Friday, August 2, 2013

Whatever happened to robotic thyroidectomy?

In case you missed it, there was a brief romance between thyroid surgeons and robots. Thyroid surgeons, itching to join the crowds migrating to robot-assisted surgery, came up with the idea to use the robot to perform thyroidectomies.

It appears that the push began in Korea, and to add some pizzazz to the mix, a trans-axillary approach to avoid a scar in the neck was incorporated. As is often the case, the initial results were favorable.

Then reality set in.

The early euphoria gave way to the revelation that American patients were larger and more difficult to operate on than patients in Korea. But randomized trials of selected patients were suggested.

A paper from Wayne State in Detroit found complications in 4 (22%) of 18 cases—3 temporary vocal cord pareses and a post-operative hematoma that required re-operation. Hospital stay was a median of 2 days.

More than 90% of conventional thyroidectomy patients are done as same day surgeries.

After receiving 13 reports of complications, Intuitive Surgical, the company that manufactures the robot, decided it could no longer support the use of its robot for thyroid surgery.

At this point, a surgeon from the MD Anderson Cancer Center took the unprecedented step of publicly renouncing her previous stand on robotic-assisted thyroid surgery (RATS).

In an editorial in the December 2012 issue of the journal Surgery, she said, "After performing nearly 40 RATS procedures, we came to the conclusion that the main benefit of RATS—translocation of the surgical incision to the axilla—did not offset the risks and liability of performing an operation that was not supported by the equipment manufacturer, took twice as many resources to perform as open surgery, and faces complex legal hurdles beyond our control that currently prevent implementation of telerobotic/distant access surgery across the United States. Justifying the expense in a time when demands outweigh resources obligated us to focus on outcomes. When we did that, we proved that we could perform RATS, but not that we should."

Here's a link to a series of photos showing exactly how robot-assisted thyroidectomy was done. It looks like one trades a thin scar in the neck for an ugly scar in front of the armpit.

There are still hospital websites that say they offer the procedure. Here is one. Google "robotic thyroidectomy" and you will see. 

Maybe they didn't get the memo.


Anonymous said...

You'd think the acronym would have given them pause.

Skeptical Scalpel said...

Yes, RATS is not the most appealing acronym. How does one say to a patient "I am booking you for a RATS?"

Anonymous said...

Obviously there is a strong bias. Only a true skilled surgeon can perform the surgery properly. In all surgeries there are risks. As far as I have researched it's more precise and accurate. I am a patient who needs this surgery and I don't wish to have an ugly archaic Frankenstein scar across my young pretty neck. I small scar under my arm is more unsightly not to mention easier to heal. I'm may not even go through surgery if it's not cancer, but I F I do, I'll stick with the more precise surgery.

Skeptical Scalpel said...

Ritalee, thanks for commenting. Many scars from standard thyroid surgery are invisible if placed in a neck skin crease. If you go to the link about how robotic thyroidectomy is done that I posted, you will see that the scar is neither small nor under the arm. And that was presumably a good result or it would not have been used to illustrate the procedure.

Whatever happens, I hope you do well. Good luck.

Anonymous said...

I just finished my gen surg rotation as an M3 at a community hospital that serves the more affluent population of our town (capital in a Midwest state) and they still do RATS there.

However at the academic center that typically doesn't get affluent patients they do the standard approach.


Skeptical Scalpel said...

Isn't that strange? What could possibly account for that difference? :-)

Anonymous said...

Obviously it is the cost of procedure.Robotic thyroidectomy is a step forwards but probably it's time has not come globally yet.

Skeptical Scalpel said...

Honestly, I doubt that its time will ever come.

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