Robotic Thyroidectomy: A Bilateral Axillo-Breast Approach (BABA)

Bilateral axillo-breast approach (BABA) is a contemporary technique for remote-access thyroidectomy. Early attempts at BABA endoscopic thyroidectomy (ET) encountered technical challenges and safety concerns, which have been significantly minimized with the development of BABA robotic thyroidectomy (RT).^1,2

BABA RT offers a number of benefits over other remote-access thyroidectomy techniques, such as provision of a three-dimensional symmetric view of bilateral thyroid lobes and optimal visualization of important anatomical landmarks, including the recurrent laryngeal nerve (RLN), thyroidal vessels, parathyroid glands, and the trachea. This approach is comparable to a traditional open thyroidectomy (OT) because it uses midline access, which is well-known to surgeons. Unlike ET, BABA RT allows for greater positioning angles between instruments, thus minimizing the risk of instrument dueling. Additionally, having four distinct small wounds instead of one long scar on the neck results in better scar appearance and patient satisfaction.^3,4 Due to the necessity for skin flap dissection as part of BABA, anterior chest paresthesia is a common postoperative complication; however, this sensory disturbance can fully normalize within three months.² Furthermore, the existing data seem to indicate that BABA RT does not increase the risk of RLN injury compared to OT.^5,6

BABA RT has no absolute contraindications except for large substernal goiters. Relative contraindications for BABA RT surgery include patients with thyroid nodules larger than 8 cm in diameter, thyroid malignancy located posteriorly around Berry’s ligament and the RLN, and patients with breast malignancy. Previous breast surgeries are not a contraindication for BABA, since the latter does not interact with the breast parenchyma.⁷

This educational video is a thorough demonstration of BABA RT performed on a young female patient diagnosed with a left-sided thyroid nodule in her early thirties. The thyroid fine needle aspiration biopsy of the 4-cm nodule was indeterminate. Additional molecular testing of the specimen had revealed one of the mutations associated with thyroid cancer. Therefore, a diagnostic thyroid lobectomy was planned. The patient had expressed a strong desire to avoid an obvious neck scar, and therefore, the BABA RT was offered.

The patient’s informed consent was obtained to record the surgery and use the recorded footage for publication, with her face de-identified using a bat mask throughout the entire procedure.

The BABA RT is initiated with the patient placed in a supine position with slightly opened armpits for axillary incisions. A pillow is placed beneath the patient's shoulders to elevate the head and neck. An ultrasound is conducted prior to the surgery to verify the tumor's location and delineate important anatomical landmarks. During the surgery, a neural integrity monitor (NIM) tube is employed to monitor the RLN. It is crucial to preserve its function during the surgery to avoid any postoperative vocal cord palsy. The nerve monitoring system includes a monitor that displays an electromyography (EMG) reading of the nerve.

The thyroid gland is carefully palpated, and the surgical landmarks are marked, including the clavicle, the midline, sternocleidomastoid muscles (SCMs), and the supraclavicular nerve. The latter is marked to avoid injury and minimize postoperative numbness and tingling of the anterior chest wall. The area of the subplatysmal flap space is marked, which is similar to the flap space created during an OT. Marking of lines for four small incisions for RT follows: two on the axilla and two on the periareolar region. The natural skin folds in the axillary areas and the pigmentation of the nipple-areola complex aid in concealing the port-site scarring and discoloration, granting favorable cosmetic outcomes.

The next step comprises the use of the hydrodissection, creating a saline-filled pocket within the subplatysmal layer, thus reducing the risk of bleeding in the flap and aiding in the dissection process. The injection of epinephrine-mixed saline (1:200,000) begins at the trocar incision site of the right areola and progresses into the subcutaneous tissue of the breast, while avoiding the penetration of the glandular tissue. The same process is repeated on the other breast and toward both axillary markings. Following hydrodissection, incisions are made with a scalpel along the superomedial margin of both areolar regions. The initial portion of skin tunneling is achieved using a straight mosquito forceps, gently separating tissue layers. Then, a flap space is created using a vascular tunneler, ensuring its capacity to accommodate trocars and provide access to the surgical site. The ports are then inserted through the periareolar incisions to meet in the middle. The working space is insufflated with CO₂ gas at a pressure of 6 mmHg via the right periareolar port. Two additional incisions are made at the markings of the axillary regions. After creating an adequate flap space under visual guidance, a trocar is inserted through the right axillary incision. Under guidance, a linear mosquito forceps is inserted into the same spot. A pediatric chest tube is threaded through the trocar and attached to a 3-way stopcock for suction and pressurized irrigation. The last trocar is inserted using a similar path via the contralateral axillary incision. The created flap space serves as a unified workspace for all four trocars, providing access to the entire surgical site and allowing the surgeon to perform the procedure with precision and efficiency.

Subsequently, the docking of robotic arms follows. Once the robotic system is properly positioned, the robotic arms are connected to each port. The camera is inserted through the right areolar port site, the left areolar port is used for monopolar electrocautery and harmonic scalpel, and graspers are inserted through both axilla ports. The flap dissection is completed utilizing robotic arms.

The next step in BABA RT involves division between the infrahyoid in the midline. If the midline is not visible, the assistant should palpate the prominence of the thyroid cartilage externally. A midline cut should be made from the suprasternal notch to the thyroid cartilage to reveal the thyroid gland and trachea. The trachea and thyroid isthmus are exposed using hook monopolar electrocautery after dividing the midline. The isthmus is divided by Harmonic scalpel. Isthmectomy aids the retraction of the thyroid gland. Serrated grasping forceps are used to retract the thyroid gland in a medial direction, and dissecting forceps are used to retract the right side of the strap muscles laterally. Carefully, the infrahyoid muscles are separated from the thyroid gland's capsule, and lateral dissection is then carried out to reveal the common carotid artery by reaching the deep aspect of the gland. The inferior parathyroid gland and inferior thyroid artery are visualized following the completion of lateral dissection. The tracheoesophageal groove, identified between the common carotid artery and the trachea, is where one can easily locate the RLN. Using the nerve monitor, one can verify the location of the RLN and test for its function. Around the thyroid gland's lower pole, above the RLN, is the inferior parathyroid gland. The parathyroid gland and its vasculature must be carefully preserved.

Dissection is continued to the upper part of the thyroid gland near the point of the RLN entering the larynx under the cricopharyngeus muscles. The most common location of nerve injuries is around Berry's ligament, which firmly connects the thyroid gland to the trachea. It is important to take precautions to avoid injuring the RLN. While dissecting the lower pole, large vessels such as the inferior thyroid vein and thyroidea ima artery (TIA) can be encountered. Care must be taken to ligate these vessels with bipolar electrocautery or ultrasonic shear after identifying the exact location of RLN. Once the insertion point of the nerve is identified, the cricothyroid muscle, innervated by the superior laryngeal nerve’s external branch, is dissected. Damage to this nerve can lead to changes in voice over time. Care is also taken to avoid any injury to the small vessels, while maintaining focus on freeing up the thyroid gland and staying away from the RLN’s insertion site.⁵

The superior pole vessels and upper pole of the thyroid gland are isolated and divided. The left thyroid lobe is completely mobilized and resected. After the thyroid lobectomy is completed, the specimen is wrapped with a plastic pouch and pulled out through the left axillary port. If the left axillary incision is not large enough to allow for specimen extraction, the incision can be extended posteriorly along the axillary crease with a knife. Hemostasis is verified and the strap muscles are reapproximated.

After specimen removal, both axillary and right periareolar trocars are pulled out, the subplatysmal space is desufflated, and the robot is undocked. To facilitate postoperative pain management, bupivacaine is infused through the left periareolar port site into the flap space. The area is gently massaged to evenly disseminate the solution throughout the flap space. The last trocar is then removed. Interrupted sutures are used to close the skin, with 2–3 sutures on each site. Topical skin adhesives are applied to the incision sites for additional protection and to facilitate healing. Compression dressing is applied to the flap area.

Following surgery, the patient is monitored for approximately 3 hours in the recovery room before being discharged home on the same day. The patient is advised to wear a compressive bra for 4–5 days and have a follow-up appointment scheduled at the clinic one week postsurgery.

We usually refrain from using drains during BABA to maintain the cosmetic appearance of the wounds. We advise patients to wear a compressive dressing for 4–5 days postoperatively. In the event of seroma formation, we aspirate the seroma either through the incision sites or percutaneously under ultrasound guidance.

BABA RT is a safe and effective procedure that offers excellent cosmetic results and comparable safety outcomes to conventional open surgery. Since BABA RT is not technically feasible for every patient, and thyroid pathology and patient factors should be carefully considered in patient selection. While it may be associated with higher costs, it has the potential to enhance the quality of life for patients undergoing thyroidectomy.¹ As robotic systems and procedures continue to evolve, more cost-effective alternatives may be developed to execute the same surgical goals, ultimately leading to higher patient satisfaction and improved outcomes. Minimally invasive thyroidectomy, including robotic approach, has the potential to reduce postoperative pain, hospital stay, and recovery time, while also improving patient satisfaction and overall quality of life.⁸

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.