Who is difficult for transoral robotic thyroidectomy? A prospective analysis of 76 lobectomies

Transoral robotic thyroidectomy can be technically demanding, particularly during the early learning phase. This study aimed to identify preoperative factors associated with increased surgeon's subjective difficulty in transoral robotic thyroidectomy lobectomy.

This prospective observational study included consecutive 3-port transoral robotic thyroidectomy lobectomy cases performed between January and September 2025 by a single endocrine surgeon. The procedure was divided into 4 key steps, each graded on a 1-3 subjective difficulty scale. An overall difficulty score (range, 4-12) was calculated by summing step scores, and cases were classified as standard (4-5) or difficult (≥6). Patient anthropometric, clinicopathologic, operative, and postoperative variables were compared between groups.

A total of 76 transoral robotic thyroidectomy lobectomies (38 right-sided and 38 left-sided) were analyzed; 62 patients (81.6%) were female. Overall, 27 cases (35.5%) were classified as difficult. Difficult cases had longer operative time than standard cases (91.8 vs 71.7 minutes, P < .001), representing a 28.0% increase. Compared with the standard group, the difficult group had a higher proportion of male patients (37.0% vs 8.2%, P = .004), higher body mass index (25.7 vs 23.8 kg/m², P = .038), and deeper tracheal depth (24.4 vs 22.1 mm, P = .002). Clinicopathologic factors were not significantly associated with overall difficulty.

Male sex, higher body mass index, and greater tracheal depth were associated with increased technical difficulty in transoral robotic thyroidectomy lobectomy. These factors may help inform preoperative case selection and operative planning in appropriately selected transoral robotic thyroidectomy candidates; however, further validation is needed before direct applicability to surgeons in the early learning phase can be assumed.