Cancers are rare among children, and thyroid cancer is more so. The management of thyroid cancer in children presents unique challenges owing to their delicate anatomy, ongoing growth and increased susceptibility to surgical complications.
In recent years, a groundbreaking development has emerged in India in the form of a robotic thyroidectomy technique called RABIT (robotic assisted breast-axillo insufflated thyroidectomy) and neck lymph node removal technique called RIA-MIND (robotic infraclavicular approach for minimally invasive neck dissection). These techniques do not require special equipment (other than the robot), thus reducing the cost. This minimally invasive surgical approach is gradually gaining traction for its numerous advantages, including smaller incisions, reduced pain and quicker recovery. My team has performed more than 150 cases of RABIT and RIA-MIND on adults. The adoption of robotic thyroidectomy and neck dissection for children in India has been limited, primarily because of unavailability of the technique, technology and training.
A FIRST IN INDIA
In 2023, India marked a significant milestone in the management of thyroid cancer in children. My team from Fortis Hospital, Bannerghatta Road, Bengaluru, performed the nation’s first robotic thyroidectomy and neck dissection in a child, employing the RABIT technique. The patient was a seven-year-old girl diagnosed with papillary thyroid carcinoma, the commonest form of thyroid cancer. The groundbreaking surgery was a success, resulting in a recovery with no complications. This achievement serves as a testament to the safety and efficacy of the technique for children and is poised to catalyse further progress in the field. This was not only India’s first but also one of the first few robotic thyroid surgeries on a child of this age in the world.
Challenges of robotic thyroidectomy and neck dissection in children
First and foremost, children’s smaller and delicate anatomy can make the surgical procedure inherently more complex. Precision is paramount, and the robotic system’s capability to provide a magnified view of the surgical field becomes invaluable. Second, the fact that children are still in the midst of their growth and development raises concerns about the impact of surgery on their physiological and psychological wellbeing. An open surgery leaves a scar of 15-20cm, which may look very bad in front of the neck of the child. We can never predict how this scar will look as the child grows. Third, children's heightened vulnerability to surgical complications, such as infection and bleeding, necessitates utmost caution and expertise. Children do not tolerate blood loss as well as adults, as their overall blood volume is low.
HOW THE TECHNIQUES WORK
The RABIT technique involves making small incisions in the armpit to access the thyroid gland and associated structures. It offers significant advantages over conventional open surgery. The incisions made are notably smaller, leading to reduced postoperative pain, minimal scarring and enhanced cosmetic outcomes. The minimised surgical trauma allows for quicker recovery time and less discomfort. The RABIT technique exemplifies the potential for precise, minimally invasive procedures even in paediatric cases.
In tandem with the RABIT approach, the RIA-MIND technique builds on the concept of minimally invasive surgery by employing robotic technology in the best way possible. By accessing the neck lymph nodes without conventional incisions, it further mitigates the visual impact of surgery. The open surgery for neck lymph node removal is associated with wound-related problems, which can be avoided by using RIA-MIND. It demonstrates the commitment to minimising the psychological burden for children who often contend with self-esteem issues arising from surgical scars. Additionally, it significantly reduces the risk of complications associated with open neck dissection procedures.
ADVANTAGES
Apart from faster recovery and less pain and minimal scarring owing to smaller incisions, the RABIT and RIA-MIND techniques allow for more precise dissection during surgery. This precision enhances the preservation of critical nerves and blood vessels, further improving the surgical outcomes. One of the most important structures that must be preserved during thyroidectomy is the parathyroid gland, which is responsible for calcium in the blood. With the magnification and special technique developed by me, it is now possible to save this gland with better precision. The cost-effectiveness of the two techniques is a key feature, ensuring that these advancements are accessible to patients in developing countries such as India. This paves the way for more equitable health care and improved treatment outcomes for a broader population.
FUTURE IN INDIA
The successful completion of India's first robotic thyroidectomy and neck dissection in a child marks the start of a new era in paediatric thyroid surgery. This landmark procedure underscores the feasibility and safety of robotic thyroidectomy and neck dissection in children and serves as a beacon of hope for countless young patients and their families. With the growing recognition of the advantages offered by the RABIT and RIA-MIND techniques, the trajectory of thyroid cancer treatment in India is set to evolve drastically.
Presently, RABIT is being practised in over 10 medical centres across India by surgeons trained by me. Remarkably, this technique received the K.S. International Innovation Award in 2023. It is worth noting that RABIT is a homegrown innovation.
As more surgeons in India and around the world adopt these innovative techniques, it is highly likely that robotic thyroidectomy and neck dissection will emerge as the standard of care for patients with thyroid cancer.
The writer is senior director of surgical oncology, robotic and laparoscopic surgery, Fortis Hospitals, Bengaluru.