Modification of two-incision trans-axillary robotic thyroidectomy

The objective of this study is to describe the modification of port placement for the four-arm technique of robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. The study methodology involved description of port placement modification to avoid chest incision and report of two cases with appropriate literature review is presented. Trans-axillary robotic thyroidectomy (TART) is often performed with a second chest incision, but the move toward single incision operation and placement of four arms via a single incision require expertise. We describe two patients who underwent TART using a trans-axillary incision and a separate 1 cm incision in the anterior axilla 2.5-cm below the trans-axillary incision for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port was used for surgical drain placement Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and not occupying the working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.