Duke Health Referring Physicians

Quick Case Study

Novel Approach to Thyroidectomy to Avoid Scarring

During a routine examination, a 43-year-old woman was found to have an enlarged thyroid. Ultrasonography revealed a thyroid nodule, and cytologic analysis of a specimen obtained by fine needle aspiration indicated her cancer risk was approximately 40%.

The patient carefully considered her options and consulted with thyroid surgeons in several states. She knew that surgery was necessary, but she was dissatisfied with the surgical options presented to her that required a neck incision, leaving her with a visible scar.

Question: What surgical approach could be used to remove all or part of the thyroid without leaving a visible scar on this patient's neck?

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Answer: The surgical approach chosen by the Duke team was axillary robotic-assisted thyroidectomy.

In axillary robotic-assisted thyroidectomy, a surgeon makes an incision in the axilla and performs the surgery by manipulating small, remote-controlled instruments.

“The robot helps me miniaturize my movements and allows me dexterity and stability in a small space. Yet, I can still do the surgery exactly as if my hands were in there doing it,” says Michael Stang, MD, an endocrine surgeon at Duke Raleigh Hospital and a pioneer in the field of minimally invasive and robotic-assisted techniques for the treatment of endocrine tumors.

The patient’s consultations with several surgeons led her to Stang when she learned of his expertise in this technique. After examining her and reviewing her test results, he performed thyroidectomy using robotic assistance. The patient was able to go home the day after surgery.

She elected to have one-half of her thyroid removed, and the pathology analysis revealed a benign nodule requiring no further treatment.

The patient continues to have good thyroid function with her remaining gland.

A robotic-assisted approach is not appropriate for everyone, and it is not indicated in circumstances when the thyroid gland or tumor is too large, the cancer is too advanced, the patient is obese, or the patient has had shoulder surgery that limits shoulder mobility.

Approximately 1,000 thyroid surgeries using robotic assistance have been performed in the United States, and Stang is responsible for more than 350 of them. He studied with the surgeon who pioneered the technique at Yonsei University in Seoul, South Korea. In addition to being the US leader in robotic-assisted thyroidectomies, he also performs a high-volume of conventional thyroid surgeries each year.

“I tell patients that the most important thing—regardless of what kind of surgery is done—is to make sure whoever doing it does a high volume of thyroid surgeries,” Stang says. For high-volume thyroid surgeons, the complication rate is at or below 1%, compared with a rate between 2% and 10% for the surgery overall.

For his patients, Stang says that their outcomes are the same using either robotic-assisted or traditional surgery in terms of recovery time, pain control, tumor removal, and complications.

In the end, he adds, “The decision of which surgery to use comes down to personal choice. Most patients don’t mind having traditional surgery with a scar on their neck."

For others, like this patient, "It is a bigger concern, and they are the ones who seek out the robotic technique,” comments Stang.

Stang and his fellow Duke endocrine surgeons, Julie Ann Sosa, MD, Sanziana Roman, MD, and Randall Scheri, MD, perform nearly 1,000 thyroid, parathyroid, adrenal, and pancreatic neuroendocrine surgeries every year. With longtime expertise in advanced techniques, such as axillary robotic-assisted thyroid surgery, Duke can offer patients many types of surgical options.