1. Preoperative Setup

A. Patient Positioning

Place the patient in supine position, with right arm extended cephalad to expose the axilla. Rest arm at approximately 25 degrees above the table in an arm board to minimize dissection distance from skin incision to thyroid.
Place a shoulder pillow beneath the patient’s shoulder and back, rest a gel donut under the patients head, and slightly extend the neck. This patient orientation will rotate and lower the medial aspect of the clavicle and facilitate thyroid exposure. To decrease the possibility of shoulder injury, place patient’s left arm alongside the body, and pad pressure points and bony prominences.

(Figure 1)
(Figure 2)

B. Anatomical Landmarks and Incision Location

a. Anatomical Landmarks: Establish the anterior axillary Line. Next, mark the location of the clavicular notch and thyroid using a sterile pen. Draw a vertical line from the midline of the thyroid to the sternal notch.
b. Superior Limit of Incision: Draw an oblique line from the area between the hyoid bone and the laryngeal prominence of the thyroid cartilage to the axilla.
c. Inferior Limit of Incision: Draw a transverse line from the sternal notch laterally.
d. Location of Incision:Connect the ends of the lines at the right axilla to define the incision location, sized in approximately 5-6cm.
e. 3rd Arm Port: Place 2 cm superior and 6-8 cm medial to the right nipple (between the breast and sternum).

(Figure 3)
(Figure 4)

C. Port Placement

a. da Vinci Camera Port, 12mm: Position the camera in the center of the incision anteriorly, just posterior to the retractor.
b. da Vinci Instrument Arm 1, 5mm: Position the cannula in the superior limit of the incision with the remote center just inside the edge of the skin.
c. da Vinci Instrument Arm 2, 8mm: Position the cannula in the inferior limit of the incision with the remote center just inside the edge of the skin.
d. da Vinci Instrument arm 3, 8mm: Create the skin incision and place the cannula between the platysma muscle and pectoralis fascia.

(Figure 5)
(Figure 6)
(Video 1)

2. Making the working space

A. Flap dissection

a. procedure
Utilize hand-held cautery to create a 5-6 cm longitudinal incision along the anterior axillary Line. Extend dissection through the subplatysmal plane by retracting the axilla skin flap anteromedially, and continuing dissection anterior to the pectoralis muscle in the direction of the thyroid. Continue dissection and adjust hand-held cautery tips as necessary.
A change in muscle fiber direction will indicate transition to the sternocleidomastoid muscle.
Proceed with dissection through the avascular plane between the sternal head and clavicular head of the sternocleidomastoid and beneath the strap muscle.
Extend the dissection until the contralateral lobe of the thyroid is exposed.
b. Keynote
Proper avascular subplatysmal plane development
Identification of the following: sternal and clavicular heads of sternocleidomastoid.
Identification of strap muscles, jugular vein, omohyoid muscle, and carotid artery.
Exposure of ipsilateral and contralateral lobe of thyroid.

(Video 2)
(Video 3)

B. Retractor Blade Positioning

- A thyroid retractor system will provide consistent exposure of the working space, in addition to aiding smoke evacuation during electrosurgery.
- Insert the retractor blade through the axillary incision to raise the skin flap, sternal head of the SCM, and strap muscles.
- Further retraction of the omohyoid muscle will bring the right lateral thyroid in view.
- Aim the retractor toward the thyroid and attach the table mount to the OR table above the patient’s left shoulder and set the arm to extend diagonally across the patient’s left shoulder towards the Thyroid.
- Attach the blade to the mount and lift slowly using the lifting mechanism on the table mount.
- Aim to establish approximately 4cm of posterior-anterior exposure without inadvertently raising the patient from the shoulder roll.

(Figure 7)

3. Patient Cart Positioning and Instrumentation

A. Procedure

- Ensure that the patient cart is positioned contralateral to the skin incision (e.g., patient cart on the left side of the patient for a right-side approach).
- Align the LED-3rd Joint-Center Column with the axis of the retractor (approximately 60-85 degrees to the table).
- Position the camera arm 2nd Set-up Joint towards the patient’s head to insure maximum clearance for instrument arm.
- Center the camera arm with the center of the incision in the patient’s right axilla.
- To prevent collisions between the robotic arms, the introduction angle should be different. The the camera arm is contact the bottom of the axillary incision entrance and inserted to upward direction until the internal camera tip is located just below the retractor blade (introduced down to upward direction). The HarmonicTM curved shear and 5-mm Maryland dissector arms should be inserted through the opposite way (up to downward direction). Finally the external three LEDs of the robotic arms in the armpit should form an inverted triangle.

B. Keynote

- Equal spacing between each da Vinci arm.
- Atraumatic adjustment of instrument arms utilizing port clutch button.
- Accurate understanding of how master manipulation will relate to external instrument arm movement.

(Figure 8)
(Figure 9)
(Video 4)

4. Thyroidectomy

(Video 5)

A. Superior Pole Dissection

a. Procedure
- Upon identification of the upper pole, utilize the ProGrasp forceps to retract the upper pole infero-medially to facilitate the identification of the superior thyroid vessels.
- Utilize the Harmonic curved shears close to the gland to prevent inadvertent damage to the external branch of the external laryngeal nerve.
- Identify the superior thyroid artery utilizing Harmonic curved shears. Detach the upper pole of the thyroid from the cricopharyngeal and cricothyroid muscles until the superior parathyroid gland is identified and preserved.
- Utilize the snake-like wrist architecture of the Maryland dissector (turning radius) to prevent cephalad structures from obstructing the surgical field.
- Utilize smooth, sweeping lateral movements to establish proper planes and delineate arterial structures.
- Re-establish the ProGrasp forceps with proper tension by regrasping the thyroid gland as dissection is continued downward.
b. Keynote
- Identification of superior thyroid artery and vein.
- Collision-free retraction of the thyroid.
- Utilization of 5mm snake-wrist to maximize operative field.
- Toggling from active / deactive instrument arm during thyroid retraction.
- Proper clutching maneuvers to maintain neutral/ergonomic operating position.

(Figure 8)
(Figure 9)

B. Inferior Pole Dissection

a. Procedure
- Utilize the ProGrasp forceps to retract the thyroid superomedially.
- Establish equal and opposite tension using the Maryland to stabilize the thyroid as dissection is continued inferiorly.
- Expose the common carotid and inferior thyroidal arteries. Detach lymph nodes in the pretracheal area from the cervical thymic tissues and continue dissection towards the suprasternal notch.
- Slow sweeping movements with the Harmonic curved shears can be applied to sweep vessels laterally.
- Careful attention paid to recurrent laryngeal nerve traveling parallel to the dissection plane.
b. Keynote - Identification of recurrent laryngeal nerve
- Multi-directional 3rd-arm retraction of thyroid.
- Importance of fine, fluid wrist movements to prevent external collisions and atraumatic dissection.

(Video 6)

C. Recurrent Laryngeal Nerve Dissection and Preservation

a. Procedure
- Upon identification of the recurrent laryngeal nerve (RLN), continue dissecting medial structures to allow the RLN to fall away laterally.
- Additionally, identify the ligament of Berry (posterior suspensory ligament) and divide to allow further displacement of RLN from the trachea.
- Isolate and trace the whole cervical course of the RLN.
Identify the superior parathyroid gland during RLN tracing
(if the superior Parathyroid Gland could not be identified in Step A).
b. Keynote
- Atraumatic retraction of the recurrent laryngeal nerve
- Identification of superior parathyroid gland and posterior thyroid access.
- Accurate identification and division of posterior suspensory ligament of thyroid (Berry's ligament).
- Appropriate techniques for Harmonic curved shears usage and thermal spread management.

(Video 7)

D. Thyroid Detachment & Division of Isthmus

a. Procedure
- Activate the 3rd arm (ProGrasp forceps) to retract medially in order to access the base of the thyroid (attached to the trachea).
- Continue dissection in alternating inferior to superior manner toward the midline.
- Utilize Maryland to provide lateral tension as thyroid is displaced from the trachea.
- Utilize the 3rd arm to retract the contralateral lobe.
- The Maryland dissector can now be used to retract the right lobe laterally in order to establish tension on the Isthmus.
- Transect the isthmus using the Harmonic curved shears.
b. Keynote
- Atraumatic thyroid release from the trachea
- Reinforce electro-cautery techniques to minimize thermal spread.
- Collision-free retraction of the contralateral lobe.

E. Central Compartment Neck Dissection (Option)

a. Procedure
- Initiate the central compartment neck dissection (CCND) along the carotid arteries laterally, hyoid bone superiorly, and suprasternal notch inferiorly.
- Continue the dissection below the sternal notch at the level of the carotid artery arcade.
- In addition, lymph nodes are presented both anterior and deep to the right RLN.
- The RLN can be dissected inferiorly to the level of the clavicle to achieve atraumatic mobilization of the surrounding lymph node bearing tissue.
b. Keynote
- Accurate identification of the RLN.
- Atraumatic mobilization of lymph nodes.
- Distal ligation of inferior thyroidal artery.
- Central compartment exploration of inferior/superior/medial/lateral boundaries.
- Collision-free manipulation of camera arm and instrument arms.

F. Contralateral Thyroidectomy

a. Procedure
- After removal of the ipsilateral specimen, repeat the procedure steps on the contralateral side of the thyroid gland.
- The ProGrasp forceps can now be utilized to provide lateral or medial retraction of the thyroid.
- Contralateral thyroidectomy usually proceeds with subcapsular dissection to preserve the parathyroid gland and RLN.
- If the contralateral side of the thyroid is deeply located, the OR table can be tilted by 10-15 degrees to facilitate access to the tracheo-esophageal groove.

(Video 8)

G. Postoperative

- Deliver the specimen tissues through the incision to the assistant to examine for thyroid nodules.
- After saline irrigation, visually explore the left side to ensure that no vessels are left unsealed and that the thyroid is completely removed.
- Apply fibrin glue and anti-adhesion material to the surgical site to reduce postoperative bleeding and to prevent chest adhesions.
- Remove all endowrist instruments; disengage camera assembly, position arms away from the patient and toward the center column.
- Remove Chung retractor without placing additional tension on the skin.
- Place a drain and close the wound using a continuous skin stitch.
- Apply skin sealant if preferred.

(Video 10)