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Choi Et Al., 2020

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ORIGINAL ARTICLE

pISSN 2288-6575 • eISSN 2288-6796


https://doi.org/10.4174/astr.2020.98.6.307
Annals of Surgical Treatment and Research

Comparative study of bilateral axillo-breast approach


endoscopic and robotic thyroidectomy: propensity score
matching analysis of large multi-institutional data
June Young Choi1,2,*, In Eui Bae3,*, Hyun Soo Kim4, Sang Gab Yoon4, Jin Wook Yi4, Hyeong Won Yu1,2,
Su-jin Kim2,4, Young Jun Chai2,5, Kyu Eun Lee2,4, Yeo-Kyu Youn6
1
Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
2
Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
3
Department of Surgery, Konyang University Hospital, Daejeon, Korea
4
Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
5
Department of Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
6
Yeo-Kyu Youn Thyroid Clinic, St. Peter’s Hospital, Seoul, Korea

Purpose: The aim of this study was to compare the large multi-institutional data of surgical outcomes of bilateral
axillo-breast approach (BABA) robotic (RT) and endoscopic thyroidectomy (ET) and to evaluate the merits of robotic
thyroidectomy.
Methods: From 2004 to 2015, 1,029 patients underwent BABA ET, and from 2008 to 2015, 2003 patients underwent
BABA RT in 3 large volume centers in Korea. Two groups were retrospectively compared in terms of clinicopathologic
characteristics, complications, surgical completeness, and long-term outcomes using propensity score matching analysis.
Results: Both groups had similar demographic characteristics including age, sex, tumor size, pathologic stage, and
hospital stay after matching. Each group had similar rate of transient hypoparathyroidism, however, ET showed
significantly higher rate of permanent hypoparathyroidism (ET 5.2% vs . RT 2.3%, P = 0.05), and transient vocal cord palsy (ET
14.4% vs . RT 9.1%, P = 0.006). Total operation time was longer in the ET group irrespective of surgical extents, including
lobectomy (P = 0.016), total thyroidectomy (P = 0.031), and total thyroidectomy with central lymph node dissection (P = 0.019).
The rate of patients with off-Tg under 1.0 ng/mL after 1st ablation was significantly higher in RT than ET group (ET 64.6%
vs . RT 92.7%, P < 0.001). In long-term follow-up of cancer patients, 1.4% experienced recurrence after ET (10 cases), while
0.3% cases experienced recurrence after RT (5 cases) (P < 0.001).
Conclusion: Both ET and RT can be safe and effective methods to treat thyroid diseases. However, the application of robotic
system may help to overcome the limitations of the instruments and surgeon’s skills.
[Ann Surg Treat Res 2020;98(6):307-314]

Key Words: Minimally Invasive surgical procedures, Propensity score, Robotic surgical procedures, Thyroidectomy

INTRODUCTION in 1996 in the concept of avoiding anterior collar incision by


Gagner [1]. Thence, various methods for thyroid surgery have
An endoscopic approach for neck surgery was first introduced been presented [2-5]. However, endoscopic method encloses

Received November 28, 2019, Revised January 30, 2020, *June Young Choi and In Eui Bae contributed equally to this study as co-
Accepted March 6, 2020 first authors.
Corresponding Author: Kyu Eun Lee Copyright ⓒ 2020, the Korean Surgical Society
Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, cc Annals of Surgical Treatment and Research is an Open Access Journal. All
Jongno-gu, Seoul 03080, Korea articles are distributed under the terms of the Creative Commons Attribution Non-
Tel: +82-2-2072-0393, Fax: +82-2-766-3975 Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which
E-mail: kyueunlee@snu.ac.kr permits unrestricted non-commercial use, distribution, and reproduction in any
ORCID: https://orcid.org/0000-0002-2354-3599 medium, provided the original work is properly cited.

Annals of Surgical Treatment and Research 307


Annals of Surgical Treatment and Research 2020;98(6):307-314

several shortages, especially for malignant tumor resection, Preoperative diagnoses of thyroid nodules were assisted
such as 2-dimensional image, dependency on camera operator’s by ultrasound and ultrasound-guided fine-needle aspiration
proficiency, and nonflexible instruments consenting limited cytology. Computed tomography was performed to evaluate
movement [6,7]. tumor location and cervical lymph node metastasis. All female
Some of these limitations have been overcome by the use patients underwent physical examination of the breast to detect
of robotic systems for thyroid surgery. The robot provides a breast lumps. Thyroid lobectomy was considered in patients
view magnified 15-fold, a 3-dimensional surgical view and with small (<1 cm), unifocal, intrathyroidal malignant nodules
flexible arms. Using the robotic system allows the operator to without radiologically or clinically involved cervical nodal
also perform the work of the camera operator simultaneously. metastases. Most patients with malignant thyroid carcinoma
The robot facilitates precise manipulations during parathyroid also underwent prophylactic ipsilateral central compartment
and recurrent laryngeal nerve (RLN) preservation, and central lymph node dissection. Some patients suspected of having
lymph node dissection. metastases in a few lymph nodes on preoperative imaging also
One remote approach is the bilateral axillo-breast approach underwent selective lateral neck dissection.
(BABA), developed in our institutions in 2004 [5]. Since the
introduction of BABA robotic thyroidectomy (RT) in 2008 [8], Operative methods
our institutes have used BABA endoscopic thyroidectomy (ET) The procedures used for ET and RT have been described
for over 1,000 patients and BABA RT in over 2,000. [6,12,13]. The first steps of ET and RT were similar. Under
Although BABA ET and RT have been individually compared general anesthesia, the patient was placed in a supine position,
with conventional open surgery [2,9-11], few studies have with the neck extended. After draping, landmarks and
directly compared BABA ET with BABA RT [12,13]. The aim of trajectory lines were drawn on the patient’s chest and neck.
this study was to compare surgical outcomes and completeness Hydrodissection, or the subcutaneous injection of epinephrine
of BABA ET and RT, to prove the process of transition from ET mixed with 0.9% NaCl solution (1:200,000) under the working
to RT is eligible. space, enabled insertion of 8- to 12-mm ports through incisions
of bilateral breast areolae and axillary folds. The flap extended
METHODS from 2 cm below the clavicle to the thyroid cartilage superiorly
and beyond the medial border of the sternocleidomastoid
Patients muscle laterally. The working space was created by insufflating
This retrospective, propensity score-matched study analyzed low pressure (5–6 mmHg) carbon dioxide (CO2) gas through
patients who underwent ET or RT using the BABA method one of the ports. The midline division between strap muscles
for benign or malignant thyroid diseases between February, was made for ET, whereas additional steps of robot docking
2004, and March, 2015. All operations were performed by were needed for RT. The camera was inserted through the right
surgeons in the departments of surgery at 3 institutions, breast port, and robot arms were equipped with energy devices
Seoul National University Hospital, Seoul National University or graspers (Prograsp and Maryland forceps, Intuitive Surgical
Bundang Hospital, and Seoul National University Boramae Inc., Sunnyvale, CA, USA).
Medical Center. The protocol of the study was approved by After separating the midline of the strap muscles, the thyroid
the Institutional Review Board of Seoul National University isthmus was divided with the ultrasonic shears. Each thyroid
Bundang Hospital (B-1610/366-104). Eligible informed consent lobe was dissected, as well as each central lymph node, if
was got from the enrolled patients. necessary, while identifying and preserving the parathyroid
Indications for BABA ET included benign thyroid nodules glands and RLN. The resected specimen was removed, while
or follicular neoplasms of size <5 cm or malignant thyroid wrapped in an endoscopic plastic bag, through the left axillary
nodules at low risk (age <45 years, tumor size <2 cm, and port. The contralateral lobe was dissected in the same manner.
no evidence of local invasion, lymph node metastasis, or After meticulous hemostasis, the midline was closed with
distant metastasis), and those who underwent completion endosutures. For selective lateral neck dissection in RT, the
thyroidectomy after initial endoscopic or robotic lobectomy. sternocleidomastoid muscle was retracted with a double looped
Additionally, indications of BABA RT included Graves’ disease, polydioxanone (PDS*II, Ethicon Inc., Cincinnati, OH, USA).
benign thyroid nodules up to 8 cm in size, male patients, and
obese patients. Patients were excluded from ET and RT if they Follow-up
had undergone previous neck surgery, had distant metastasis All patients were followed as out-patients at 2 weeks, 3
or definite tumor invasion of adjacent organs, or lesions months, and 6 months after surgery. RLN function and vocal
located in the posterior part of the thyroid gland near the cord abnormalities were evaluated by video laryngoscopy
tracheoesophageal groove or Berry’s ligament. during the second postoperative week. Patients with vocal cord

308
June Young Choi, et al: Comparison of endoscopic and robotic BABA thyroidectomy

abnormalities were assessed by repeat laryngoscopy until vocal included all patients with stage III and IV tumors; all stage
cord function was restored. Transient vocal cord paralysis was II patients aged ≥45 years; most stage II patients aged <45
defined as the recovery of vocal cord function within 6 months years, and selected stage I patients with multifocal nodules,
after the operation, whereas permanent vocal fold paralysis nodal metastasis, extrathyroidal extension, or other aggressive
was defined as the persistence of the vocal cord abnormality for histology according to the American Joint Committee on Cancer
more than 6 months after surgery. Cancer Staging 8th edition [14]. Thyroid-stimulating hormone
Serum concentrations of total calcium, ionized calcium, (TSH)-stimulated serum thyroglobulin level (stimulated-Tg) was
phosphorus, and parathyroid hormone (PTH) were measured measured prior to administration of 131I. On the second day
to assess postoperative hypoparathyroidism. Transient after RAI, 131I whole-body scan was performed. TSH-suppressed
postoperative hypoparathyroidism while hospitalized was serum thyroglobulin level (suppressed Tg) was measured
defined as the presentation of hypocalcemic symptoms with 3 months after the surgery in patients with differentiated
serum total calcium level <8 mg/dL. Permanent postoperative thyroid carcinoma who did not undergo RAI ablation. All cancer
hypoparathyroidism was defined as a prolonged need for an patients underwent ultrasound and Tg annually.
oral calcium supplement and serum PTH level <15 pg/mL
lasting longer than 6 months. Statistical analysis
If warranted, radioactive iodine (RAI) ablation was performed Clinicopathologic characteristics, surgical outcomes,
8–12 weeks after thyroidectomy. Indications for RAI ablation surgical completeness, postoperative complications, and

Table 1. Clinicopathologic characteristics


Characteristic ET (n = 1,029) RT (n = 2,003) P-value

Age (yr) 38.4 ± 8.86 39.3 ± 9.90 0.821


Sex ratio (n)
Male:female 1:34.5 (29:1,000) 1:7.8 (227:1,776) <0.001
Mean tumor size on preoperative USG (cm)
Malignant or suspicious malignant 1.02 ± 0.96 0.84 ± 0.69 0.183
Indeterminate or benign looking 3.11 ± 1.38 2.55 ± 1.43 0.095
Extent of the operation
Total thyroidectomy alone 145 (14.1) 115 (5.7) <0.001
Total thyroidectomy with CND 334 (32.5) 1375 (68.6) <0.001
Total thyroidectomy with LND 29 (2.8) 116 (5.8) 0.004
Subtotal or lobectomy 443 (43.1) 367 (18.3) <0.001
Completion lobectomy 78 (7.6) 29 (1.4) <0.001
Operation for recurrent disease 0 (0) 1 (0.1) NS
Pathologic classification
Papillary cancer 617 (60.0) 1649 (82.5) <0.001
Follicular variant papillary cancer 48 (4.7) 55 (3.0) 0.025
Follicular cancer 61 (5.9) 24 (1.2) <0.001
Medullary cancer 1 (0.1) 2 (0.1) 0.554
Graves’ disease 10 (1.0)a) 50 (2.5)b) 0.007
Adenomatous goiter 292 (28.4) 230 (13.0) <0.001
Others 4 (3.9) 4 (0.2) 0.559
AJCC 8th stage
I 530 (72.9) 1367 (79) NS
II 27 (3.7) 106 (6.1) NS
III 181 (24.9) 224 (12.9) NS
IVa 1 (0.1) 5 (0.3) NS
Number of retrieved central lymph nodes 3.0 ± 3.63 5.2 ± 4.78 <0.001
Cancer recurrence on follow-up 10 (1.4) 5 (0.3) <0.001
Hospital stay (day) 3.3 ± 0.78 3.2 ± 0.72 0.784
Follow-up period (mo) 76.2 (6–132) 56.2 (5–96) 0.109

Values are presented as mean ± standard deviation, number (%), or median (range).
ET, endoscopic thyroidectomy; RT, robotic thyroidectomy; USG, ultrasonography; CND, central neck dissection; LND, lateral neck
dissection; AJCC, American Joint Committee on Cancer.
a)
Four patients had papillary cancer. b)Eleven patients had papillary cancer.

Annals of Surgical Treatment and Research 309


Annals of Surgical Treatment and Research 2020;98(6):307-314

long-term results were compared in the ET and RT groups. Comparison of surgical complications
To reduce selection and information bias between these The matched groups of patients in the ET and RT groups
groups, propensity score matching was performed based on had similar rates of transient hypoparathyroidism after total
9 covariates: mean age; mean tumor size; and percentages of thyroidectomy (31.7% vs. 28.0%, P = 0.303), but the ET group had
patients who were female, underwent total thyroidectomy, a significantly higher rate of permanent hypoparathyroidism
and had thyroiditis, malignancy, multifocality, extrathyroidal (5.2% vs . 2.3%, P = 0.05) (Table 3). The ET group had a higher
extension, and lymph node metastasis. Data were analyzed rate of transient vocal cord paralysis than the RT group (14.4%
using IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA), vs. 9.1%, P = 0.006), but the difference had become statistically
with a P-value less than 0.05 considered statistically significant. insignificant 3–6 months postoperatively (0.8% vs . 0.2%, P =
0.219). The rates of other complications, including postoperative
RESULTS bleeding, tracheal or esophageal injury, and infection, were
very low, and the differences not statistically significant. Total
Clinicopathologic characteristics of the patients operation time was longer in the ET than in the RT group,
The mean ages of the ET and RT groups were 38.4 ± 8.86 irrespective of the extent of surgery, including in patients who
and 39.3 ± 9.90 years, respectively (Table 1). RT was performed underwent lobectomy or subtotal thyroidectomy (P = 0.016),
more frequently in male patients (P < 0.001), in patients who total thyroidectomy (P = 0.031), and total thyroidectomy with
underwent total thyroidectomy with or without lymph node central lymph node dissection (P = 0.019) (Table 4).
dissection (P < 0.001–0.004), in patients with malignancy (P <
0.001–0.025), and in patients with Graves’ disease (P = 0.007). Comparison of surgical completeness and
ET was performed more frequently than RT in patients who recurrence of disease
underwent completion thyroidectomy (7.6% vs. 1.4%, P < 0.001). Surgical completeness was evaluated by the results of the
The mean number of central lymph nodes retrieved per patient first RAI ablation. The median stimulated-Tg concentration after
was significantly greater in the RT than in the ET group (5.2 ± the first RAI ablation was 1.55 ng/mL in the ET group and 0.58
4.78 vs. 3.0 ± 3.63, P < 0.001). ng/mL in the RT group (P = 0.009) (Table 5). The percentage of
patients with stimulated-Tg concentration <1.0 ng/mL after the
Propensity score matching first ablation was significantly higher in the RT than in the ET
Propensity score matching was performed between group (92.7% vs. 64.6%, P < 0.001). The median follow-up period
the 2 groups, and 605 matched pairs were yielded. Nine was 76.2 months (range, 6–132 months) in the ET group and
covariates were used; number of females, mean age, mean 56.2 months (range, 5–96 months) in the RT group. Ten of 408
tumor size, number of thyroiditis, total thyroidectomy,
malignancy, multifocality, extrathyroidal extension, and
Table 3. Comparison of surgical complications after propensity
lymph node metastasis (Table 2). There were no longer score matching
significant differences, which observed before matching, in
clinicopathologic characteristics between the 2 groups. Variable ET (n = 605) RT (n = 605) P-value
Transient 121/382 (31.7) 109/389 (28.0) 0.303
hypoparathyroidisma)
Permanent 20/382 (5.2) 9/389 (2.3) 0.050
hypoparathyroidisma)
Transient RLN paralysis 87/605 (14.4) 55/605 (9.1) 0.006
Table 2. Result of propensity score matching using 9 covariates
Permanent RLN 5/605 (0.8) 1/605 (0.2) 0.219
Matched variable ET (n = 605) RT (n = 605) P-value paralysis
Postoperative bleeding 1/605 (0.2) 0/605 (0) >0.999
No. of females 584 (96.5) 587 (97.0) 0.745 Tracheal injury 1/605 (0.2) 0/605 (0) >0.999
Age (yr) 39.0 ± 9.16 37.9 ± 10.02 0.907 Esophageal injury 0/605 (0) 0/605 (0) NS
Tumor size (cm) 1.41 ± 0.98 1.45 ± 1.07 0.827 Wound infection 4/605 (0.7) 3/605 (0.5) 0.997
Thyroiditis 199 (32.9) 196 (32.4) 0.934 Horner’s syndrome 2/605 (0.3) 2/605 (0.3) >0.999
Total thyroidectomy 382 (63.1) 389 (64.3) 0.719 Skin injury/burn 2/605 (0.3) 0/605 (0) >0.999
No. of malignancy 408 (67.4) 407 (67.3) 1.000 Pneumothorax 1/605 (0.2) 0/605 (0) >0.999
Multifocalitya) 251 (61.5) 262 (64.4) 0.442 Conversion to open 1/605 (0.2) 0/605 (0) >0.999
Extrathyroidal extensiona) 243 (59.6) 264 (64.9) 0.136 surgery
Lymph node metastasisa) 156 (38.2) 170 (41.8) 0.338
Values are presented as number (%).
Values are presented as number (%) or mean ± standard deviation. ET, endoscopic thyroidectomy; RT, robotic thyroidectomy; RLN,
ET, endoscopic thyroidectomy; RT, robotic thyroidectomy recurrent laryngeal nerve.
a) a)
In cancer patients. PTH < 15 ng/mL.

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June Young Choi, et al: Comparison of endoscopic and robotic BABA thyroidectomy

Table 4. Comparison of operation times (min)a)


Overall Propensity score matching
Variable
ET (n = 1,029) RT (n = 2,003) P-value ET (n = 605) RT (n = 605) P-value

Total thyroidectomy only 149.7 ± 37.6 116.1 ± 36.8 0.015 147.1 ± 38.3 117.5 ± 39.5 0.031
Total thyroidectomy with CND 165.3 ± 38.1 121.6 ± 41.6 0.027 171.3 ± 35.2 120.4 ± 39.6 0.019
Total thyroidectomy with CND and LND 259.4 ± 69.1 241.5 ± 78.3 0.284 271.2 ± 73.3 240.6 ± 72.2 0.107
Subtotal or lobectomy 135.7 ± 49.6 98.7 ± 34.1 0.035 126.5 ± 51.7 92.1 ± 36.9 0.016
Completion lobectomy 115.0 ± 39.1 98.1 ± 49.0 0.067 - - -

ET, endoscopic thyroidectomy; RT, robotic thyroidectomy; CND, central neck dissection; LND, lateral neck dissection.
a)
From skin incision to skin closure.

Table 5. Comparison of surgical completeness after first radioiodine (RAI) ablation


Overall Propensity score matching
Variable
ET (n = 1,029) RT (n = 2,003) P-value ET (n = 605) RT (n = 605) P-value

No. of patients who underwent RAI 326/726 950/1,728 NS 175/382 191/389 NS


ablationa) (44.9) (54.9) (45.8) (49.1)
Stimulated-Tg after first RAI ablation 1.64 0.71 0.021 1.55 0.58 0.009
(ng/mL) (<0.2–55.1) (<0.2–79.8) (<0.2–55.1) (<0.2–47.2)
No. of patients with stimulated-Tg 196/326 863/950 <0.001 113/175 177/191 <0.001
<1.0 ng/mL after first RAI ablation (60.1) (90.8) (64.6) (92.7)

Values are presented as number (%) or median (range).


ET, endoscopic thyroidectomy; RT, robotic thyroidectomy; Tg, thyroglobulin.
a)
In patients with total thyroidectomy due to differentiated thyroid cancer.

Robot contralateral lobe, 2 cases in the operative bed, 1 case in the


Endoscopic
lateral neck lymph nodes. The 5-year recurrence-free survival
100
rates were 98.7% in the ET group and 99.7% in the RT group (P
< 0.001) (Fig. 1).
Recurrence-free survival (%)

95 P < 0.001

DISCUSSION
90
The incidence of thyroid cancer had been increasing
markedly worldwide. This increase may be due primarily to
85 increases in screening rates, although the exact cause has
not yet been determined [15]. Indications for thyroid surgery
have also been expanding to include various benign thyroid
80
0 20 40 60 80 diseases, as well as thyroid cancer. For example, thyroidectomy
Duration of follow-up (mo) is performed on patients with uncontrolled Graves’ disease,
huge nodular hyperplasia, and follicular neoplasm, which
Fig. 1. Recurrence-free survival of propensity score-
matched patients with malignancy (ET = 408, RT = 407). ET,
cannot be determined by fine needle aspiration cytology [16].
endoscopic thyroidectomy; RT, robotic thyroidectomy. Because conventional thyroid surgery cannot avoid making an
anterior collar incision, scarring is of great concern, especially
in young female patients. Methods to reduce surgical scarring
patients (1.4%) in the ET group and 5 patients of 407 (0.3%) in in thyroid surgery include minimally invasive video-assisted
the RT group experienced recurrence of malignancy (P < 0.001). thyroidectomy, video-assisted neck surgery [17,18], scarless
In the ET group, 3 cases were recurred in the contralateral endoscopic thyroidectomy [19], and BABA and transaxillary
lobe, 3 cases in the operative bed, 4 cases in the lateral neck methods [5,20].
lymph nodes. In the RT group, 2 cases were recurred in the Surgical outcomes have been reported for 512 patients who

Annals of Surgical Treatment and Research 311


Annals of Surgical Treatment and Research 2020;98(6):307-314

underwent BABA ET and 1,026 who underwent BABA RT at our levels <1.0 ng/mL, an indicator of successful treatment, was
institution [6,12]. One of the primary advantages of BABA is significantly higher in the RT group, both before and after
the symmetric surgical view exposing clear anatomic markers, propensity score matching. At a long-term, 5-year follow-up,
allowing surgeons to operate in equivalent circumstances on the recurrence rates in the 2 groups were low and similar to
both sides of the thyroid glands. Moreover, the BABA methods those reported previously [5,23]. A comparison of the 2 groups
of ET and RT have demonstrated feasibility and surgical showed that the rate of recurrence of malignant thyroid disease
completeness [7,9,10,21,22]. BABA was associated with low was lower in the RT group, with 5-year recurrence-free survival
rates of postoperative complications and recurrence, as well as rates of 99.7% in the RT group and 98.7% in the ET group.
satisfaction with cosmetic outcomes. There were a few concerns about utilizing the BABA for
The current study was performed to compare the surgical thyroid surgery. The first was the possibility of postoperative
outcomes and completeness of ET and RT using BABA methods. chest paresthesia due to the skin flap made underneath the
Prior to propensity score matching, the BABA ET and RT groups anterior chest wall during the BABA operation. However,
differed significantly in gender distribution, the extent of sensory impairment of the anterior chest was reported to be
the operation, pathologic characteristics, number of central temporary, improving within 3 months after surgery [24,25].
lymph nodes, and recurrence rates. Following propensity score Indeed, none of the patients in the current study complained
matching based on 9 covariates, the 2 groups did not differ of chest paresthesia 3 months after surgery. Another concern
significantly in the above characteristics. Thus, propensity score about BABA regarded the complications related to CO2 toxicity
matching balanced the covariates and minimized the baseline [26]. CO2 insufflation in the neck has been reported to cause
discrepancies between the 2 groups. serious problems, including subcutaneous emphysema,
A comparison of postsurgical complications showed that pneumomediastinum, and absorption of CO 2 into the
rates of postoperative hypoparathyroidism and RLN paralysis bloodstream. However, insufflations of up to 9 mmHg of CO2
were lower in the BABA RT than in the BABA ET group, has been regarded as safe from the complications of toxicity
both before and after propensity score matching. Rates of [27,28]. Furthermore, a low insufflations pressure, of 5–6
permanent hypoparathyroidism and transient RLN paralysis mmHg, was regarded as sufficient to visualize the surgical
were significantly lower in the BABA RT than the BABA ET field, and none of patients in this study experienced any of the
group. Rates of transient hypoparathyroidism were similar in above complications. Finally, concerns were raised about tumor
both groups, and it was probably due to the thorough central dissemination during specimen removal, but this could be
neck dissection according to the policy of our institute. Rates of resolved by using an endoscopic bag through the axillary port.
wound infection were also significantly lower in the RT group The current study had several limitations, including its
before matching, but the percentages after matching were too retrospective design. Prospective, randomized controlled trials
low to assess statistical differences. Although all other surgical are required to determine the superiority of BABA RT over BABA
complications, such as postoperative bleeding, adjacent organ ET. In addition, most surgeons who took part in this study had
injury, skin injury, and conversion to open surgery, did not experience with ET prior to gaining experience with RT. This
differ significantly in the 2 groups, the rate of each in the RT may have affected operating times and surgical completeness.
group was equal to or lower than the rate in the ET group. In conclusion, BABA ET and RT are safe and effective
Operation time was significantly shorter in the BABA RT methods of managing various thyroid diseases. Use of the
than in the BABA ET group, both before and after matching, robotic system, however, may help overcome the limitations
regardless of the extent of surgery and despite the time of instruments and surgeon’s skill, especially in patients with
required for robot docking and exchanging robot arms in BABA malignant diseases.
RT. The time required for total thyroidectomy plus lateral neck
dissection did not differ significantly in the ET and RT groups, ACKNOWLEDGEMENTS
perhaps due to the additional procedure required for lateral
traction of the sternocleidomastoid muscle. Conflict of Interest
Surgical completeness of ET and RT was assessed by No potential conflict of interest relevant to this article was
measuring serum Tg level, especially stimulated-Tg level reported.
after first RAI ablation therapy in cancer patients. The serum
concentration of stimulated-Tg is considered a reliable indicator ORCID iD
of remnant thyroid tissue after total thyroidectomy. The June Young Choi: https://orcid.org/0000-0001-9990-607X
median stimulated-Tg concentration after first ablation therapy In Eui Bae: https://orcid.org/0000-0002-9220-8815
was significantly lower in the RT than in the ET group. More Jin Wook Yi: https://orcid.org/0000-0002-9296-8443
importantly, the percentage of patients with stimulated-Tg Hyeong Won Yu: https://orcid.org/0000-0001-7338-5157

312
June Young Choi, et al: Comparison of endoscopic and robotic BABA thyroidectomy

Su-jin Kim: https://orcid.org/0000-0001-5511-3596 Formal Analysis: IEB, JYC, HWY, YJC


Young Jun Chai: https://orcid.org/0000-0001-8830-3433 Investigation: IEB, JYC, KEL
Kyu Eun Lee: https://orcid.org/0000-0002-2354-3599 Methodology: HSK, SGY, JWY. SK
Yeo-Kyu Youn: https://orcid.org/0000-0003-2349-4624 Project Administration: YJC, YKY
Writing – Original Draft: IEB, JYC, KEL, SK
Author Contribution Writing – Review & Editing: HSK, SGY, JWY, HWY, YJC, YKY
Conceptualization: KEL, YKY

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