Hybrid Approach for Complex Intrathoracic Goiter: Transcervical Open Surgery and Robotic-Assisted Intrathoracic Resection

A 35-year-old physically active female patient presented with exertional dyspnea and was referred from the otolaryngology department with a diagnosis of intrathoracic multinodular goiter. The CT scan illustrated a diffuse multinodular goiter with marked intrathoracic extension of the right thyroid lobe, forming a mass measuring approximately 89 x 63 x 62 mm. The goiter produced posterolateral compression and displacement of the trachea and esophagus toward the left. Additionally, moderate-to-severe tracheal stenosis at the level of the aortic arch was present. No other lesions or pathological enhancements were identified in the upper aerodigestive tract, and no suspicious lymphadenopathy was observed. Laboratory evaluation revealed subclinical hyperthyroidism, characterized by suppressed thyroid-stimulating hormone (TSH) levels with normal peripheral thyroid hormone concentrations.  

The treatment plan involved a two-stage surgical strategy. The surgical procedures could have been performed on the same day; however, due to the unavailability of the robotic operating theater at the time, the decision was made to schedule them on separate days with a one-week interval. Unfortunately, the patient developed acute tonsillitis during this period, necessitating a postponement of the second procedure until full recovery to minimize surgical risks associated with active infection. While a single-session approach might have reduced the risk of fibrosis, the combination of logistical constraints and the patient's interim illness required a staged surgical plan.  

The first stage consisted of a transcervical approach via standard cervicotomy. Under general anesthesia with orotracheal intubation, the patient was positioned supine with her arms alongside her body. After cervical exploration and identification of the goiter, the surgeons performed a right hemithyroidectomy. Thorough right-sided tracheal dissection allowed for the identification and preservation of the superior laryngeal and recurrent laryngeal nerves through intraoperative neuromonitoring. No additional cervical lesions were palpable upon completion of the resection. Meticulous hemostasis was achieved, followed by the placement of a 14 Fr Redon drain and layered wound closure. The postoperative evaluation confirmed preserved vocal cord function.  

The patient returned four weeks later to complete the hemithyroidectomy. For the robotic-assisted thoracic surgery (RATS), the patient underwent selective orotracheal intubation and was placed in the left lateral decubitus position. A multiport robotic technique was employed, with three 8 mm robotic trocars inserted in the sixth intercostal space and one 8 mm assistant port positioned in the seventh intercostal space. Intraoperative findings revealed a sizeable intrathoracic goiter occupying the paratracheal region, extending from the cervicothoracic junction inferiorly to the azygos vein and from the vena cava posteriorly toward the vertebral column and esophagus. After the circumferential opening of the mediastinal pleura around the goiter, careful and complete capsular dissection was performed, which proved especially challenging superiorly due to fibrosis from the previous cervical procedure.  

The specimen was removed using an endo bag through an enlarged anterior incision. After confirming rigorous hemostasis, Floseal was applied to the mediastinal surgical bed, and Coseal was utilized along the pleural margins to minimize future adhesions. A 24 Fr chest drain was placed via the assistant incision, and the wounds were closed in layers using Novosyn sutures for deeper tissue and Novosyn Quick for skin closure. The chest drain was removed on postoperative day one, and the patient was discharged home in good condition on postoperative day three. 

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