The da Vinci SP is changing the way we think about remote-access neck surgery. A single cannula, a flexible 3D endoscope and three wristed instruments open possibilities that were simply not available with previous robotic platforms. We have already discussed SPRA (Single-Port Robotic Areolar) thyroidectomy and we certainly will continue to do so.
The new paper by Raffaelli et al. describes SMART-T: Single-incision, Midline Approach Robotic Transaxillary Thyroidectomy. The concept is: instead of accepting the lateral view of conventional transaxillary surgery, the authors use a single axillary incision, create a subcutaneous tunnel, and then use the SP cannula to obtain a BABA-like midline view. Sixteen carefully selected patients underwent lobectomy, with encouraging early results.
But here is my question: if the operation is essentially a midline operation, why enter from the axilla? The authors describe SMART as combining the advantages of transaxillary and breast approaches. But anatomically, I would argue that SMART is actually much closer to the transaxillary family than to BABA: the incision is lateral, the access tunnel runs over the pectoralis major, and the axilla remains the entry point. And that brings us to the elephant in the room: why prefer the axilla to the breast?
The axilla is certainly a concealed location. But it is also an area where scar quality can be unpredictable, and where the incision is subjected to considerable movement and tension. By contrast, a carefully positioned periareolar incision can become remarkably inconspicuous, while providing a much more medial and, to me, more logical route to the anterior neck.
This is precisely why SPRA is so interesting. It starts from the breast and exploits the SP platform to transform what used to require a four-port BABA operation into a single-port procedure. The paper itself acknowledges that SPRA provides a craniocaudal, bilateral view, while avoiding the extensive chest-wall flap of conventional BABA.
“SMART” sounds like a new conceptual paradigm, when in reality the most interesting innovation may simply be what the SP platform allows us to do things in a different way. So the discussion should be about asking a much simpler question: what is the shortest, safest and most cosmetically rational route that the technology now allows us to take?
We will keep exploring that question at headneckroboticsurgery.com
J Granell. Sept 18, 2026
Raffaelli M, Gallucci P, Hoxhaj I, Pennestrì F. Single-port, via a midline approach, Robotic Transaxillary Thyroidectomy (SMART-Thyroidectomy): description of the technique and evaluation of feasibility in the first case series. J Robot Surg. 2026 Sep 18;20(1):1001. doi: 10.1007/s11701-026-03960-y
Dear Dr. Granell,
thank you for your comment on SMART-Thyroidectomy.
I completely agree that SPRA is a very interesting technique I have learned from my friend Jin Wook Yi.
So why modify this approach? For 2 main reasons. First, SPRA is not a true single-port approach since it requires an additional port (in the ipsilateral axilla, in the contralateral breast or in the contralateral axilla) for the bedside assistant. The second, and most important one, is that patients, especially females, at least in European countries, are often reluctant to consider an areolar incision, albeit it is well tolerated and barely visible. In my experience, they are more prone to have an axillary incision. That applies also to BABA, that I routinely perform, albeit the areolar incisions are smaller (8 mm) than in SPRA (3 cm).
Consequently, we developed SMART-T that tries to combine the advantages of a single axillary incision with those of a BABA-like procedure as SPRA is. The preliminary results, albeit with limited indications and in selected patients, are extremely encouraging.
Best regards,
Marco Raffaelli