Commentary on: Comparative Study between Robotic Total Thyroidectomy with Central Lymph Node Dissection via Bilateral Axillo-breast Approach and Conventional Open Procedure for Papillary Thyroid Microcarcinoma

In the article of He et al.,[1] authors compared robotic bilateral axillo-breast approach (BABA) with conventional open procedure in papillary thyroid microcarcinoma and showed that robotic BABA was safe and effective. The content of this study is novel, and the information is complete and credible. Robotic surgery for head and neck surgery under endoscope provides readers with a good understanding of this new thing, but the practical significance of the surgical treatment of malignant tumors of the neck is limited, at least not recommended. I would like to exchange views on some issues:

The first concern is the safety and efficacy of surgical treatment for malignant tumors. Safety includes two aspects: the operation process and the oncological safety; and efficacy includes the short-term and long-term effects. The data and results of this article should be said that it cannot be accurate to reflect the conclusion of “safe and effective”. The authors chose papillary thyroid microcarcinoma as the research object, just because there is more controversy. The focus of the controversy is the thorough tumor or lymph node dissection. In this article, after condition screening for papillary thyroid microcarcinoma, the robotic surgery could have a similar effect as conventional surgery; this can only prove the safety and feasibility of robotic surgery for the total thyroidectomy from a technical point of view, but the design of this study might be flawed to prove the safety and effectiveness from an aspect of tumor treatment. In the paper, it was mentioned that “Next we intend to compare the long-term follow-up results and oncologic safety in a larger number of thyroid cancer patients”, the authors should note that this “randomized controlled study” has adopted strict inclusion and exclusion criteria, which made the samples involved in the study be strongly representative but lack of universality, so the results of this study could not represent the overall sample of thyroid papillary microcarcinoma, and could not come to the conclusion of “According to the results of the study, going to broaden our indications”.

Endoscopic diagnosis and treatment of some diseases through the human natural cavity tract has a huge advantage, and the addition of the robot may change the traditional surgical operation mode. However, from the existing data, there was no clear evidence to show that the robotic surgery had the same or better effect than the conventional surgery, except for cosmetic result. Some experts, who recommend endoscopic surgery for the treatment of cancers in head and neck, define endoscopic surgery as “minimally invasive” surgery, but more data showed that it is actually an “extended trauma” procedure; the data of this study also showed that the anesthesia time of endoscopic surgery was twice as long as that of conventional surgery. Surgical trauma includes operation time, anesthesia time, and tissue damage scope, and the general knowledge is that the surgical trauma is positively related with anesthesia time. Of course, some of the patients might benefit from a lighter “psychological trauma”. From the point of view of cost-effectiveness, this surgery increase expensive medical costs only to meet the cosmetic requirement, which ignore medical and social benefits and does not accord with Chinese actual conditions; therefore, it is not a good choice for patients, with the exception of few individuals having strong or special cosmetic requirements. The patients should also be fully informed of the possible risk, especially the risk of unknown potential oncology before this surgery. After all, “the oncological safety is more important than the cosmetic demand”.

In the field of tumor therapy, we never reject advanced treatment ideas and the use of new technologies. However, there has been a lot of controversy regarding the endoscopic technique applied to the surgery for cancers in head and neck, especially in the neck. The academic controversy often exists between the oncology experts and the experts in the field of general surgery or otolaryngology, which might be related to the different professional background and the tumor therapy concept. I have the opportunity to watch the whole thyroid cancer radical surgery with endoscopic technique operated by skilled experts, many physicians appreciated it, but from the view of my oncological professional, this technique still has larger limitations in some key points and conditions.