Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform.

BACKGROUND: Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy. METHODS: We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter). RESULTS: Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy. CONCLUSIONS: Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial. TRIAL REGISTRATION: Retrospectively registered on 20 july 2018 . TRIAL REGISTRATION NUMBER: researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

[Laparoscopic cholecystectomy for acute cholecystitis in pregnancy: a case report in woman with situs viscerum inversus]. / Colecistectomia laparoscopica per colecistite acuta in gravidanza: il caso di una portatrice di situs viscerum inversus.

We report a case of a three month young pregnant woman (In Vitro Fertilization and Embryo Transfer - IVF-ET - twin pregnancy) with situs viscerum inversus totalis affected by acute cholecystitis. As already happened in other pregnant women, we use laparoscopic approach and cholecystectomy is performed successfully without any morbidity for mother and fetuses.

Incidental thyroid carcinoma in patients with TIR1, TIR2 and TIR3 FNA.

AIM: The aim of our study was to evaluate the presence of incidental differentiated thyroid carcinomas, at final histological examination, in patients undergoing thyroidectomy or lobectomy for presumed benign pathology or in those with cytological diagnosis of indeterminate nodules (TIR3). MATERIAL OF STUDY: 457 patients who underwent surgery for benign disease and 179 patients with indeterminate FNA were included in our study. RESULTS: 77 out of 457 patients had the diagnosis of differentiated thyroid carcinoma. 29 out of 179 patients had the same diagnosis as previous ones, but not on the undetermined FNA nodule. In the most of the cases, the istotype was follicular variant of papillary carcinoma. DISCUSSION: The incidence of incidental carcinomas, approximately the same in the two groups of patients, respectively 16.8% and 16.2%, shows that there is still a group of patients with benign thyroid disease escaping a careful ultrasound evaluation and therefore a targeted FNA. Even in patients with indeterminate cytology, the presence of an incidental carcinoma suggests that on the one hand there has been an overestimation and on the other a non-recognition of the really suspect nodule. Although in most cases it is a microcarcinoma, we must not overlook the presence of many tumors at stage T3. CONCLUSIONS: Surely the analysis of the set of risk factors with a wider application of molecular biology surveys will in the future lead to better selection of patients to undergo surgery sooner than those that can be followed in follow up even for a longer period of time. KEY WORDS: Differentiated thyroid carcinoma, Fine needle aspiration, Incidental carcinoma.