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Thyroid Surgery Without a Neck Scar

Exploring Scarless Transaxillary Robotic Thyroid Surgery with Dr. Emad Kandil


Updated June 12, 2014

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

emad kandil

Emad Kandil, MD, FACS

One of the lasting effects of thyroid surgery - known as thyroidectomy - is the scar left behind by the incision. The best thyroid surgeons have expertise at carefully positioning the incision so the scar is hidden in a neck crease. In recent years, incisions have gotten smaller, thanks to video assisted surgery techniques. The visual appearance of thyroid scars have certainly improved to a large extent, but thyroidectomy with a neck incision still leaves a visible scar.

Some surgeons are now performing thyroid and neck surgery with robotic assistance, placing the incision in the underarm (axilla) area. This is known as "transaxillary robotic" surgery. The FDA approved this procedure in 2009 and three medical centers are currently using advanced robotics for thyroidectomy. (See Resources).

In addition to the cosmetic benefit of having the only scar in the underarm area - rather than on the neck -- the underarm area has fewer nerve endings per square inch than the throat area, so healing is less painful and with good care, the incision will heal faster than in the neck area.

Emad Kandil, MD, FACS, is Chief of Endocrine Surgery at Tulane University School of Medicine. Dr. Kandil has helped revolutionize and develop transaxillary robotic neck surgery techniques, using intraoperative nerve monitoring to protect the laryngeal (voice box) nerve. Dr. Kandil has participated in this Question and Answer session to help About.com Thyroid site readers learn more about robotic assisted thyroid and neck surgery.

Question: The transaxillary robotic neck surgery is considered an advancement beyond the video-assisted endoscopic surgery that has been increasingly used for thyroid and neck surgery, and endoscopic surgery is considered more state-of-the-art than traditional surgery. Can you tell about these forms of surgery?

Dr. Kandil: Traditional thyroid surgery usually involves a fairly long incision at the base of the neck. A permanent visible scar is possible. More recently, the video-assisted endoscopic surgery of the thyroid and neck has come into use. This surgery is done with a smaller neck incision, using endoscopic visualization with a small camera. This procedure was pioneered in Italy by Dr. Paolo Miccolli and gained popularity in the United States after Dr. David Terris adopted this procedure. I have been offering this procedure to my patients with the addition of a nerve monitoring system - as well as training other surgeons in this technique -- over the last two years. This technique does, however, still result in a scar on the neck.

About Transaxillary Robotic Thyroid Surgery

Question: What is transaxillary robotic assisted thyroid surgery and how is it performed?

Dr. Kandil: Dr. Woong Youn Chung in Seoul, Korea, developed the technique of scarless neck surgery with robotic assistance.

Initially, the robotic neck surgery approach was done with carbon dioxide (CO2) gas insufflation (introduction of gas into the surgical area) to the neck area. The use of gas has the potential to cause some post-surgical side effects, however, as patients can experience pain due to retained gas in the tissues surrounding the lungs (a condition known as pneumomediastinum) or subcutaneous air with crepitations. The pain and discomfort can remain until the gas is eventually absorbed.

Robotic, gasless, transaxillary thyroidectomy is a newly developed, minimally-invasive surgical technique to remove all or part of the thyroid. It is also sometimes called robot-assisted thyroid surgery, or robot-assisted endoscopic thyroid surgery.

With this new approach, gas insufflation is avoided, so problems related to retention of the gas are also avoided.

With this new technique, a small incision is made under the arm, and the specially-designed robotic arms work just like hands, allowing the surgeon to operate with very precise control and movements. The robotic system also allows the surgeon to see in stereo-optic three-dimension (3D), with a specially designed high-definition camera that offers magnification to ten times the normal vision. We also modified the procedure to include the use of routine intraoperative nerve monitoring.

This procedure was recently approved by FDA in 2009 and is proven to be a very safe approach.

Question:Please describe the benefits of transaxillary robotic thyroid surgery compared with traditional thyroidectomy.

Dr. Kandil: A key benefit is that transaxillary robotic surgery does not result in a visible, permanent neck scar.

A risk of thyroid surgery is the risk of injury to the laryngeal nerve, which goes to the voice box. This can cause temporary or permanent hoarseness. Thyroid surgery can also cause trauma to nearby structures, including the parathyroid glands, which are near the thyroid. Parathyroid damage can result in temporary or permanent hypocalcemia, a condition that is treated with calcium supplementation.

From a safety standpoint, in transaxillary robotic thyroid surgery, the use of the high-definition robotic equipment with 10X magnification of the field and 3D vision allows us to perform a very precise operation. This means that there is a reduced likelihood of nerve damage and less risk of trauma to the nearby structures like the laryngeal nerve or parathyroid glands. It's very hard to injure the nearby structures if you can visualize the field at ten times their normal size. We are also able to monitor the nerve function during the entire operation to avoid the risk of postoperative hoarseness.

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