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

1. Introduction

2. Marking and Surgical Approach

1. Position Patient
2. Examine Ultrasound
3. Mark Patient

3. Exposure

1. Conduct Hydrodissection with Epinephrine Solution
2. Dissect Bluntly Using Clamps and Vascular Tunneler via Bilateral Peri-areolar and Axillary Incisions
3. Place Peri-areolar Trocars (8-12 mm)
4. Insufflate with CO2 (5-6 mmHg)
5. Place Axilla Trocars (8-12 mm)

4. Docking the Robot

5. Subplatysmal Flap Dissection under Direct Visualization

6. Thyroid Dissection

1. Open the Strap Muscle at the Median Pharyngeal Raphe
2. Expose the Isthmus, Trachea, and Cricothyroid Cartilage
3. Dissect Strap Muscle with Medial Traction of Thyroid Down to the Carotid
4. Divide Sternohyoid from Sternothyroid Muscle
5. Dissect Strap Muscle with Medial Traction of Thyroid Down to the Carotid
6. Check Vagus Nerve Signal
7. Localize Recurrent Laryngeal Nerve (RLN)
8. Dissect along the RLN
9. Localize and Dissect Superior and Inferior Parathyroid Glands
10. Dissect Ligament of Berry and Isolate Superior Pole Vessels
11. Localize External Branch of Superior Laryngeal Nerve
12. Divide Superior Pole Vessels
13. Check Right Vagus Nerve and RLN Signal
14. Check for Hemostasis & Reapproximate Strap Muscles
15. Extend Axillary Incision
16. Remove Specimen via Endoscopic Retrieval Bag

7. Closure

1. Remove Robot and Trocars
2. Inject Local Anesthetic
3. Suture Incision Sites

8. Post-op Remarks