Thyroid Surgery Without a Neck Scar

Exploring Scarless Transaxillary Robotic Thyroid Surgery with Dr. Emad Kandil

emad kandil
Emad Kandil, MD, FACS.

One of the lasting effects of thyroid surgery - known as thyroidectomy - is the scar left behind by the incision. The best thyroid surgeons have expertise at carefully positioning the incision so the scar is hidden in a neck crease. In recent years, incisions have gotten smaller, thanks to video-assisted surgery techniques. The visual appearance of thyroid scars have certainly improved to a large extent, but thyroidectomy with a neck incision still leaves a visible scar.

Some surgeons are now performing thyroid and neck surgery with robotic assistance, placing the incision in the underarm (axilla) area. This is known as "transaxillary robotic" surgery. The FDA approved this procedure in 2009 and three medical centers are currently using advanced robotics for thyroidectomy.

In addition to the cosmetic benefit of having the only scar in the underarm area - rather than on the neck -- the underarm area has fewer nerve endings per square inch than the throat area, so healing is less painful and with good care, the incision will heal faster than in the neck area.

Emad Kandil, MD, FACS, is Chief of Endocrine Surgery at Tulane University School of Medicine. Dr. Kandil has helped revolutionize and develop transaxillary robotic neck surgery techniques, using intraoperative nerve monitoring to protect the laryngeal (voice box) nerve. Dr. Kandil has participated in this Question and Answer session to help Thyroid site readers learn more about robotic-assisted thyroid and neck surgery.

Question: The transaxillary robotic neck surgery is considered an advancement beyond the video-assisted endoscopic surgery that has been increasingly used for thyroid and neck surgery, and endoscopic surgery is considered more state-of-the-art than traditional surgery. Can you tell about these forms of surgery?

Dr. Kandil: Traditional thyroid surgery usually involves a fairly long incision at the base of the neck. A permanent visible scar is possible. More recently, the video-assisted endoscopic surgery of the thyroid and neck has come into use. This surgery is done with a smaller neck incision, using endoscopic visualization with a small camera. This procedure was pioneered in Italy by Dr. Paolo Miccolli and gained popularity in the United States after Dr. David Terris adopted this procedure. I have been offering this procedure to my patients with the addition of a nerve monitoring system - as well as training other surgeons in this technique -- over the last two years. This technique does, however, still result in a scar on the neck.

About Transaxillary Robotic Thyroid Surgery

Question: What is transaxillary robotic-assisted thyroid surgery and how is it performed?

Dr. Kandil: Dr. Woong Youn Chung in Seoul, Korea, developed the technique of scarless neck surgery with robotic assistance.

Initially, the robotic neck surgery approach was done with carbon dioxide (CO2) gas insufflation (introduction of gas into the surgical area) to the neck area.

The use of gas has the potential to cause some post-surgical side effects, however, as patients can experience pain due to retained gas in the tissues surrounding the lungs (a condition known as pneumomediastinum) or subcutaneous air with crepitations. The pain and discomfort can remain until the gas is eventually absorbed.

Robotic, gasless, transaxillary thyroidectomy is a newly developed, minimally-invasive surgical technique to remove all or part of the thyroid. It is also sometimes called robot-assisted thyroid surgery, or robot-assisted endoscopic thyroid surgery.

With this new approach, gas insufflation is avoided, so problems related to retention of the gas are also avoided.

With this new technique, a small incision is made under the arm, and the specially-designed robotic arms work just like hands, allowing the surgeon to operate with very precise control and movements. The robotic system also allows the surgeon to see in stereo-optic three-dimension (3D), with a specially designed high-definition camera that offers magnification to ten times the normal vision. We also modified the procedure to include the use of routine intraoperative nerve monitoring.

This procedure was recently approved by FDA in 2009 and is proven to be a very safe approach.

Question:Please describe the benefits of transaxillary robotic thyroid surgery compared with traditional thyroidectomy.

Dr. Kandil: A key benefit is that transaxillary robotic surgery does not result in a visible, permanent neck scar.

A risk of thyroid surgery is the risk of injury to the laryngeal nerve, which goes to the voice box. This can cause temporary or permanent hoarseness. Thyroid surgery can also cause trauma to nearby structures, including the parathyroid glands, which are near the thyroid. Parathyroid damage can result in temporary or permanent hypocalcemia, a condition that is treated with calcium supplementation.

From a safety standpoint, in transaxillary robotic thyroid surgery, the use of the high-definition robotic equipment with 10X magnification of the field and 3D vision allows us to perform a very precise operation. This means that there is a reduced likelihood of nerve damage and less risk of trauma to the nearby structures like the laryngeal nerve or parathyroid glands. It's very hard to injure the nearby structures if you can visualize the field at ten times their normal size. We are also able to monitor the nerve function during the entire operation to avoid the risk of postoperative hoarseness.

Additionally, my preliminary data showed that postoperative pain is significantly less. This is likely due to the fewer number of nerve endings under the arm, compared to the sensitive skin of the neck. Many of my patients didn't require any pain medicine after surgery.

In general, recovery is also quicker for transaxillary robotic surgery, compared to other thyroid and neck surgeries.

Question: Does transaxillary robotic surgery offer anytime and cost savings?

Dr. Kandil: The time to perform the surgery is comparable to the traditional thyroid surgery in experienced hands. To date, we don’t have studies that have evaluated the cost-effectiveness of this procedure compared to traditional thyroid surgery. When this research is done, however, it should include the risk of complications and the cost to manage these complications.

Question: How long does it take to train surgeons in transaxillary robotic surgery?

Dr. Kandil: I honestly don’t know the answer to this question. I was performing robotic surgery for other endocrine and oncological procedures, so it was easy for me to adopt this technique. To my knowledge, this procedure was performed in eight institutions in the United States, however, there are only three institutions that are actively offering this type of surgery. I really believe part of this is the required experience to perform robotic surgery because specialized training and experience with robotic surgery are essential.

As more surgeons become experienced in this technique, more patients can be offered this alternative, however.

See the Surgery in Action

Dr. Kandil’s colleague, Dr. Ronald Kuppersmith, from College Station Medical Center in Texas, made several videos demonstrating the surgical techniques Dr. Kandil is describing.

[Warning: these videos graphically depict actual surgery.]

Patient Aftercare

Question: How soon after surgery will a patient typically learn the outcome of the surgery and if there is a cancer diagnosis? If cancer were found, do you recommend radioactive iodine (RAI) treatment in all cases?

Dr. Kandil: Usually, one to three days are needed to have the final pathology report. Most patients with papillary thyroid cancer will require radioiodine therapy treatment except if the tumor is small. I also prefer to perform a pretreatment scan to see if there is any microscopic tissue left behind. Ten percent of the time, some patients will avoid the need for radioiodine therapy because they underwent a good oncological resection. However, this is not guaranteed. We plan to perform a prospective study in our institution to see if robotic surgery can provide a better oncological outcome due to the better visualization provided by the system.

Question: While the scar is very small, the trauma of removing the thyroid gland is significant. What do you tell your patients to expect as a timeline for the healing process?

Dr. Kandil: We start the thyroid hormone replacement two days after the surgery. Thyroid function tests are then checked four to six weeks after the operation. Most patients usually follow up with the endocrinologist to adjust the dose and it is usually very straightforward to do that. Some patients do well with a suppressed TSH level, especially those with thyroid cancer, although whatever it takes to make the patient feel well should be the object of treatment.

Question: At follow-up office visits, are patients generally pleased with their healing progress? As a physician, are you generally pleased with their progress, compared with patients who have undergone traditional thyroidectomy?

Dr. Kandil: Absolutely. This is an exciting new treatment option for our patients. No neck scar, less risk of complications, less pain and faster recovery. Many of my patients are actually self-referred because they are looking for the form of thyroid surgery with the least visible scars.

Into the Future

Question: In your estimate, how long will it be before scarless thyroidectomy is readily available at major surgical centers? Is there a point in the future when we can expect robotic-assisted thyroid surgery to be the preferred surgery for thyroid removal?

Dr. Kandil: Video-assisted thyroid surgery is offered in a large number of institutions across the country over the last two years. There are many courses that teach surgeons how to perform this procedure and many surgeons are adapting to this technology.

It is different, however, for the scarless transaxillary robotic neck surgery.

First, you need an advanced robotic system to perform the operation, such as the da Vinci Surgery system. Second, experience with the technology is definitely required to perform this operation safely. I have been working to help Dr. Floyd C. Holsinger at the University of Texas MD Anderson Cancer Center with his course to teach scarless robotic neck surgery. I'm also teaching courses at Tulane, where we are bringing in surgeons from all over the U.S. and abroad to learn more about this transaxillary robotic surgery.

Researcher and patient advocate Leslie Blumenberg contributed to this article.

Source: February/March 2010 Interview with Emad Kandil, M.D., FACS, Assistant Professor of Surgery, Clinical Assistant Professor of Medicine, Adjunct Assistant Professor of Otolaryngology, Chief, Endocrine Surgery Section, Endocrine and Oncological Surgery, Tulane University

Contact Information for Dr. Kandil

Emad Kandil, M.D., FACS
Assistant Professor of Surgery, Clinical Assistant Professor of Medicine, Adjunct Assistant Professor of Otolaryngology, Chief, Endocrine Surgery Section, Endocrine and Oncological Surgery
Tulane University
Tel: 504-988-7520, Fax: 504-988-4762
Toll-free: 1-877-378-7874
Appointments: 504-988-3589
Dr. Kandil's Curriculum Vitae (PDF)

Medical Centers Offering Transaxillary Robotic Thyroid Surgery

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