The answers to the following questions were offered in an interview by CENTA's Dr. Tod Huntley.
This surgery can be considered for many people who need to have a portion of their thyroid removed who do not want a neck scar. The ideal patient for a da Vinci® robotic thyroid surgery is not obese and is otherwise healthy, and has not had other surgery or radiation to the neck for any reason. It is best for those select patients with benign or suspicious thyroid tumors less than 5cm in size and which are limited to one lobe or side of the gland. Though in the future we might offer the surgery to people with thyroid cancer who need the entire gland removed, we are not doing so at this time.
In the 20 years or so since I completed my residency and fellowship training, huge strides have been made with endoscopic surgical techniques. Surgeons have learned how to do many procedures through smaller and smaller incisions. When I was new in practice in the early 1990s, thyroid surgeries were still done through large incisions in the neck, often 4-5 inches in length. By the turn of the century, new techniques allowed surgeons to shrink the size of thyroid neck incisions to just an inch or two, depending on the case. The use of the da Vinci® robot has allowed us to take this even a step further. No neck incision at all. And if a 1-2 inch incision is better than a 4-5 inch incision, then you can see why many people would agree that no neck incision might be even a better option.
There are a number of reasons for a thyroid gland to become enlarged. Sometimes, the entire gland enlarges, perhaps due to an autoimmune or inflammatory disorder. In other instances, the gland enlarges due to an abnormal growth or nodule in the gland. Physicians generally use the term "tumor" when referring to abnormal growths in the body, but the term tumor itself does not signify whether the lump or mass is due to cancer or not. Such tumors can be benign, which means non-cancerous, or they can be malignant, which is another word for cancerous. Luckily, most thyroid masses are benign. A generic term that describes many cases of benign thyroid enlargement is "goiter," and some goiters can grow to surprisingly large sizes, but most people receive treatment long before this is the case.
We can usually determine whether tumors are benign or malignant by doing an ultrasound examination of the thyroid in our office, often accompanied by a fine needle aspiration (FNA) biopsy. The term biopsy refers to a sampling of the abnormal tissue with examination by a pathologist. A FNA biopsy is an extremely safe and simple procedure that is done under local anesthesia in the office, and takes less than a half hour to perform. It is relatively painless, and involves sticking a very thin needle into the mass and aspirating some of the abnormal cells into the needle. These cells are then squirted onto a microscope slide for the pathologist to analyze under the microscope, and we can often have an answer for the patient at that same visit, as the pathologist is usually in the office with us during the procedure.
Once we have a diagnosis, we can immediately start treatment planning. If a nodule is found to be benign, and if it is small and is not causing any symptoms, we might not need to do anything other than observe it over time. If is benign but is causing symptoms, we might offer removal of that part of the thyroid gland. Typical symptoms that might lead us to such surgery could include a cosmetic change – in other words, the nodule sticks out and can be seen or felt by the patient or others. Some nodules can press on surrounding structures like the windpipe or throat and cause breathing or swallowing problems, or feel like something is pushing in on the throat from the outside. In these cases, removing the offending portion of the thyroid can lead to relief of the problem. And many of these cases are appropriate for da Vinci® robotic thyroid surgery.
When the tumor is malignant, particularly when the cancer is a cm in size or more, surgery is offered, but generally not with the robot. This surgery generally involves removing all of the thyroid, not just part of it. And because many thyroid cancers can spread to lymph nodes in the neck, we would also assess the chances of lymph node involvement and might have to remove some of the lymph nodes in the area at that time. Thyroid cancer cases require long-term follow-up, periodic re-examinations, and possibly postoperative treatment with radioactive iodine. Though these types of cases are generally not the kind of cases we are doing with the da Vinci® robot, we generally get superb results with traditional thyroid surgery. Luckily, most thyroid cancers that we treat don't kill, but they still need to be treated appropriately and in a timely fashion.
There are a couple of ways to answer this question. As mentioned earlier, ultrasound examination is a very sensitive way of evaluating the thyroid gland, and ultrasounds can find thyroid masses that are a fraction of an inch in size, long before they can be felt. Most of these masses need no treatment. It has been estimated that up to half of the population may have one or more thyroid nodules, but less than 10% of the nodules seen on ultrasound can be felt on examination. Thyroid nodules are more commonly found in women than in men.
Again, if the mass is benign, treatment is optional. Most people with visibly enlarged or symptomatic thyroid masses opt for removal. Removal of part or all of the thyroid is referred to as a thyroidectomy, and a thyroidectomy can involve removal of all of the gland (referred to as a total thyroidectomy) or part of it (partial thyroidectomy).
The thyroid gland secretes a very essential hormone, thyroid hormone, which is sort of like the gasoline that runs all of the organs in the body. You cannot survive without thyroid hormone, and a patient who undergoes a total thyroidectomy must replace this missing hormone in pill form daily. Generally, though, a patient who undergoes a partial thyroidectomy has enough remaining thyroid left behind that this is not necessary. We therefore like to keep half of the gland in place when it is appropriate and safe to do so.
The surgery takes a bit longer when performed with the da Vinci® robot when compared to traditional thyroid surgery through a neck incision—about an hour or more than when a neck incision is used. This is because it takes a little longer to reach the thyroid gland from the axillary or armpit incision than when the approach is directly through the front of the neck directly over the gland. But once the gland is reached and the work with the da Vinci® robot begins, the surgery is usually completed within about an hour. And, since the procedure is done under general anesthesia, the patient is not aware of the extra time spent, but he or she should certainly appreciate it afterwards, when there is no possibly unsightly neck incision to deal with. Our first case took us about three hours to perform "skin to skin," and we whittled this down to about two hours by just our third one.
Not many da Vinci® robotic thyroid surgeries have been done so far in the US, but the procedure is starting to gain in popularity. We now have patients seeking us out for it, and as more and more people become aware of the technique, it will become more widely available. In some parts of the world, such as South Korea, where neck incisions are culturally less accepted by patients, this type of surgery is much more common, and has been done for a longer period of time. But it has been available in the US for not much more than a year.
In fact, my partner Ed Krowiak and I were among the first two dozen US surgeons trained in the procedure, and to date are the only ones in the entire state of Indiana who have undergone this training. But within days of the word spreading in the local medical community following our first case, a number of surgeons in the community and around the state immediately expressed interest in learning the procedure, but none have done so yet, as it is not easy to learn and takes a big commitment on the part of the surgeon. It is not for the casual thyroid surgeon.
We would be happy to help teach our colleagues how to learn to do the procedure, as we have done in the past with a variety of new surgical techniques that we have either helped pioneer or been first to bring the state—including a number of snoring, sleep apnea, and throat cancer procedures that are now widely offered worldwide but pioneered with our group. We enjoy teaching, and Dr. Krowiak and I have written up our variation of the da Vinci® robotic thyroidectomy technique for publication and have been asked to share it with others in the country.
Transoral robotic surgery, or TORS, is a real ground-breaking advancement in head and neck cancer treatment. It might be the single biggest development in the surgical treatment of cancers of the throat in decades. It allows us to remove cancers cleanly and safely that we otherwise could only do by huge surgeries which involve big incisions, sometimes involving even splitting the lower lip and jaw. Now we can do these with no external incisions by working through the mouth using the da Vinci® robot. The two-foot long pencil thin surgical arms of the robot are ideally suited for work through the mouth and deep in the throat. And the high-definition 3D visualization provided by the camera system is superb, and lets us see much better than we can with the naked eye. We are now removing cancers with so much less trauma that patients who previously would be hospitalized for two weeks are now going home in a couple days, often swallowing well with no feeding tubes. This is a real paradigm shift for head and neck surgeons.
Not yet, though I feel that in the future it will be part of the mainstream treatment options for this type of cancer. At present, it is offered in only a select number of tertiary treatment centers, and we are the only ones offering it in Indiana at this point. And we are very fortunate that CENTA was among the first such centers in the US selected for TORS training. In fact, we were the first single specialty private practice group anywhere in the world trained in TORS techniques. We feel pretty special about that accomplishment.