Avoiding the sternum: Perioperative outcomes of hybrid cervical and robotic-assisted thoracoscopic resection versus sternotomy for substernal goiters.

BACKGROUND: Substernal goiters occasionally require sternotomy for safe resection. Hybrid cervical and robotic-assisted thoracoscopic surgery offers a less invasive alternative, though it is underutilized in the United States. We report one of the largest United States series comparing hybrid and sternotomy approaches. METHODS: We performed a retrospective cohort study of 7,370 thyroidectomies performed at a single tertiary academic center between 2012 and 2023. Patients with substernal goiters extending below the sternal notch on preoperative computed tomography imaging were identified. Thoracic surgical assistance was involved when mediastinal mobilization was anticipated based on preoperative imaging and multidisciplinary evaluation. Patients requiring thoracic involvement were categorized into 3 operative groups: hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery, sternotomy, or cervical thyroidectomy with deep mediastinal dissection. Perioperative outcomes, including operative time, blood loss, chest tube use, intensive care unit admission, length of stay, and postoperative complications, were compared between hybrid and sternotomy groups. Complications included hypocalcemia, recurrent laryngeal nerve injury, and voice changes. Continuous and categorical variables were compared using appropriate parametric and nonparametric statistical tests. RESULTS: Among 34 patients requiring thoracic surgical assistance, 16 underwent hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery, and 13 underwent sternotomy. Baseline demographics were similar between groups, including age (62 ± 13 vs 58 ± 10 years), female sex (56% vs 46%), and body mass index (33.7 ± 7.4 vs 32.1 ± 8.7). Racial distribution within the hybrid and sternotomy groups was 37.5% vs 76.9% Black and 62.5% vs 23.1% White, respectively. Preoperative symptoms were comparable between groups. Operative outcomes favored the hybrid approach, including shorter operative time (3.2 vs 5.0 hours, P < .001), lower estimated blood loss (180 [120-250] vs 344 [200-533], P < .001), shorter hospital stay (2 vs 4 days, P < .001), and fewer chest tubes (25% vs 92%, P < .001). Intensive care unit admission occurred less frequently in the hybrid group (13% vs 29%). Rates of hypocalcemia (14%), hoarseness (29%), and recurrent laryngeal nerve injury (7%) were similar between groups. Intraoperative complications and perioperative mortality occurred only in the sternotomy group (15%). CONCLUSION: Hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery mobilization was associated with improved perioperative outcomes compared with sternotomy and may represent a safe minimally invasive alternative for select patients with substernal goiters requiring thoracic access.