CLINICAL REVIEW David W.

Eisele, MD, Section Editor

Safety of robotic thyroidectomy approaches: Meta-analysis and systematic review

Nicole R. Jackson, BS,1,2* Lu Yao, MD, MS,2 Ralph P. Tufano, MD,3 Emad H. Kandil, MD1

1
Department of Surgery, Division of Endocrine and Oncological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, 2Department of Epidemiology, Tulane
University School of Public Health and Tropical Medicine, New Orleans, Louisiana, 3Department of Otolaryngology–Head and Neck Surgery, Division of Thyroid and Parathyroid
Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Accepted 19 March 2012

Published online 8 March 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23223

ABSTRACT: Background. This study compared the efficacy of robotic
1.35 (95% confidence interval [CI]:
1.69,
1.09). Robotic approach
thyroidectomy via a gasless, axillary approach with conventional cervical operative time was longer than that of the conventional approach (95%
and endoscopic techniques by meta-analysis. CI: 29.23, 54.87), with a trend to be shorter than the endoscopic
Methods. Articles were identified from the following keyword searches: approaches. Robotic surgery had similar risks to open and endoscopic
robotic/robot-assisted thyroidectomy/thyroid surgery. Outcomes included approaches.
operative time, hospital stay, complications, and cosmetic satisfaction Conclusions. Our meta-analysis suggests that robotic thyroidectomy is as
after surgery. Between-group outcome differences were calculated safe, feasible, and efficacious as conventional cervical and endoscopic
using random-effects models. thyroidectomy, showing superior cosmetic satisfaction than that of conventional
Results. In all, 87 publications were identified and 9 studies met thyroidectomy. V
C 2013 Wiley Periodicals, Inc. Head Neck 36: 137–143, 2014

inclusion criteria, totaling 2881 patients, 1122 of whom underwent

robotic thyroidectomy. Those who underwent robotic surgery reported KEY WORDS: minimally invasive, thyroidectomy, robotic, transaxillary,
greater cosmetic satisfaction, with a pooled net mean difference of meta-analysis

INTRODUCTION report in 2008, robotic thyroidectomy has generated much

interest and development.9 Several groups have published
With the emergence of antiseptic techniques in the mid- on their successful experience using the robotic gasless
1800s, thyroidectomy successfully developed into a low- approach.9–11
mortality procedure refined by Dr. Theodor Kocher in the The aim of this study was to examine the efficacy of
late 19th century.1 Since its incipience over a century robotic thyroidectomy in an adult population using a
ago, little has changed procedurally in conventional open meta-analysis. The procedure is evaluated on terms of op-
thyroidectomy. This approach affords direct access to the erative time, postoperative complications, length of hospi-
thyroid and is a relatively fast procedure. Although it has tal stay, postoperative pain scores, and patient cosmetic
improved over time to leave a barely noticeable scar on satisfaction as compared with conventional cervical and
the anterior neck, especially for those with hypertrophic endoscopic techniques.
scarring or keloid formation, an incision in a less readily
visible location is cosmetically advantageous.2,3
Endoscopic thyroid surgery has developed into multiple MATERIALS AND METHODS
approaches that further hide the surgical scar, as well as Identification of trials and data extraction
decrease postoperative neck discomfort.4,5 Although the
endoscopic approach has improved cosmetic outcomes, Two independent reviewers conducted a systematic
the tight space of the neck makes the procedure difficult. review of publications in MEDLINE, EMBASE, the
Indeed, the limited workspace of the neck is a main rea- Cochrane Database of Systematic Review, and Web of Sci-
son why minimally invasive techniques have found ence, and extracted data pertaining to specified outcomes.
delayed application in head and neck surgery.6 Databases were searched until October 2011 using the med-
Robotic surgery has potential for many advantages over ical subject headings (MeSH) terms "robotic surgery’’ and/
both conventional open and endoscopic thyroidectomy, or "robotic thyroidectomy,’’ "robot-assisted thyroidectomy,’’
including improved access and visualization, decreased and "robot-assisted thyroid surgery.’’ The inclusion criteria
tremor translated to instrumentation, and superior range for eligibility were as follows: (1) articles that compared ei-
of motion via the endowrist feature.7,8 Since its initial ther conventional open thyroidectomy to robotic thyroidec-
tomy or conventional endoscopic thyroidectomy to robotic
thyroidectomy; (2) randomized controlled trials, controlled
clinical trials, or observational studies; (3) studies that
*Corresponding author: N. R. Jackson, Department of Surgery, Tulane University reported outcomes of total operative time, length of hospital
School of Medicine, New Orleans, LA. E-mail: [email protected] stay, and postoperative outcomes including transient and

HEAD & NECK—DOI 10.1002/HED JANUARY 2014 137

JACKSON ET AL.

permanent recurrent laryngeal nerve (RLN) palsy/transient

hoarseness, transient and permanent hypoparathyroidism/
hypocalcemia, hematoma, seroma, chyle leakage, postopera-
tive serum thyroglobulin (TG) levels in thyroid cancer
patients, neck and chest pain scores, and cosmetic satisfac-
tion; and (4) studies that reported a measure of variance
(SE, SD, or confidence interval [CI]). Excluded from our
analysis were preclinical studies (cadaveric experience),
studies on a pediatric population, and nonclinical review
articles. In situations where studies were reporting repeat-
edly on a specific group experience, only the most recent
publication by that specific group was included for analysis.
References were reviewed for additional study identifica-
tion. Results of the 2 reviews by the two independent
reviewers were compared for accuracy, with all disagree-
ment resolved by consensus.

Statistical analysis
In the present study, the outcomes were total opera-
tive time, length of hospital stay, patient satisfaction
score, postoperative TG levels in cancer patients, tem-
porary RLN injury, permanent RLN injury, temporary
hypoparathyroidism, permanent hypoparathyroidism, he-
matoma formation, seroma, and chyle leakage. For
those continuous outcomes, such as total operative time
FIGURE 1. PRISMA flowchart demonstrating study selection.
and postoperative TG levels in patients with cancer,
PRISMA; preferred reporting items for systematic reviews and meta-
mean differences between the 2 groups were used as analyses.
primary outcomes, whereas, for those categorical out-
comes, such as length of hospital stay, patient satisfac-
tion score, temporary RLN injury, permanent RLN
injury, temporary hypoparathyroidism, permanent hypo-
parathyroidism, hematoma formation, seroma, and final analysis (Table 1). Two independent reviewers
chyle leakage, an odds ratio was used. DerSimonian and obtained the same search results.
Laird random-effects models were used to pool mean dif-
ferences or odds ratios across the studies. The presence of Description of included trials
heterogeneity was assessed with Q test and the extent of
A total of 2881 patients are represented in this analysis,
heterogeneity was quantified with the I-square index. To
with distribution across open (794 patients), endoscopic
assess publication bias, funnel plots were constructed for
(965 patients), and robotic (1122 patients) approaches to
each outcome. Begg’s rank correlation test was used to
thyroidectomy. Of the 1122 patients undergoing robotic-
examine the asymmetry of the funnel plot, and Egger’s
assisted thyroidectomy, 69 patients underwent the bilat-
weighted linear regression test was used to examine the
eral axillo-breast approach (BABA) and 1053 patients
association between the mean effect estimate and its var-
underwent the gasless, transaxillary approach. Four
iance. Additionally, sensitivity analyses were conducted by
articles directly compared conventional open thyroidec-
excluding each study in turn, to evaluate their relative
tomy with robotic thyroidectomy, 4 articles compared en-
influence on the pooled estimates. All analyses were con-
doscopic thyroidectomy with robotic thyroidectomy, and
ducted in STATA analytical software (version 10; College
1 article used BABA to compare with all 3
Station, TX).
approaches.10,13–20

RESULTS Operative time

Search results All publications reported this outcome, with a signifi-
cant increased mean difference of 42.05 minutes in
In all, 143 references were identified from 4 databases,
robotic thyroidectomy versus open conventional (95% CI:
with an additional article obtained by manual search and
29.23, 54.87).10,14,18,19 However, as compared with endo-
no additional publications identified via reference review.
scopic thyroidectomy, robotic thyroidectomy evidenced a
The Preferred Reporting Items for Systematic Reviews
nonsignificant 20.99-minute shorter procedure (95% CI:
and Meta-Analyses (PRISMA) was followed to obtain the

59.03, 17.05)15,16,18 (see Figure 2).
final group of publications to undergo analysis (see Fig-
ure 1).12 Fifty-seven articles were manually removed as
duplicates, and an additional 78 publications omitted by Length of hospital stay
title and abstract review. All 9 of the remaining publica- All studies reported this outcome, with patients under-
tions underwent full text review and were included in going open conventional thyroidectomy having a

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 SAFETY COMPARISON OF ROBOTIC THYROIDECTOMY: a META-ANALYSIS

TABLE I. Studies selected for inclusion in systematic review.

No. of total
patients
Authors/Reference Year Journal Study type in study Results

Kang et al10 2009 Surg Endosc RT vs. OT 324 Longer operative time in RT, but lower rates of transient hypocalcemia.
in PTC
patients
Lee et al13 2010 Surg Endosc RT vs OT 84 Longer operative time in RT.
Increased postoperative neck discomfort and dysphagia at 1 week and 3
months post-operation in OT. Higher cosmetic satisfaction in RT.
Tae et al14 2011 Surg Endosc RT vs OT 204 Longer operative time and increased drainage in RT, as well as increased
anterior chest pain scores in the first postop week. RT had greater cosmetic
satisfaction.
Lang and Chow15 2011 Surg Endosc RT vs ET 46 RT had a higher pain score on the first day, with similar scores thereafter.
Lee et al16 2011 Ann Surg RT vs ET 259 RT had a shorter mean total operation time for thyroidectomy with central
Oncol compartment neck dissection and a higher number of retrieved central lymph
nodes. RT showed a lower learning curve.
Lee et al17 2011 Ann Surg RT vs ET in 1150 RT had an increased mean number of central nodes retrieved and a higher
Oncol PTMC incidence of transient hypocalcemia.
Kim et al18 2011 World J Surg RT vs OT 302 RT had a longer operative time and drainage, lower postoperative serum
and ET thyroglobulin off thyroid hormone than ET and the same as that of OT.
Tae et al19 2012 Head & Neck RT vs OT 301 RT showed increased transient hypoparathyroidism. Superior cosmetic
in PTC satisfaction reported in RT.
Yoo et al20 2012 J Surg Oncol RT vs ET 211 RT was costlier, had a longer operative time, and increased drainage.
Abbreviations: RT, robotic thyroidectomy; OT, conventional open thyroidectomy; ET, endoscopic (Endo) thyroidectomy; PTC, papillary thyroid cancer; PTMC, percutaneous transvenous mitral
commissurotomy.

significantly increased length of hospital stay, with a Postoperative complications

mean difference compared with robotic thyroidectomy of Robotic surgery was comparable to both open conven-

0.05 (95% CI:
0.44, 0.35). However, there was no sig- tional and endoscopic thyroidectomy in all postoperative
nificant difference in length of hospital stay in the robotic complications, with the exception of a higher risk of tran-
group as compared with that of the endoscopic group, sient hypocalcemia.10,13–20 Specifically, there was an
with a mean difference of
0.007 (95% CI:
0.112, increased risk of this complication in robotic total thy-
0.097)10,13–20 (see Figure 3). roidectomy versus open conventional thyroidectomy of

FIGURE 2. RT vs OT and RT vs ET total operative time. ET, endoscopic thyroidectomy; OT, conventional open thyroidectomy; RT, robotic thyroidectomy.

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JACKSON ET AL.

FIGURE 3. RT vs OT and RT vs ET length of hospital stay. ET, endoscopic thyroidectomy; OT, conventional open thyroidectomy; RT, robotic
thyroidectomy.

TABLE 2. Relative risk of complications in RT versus OT and RT esthesia. There was no difference in neck pain scores
versus ET. between groups. Another study reported only neck pain
and anterior chest pain scores, with the only difference of
Complication Robot vs. p value† Robot vs. p value‡ significance being higher anterior chest pain scores in the
Open Endo first week postoperation in the robotic group, which was
Temporary RLN injury 1.78 .83 0.66 .96 comparable by the first month.14 Lee et al13 reported that
Permanent RLN injury 1.67 .99 1.89 .22 the open conventional group had significantly more com-
Temporary hypocalcemia 0.39 .001 2.37 .06 plaints of hyperesthesia or paresthesia in the neck after 1
Permanent hypocalcemia 0.76 .93 0.81 .56 week and after 3 months. Using postoperative analgesics
Hematoma 0.90 .94 0.73 .34 as a gauge of postoperative pain, researchers found equal
Seroma 1.36 .99 1.79 .62 usage between groups.10
Chyle leakage 2.24 .84 0.98 .44
Abbreviations: RT, robotic thyroidectomy; OT, conventional open thyroidectomy;ET, endo-
scopic (Endo) thyroidectomy; RLN, recurrent laryngeal nerve. Cosmetic satisfaction
†
Value between the open and robot groups.
‡
Value between endoscopic and robot groups.
Three publications, all evaluating robotic versus open con-
ventional thyroidectomy, reported measures of patient cosmetic
satisfaction.13,14,19 Greater cosmetic satisfaction was reported
0.39 (95% CI: 0.13, 1.16),10,13,14,18,19 and a nonsignifi- by patients in the robotic group, all undergoing a gasless, trans-
cant increased relative risk in robotic versus endoscopic axillary approach, with a pooled net mean difference of
1.35
thyroidectomy of 2.37 (95% CI: 1.12, 5.02). There was a (95% CI:
1.69,
1.09)14,19 (see Figure 5).
nonsignificant trend in heterogeneity between groups (I2
¼ 59.4% and p ¼ .06) (Table 2, Figure 4).
Postoperative TG levels
Four articles reported this outcome: 3 analyzing trans-
Postoperative pain axillary robotic versus endoscopic thyroidectomy, and 1
Four studies reported this measure, with all comparing comparing BABA robotic thyroidectomy with open con-
gasless, transaxillary robotic thyroidectomy with open ventional and endoscopic thyroidectomy.14,17,18,20 Authors
conventional thyroidectomy.10,13,14,19 One study reported showed a mean difference of 0.013 (95% CI ¼
0.084,
postoperative pain scores over a 3-month period.19 Here, 0.111) in robotic versus endoscopic thyroidectomy, with
robotic thyroidectomy reported a higher anterior chest both groups having very similar levels (p ¼ .788). There
pain and paresthesia over the first month, but had pain was no difference between robotic and open conventional
scores equal to those of open conventional thyroidectomy groups for this measure (p ¼ .978) (see Figures 6).
thereafter. Conversely, at 3 months postoperation, open In sensitivity analysis, the exclusion of any single study
conventional thyroidectomy reported increased neck par- did not change the result significantly.

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 SAFETY COMPARISON OF ROBOTIC THYROIDECTOMY: a META-ANALYSIS

FIGURE 4. RT vs OT transient hypocalcemia. OT, conventional open thyroidectomy; RT, robotic thyroidectomy.

FIGURE 5. RT vs OT patient cosmetic satisfaction. OT, conventional open thyroidectomy; RT, robotic thyroidectomy.

DISCUSSION tive measures to report between groups. Furthermore,

robotic thyroidectomy was associated with equivalent
The benefits afforded by robotic surgery, such as
postoperative results, a shorter length of hospitalization,
increased visualization and improved dexterity, have led
to its increased implementation. This meta-analysis of and superior patient satisfaction as compared with that of
published articles suggests that robotic thyroidectomy is an open approach. Additionally, 1 study found that
as safe and as effective as both open conventional and en- robotic thyroidectomy eliminated the need for an addi-
doscopic thyroidectomy. Robotic thyroidectomy showed a tional surgical assistant. Postoperative serum TG levels
longer operative time and an increase in temporary hypo- were equivalent between robotic and open conventional
parathyroidism as compared with either alternative thyroidectomy, and lower in robotic as compared with en-
approach. There were no differences in other postopera- doscopic thyroidectomy.

FIGURE 6. RT vs ET postoperative serum TG (ng/mL). ET, endoscopic thyroidectomy; RT, robotic thyroidectomy; TG, thyroglobin.

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JACKSON ET AL.

The 9 studies included in this analysis reported a major-

ity of the outcomes of interest. Included in these reports
was a net finding of increased incidence of transient hypo-
calcemia in robotic thyroidectomy. However, not all
research groups reported this finding. The 2009 study by
Kang et al10 reported more cases of postoperative transient
hypocalcemia in their nonrobotic group as compared with
their robotic group. Limited publications paired with the
varying sample sizes of these studies necessitate further
documentation of this outcome before comparative infer-
ences can be drawn on the postoperative outcomes of this
variable between robotic and nonrobotic approaches.
Potential new complications introduced by robotic thy-
roidectomy include tracheal injury and brachial plexus neu-
ropathy. Of the articles included in this analysis, few
reported any of these complications, thereby limiting their
further analysis. However, these variables warrant discus-
sion and consideration to provide a more complete view of
robotic thyroidectomy, as well as to ensure the safety of
the .patient.21 In our experience, only minor tracheal injury
has been encountered, with intracorporeal repair and no
need to convert to an open cervical approach. The distinc-
tive body positioning implemented in robotic thyroidec- FIGURE 8. The transaxillary approach to thyroidectomy. [Color
tomy, with 180 extension of the arm, introduces the risk figure can be viewed in the online issue, which is available at
of brachial plexus neuropathy not commonly encountered wileyonlinelibrary.com.]
in head and neck procedures. Such risk is reported to be
reduced by proper arm positioning, with the supine
patient’s ipsilateral arm extended at the shoulder, flexed at
Although robotic thyroidectomy is generally associated
the elbow, and fixed to an elevated padded board.23 This is
the current method used by our group and most other with longer operative time due to robot docking and crea-
groups performing this operation. Additionally, somatosen- tion of a workspace for the robot, 2 articles reported a
sory evoked potentials (SSEPs) monitoring for ulnar, radial, decrease in operative time in robotic thyroidectomy asso-
and median nerves, if properly used, are suggested to fur- ciated with increased surgical experience as compared
ther reduce the possibility of brachial plexus nerve injury with endoscopic thyroidectomy.15,16 In the 2011 study by
by intraoperative identification of any stretch on these Lee et al,16 authors reported a lower learning curve in
nerves.22 Successful implementation of this technology has their robotic group as compared with their endoscopic
been reported to be able to detect impending nerve damage group, suggesting that with increased training and experi-
and reactively adjust the patient position so as to avoid fur- ence, robotic thyroidectomy could be performed with
ther, lasting complications22 (see Figure 7). However, there equivalent success at similar speeds. Indeed, other publi-
is a lack of comparative analysis between appropriate arm cations on robotic thyroidectomy have analyzed the learn-
positioning with or without the use of SSEP monitoring. ing curve at various institutions to determine the amount
Appropriate arm positioning should still be considered the of cases a surgeon needs to become efficient in execution
gold standard to minimize the risk of this complication. of this procedure, showing that with increased experience
comes decreased total operative time.23,24
All publications that met our inclusion criteria were
conducted in Asia. The generalizability of our results to
North American practice is limited due to differences in
average body habitus between the populations. The suc-
cess of this procedure depends on the scope of access
that can be achieved through the axilla, which is re-
stricted by increased body tissue, as well as increased
height. Body mass index (BMI) was reported in only 3 of
our analyzed studies, reporting an average BMI of 22.8
kg/m2 in both the endoscopic and the robotic thyroidec-
tomy groups, and a mean BMI of 24.4 kg/m2 in the con-
ventional open group.16,18,20 The remaining 5 studies did
not report BMI values, leaving the average BMI of par-
ticipants represented in this analysis unknown. However,
recent reports of gasless transaxillary robotic thyroidec-
FIGURE 7. Somatosensory evoked potentials electrode tomy conducted in North America indicate that this
placement on the right arm. [Color figure can be viewed in the approach is sustainable in a Western population, with no
online issue, which is available at wileyonlinelibrary.com.] difference in complications between obese and normal-
weight patients (p ¼ .23).25,26

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 SAFETY COMPARISON OF ROBOTIC THYROIDECTOMY: a META-ANALYSIS

Additionally, cases represented in this analysis were of of Public Health and Tropical Medicine, for overseeing
patients with minimally invasive tumors or enlarged thy- methodology and statistical analysis of this study.
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