LAUSR

Over the past few years, many different remote‐access techniques have been described as a method of removing the thyroid gland without an incision in the neck. These techniques have been developed to potentially provide a cosmetically more appealing result for some patients. However, they have been approached with caution by the surgical community because of technical challenges, new complications introduced, concerns about oncologic equivalency, and medicolegal and cost issues. In this issue of the Journal of Surgical Oncology, Kim et al from Korea have presented a single‐surgeon experience comparing two approaches used to avoid a cervical incision: transoral (TORT) and bilateral axillo‐breast approach (BABA) in robotic thyroidectomy. A total of 90 patients were enrolled prospectively between September 2016 and April 2017. The BABA group included 43 and the TORT group included 47 patients, respectively. The study showed that patients in the TORT group had less postoperative pain and a greater cosmetic satisfaction than those in the BABA group. There were no significant differences in the postoperative surgical results between the two groups. They concluded that TORT is comparable to the BABA procedure, with higher cosmetic satisfaction and less pain. We would like to take this opportunity to congratulate Dr Kim for his technical expertise and for being a leader in remote‐access thyroid surgery. Studies like this are essential to systematically assess new technologies and their use. Similar to most studies regarding remote‐access thyroid surgery, this study was limited in that it was a single‐surgeon series. There may be a selection bias as to which procedure was chosen, leading to a bias in the perceived cosmetic satisfaction. In addition, because the TORT procedure is relatively new, the outcomes may be slightly better in the BABA group. Finally, preoperative and postoperative vocal fold evaluation was performed by translaryngeal ultrasound that could possibly underestimate the vocal fold paralysis rate. Most remote‐access thyroidectomy procedures have not been adopted into mainstream surgical practice for multiple reasons in the United States. This is mainly because the procedures are difficult to justify in terms of cosmesis only. The significance and durability of this cosmetic advantage has not been well studied, and its ultimate merit is still unproven. Additional studies are required to determine its equivalency to the standard and well‐ tolerated transcervical thyroidectomy. The fact that a technique or technology may be available does not imply that it is appropriate. The newer TORT approach seems to be attracting much attention and several high‐volume centers in the United States have increasing experience with this approach. With any new technology or approach, complications during the learning curve, expense, instrument limitations, and overall safety may affect its ultimate adoption and utility. To ensure patient safety, it is imperative to define steps that should be considered by any surgeon or group before adoption of any new approach. Recently, a basic framework was established to facilitate safe and responsible implementation, evaluation and potential integration of new technologies or techniques. This framework provides surgeons the ability to determine cautiously how and when implementation of a new technique should occur and in what specific clinical context. There are no uniform guidelines about credentialing in remote‐access robotic thyroid surgery, with each institution having its own regulations. However, as suggested for training in any other robotic procedure, recommendations include starting a program initially with a series of simple lobectomies performed under the supervision of a proctor and only after appropriate experience with acceptable results to target more challenging procedures. A recent report has looked at the trends in robotic surgery in the United States from 2009 through 2013. This study reported that the increase in the initial annual case volume dropped after 2011, with lower volume centers (fewer than five cases annually) contributing to the recent increases in use. Overall, 22% of the procedures were total thyroidectomies and 72% lobectomies. Complication rates at lower volume centers were higher than those at higher‐volume (five or more annual cases) institutions. The average cost of a robotic thyroidectomy was $13 287. There are significant barriers to the use of remote‐access thyroid surgery in the United States related to patient selection, technical challenges, outcomes, cost, and medicolegal considerations. Although equivalency to the conventional thyroidectomy has not been proven, the data show that remote‐access thyroidectomy may be conducted safely in high‐volume centers. There are insufficient data to draw conclusions about oncologic equivalency and future course of action if the disease recurs. Although new technologies and approaches should be encouraged, a rational and thoughtful approach ensures optimal