Robot Assisted Endocrine Surgery: Thyroid and Adrenal Nancy D. Perrier, MD, M.D. Anderson Cancer Center Department of Surgical Oncology Surgical Endocrinology Major Revolution in Surgery The Evolution of Modern Surgery • The art of the surgical discipline • The combination of science and technological advances • The application of art and science towards healing 1987 1
Scarless Surgery: The Thyroidectomy Evolution the Millenium Thyroidectomy Trans Scarles BABA Lap Bil Trans Bilatera s Trans axillar Trans Post Trans Laparos l Insuff Ant Axillary y Endosc axillar Robot copic Oral axillary Chest and Axillary Auri cervical opic End y Insuffl Ass Robotic Breast Breast Wall Percuta Endo Breast & Axil ation Insuffl neous App Thyroid Richm scopic ating BABA App Sx Yoon, on, Love, Ohgami Shima Pattani Wright, Park, BRATS Sasaki, , Ishi Takami, z, Ikeda, Chung Irish Koh Tufano Najami Ikeda, Landry, Surg Taka Shiba, YW, ma, J Lapar Surg Lee, Grubbs, Ikeda, Lap Tamak mi, Current Kim, Lap Ikeda Kim, Taka Adv Perrier Endo Niimi i Opin Lee Head Surg Endo Park miSas Percut World J Gagner Oncol and Arch Surg Surg Per aki Tech of Surg Surg Tech WJS 1996 2006 Endos Neck Endo 2008 Surg 2005 Tech Endosc 2009 2000 JACS 2008 c 2009 2001 2006 2010 2008 2000 Thyroidectomy Options Transaxillary Approach Approach Techniques • Open • Exposure • Endoscopic – Insufflation vs – Direct Gasless – Indirect • Instrumentation • Transcervical – Robotic vs not • Transaxillary (30/0 0 ) • Remote access • Anterior Chest Wall • Peri Areolar Breast • Trans-oral Kang et al. J Am Coll Surg Aug 2009 2
Transaxillary Dissection Transaxillary Pectoralis Exposure Space between the SCM branches Right Side Sternal Head of SCM Elevation Surgical Dissection 3
Korean Experience • Multicenter study • 1043 consecutive cases Lee, Han, Chung Surg Endo 2010) Korean Experience Cadaveric Dissections • Differences in outcome • Prospective study –Preop, 1, 12 weeks post op –OR time longer –No difference in pain, LOS, voice –Less discomfort and swallowing disturbances than open –Cosmetic satisfaction higher in robot Lee, Han, Chung Surg Endo 2010) 4
Port Placement- Axillary Space Robotic Positioning Chung Retractor 8 mm 8 mm Curved Pro Grasp R Harmonic Retractor Scalpel 2 C 3 1 s Head Foot 30 ° Dual Endoscope at 40 ° angle 12mm 5mm Maryland Dissector Laparoscopic Suction ‘ Chung Retractor Transaxillary Thyroidectomy Mean tumor size: 1.0 cm Complications: Major- 1% Minor 6.3% Commercially Available 2010 Chung JACS 2009 5
Operative Times for RATS Evidence Based Principles Total Thyroidectomy – Define the question & problem – Search for evidence – Evaluate literature – Apply results – Audit outcome Single Institution Cost of Robotic Single Incision Expense of Robotic Thyroidectomy: A Cost Analysis at a Single Institution Bilateral Transaxillary Thyroidectomy Thyroidectomy . Arch Surg. 2012;147(12):1102-1106. 6
Robotic Thyroidectomy s/p Thyroidectomy Complications • Massive emphysema and hypercarbia (Gottlieb, Anes Analgesia 1997) • Effect on intracranial pressure (Rubino, Gagner Surgery 2000) • Brachial Plexopathy • Tracheal Injury • Chest Wall Numbness Summary: Why I have abandoned RATS Robotic Thyroidectomy • Main benefit- translocation of the surgical • More Expensive incision to the axilla –Higher equipment depreciation costs • Requires 2X resources (personnel, –Substantially longer operating room sterilization, scheduling) time • Unable to justify the expense in a time of –Flat reimbursement schedule which is cost effectiveness and when demands a disincentive to implementation outweigh resources –Cost prohibitive • Outcome not superior • Niche Operation • Not likely a bridge to telesurgery Sturgeon, Clin Thyroidol (2013) Perrier, N. Stang, M. Surgery Dec 2012 7
Reserved…… Robotic Assisted Adrenalectomy Cushing’s Syndrome Robotic Technology • Potential Benefits – Increased articulation of instruments: provides a flexible approach to dissection, – Magnified, 3 D optics: better visualization – Motion Scaling – Ergonomic advantages • Disadvantages – Cost (non reusables, staff, maintenance, sterilization) – Time – Complexity Dickson, P Am Surg (2013) Vol 79 8
Retroperitoneoscopic Adrenalectomy Patient Positioning Laparoscopic Operative Technique 9
Left Sided Port Placement Robotic Docking Camera Robot Docked 1 Here Prograsp Camera Suction Harmonic 8mm cannula 8mm cannula 12mm port balloon trocar 5mm trocar for suction, irrigation, clip applier Left Sided Set Up Ideal Instrument Articulation 1 Camera 2 10
Situations that Beckon Case 1 1. Cushing ’ s disease with prolonged Robotic Instrumentation 39 y/o F with C618S MEN IIA RET mutation preoperative medical (ketaconazole) therapy Biochemical evidence of pheochromocytoma 2. Cortex preservation critical- may optimize the ability to maintain a vascularized remnant Bilateral lesions > 4 cm 3. Adrenal metastatic disease s/p neoadjuvant Cortical preservation critical chemotherapy dense adherence to IVC 4 of 4 young children + RET 4. Adrenal vein anterior aspect of renal hilum 5. Morbid Obesity Cortical-Sparing Strategy Case 2 • 49 y/o F dx with small cell lung cancer • Treated with XRT and whole brain radiation • New isolated left adrenal metastasis • Received systemic Cytoxan, Taxotere, •Preservation of adrenal vein Adriamycin •Minimal peripheral dissection of spared remnant 11
Systemic Treatment of Isolated Case 3 Adrenal Metastasis 41 y/o M with severe HTN Right adrenal mass Elevated aldosterone with right sided lateralization Decreased from 5.6 to 3.1 cm Weight 152 Kg (334 • lbs) Limitations Robotic Adrenalectomy • Available Instruments • Robotic assistance is complimentary to PRA and – Robotic Clip Appliers may provide advantage in complex procedures – Articulating electrothermy instrumentation • Angled articulation appears to be beneficial in • Hardware is bulky select PRA dissection • Access to robotic devices requires • The technology continues to evolve and further refinements are necessary intermediate scheduling • Requires experienced bedside assistant • Theoretic advantages should be rigorously validated in the clinical arena • Dependent on multiple vendors 12
Summary: Principles of Safe Introduction of New Technology Robotics in Endocrine Surgery Thyroid Adrenal • Broad diseased based knowledge • Twice the time • Select cases • Skill set for the operation; not technology • Articulation and • >Twice the expense view beneficial • Comprehensive educational experience • Further instrument • N ot superior improvement • Skill acquisition by a team rather than • Translocation of • Bulky hardware only a primary surgeon incision • Different Sachdeva AK: Acquiring skills in new procedures and technology: the challenge and the opportunity. Complications Arch Surg 2005; 140: 387. Endocrine Surgery: Robotics “…surgeons as fiduciaries Implementation must balance technologic advancement and ethical • Establish research aims responsibilities, a subject rarely broached in our • Design data acquisition forms with data-driven surgical definite endpoints publications.” • Employ a consistent technique --James W. Jones, M.D . • Develop and refine • Objective review of outcomes Ethics of Rapid Surgical Technological Advances Ann Thorax Surg 2000;69:676-67 7 13
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