To do the surgery, four small robotic arms are used, each one being able to hold on to things as well as being able to turn and rotate. Along with the arms there is a 3D camera with up to ten times zoom, giving the surgeon a high-definition view of inside the patient’s body so that the arms can be used to make precise movements. To control each of these there is a remote control and so the surgeon is always in control and can accurately remove the thyroid. The robot can also currently not be programmed to do the surgery and so the surgeon always needs to be there for it to move, meaning that there is no fear of the robot being programmed by someone to cause harm to patients. Together this machine is called a daVinci robot.8
At the moment there are 300 robots in Europe and 1,300 in the USA and so 200,000 procedures are being done every year using the robots.9
The reason of why this method is appropriate for solving the problem is because creating an incision under the arm means that the scar created is hidden from view compared to the scarring of the conventional method of thyroidectomy. Figure 3 shows the scar made by open surgery compared to the location of the scars made in a robotic thyroidectomy. The red lines on the image show the scars made by each method, with the scars made by the robotic thyroidectomy being much more discrete than the scar of the open method.
A study has been done by Jae Hyun Park et al at Yonsei University, Korea, into whether a robotic thyroidectomy really does give better results than an open thyroidectomy. This study used 165 patients, of which they were all similar ages, 56 of these underwent the robotic thyroidectomy and the other 109 underwent open surgery. The patients were all suffering from cancer of the thyroid rather than hyperthyroidism although the procedure is very similar and the results of the study can be directly compared. The participants in the study needed lymph nodes (the location of the cancer) removed. The patients were assessed on factors such as hospital stay, complications, operation length and the number of lymph nodes removed.
The results of this study showed that, although the average operating time for the robotic surgery was significantly longer than the open surgery with robotic surgery taking an average of 4 hours and 37 minutes and open surgery taking an average of 3 hours and 38 minutes. The average number of lymph nodes removed was 39.4 for open compared to 37.3 for robotic. After the operation, the average stay in hospital for the patients who underwent the robotic surgery was just 6 days whereas the stay for those who underwent the open surgery was 8 days. After the surgery, 72.5% of the open surgery group suffered complications whereas 72.2% of the robotic group suffered complications, showing that there is very little difference between the two methods. Neither of the surgery options gave any indication of the cancer returning.
It was concluded that the robotic thyroidectomy is a safe procedure and so is an acceptable alternative to open neck surgery. It was also concluded that a large advantage of the robotic thyroidectomy was the cosmetic results of the scar being under the arm rather than across the neck.13
Figure shows the post-operation pain score on a scale of 1 to 10, with the red line representing the robotic surgery and the blue line representing the open surgery. Each of the points shown on the graph represent the pain score from the day of the operation up until the third day after the operation.
Implications
One social implication is that the surgery is limited to a certain type of person and so, for example, obese patients cannot have the surgery done through robotics currently. This means that at the moment, a robotic thyroidectomy is only used on patients who strongly wish to avoid obvious scarring on the neck for cosmetic reasons. As confidence in the surgery grows, the currently limited criteria will also grow and so the numbers of eligible patients will increase. At the moment, a robotic thyroidectomy is limited to patients with smaller thyroids of a diameter of 4cm or less.7 Patients must also only have nodules on one side of the gland for the surgery to work at its best.8
One economic implication is that each robot costs over $2.5 million and so they are only available to specialist clinics. Also, specialist training is needed for each new surgeon who is going to use the robot, which again will cost the facility for the training. This means that the machines can only be purchased at specialist hospitals and cannot be used by everyone as it will no doubt be expensive to use the procedure. This means that only a selective group can use this method of surgery until it becomes more widely used.9
Risks/disadvantages
One risk of having a thyroidectomy is the general anaesthetic. Within this are several risks, ranging from very common to very rare. The very common risks have a one in ten chance of happening and the common risks have a one in 100 chance. These are:
Feeling sick/vomiting
Sore throat
Dizziness
Blurred vision/headaches
Itching
Aches
Pains/backache
Bruising and soreness around the area of injection
Confusion/memory loss
The uncommon risks are at a chance of one in 1,000, these are:
Chest infections
Bladder problems
Muscle pains
Slow breathing
Damage to tongue and lips
Experiencing a medical condition worsening
Waking up and becoming conscious during the surgery
The rare and very rare risks are a chance of one in 10,000 or 1 in 100,000, these are:
Death
Equipment failure
Nerve damage
Responding with a serious allergy to the drugs used
Damage to eyes10
Wider Benefits
A wider benefit is that, when operating, the high-definition 3D camera gives a much more accurate image of the gland and surgeons can see nerves surrounding the thyroid. This is compared to looking at the thyroid from above as is done in open surgery. The camera also enables surgeons to zoom in on the thyroid, giving a clearer view of important structures around the thyroid gland such as the nerve leading to the voice box (the laryngeal nerve) and the parathyroid glands. The ability of the robotic arms to rotate means that surgeons have increased accessibility to the thyroid gland compared to in open surgery, meaning that a thyroidectomy becomes more accurate and precise in the amount of thyroid removed.8 Another benefit is that patients do not suffer from difficulty swallowing food as the incision is made away from neck and so the post-operative pain is largely reduced (as shown in figure 4).9
Two alternative solutions
An alternative solution to the hyperthyroidism caused by Grave’s disease is the use of antithyroid drugs, the most common of these being carbimazole. These work by reducing the amount of thyroxine, although they cannot affect the amount of hormone which has already been made and stored by the thyroid. This means that drugs can take between 4 and 8 weeks to take effect and reduce hormone levels.11
There are two ways to reach the correct dosage of the drugs. The first of these is to take the first dose much higher than a normal dose so as to regulate the amount of thyroxine in the blood. The same dose will then have to be taken for the initial 4 to 8 weeks before the drugs can properly take effect in the thyroid. The high dose is gradually decreased to the amount which is right for the patient. Judging the dosage needed by individual patients is difficult as each one will produce different amounts of thyroxine and so will needed different amounts of the medicine. To make sure that this dose is correct, the patients are monitored with a blood test every month. This ensures that the patient’s thyroxine levels are regulated properly by the drugs. This method of treatment is called ‘titration’.
The second method of prescribing the medicine is for the patient to take a high dose of carbimazole every day which prevents the thyroid gland from producing any hormones and so must be balanced by a prescription of thyroxine. This is effectively doing the job of the thyroid. This method is called ‘block and replace’ and is the more commonly chosen of the two drugs methods.
Within six months of taking the medicines, 50% of patients who use the ‘block and replace’ method get better whereas it takes 18 – 24 months for this to happen using the ‘titration’ method.
Like any drugs there are side effects. These include rashes, headaches, sore throat or mouth ulcers.11
Radioactive iodine treatment (RAI) is a type of radiotherapy which implants radioactive iodine into the thyroid. This then builds up within the thyroid and causes it to decrease in size which then decreases the amount of thyroxine made. This can be done either in a drink or in a pill but neither of these methods contain harmful amounts of radioactivity. There are limitations in that the treatment is unsuitable during pregnancy and if the patient has eye problems.5
RAI is often given in doses which are too large; leading to hypothyroidism due to the difficulty in controlling how much is needed. There has recently been work to try and make this a more efficient cure although it is challenging and currently, 20% of all patients suffer from hypothyroidism in the first year after treatment and another 3-5% more every year following. This shows it to have a low total success rate. 6
In conclusion, you can see that this is not a minimally invasive procedure due to the distance needed to reach the thyroid from under the arm, although it does not leave a scar and so is a suitable method to be used on patients who are worried about the cosmetic look of the scarring.
Bibliography
1 Sagmiller. G. J. (2011) All about Thyroid Disease, Grave’s disease, Hyperthyroidism and Hypothyroidism, The Gifted Learning Project
2Grave’s disease and thyroid foundation, 2012, available at: (accessed 10/03/12)
3Grave’s disease and thyroid foundation, Thyroidectomy, authors: Robert F. Dons, M.D., Ph.D.; Angelita Ramos-Gabatin, M.D. and Jon B. Getz, M.D., 2012, available at:
(accessed 10/03/12)
4NHS: Thyroid, overactive, Causes, last reviewed 2010, available at: (accessed 11/03/12) This source is reliable as the NHS aims to help with health problems and has pages specifically for a range of health problems. The page I have used is for the causes of Grave’s disease and the NHS is a respectable group and will not gain anything from people following information on the site.
5 NHS, Thyroid, overactive treatments, last reviewed 2010, available at: (accessed 11/03/12)
6 BBC health: Grave’s disease, last reviewed by Dr Trisha Macnair, 2009, available at:
(accessed 11/03/12) The BBC is a respectable media source and is unbiased towards anyone. This article has also been reviewed by Dr Trisha Macnair, a PHD student in medicine, meaning that it is more reliable than it would have been otherwise and the article has been agreed with. It is also reliable because I have found similar or the same information on other websites and so this shows that it has been backed up. Dr Trisha Macnair graduated from Bristol University and is now a Speciality Doctor in Medicine for the Elderly at Milford Hospital, near Gilford in the UK. In 2001, Dr Trisha Macnair, won an award from The Medical Journalists Association for her article on Genetics for the BBC health website and has an MA in Medical Ethics and Medical Law, from Kings College, University of London as well as being a member of the British Medical Association.
7Mayo clinic, available at: (accessed 11/03/12)
8Endocrine web, Robotic thyroidectomy, written by Kamiah A. Walker, last reviewed by , 2010, available at: (accessed 11/03/12) This source is a website specialised for endocrine disorders and the article I have used was written by Kamiah A. Walker who is a Senior Medical writer in Illinois and works closely with the editors of the site to ensure that all information posted is trustworthy. She is also a Doctor of Medicine or an MD. The article has also been reviewed by Brendan C. Stack Jr. MD, FACS, FACE who is a professor and Chair in Otolaryngology-Head and Neck surgery at the University of Arkansas for Medical Sciences. He has written 150 articles which have then been peer-reviewed and has presented at over 200 meetings and conferences. Having the article reviewed by Brendan C. Stack Jr. MD, FACS, FACE increases the reliability of the article as it shows that it has been supported by a nationally known professor in the USA. The source is also reliable as I have found the same information on a second website. ()
9Thyroid gland surgery, Dr. Patrick Aiden, 2011, available at: (accessed 11/03/12)
10Patient information, NHS, published 2008, reviewed 2010, available at: (accessed 11/03/12)
11Patient, diseases and conditions, antithyroid medicines, written by Jenny Whitehall and peer reviewed by Dr. Tim Kenny, last reviewed Jan 2012, available at: (accessed 12/03/12)
12, , , , and (2010), Surgical Endoscpy, Volume 24, number 12; difference in postoperative outcomes, function, and comesis: open versus robotic thyroidectomy, Springer New York
13Global Robotics Institute, 2011, available at (slide 52 – 58): (accessed 29/03/12)
Figure 1, an image of the thyroid gland, thyroid gland – grave’s disease, available at: (accessed 11/03/12)
Figure 2, an image of where the incision is made compared to the location of the thyroid gland, mayo clinic – robotic thyroidectomy, 2001 – 2012, available at: (accessed 11/03/12)
Figure 3, a comparison of the scars made by each method, thyroid gland surgery, Dr. Patrick Aiden, 2011, available at: (accessed 11/03/12)
Figure 4, a graph to show the post-operation pain score, Global Robotics Institute, 2011, available at: (accessed 29/03/12)
Figure 1: the thyroid gland
Figure 2: where the incision is made compared to the location of the thyroid
Figure 4: A graph to show the post-operation pain score
Figure 3: a comparison of the scars made by each method