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

CHAPTER 1

My name is Hyunsuk Suh. I'm one of the general surgeons at The Mount Sinai Beth Israel, specializing in endocrine surgery. And today we're performing a BABA: bilateral axillo-breast approach, robotic left hemithyroidectomy on this young patient who is in her early thirties, who presented with an indeterminate left-sided thyroid nodules positive for molecular testing. And she's here for the diagnostic thyroid lobectomy. So, the surgery, uh, the bilateral axillo-breast approach, are also known as BABA surgery. It was initially developed in Seoul National University in Seoul, South Korea. And after learning the approach during my fellowship in Korea, I have brought to the technique to the US, and started to offer the approach at Mount Sinai. And as far as my understanding, we were the, uh, first place to perform the BABA robotic thyroidectomy. And so far, we have performed over 50 cases in the US. Today our patient is young, and she wants to avoid conspicuous neck scars, so therefore we offered the BABA robotic thyroidectomy. And she has a 4-cm nodule, where needle biopsy showed that it was indeterminate in nature, and additional testing, molecular testing, demonstrated that she had one of the - mutations associated with thyroid cancer. Therefore we offered a diagnostic thyroid lobectomy. As the name implies, a BABA thyroidectomy involves making four small incisions. Two on the axilla and two on the periareola. The incisions are made on the natural skin crease, as well as the skin discoloration around the areolar complex, so that once the incisions are healed, the small scars will contract and become nearly invisible.

CHAPTER 2

So this is the setup for the bilateral axillo-breast approach robotic thyroidectomy. The patient is placed in the supine position with the neck extended, with a special pillow that allows to stabilize the entire back as well as support for the neck and then the head. So you have the thyroid gland, and then the thyroid nodule that you can see, that's well exposed. The arms are to the side, resting comfortably to the side, without any hyperextension of the shoulder. And prior to the surgery we also do the ultrasound to confirm the side of the tumor. So, the relevant anatomic landmarks. And, in terms of the set up, we use a nerve monitoring tube to monitor the recurrent laryngeal nerve which controls your voice box. And it's an important structure during surgery to preserve patients voice function after the surgery. For the nerve monitoring, this is the the actual monitor, where you can see the actual EMG of the nerve, as well as a - what's called a Nerveana power index that tells me how healthy the nerve is. So that can give me a feedback throughout the surgery, whether I need to ease up on the retraction, or whether I need to separate the thermal injury from the electrocautery as well as the energy devices. And I'll be seeing the nerve monitoring throughout the surgery from the actual console, where I can, with a foot pedal, I can toggle in and out between the nerve monitor view on top of the actual surgical view. I'm going to perform the ultrasound for the surgery.

So, this patient presented to the clinic with an enlarged left-sided thyroid nodule, that was measured up to 5 cm. As you can see, she has a large, somewhat isoechoic, or similar echogenicity, compared to a normal thyroid gland. And then the final aspiration biopsy came back as indeterminate, meaning that we don't know whether this is benign versus cancer. And to complement the diagnosis, we did a molecular testing, or genetic testing, which came back, which raises the the likelihood of, you know, this nodule being a cancer. And she had signed up for the diagnostic thyroid lobectomy for that reason. This is the trachea, the airway. And this is the isthmus, the connection of the the right and the left thyroid gland. As you can see, she has a small cystic nodule on the other side; however, the rest of the thyroid gland is normal. I pay attention to how high the thyroid gland goes up. it will determine how much of the skin flap that I create for the surgery. So, I'm drawing the lines. So this is the basic drawing for the surgical landmarks, including the clavicle, the midline, sternocleidomastoid on each side to give us the lateral borders. And I try to feel for the supraclavicular nerve, and this nerve is called the supraclavicular nerve because that nerve comes over the clavicle and innervates the sensation for the upper chest wall, as well as the neck. So I mark that nerve, so that we don't injure that nerve, and minimize the postoperative numbness and tingling. And that nerve is actually palpable over the clavicle so we've marked it out.

That's her thyroid cartilage, it is very palpable. And this demarcates the area of - subplatysmal flap space, similar to the flap space that we create during the open operation. Then I mark out the actual incisions, on the areola between 12 and 3 o'clock. This will be 12-mm incision for the camera. And it goes along the skin discoloration margin of the areola complex. And left breast incision is slightly smaller, 8 mm in length. And the axilla, also put in two incisions here. These markings were done preoperatively, when the patient was awake and sitting up so that I can know which incisions are most hidden when they're sitting up. There will be an 8-mm incision here. Another 8-mm incision here. And draw a line kind of marking the general direction of the trocars that's going to go in. That's the completed drawing for the surgery. It's a schematic drawing of the insertion of the 1, 2, 3, and 4 trocars. One for the camera, one for the energy device, including a hook cautery, monopolar, or the harmonic scalpel. And then the two dissectors. One on the axilla, and the other one on the left axilla.

CHAPTER 3

So this is the hydrodissection where we inject the diluted epinephrine solution, for hydrodissection as well as for hemostasis. So we start at the trocar incision site, and then go into the subcutaneous tissue of the breast, not violating into the glandular tissue of the breast. And inject as I go. So, this is going into the subcutaneous fat layer of the breast and the chest wall. Take some Ray-Tec. It's important to get into the right plane, so that you don't get into the chest wall or the fascia. And do the same thing on the other side, please. The idea is for these two remote access incision sites to meet in the same confluence, the same workspace underneath the skin. I go back right into the same hydrodissection plane that I created and then just expand that space and work my way over. Do we have the Kelly Wick tunneler? What size? 6 mm or 8? No, I think it was 8. Yeah, show me first, and then - it was a straight one, straight, yeah. Okay, pretty good. Okay. Stop there. And I do the same thing for the axilla. Again, inserting into the subcutaneous tissue. and creating a hydrodissection plane. And again, over the clavicle to raise the supraclavicular nerve that's penetrating through the platysma I inject the solution to create that space and to raise the nerve so that it's not in our path of a flap dissection. And when patients have a large goiter or large tumor like this, it's hard to inject the saline into the proper space, so I try to minimize the hydrodissection on this plane and try to do it under direct visualization. Take a 15 blade, please.

All right, making the incision, follow the curvilinear, the line of the periareola. Okay, it's the same thing here. Okay, let's make it slightly bigger. Same thing here, let's make it slightly bigger. Okay, knife down. Bovie. Got thick skin. And using a straight mosquito, I create the initial tunneling process and this should follow the same exact, the path that we injected the epinephrine solution, following the subcutaneous, the tissue plane. Let's see the vascular tunneler. The other one is 8. The one that I've been using. Let's use the 8, then. Nothing. More skin? No, no, no, I said don't try something new. Yeah. Try that. Excellent. Ray-Tec. So here we're using the vascular tunneler in creating the flap space, which is done initially as a blunt process here. And this initial space will serve as a confluence of two trocar sites coming together. Can you dry that up for me? Got to make everything look cleaner. It's a gentle kind of pressure, with a feel- with my left hand providing traction as well as feeling the depth of the flap space. Okay, good, all right, okay. And the same thing there. Get a 15 blade and go through the dermis. Her dermis is very thick. Try not to bevel, go straight down, yep. Okay, all right, use the Bovie now. Another Adsons. Use the cutting. Thank you.

Okay, let's keep that there, and I'll take the obturator from you. I'm going to insert the obturator, the 12-mm camera, through the same channel here. Actually, let's keep the obturator there. I'm going to have you try to push in and then lift up and I'm going to try to get underneath you. So with your left hand here, if you can lift this up like this. Sure. Yeah. Okay. Good. You want the Kelly? No, it's okay. Straight through this. Again, the plan is to meet the two trocars in the same space. If I'm touching each other, I know that I'm in the same space from there. Okay, that's it. Trocar? Hold on, let's do some - you can let go now. Ray-Tec? Gas on, please.

And if you're in the same space, you can hear the air going in through the camera trocar, and the air coming out through the instrument, the robotic trocar. All right, let's switch sides. Phan, can you do me a favor? The TilePro is turned on, and showing the Nerveana. Can we go to the console? Yeah, go to the console and then, you know how to change the view preference and turn the TilePro - let me help you.

You're going to put in robotic camera, into the trocar from the right breast and get a view of the inside. Okay, and then we're going to pull back the trocar a little bit to show us that tunnel that we just created. Okay, pull back a little bit, okay, good. Lift up the camera. All right, so, that's the actual tunnels that we created using the vascular tunneler, in the subcutaneous space. The goal is to show the most medial side on the right side. There, good, perfect, okay. You have the obturator? Um, actually, no, I'm already there. And then you can see that the other trocar is coming in through the same space. So, from here I'm going to be open up the spaces, connecting the dots. So, taking the, all the columns down here. Okay, pull back the entire camera a little, the trocar. Good. All right. Okay, look to the left now, please. I'm going to take each bridge to connect the, the columns. All right, Angelly, can you look up a little bit, okay? Good. Come in with a camera trocar. Oh, let me take that band, so it's not in your face. Pull back the camera. So you don't smudge yourself. Good. All right, come on in. And our goal is to expand the subcutaneous flap space, so that I can insert another trocar maintaining the appropriate depth of the skin flap, and then the distance. Look up here, now, to the right. That's it, nice, yeah. Okay, all right, let's go to the other side here, so we can try to... Come in and turn the camera like this, so they can, exactly, yeah, that's it. I'll take one more bite here. All right, that's good. Look straight up. All right. That's right midline, there. Okay, good. And once you have created enough of a flap space here, you're going to put another trocar from the right axilla. Put one hand here, please. All right, mosquito. Now you're going to turn around, yeah, exactly. Go all the way around and then look at the corner from here. So, here I'm putting in the mosquito, straight mosquito. The goal is to put into the same space that we created there. There we go. So, there is an instrument coming in. Show me around there, more like there. You're right here just push. Yeah. All right, there we go. So, we have another access there. Then we're going to continue the dissection across the chest wall. Now you are going to move your body towards me, now Angelly, and then look across the chest wall. All right, so show me the column right there. Perfect. Fix the horizon, now. Where's the other trocar? All right, okay, coming in- Yep, exactly, that's it. Up here. Through this very avascular plane. A little more here. Show me this area here, please, the midline. Okay, look across. Okay. All right, and this is the pediatric chest tube, which we use as a suction irrigation catheter. We'll show you how it's connected later. I thread this in through the trocar, to have the suction irrigation available inside. Obturator, blunt. And this gets connected to the 3-way stopcock, that has the suction as well as the pressurized irrigation, okay? Is this the suction? Right? Okay, so this goes to the- Um, well right now, the suction can be off here. And this is to the suction, irrigation, off, right? So when I want to do the irrigation, turn this quickly up to - boom, boom. A quick irrigation, and up, back to suction. But otherwise, leave it on suction? Exactly, exactly, yep. I was doing them with my thumb! Yeah, that's right, then you control it with your thumb. Okay, I'm putting the last trocar site now, here. Do you have a Ray-Tec? There's an instrument on the inside, so I'll be putting another trocar through the same path there. Okay. Okay, so show me the midline view now. So, this is our initial work space created, where we have the subplatysmal space there, and a confluence in the middle where all four trocars are docked inside. And at this point, we can dock the robot into the rest of the subplatysmal flap creation of the robotic platform. Okay, all right. Show me to the right side, please. Okay. All right, we're ready for the robot. Lights on. Yep. And to minimize the irritation on the nipple-areolar complex, we put this IV dressing over the nipple area. This will minimize the irritation on the nipple-areolar complex. Same thing there. All right, let's, let's bring the robot down.

CHAPTER 4

So, to line this up, the general rule is that the camera trocar and your target organ, which is, in our case, the thyroid gland, and then the post of the robotic - the arms, needs to line up in the same line. So, we're going to have the robot arm come in straight forward. And then start turning to the right. Back up a little bit, please, and do a little parallel movement. Too much of an angle, Phan, so you've got to come a little closer to the midline. Yeah, good, all right. Come in straight. Turn back, I mean, go back. All right, make sure the numbers are facing out. 90, 90°. Needs to be perpendicular to the post, so make sure it's facing out. I'll come help you. The BABA approach allows for wide spacing of the incisions and trocar sites, that minimize the fighting of the robotic arms. The four incisions are spread out widely from each other. You mean "out" like this? Yeah, like so, the number 2- It doesn't necessarily have to face out, but, like, more kind of perpendicular, so like that. So your arms are - I see. Faces facing the same way. Yeah. Try to dock it, go ahead. So, yeah, I generally try to put my hands here, and then just pop it in. Okay, gonna switch sides then. Adjust the angle for now. Okay? That's it. And then there's clearance between the the arm. And close all the gaps here for the robotic instruments. The green caps have got to stay open, and then let it drop down. So for the endoscopic instrument, you've got to close this, but for the robotic instruments, you keep this flap open. Again, and the camera. Now, the main thing for for camera is that- You see that blue range there, right? So keep that arrow in that sweet spot range there. And then as long as you do that, that's holding there. Adjustment of the angle doesn't really change that. Right?So as long as you're... It keeps that one fixed. Exactly, yep, exactly. Let me have that. This is not seated properly, right, so we're just going to sit it in there, with our fingers, kind of pushing in. and then go down onto the trocar, like that, and we shouldn't pinch the skin. Pull the trocar out a little bit more. Just slightly more, okay, that's it. So we're going to- see that range there? So none of the arms are, you know, fighting each other. So this is completed docking now, and we're going to put the robotic camera back in there. Okay. Did it snap? Okay. Yeah, it snapped. Okay, all right. That's good. Can we load the suction, please, Phan? Okay, we're watching the instrument coming into the workspace there. Then I said that I have room to go back, so I'm going to- show me the trocar, how much length I have. and then I'm going to pull back, relax. That's it, okay. This is a bipolar coming in from the right breast, I mean right axilla. And go. Again, I think I there's room for me to come back, to increase the maneuverability inside, so show me the length of the... So I'm going to pull back the entire arm and the trocar, to have that flexibility. Okay, all right. Okay. This is the ProGrasp, one of the strongest graspers for the robot. Okay. Okay, alright. I know, but once it's connected, I should be able to control it without connecting- that's the whole idea. I see. So- yeah. It's a new cord. Yeah, well now you've got to use that for the entire thing's stimulator, and then when I push the foot switch, we'll switch over to the monopolar automatically. He can control it with the robot. Yeah, so you've just got to plug that one thing now. Yeah, and then it's all controllable by him. Okay, so this is the robotic console where I'll be controlling all four arms, including camera, energy device, and dissectors here. A pedal here also to switch back and forth between the monopolar, as well as the nerve stimulator, because we'll be using a hook cautery as a nerve stimulator when we're not using it as a monopolar cautery.

CHAPTER 5

Okay. I'm going to test the Harmonic. Okay, alright. Angelly, can you do me a favor? Can you walk down the midline and kind of hold it down so I can see exactly where the midline is? Sure. So start from the thyroid cartilage, and then walk yourself down. I'm at thyroid cartilage. Mm hmm. Push it all the way down into the flap space. Okay, alright, thank you. Okay. Good. So, I know that this is the right sternocleidomastoid, this is the left sternocleidomastoid. So I'm going to continue my flap dissection here. Okay, ready for the suction. Angelly, I'm going to use energy device. Okay? Okay. So here, you can either stay above the superficial layer of the deep cervical fascia and keep the internal jugular vein down, like what I'm doing here. Or we could either do a subfascial dissection. And Angelly, let me know how much farther I need to go back. Okay, as I go up on the flap, yep. Okay. Bipolar's plugged in, right? Okay. Yes. Angelly, about how much more, higher? It's about... I think you're, maybe... Half a centimeter. Okay. Towards the line, the drawing, the arch? Yeah, towards your midline mark. No, I mean in terms of the... Oh, you want me to push for you? Yeah, how high to go up in the flap towards the thyroid cartilage. You're here. You're almost at your mark. Almost there? Yeah. Okay. Just the columns- Yeah, this one to the left, and then to the right side. Okay. So again, I'm keeping the veins down along with the cervical fascia here. Given that she has a large nodule, 5-cm nodule on the left side, I'm going to make this dissection a little bit wider than the left side. Yeah, you have about a centimeter to go. Okay. Looks like there's a small branch going up there, so I'll take that branch. All right, so you can tell that there's the big nodule here, that lump there, and this is the midline here. Angelly, can you walk down in the midline one more time? Sure. So, I'm at thyroid cartilage, and I'm coming down. This is one fingerbreadth below thyroid cartilage, two fingerbreadths below thyroid cartilage. All right, sounds great, all right, excellent. Can you take out the Harmonic scalpel, and then the hook cautery, please? Sure. All right, let's try the suction irrigation, Angelly. So do a quick irrigation, using the 3-way stopcock. Coming. Ready? Mm hmm. Just short- Yep, perfect. Another irrigation. Good. All right, excellent, good. All right, let's go back to the hook cautery now, please. Harmonic out.

CHAPTER 6

Yes. Better. Thank you. Yep. So here we're dividing the the median raphe of the strap muscles that's covering the thyroid gland. What's the cautery setting at? Can we go up to 25-25? Thank you.

So, continuing with the opening the midline to expose the thyroid gland as well as the trachea. So, we just exposed to the sternohyoid, and then here's the sternothyroid level. Here's the trachea here. You can see that it's been deviated because of the large nodule on the patient's left side here. Instead of the trachea being here in midline, the trachea has been deviated to the patient's right side. Okay, here's the cricothyroid cartilage there. Okay, so we have exposed the superior aspect of the trachea larynx, and here's the inferior aspect of the the trachea. All right. Hook cautery out, and then let me get a harmonic, please. Wait, you don't have control yet. So when you press the button, try not to press the entire arm. And then, also, you can use the memory, right? Instead of unlocking the instrument, you can keep the memory intact. He'll just take it. Pull the suction catheter back just a little more, please. Thank you. All right. Okay, going to take care of these vessels here too, now.

So, once I expose the trachea, I immobilize the isthmus of the thyroid gland, which is the connecting thyroid tissue, that connects the left and right thyroid lobes, and then divide the isthmus. Angelly, in a bit, I'm going to have you swap the, uh, the ProGrasp, and then the bipolar. So, two instruments on the axilla need to be swapped. So, I'm going to have you take out one instrument from one side and then walk over to the other side and then swap them. Okay, go ahead. Okay, so I'm going to come out from the right axilla first. Okay, go ahead. And take out another one? Mm hmm. So, as you can see here, it gives a very nice near midline view of the entire neck. With a good triangulation of the instruments. Where the energy device comes in through the left breast, and then you have the two opposing instruments. Okay, both in. Thank you. Can you advance the, uh... Yep, got it now.

Here I'm separating the sternohyoid from the sternothyroid gla- thyroid muscle. Little bit more. I'm providing a medial traction of the thyroid gland by pulling on the ProGrasp by grabbing the divided isthmus, and that allows mobilization of the thyroid gland, so that I can continue with the lateral dissection, taking the strap muscles off the thyroid gland.

So, you can see the difference between the normal part of the thyroid gland and the tumor here. Can you get me a hook cautery, please? Harmonic out and hook cautery. Thank you. Is the hook cautery plugged in? So the nodule went actually somewhat lower and deeper than I had anticipated. Phan, is the nerve stim set up? I have the cord. So the adapter's plugged in, right, like an old fashioned?

All right, let's test the vagus nerve, see if the nerve- Let's have the nerve stim up to 3. So, you're going to unplug monopolar now, like the old fashioned. Unplug the gray. Yep, and then plug in the black. Yes. Navy-Black? Here's your black. Okay. So this is the carotid artery, and then we're testing for the vagus nerve to make sure that the nerve monitoring is working, as well as the recurrent laryngeal nerve, the entire length is tested positive, okay? So, that's a positive signal. I'm going to flip on the Nerveana view, with the clutch, so that I can actually see the EMG, and an MPI showing 340 range for the value there. Okay. All right, I'll take the... Let's see. Let me take the Harmonic, please? We have it - I don't know. This one keeps... He moves it faster than we let go, I think. So, this is the medial vein here, right? Yeah. All right. Okay.

I need another cautery cord. It fell. It fell? Okay. It fell. So, that looks like the nerve right there. Quite medial, right? Down to one, please. So, this is the recurrent laryngeal nerve, where this thyroid surgery is very nerve-oriented, where our primary goal is to preserve the function of this nerve here. So finding that is the first order of the surgery. Okay, all right.

All right, you can disconnect the Nerveana at this point. Actually, I'm going to use the Nerveana one more time, please. On. Yep, one second. On. Thank you. All right, let me get a Harmonic, please. I think the parathyroid gland is right in here. Oh yes, much better view. Thank you. Better? You got it? Yep. Now take out your Harmonic and insert the peanut, please. Okay. Do you see me? Hold on. Come on in. I'm already in. You're already in? Okay, twist, twist. So, this is a Kittner that I use to keep the field dry and for retraction throughout the surgery.

Here, once I found a nerve, my goal is to preserve the inferior parathyroid gland and its blood supply to it, so... Okay, come in with the Harmonic. Ready? Yep. Thank you. That's plenty. Okay. Okay, thanks. All right. So you can see how medial the nerve is, right? Right there, yeah. It's probably, it's probably displaced by, displaced by the large tumor there. Okay, come in with the Harmonic. Ready? Yep. Thank you. That's plenty. Okay. Okay, thanks. All right. Nerve stim one more- Nerve stim, please. Harmonic out. Okay, nerve stim on? Yep. Okay, all right. Monopolar. Let me know when you have it. Monopolar's on. Okay. All right, nerve goes down that way. Harmonic, please. Angelly. Mm hmm? When I'm retracting with my left hand, Please look out for the, uh... Please look out for the nerve. If I'm coming over the nerve, probably gonna get compression, and I want you to try to give me a warning, okay. It looks like you have clearance there right now, so we'll see. Yeah. So... Picked out an anatomically challenging case here. It's normally, the nerve should be below here, right? Yeah. Instead, the nerve is overriding the goiter, which makes the mobilization little more challenging and difficult. Okay, unfortunately I think I have to see what's on the other side of the nerve, here.

Now, the structure down here is also what, Angelly, the esophagus, right? Yep. So we don't want to, sort of, dissect into the esophagus, so we're gonna try to dissect the lateral portion here that's given to us. Nerve stim off. Okay. And then monopolar, please. Let me know when you're ready. Monopolar's on. Okay. Nerve stim. Monopolar.

Good. Phan, can you check that out? I'm going to put it on. I'm putting the cautery back on. What is it? I'm putting it back on, try again. Okay. It came off? Uh, I don't know. It didn't come off, I just unhooked it and put it back. Okay, got it. All right, it's working. Yeah, good. All right. So, trying to open up the cricothyroid space here. Giving our nerve... All right, that's the same spot that was bleeding earlier. Relax there. Now this should give a little more mobilization of the goiter now. Suction irrigation catheter. Got it. Coming in. How's that. Pull. There we go. I got it, yep. All right, let me have the Harmonic, please. Harmonic in? Yep, it's there. Okay. Suction catheter back slightly. Bipolar plugged in? Yes. Yes, in. Yes? Yes. Okay. The tissue was too thin. Okay, nerve stim, please. So, 490, still very strong. Let's see where it's going. Take it off? Yes, take it off, please. Irrigation. Ready? Yep. Suction. That may be our superior parathyroid gland right there. You see it? Right here. Let's see. Okay, more irrigation. More? Yep. Mm hmm, suction. Irrigation. Okay, suction. Uh huh. I'm not sure if I can save a blood supply to that. No, maybe, I don't think so. Yeah, we can autotransplant if we can confirm that it's parathyroid, okay. Okay, all right, let's keep moving. Monopolar, please. Thank you. What's the monopolar setting at now? Can we go back to 25-25? Let me check, one second. Okay, thank you. 20-20. Okay, let's go to 25-25. Can I actually get a Harmonic, please? Take out the hook cautery and a Harmonic. Nerve stim up to 3, please. Turn the nerve stim 3 for us? It's this first button by me. No, turn. One, keep going. One, again. Two, uh huh, again. Again. So, I'm looking at this cricothyroid muscle here, right Angelly. So, seeing where the nerve... The superior laryngeal nerve is on the medial side, so I'm going to have to dissect from the medially. Down to 2, please, nerve stim. Two clicks back. One more. Yeah. Okay, so I'm going to dissect from the medial side to see that nerve. If I can take this tissue here. Upper pole. Okay. You want the hook cautery or the Harmonic? Harmonic, please. And pull the suction catheter back slightly. Actually let's do some irrigate- suction there. Okay, one second. Can you pull the suction catheter back little bit, please? Thank you. We have another gas tank? Yep. The nerve has now dropped down, right? It's down. Yeah, it's down now, inserting down lower. So this is the window where I can connect the dot. You want some irrigation, or no? Sure. Angelly, can you do me a favor? Yep. Can you switch the instruments? Okay? I'll take the Maryland now. Look on the other side. From the other side, yep. Okay, I'll take the hook cautery, monopolar, please. Harmonic out. I think I can save the parathyroid gland now. Thank you, and some irrigation. Irrigation. Okay. Good, suction. Okay, all right. Pull it back slightly. I'm going to try to preserve the parathyroid here and then all the pedicles next to it. Ooh, that's a parathyroid gland right there, right? See? Right there. Bipolar plugged in? Yeah. Yeah? Okay. It's not working? Its working, okay. It's working, it's working. Ooh, that's a big artery, there. Yeah. That I'll take the Harmonic, soon, hold on. Let me isolate it. Okay, I'll take the Harmonic, please. Nerve is there. Harmonic out and nerve stim, please. Okay, nerve is still testing. Let's see how well it's testing. So, 550, so - good number. All right, let's see where it inserts. Can we go... You're on 2. So I think that's the insertion point, right there. Okay, all right. Harmonic, please. So, this is the cricothyroid muscle. Yeah. The only muscles that's controlled by the superior larygneal nerve external branch and not the recurrent laryngeal nerve, right? So, there are usually small vessels that are here that can bleed, so I like to take - fine dissection here, identify the vessel, and then try to get it off the muscle. You know that nerve is down lower, here and inserting in this area here. so staying high up here... Essentially, you're staying away from the nerve insertion site and freeing up the thyroid gland. You see how there's muscle here, right? The cricothyroid and then the inferior constrictor muscles are being tethered to the thyroid capsule, so I'm dividing them instead of taking the muscles with me. Irrigation. There is a superior pole artery there, you see? Yeah. Going underneath here.

So this is not a good angle, because I'd be taking a side bite, right? So I'd be coming from below, and then taking the entire thing all at once. So before I do that, I'm going to try to see if I can take that medial aspect. Can you take out the Maryland and put the nerve stimulator on the Maryland side? Thank you. Again, here, I'm trying to find that superior laryngeal nerve from the medial aspect. If I can get to that previous view. It's not in our field here, okay. Okay, back to the Maryland, please. I mean, back to the bipolar Maryland. Okay. Now that I've isolated the upper pole vessel, and then the upper pole of the thyroid gland, I just go right against the muscle, and then take out the upper pole vessels. Okay. So this is the completely mobilized left thyroid lobe. Here's the big tumor. Okay? And here's the isthmus. And then the normal portion of the thyroid gland. Going to put this aside. Okay, let's have the suction irrigation, please. Okay. Okay, more irrigation. Suction. So, here's a lymph node and then a parathyroid gland. Right there. A little darker orange. And then here's the superior parathyroid. Okay. All right, let's get the nerve stim, please. Harmonic out. Do we have some Fibrillar? Yep. Okay. So once we're done with dissection, we're going to test the recurrent laryngeal nerve, as well as the vagus nerve. Okay.

Okay, so that's a positive. That's a 550, very strong signal. Strong EMG. Okay. Then we're going to test the, uh, the vagus nerve. 330, okay. Very nice, okay, all right. Hook cautery out and a Fibrillar, please. You want me to take the peanut out, or no? I'll put it in a specimen bag. Okay. You want a second? Hold on. Yes please, yep. Okay, I'll take the 2-0 Vicryl. Cut them to 18 to 19 cm. Okay, perfect thank you. Here's the needle.

There we go. Okay. All right, good, I got it. One second. Mm hmm, come back out. Open, yep. Closing the strap muscles. Pull the suction catheter back, please. Pull the suction catheter back, please. Can I have the EndoSure ready, please? Okay, EndoSure. Yes, yep. A little shorter. Good. Turn it the other way, turn it, yep. All the way in. All the way in, and then cut. Yes, okay, needle driver. Hold on. Okay. I have the needle. Okay, let's take out the peanut then, too. Come in with the grasper. Yep, grab it tight. Got it? Okay, very nice. Now, you're going to undock the take out the ProGrasp, and then put it in number 1, and then you can undock number, number 3 trocar. Okay. And then we'll undock number 3. Yeah, put the ProGrasp into number 1 first, and then undock. Can you insert the ProGrasp a little bit longer, a little farther in? Sure. Okay, good. There, blue. Yes, I got it now, yep. Okay, so you're going to... You're going to take that trocar out now. Sure, one second. And then, you're going to extend the skin incision a little bit.

So, this is the extraction, uh, part, where we, uh, through the left axilla- Can come out through either left or the right. Just inferiorly? Yeah, just about another centimeter or so. Not too long. A centimeter? Yeah. Use the cautery to open up the rest of that dermis that you just extended. Can I have a Ray-Tec. You can push the arm out a little bit if you need to. Good. I'll get out of your way. All right, see if you can put the Kelly into the space. Do you have the ring forceps, too? Have them available, in case. Okay, you have to take this away now. Find the same track. If you're having any difficulty, you can use the obturator to just follow the track. You have an obturator? Can I have the obturator? Because the skin at the axilla is very elastic. You can take that large specimen through a relatively smaller incision. There we go. Yep, you're inside. No, you've got to, got to dilate it first. Put the Kelly back in, yeah. With just a Kelly? Just remember the path, the track. The specimen, okay. Turn the tip around. Exactly right, try to go in there. Before you spread, you've got to make sure you're in the space, so that you don't dilate a false track. Make sure you're completely inside. Try with the obturator again. Get the feel of where the angle and... Obturator. If there's a band, sometimes... Okay, so go in and out, and then you can try to rotate and then... If you try to lift off the Kelly and try to lead with the nose, instead of the tip, it may help to open up the track. No? It feels like... Let me see. Not this way. This way. There we go. It's in, but... Yeah. All right, so it's in there. Okay. Now, all right, start dilating. So as you come out, dilate. Dilate the mouth. Good, exactly, yep. Dilate vertically, transversely, so you have to turn your tips around too. Try to go back into the same track that you just made. Make sure it's wide open. Nope, nope. You shouldn't feel any resistance going in. Let's try to put the specimen bag in there. Ring - the specimen bag. You have a moist Ray-Tec? In, yes. Yep. All right, now, let's see. You may have to extend the skin incision a little more. Lift it up. We'll see. Just to get out the specimen. All right, let's - here, let's try it. Okay, all right, I'm going to scrub back out. Patient doing okay? Yep. Look down, all right. All right, come on in, and come on in a little more and than deploy fully. This is the better bag. Yeah, definitely, not the other bag. Yep. Now... Can you pull, you want to try to pull the bottom down? Yes, I'll do that. And then try to push the rim towards the head, so there's... Head. Not to the ceiling, but towards the- yep, good. All right, I'm going to try to, push it all the way in. Okay, now up towards the head- up towards the ceiling. Okay, yep, there we go. Close the bag, okay. Take out the rim, inner rim. You know the steps. Hold on, my instrument's caught in there, hold on. Okay, go ahead. Ring's out. Okay, all right, see if you try to pull the specimen out. Here, I'm giving that back, Vincent. If you feel too much resistance, we'll just dilate the track more. We have to dilate the track more. See? All right, sounds good. Okay, relax, I'm going to pull the bag back in. Kelly. I can push it in a little there. Okay, push in a little bit and then... Pull, pull, pull. Pull, pull. Big Kelly. Okay, that's good. Okay, all right, so why don't you come on with a ring forceps, actually. Okay. So it's usually the mouth, that opening - so yep, there you go, start dilating now. Good, okay, that's good. That's good. Keep - now pull back a little bit. That's a good opening there, all right. Coming. Okay? Okay, let's try. All right, let me know when you're ready, okay? All right. Go ahead and pull it. Out! Out? Yep. Perfect, very nice. Okay, Dr. Patel, can you give us a Valsalva, please? I'm going to check for any bleeding. You want to clean the camera? All right, holding the pressure now. Okay. Holding, holding, holding. All right, we're good, thank you. All right, let's take out the instruments now. Gas off, undock the robot. So... Number 1's coming out.

CHAPTER 7

Take out arm 2. I'll go scrub back in. Everything's out. Yep, we're clear. Yep, we're good, the face is clear. Dr. Patel, could we have the other overhead light, please? Do you have the Adsons, please? Two Adsons? You want to melt the track? No, there's just a little skin bleeder that... Oh. I need a mosquito with a Ray-Tec. I can't see, this is right over your head. Okay. Good. Come back towards the corner. Okay, let's see. Just... I think you got it mostly. Here... All right. Some pressure, I think something's coming from the track too. No, there's nothing in the track there. It's all right there. All right, we'll take the marcaine.

So this is a quarter percent marcaine. We infuse this through one of the trocar sites into the the flap space, for pain control. And we try to give a gentle massage to - disseminate the marcaine. Okay, 10 more? Okay, let it drip. Here. There's something else again or same thing again. Okay, you have a moist and dry, please? Take the Vicryls. Okay, Ray-Tec.

You do interrupted? Yeah, interrupted. 2 or 3, probably 2 on your side. Do you put a Monocryl on this as well? Or just Dermabond? No, Dermabond. Okay. There was one on the specimen bag. The suction? There was one on the suction side as well. On Dr. Suh's side. What are you looking for? The clamp. I took it off. Okay. Doing a plastic closure, huh? Two layer? Nah, I just - I did two, but the middle is... I put a third one. I don't want Dermabond to leak. Count's correct. Yep. All right, thank you. Thank you. What happens on left versus right? So, for the left side, you use the Veress needle. Oh, okay. Um, because of the... Site. Means that you have a smaller scope to do the Optiview entry. I'm going to help, I'll help out with the retraction for the axilla, yeah. She goes home? Yeah, she goes home. And you're doing Percocet for pain or something less? Yeah, Percocet. Okay, needle back. We can save that, in case. Okay, let me help with exposure. The main thing is to make it not, you know, pucker. So - that's in the natural skin fold, right? Yeah. Yeah. Dr. Patel, we should be done in 5 minutes. It's okay, Jen. You can let go. Okay, let it go. It's okay. Yeah, it's all right. Okay, I got it now. Yep. Another one? The top? I think that's good. Yeah, top, yeah, sure. I think just the top and the rest is okay. We'll take more moist and dry, please. Okay, nice and dry. Dry. And dry. Oops, sorry... I'll take Dermabond... This one still wants to ooze. Okay. You want to do these first? Let's do this first, yeah. Hold on. I'm putting on the Dermabond. Let's see. Thanks. Yeah, then you dab for me. Yeah, pull that one. Go ahead. A thin layer, yep. Okay, good. One more. Okay, yep. All right. Same thing here. Just apply some pressure there. Okay, I got one. Do it there. And one right there, just thin. Okay. Okay. Okay. Okay, relax there. Okay, that's it, all right. All right, that's it. So those are your 4 incisions. Smaller in the right axilla, and then the 12 mm for the robotic trocar, and then another 8 mm for the energy devices. And this is the side where the specimen came out, so the skin incision was extended for the extraction of a specimen. Okay, that's it. And then we're going to apply some compression dressing. This is just an elastic dressing here for gentle compression on this flap area. Good, thank you. Padding, or no? Huh? Padding, or no? For the first, and then, yeah, we'll see. After? Just fluff? Okay. Just a plus, yeah. Okay.

CHAPTER 8

After the surgery, the patient gets observed for about 3 hours in recovery and then they go home the same day. And they wear the compressive bra for about 4 to 5 days, and follow up in the clinic about one week after the surgery.