surgery+Reports%22%5BJournal%5D)">Robotic versus endoscopic transoral thyroidectomy with vestibular approach: A literature review focusing on differential patient suitability.</a> Current Surgery Reports. 10, 133-139 (2022).</li>
<li>Park, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Institutional+experience+of+200+consecutive+papillary+thyroid+carcinoma+patients+in+transoral+robotic+thyroidectomy+surgeries%5BTitle%5D)+AND+%22Head+%26+Neck%22%5BJournal%5D)">Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries.</a> Head & Neck. 42 (8), 2106-2114 (2020).</li>
</ol>

The authors declare that there is no conflict of interest.

Some scholars have reported transoral robotic thyroid surgery. In Kim's series of TORT studies, the authors used four robotic arms on's automated platforms to perform the TORT procedure. A fourth arm was used via a transaxillary incision primarily for traction of the strap muscles, and this access was also used to extract specimens and place drains when needed13,14.
In this three-port robot approach, one transverse incision of about 8 mm is located above the lower lip ligament, and a longitudinal incision about 8 mm long on both sides is located between the canine and the first molar. After the establishment of the gas space, the white line of the neck is separated, exposing part of the thyroid gland. Then the injection of nano carbon suspension is utilized for staining and negative development of the thyroid gland. The suture is then used to suspend the shoulder belt muscle to help reveal the thyroid surgery area. Compared with unilateral thyroidectomy, total thyroidectomy has more than doubled the risk of recurrent laryngeal nerve injury. Therefore, it is particularly important to locate, separate and protect the recurrent laryngeal nerve. Usually, the recurrent laryngeal nerve can be found more quickly within the triangular area formed by the medial parathyroid gland, thyroid gland, and laryngeal muscles. In the process of operation in this area, the key step to protect the recurrent laryngeal nerve is to timely deal with the bleeding in the operation field and the smoke generated by the energy equipment. The use of a smoke evacuation device (mastoid suction device) can suck up exudate and blood around the gauze for mass resection, maintaining the cleanness of the lens and the definition of the image of the local surgical area, ensuring the accurate exposure and protection of recurrent laryngeal nerve during the surgery. After the operation, the specimen can be cut into the bag through the central vestibular incision. In this technique, the oral vestibular incision, about 8 mm long, can be slightly expanded when taking out the specimen. Generally speaking, T1 tumors can be successfully removed. However, no further attempt has been made at tumors greater than or equal to T215,16. It may be easier to remove them through the axillary incision. In addition, if the patient's chin has been injured and scar tissue exists, it will be relatively difficult to take out the specimen. In addition, if necessary, a small drainage tube can be placed to poke out from the skin in front of the neck without leaving obvious scars on the skin.
Through the above technical improvements, the axillary robotic arm becomes unnecessary. In this way, transoral robotic thyroidectomy can completely avoid leaving no scars on the body surface, reducing unnecessary damage and enhancing the surgical safety and treatment effect. In the future, this technology could be applied to patients who need lateral cervical lymph node dissection so as to benefit more patients. However, the specific indications and contraindications still need to be explored.
In conclusion, the three-port transoral robotic thyroidectomy is safe and feasible in carefully selected patients. In the future, this technology can be used for T1 early thyroid cancer patients with a phobia about the defect of physiognomy.

Thyroid surgeons use different surgical approaches (bilateral axillary breast approach1 [Figure 1], axillary approach2 [Figure 2], retroauricular approach3 [Figure 3], etc.) to conceal surgical incisions and achieve scarless thyroid surgery in the neck. However, none of these technologies can completely avoid scars on the patient&#39;s skin surface. In all methods, only the oral vestibule approach (Figure 4) can achieve the shortest distance of flap separation, leaving no scar on the whole body surface4,5,6. In recent years, natural mouth endoscopic surgery (NOTES)7has been introduced in oral thyroid surgery.
Thyroid surgery performed through this method can be completed through an endoscope or robotic surgical system. Compared with the endoscopic surgery system for thyroid surgery, this robot system has an enlarged three-dimensional high-definition field of view and a rotatable mechanical wrist capable of intuitive motion, making surgeons more flexible in performing satisfactory surgeries8,9. The benefits of this innovative technology include minimally invasive dissection and channels for both thyroid glands10,11,12. However, oral thyroidectomy often requires an axillary-assisted incision to complete the surgery. To achieve the ultimate cosmetic effect, our surgical team delves into the feasibility of an oral three-port robotic thyroidectomy without an axillary incision for the treatment of early papillary thyroid cancer.
This article introduces the application of a robotic surgical system to complete oral thyroidectomy and bilateral central lymph node dissection. Furthermore, the feasibility and safety of this approach have been demonstrated by successfully completing a three-port robotic thyroidectomy without axillary incision and central regional lymph node dissection.

<table><tbody><tr><td>4-0 absorbable sutures</td><td>Covidien</td><td>VLOCM0023</td><td>Suture the linea alba cervicalis&amp;nbsp;</td></tr><tr><td>5-0 Polyglactin braided absorbable suture</td><td>Johnson &amp;amp; Johnson</td><td>VCP433H</td><td>Oral mucosa suture</td></tr><tr><td>8 mm Cadiere forceps&amp;nbsp;</td><td>Intuitive Surgical, Inc</td><td>LOT N10210823</td><td>Clamp tissue</td></tr><tr><td>8 mm Harmonic ACE scalpel&amp;nbsp;</td><td>Intuitive Surgical, Inc</td><td>REF 480275</td><td>Coagulation, expand operating space</td></tr><tr><td>8 mm Maryland bipolar forceps&amp;nbsp;</td><td>Intuitive Surgical, Inc</td><td>LOT K10210830 REF 470172</td><td>Expose the recurrent laryngeal nerve</td></tr><tr><td>8 mm Monopolar curved scissors</td><td>Intuitive Surgical, Inc</td><td>LOT K10211108 REF 470179</td><td>Fine capsular anatomy</td></tr><tr><td>Carbon Nanoparticles Suspension Injection</td><td>Chongqing Laimei Pharmaceutical Co., Ltd</td><td>N/A</td><td>1 mL/50 mg; used for tracing regional drainage lymph nodes.</td></tr><tr><td>Da Vinci Xi Surgical System</td><td>Intuitive Surgical, Inc</td><td>Xi</td><td>Surgical system</td></tr><tr><td>Endoscopy surgical specimen setrieval bag</td><td>Hangzhou Kangji Medical Equipment Co.Ltd.</td><td>LOT 22021921 REF 104Y.111</td><td>Remove specimens from air cavity</td></tr><tr><td>Medical pressure garment</td><td>Foshan qiaoke bio technology Co.Ltd.</td><td>20200149</td><td>Pressure dressing of the anterior neck area of the mandible</td></tr></tbody></table>

transoral robotic total thyroidectomy and bilateral central regional lymph node dissection for papillary thyroid carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The average operative time was ~253 min (minimum time: 205 min, maximum time: 300 min), with an average blood loss of ~20 mL (minimum blood loss: 10 mL, maximum blood loss: 50 mL). The drain was removed until the drainage fell to less than 30 mL/day, and the patients were discharged 2-3 days postoperatively. Figure 12 shows the follow-up images of the 4 patients 1-month post-surgery. The images show that there are no surgical scars on the body of the patients.&#160;The clinical data of 4 patients are shown in Table 1.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64631/64631fig01.jpg" /> 
Figure 1: Bilateral axillo-breast approach. (A) Intraoperative image (B) Postoperative image. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64631/64631fig02.jpg" /> 
Figure 2: Transaxillary approach. Postoperative image. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64631/64631fig03.jpg" /> 
Figure 3: Retroauricular approach. (A) Intraoperative image. (B) Postoperative image <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64631/64631fig04.jpg" /> 
Figure 4: Schematic diagram of the oral vestibular approach hierarchy. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/64631/64631fig05.jpg" /> 
Figure 5: Placement of trocars. Three 8 mm trocars are placed in the position of the oral vestibule. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/64631/64631fig06.jpg" /> 
Figure 6: Exposing the left thyroid gland lobe. Separate the muscles to expose the left thyroid gland lobe. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/64631/64631fig07.jpg" /> 
Figure 7: Carbon nanoparticle injection. Injecting carbon nanoparticle suspension into the right thyroid gland lobe to complete a negative image illustrating the parathyroid gland. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/64631/64631fig08.jpg" /> 
Figure 8: Dissecting the right thyroid gland lobe. Dissecting the upper pole of the right thyroid gland lobe using an ultrasound knife. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/64631/64631fig09.jpg" /> 
Figure 9: Preserved parathyroid gland. A preserved parathyroid gland seen in situ (the left side is a view in fluorescence mode, with significant interference from surrounding tissues and poor contrast) during the surgical procedure. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/64631/64631fig10.jpg" /> 
Figure 10: Tissue removal. Separating and cutting off the tissue outside the left recurrent laryngeal nerve using an ultrasonic scalpel. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 11" class="xfigimg" src="/files/ftp_upload/64631/64631fig11.jpg" /> 
Figure 11: Smoke exhaust device. The smoke exhaust device (mastoid aspirator) used for removing the exudate and blood during the surgery. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig11large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 12" class="xfigimg" src="/files/ftp_upload/64631/64631fig12.jpg" /> 
Figure 12: Follow-up photos of the 4 patients showing no scars on the body surface. (A) Patient 1&#39;s neck appearance at 1 month after surgery. (B) Patient 1&#39;s oral vestibular incision at 1 month after surgery. (C) Patient 2&#39;s neck appearance 1 month after surgery. (D) Patient 2&#39;s oral vestibular incision at 1 month after surgery. (E) Patient 3&#39;s neck appearance at 1 month after surgery. (F) Patient 4&#39;s oral vestibular incision at 1 month after surgery. (G) Patient 4&#39;s neck appearance at 1 month after surgery. (H) Patient 4&#39;s oral vestibular incision 1 month after surgery. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/64631fig12large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Table 1: Clinical data of 4 patients. The clinical details of the 4 patients who underwent surgery are listed in the table. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64631/Table 1.xlsx" target="_blank">Please click here to download this Table.</a>

Watch this Scientific Journal Video about Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma at JoVE.com

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

transoral-robotic-total-thyroidectomy-bilateral-central-regional

Universidad San Sebastian

Research

JoVE Journal

Medicine

724 Views.  Army Medical University (Third Military Medical University). The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Video: Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Computer-Aided Three-Dimensional Visualization in the Treatment of Locally Advanced Thyroid Cancer

The diagnosis and treatment of locally advanced thyroid carcinoma are challenging. The challenge lies in the evaluation of the tumor scope and the formulation of an individualized treatment plan. Three-dimensional (3D) visualization has a wide range of applications in the field of medicine, although there are limited applications in thyroid cancer. We previously applied 3D visualization for the diagnosis and treatment of thyroid cancer. Through data collection, 3D modeling, and preoperative evaluation, we can obtain 3D information regarding the tumor outline, determine the extent of tumor invasion, and conduct adequate preoperative preparation and surgical risk assessment. This study aimed to demonstrate the feasibility of 3D visualization in locally advanced thyroid cancer. Computer-aided 3D visualization can be an effective method for accurate preoperative evaluation, the development of surgical methods, shortening the surgical time, and reducing the surgical risks. Furthermore, it can contribute to medical education and doctor-patient communication. We believe that the application of 3D visualization technology can improve outcomes and quality of life in patients with locally advanced thyroid cancer.

In diagnosing and treating locally advanced thyroid cancer, the application of computer-aided three-dimensional reconstruction can provide additional information regarding the tumor scope and anatomic characteristics, thereby assisting in risk assessment and surgical planning.

The diagnosis and treatment of locally advanced thyroid carcinoma are challenging. The challenge lies in the evaluation of the tumor scope and the ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure.
The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection.
To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day.
Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter&#39;s size and mediastinal positioning.

Here, we present a protocol for retrosternal thyroid goiter resection using a thoracoscopic-assisted transcervical approach.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic ...

Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, the thyroid&#39;s unique physiological functions and intricate surrounding anatomy may result in various surgical complications. Mixed reality (MR), a real-time holographic visualization technology, enables the creation of highly realistic 3D models in the real world and facilitates multiple human-computer interactions. MR can be utilized for both preoperative evaluation and intraoperative navigation. First, semi-automatic 3D reconstruction of the neck from enhanced computed tomography images is performed using 3Dslicer. Next, the 3D model is imported into Unity3D to create a virtual hologram that can be displayed on an MR helmet-mounted display (HMD). During surgery, surgeons can wear the MR HMD to locate lesions and surrounding anatomy through the virtual hologram. In this study, patients requiring radical ET were randomly assigned to either the experimental group or the control group. Surgeons performed MR-assisted radical ET in the experimental group. A comparative analysis of surgical outcomes and the results of scales was conducted.&#160;This study successfully developed the neck 3D model and the virtual hologram. According to the NASA Task Load Index Scale, the experimental group exhibited significantly higher scores in &#39;Own Performance&#39; and lower scores in &#39;Effort&#39; compared to the control group (p = 0.002). Additionally, on the Likert Subjective Evaluation Scale, the mean scores for all questions exceeded 3. Although the incidence of surgical complications was lower in the experimental group than in the control group, the differences in surgical outcomes were not statistically significant.MR is beneficial for enhancing performance and alleviating the burden of surgeons during the perioperative period. Furthermore, MR has demonstrated the potential to enhance the safety of ET. Therefore, it is essential to further investigate the surgical applications of MR.

Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Summary

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