J Granell. Posted Dec 2025.
From BABA to SPRA
Remote‑access thyroid surgery was developed to eliminate a visible cervical scar while preserving surgical standards (e.g. oncologic safety and surgical completeness). Among the different extracervical approaches, the Bilateral Axillo‑Breast Approach (BABA) occupies a central place in the evolution of robotic thyroid and neck surgery (1).
BABA was originally conceived as a non‑robotic endoscopic technique at Seoul National University Hospital (SNUH), aiming to reproduce the familiar midline cervical view through a symmetric subcutaneous approach. Its conceptual strength lay in offering a true bilateral perspective of the neck, facilitating safe identification of the critical anatomic references. The subsequent adoption of the da Vinci multi‑port platform allowed BABA to mature into a reproducible robotic technique. Today its indications extend beyond thyroidectomy / parathyroidectomy to include lateral neck dissection, and virtually almost every neck surgery.
With BABA, surgeons demonstrated that comprehensive thyroid surgery — including central and lateral compartment dissection — could be performed through a remote access, provided that anatomical landmarks and oncologic principles were strictly respected.
The next conceptual leap came with the introduction of the da Vinci SP (Single‑Port) platform. Leveraging its flexible camera and multi‑articulated instruments deployed through a single cannula, Dr. Jin Wook Yi and colleagues developed the Single‑Port Robotic Areolar Approach (SPRA) (2). SPRA preserves the philosophical foundations of BABA — a subcutaneous anterior chest approach with a midline cervical working view — while simplifying access and docking by using a single periareolar incision.
SPRA thus represents a natural evolution of BABA adapted to single‑port robotics.
Surgical Approach
Know the key anatomic principles. SPRA is based on a subcutaneous working space extending from the anterior chest wall to the cervical region. The dissection plane remains superficial to the pectoralis major fascia. There is a single side periareolar incision, approximately 3 cm in length, performed at the superior and medial border of one areola.
This incision provides access for the da Vinci SP cannula, accommodating the camera and three articulating instruments.
For the the working space creation, blunt and sharp subcutaneous dissection is carried cranially toward the sternal notch and anterior neck. Midline orientation is critical to ensure symmetric exposure of the strap muscles and thyroid compartment.
The da Vinci SP patient cart is docked from the head, slightly oblique.
Thyroidectomy
The thyroidectomy performed via SPRA follows standard BABA principles, reproducing the same anatomic sequence as open surgery:
- Midline division of the strap muscles
- Exposure of the thyroid isthmus, division and access to the thyroid gland lobes
- Identification and preservation of the recurrent laryngeal nerve and parathyroid glands
A key technical difference with the SP platform is the absence of advanced energy devices currently available for multi‑port systems (harmonic and advanced bipolar). Plain bipolar energy is therefore used for all steps of dissection and hemostasis. Despite this limitation, thyroidectomy can be safely and reproducibly completed, provided the surgeon adapts their operative rhythm and dissection strategy.
Lateral Neck Dissection
One of the most distinctive features of SPRA is the ability to perform lateral neck dissection through the same single areolar access. This is not possible, for example, with the popular transoral/transvestibular approach (3).
Levels II–V can be approached following the same subcutaneous working space. The flexible SP instruments facilitate dissection along the internal jugular vein, spinal accessory nerve, and carotid sheath
As with BABA, oncologic principles remain unchanged: en bloc lymphatic dissection, respect for neurovascular structures, and clear definition of compartment boundaries.
Closure and Post‑operative Management
Hemostasis: careful inspection of the thyroid bed and lateral compartment. Optional use of hemostatic agents, depending on surgeon´s preference. A closed‑suction drain may be placed; the drain is typically exteriorized through the axilla. A contralateral axillary port can be used as a service port; this is usually required for lateral neck dissection, but not strictly necessary for thyroidectomy and central neck dissection. Sometimes it is unavoidable to extract voluminous surgical specimens.
Strap muscles are reapproximated using a barbed V‑Loc™ suture The areolar incision is closed in layers: subcutaneous closure and skin closure with tissue adhesive (skin glue).
A compressive chest dressing is applied to reduce dead space and seroma formation
Final Remarks
SPRA combines the oncologic robustness of BABA with the minimal access philosophy of single‑port robotics. While it requires adaptation — particularly regarding energy devices — it offers a powerful, cosmetically optimal solution for selected thyroid and neck procedures in experienced hands.
References
- Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg. 2007;31:601-6. doi: 10.1007/s00268-006-0481-y.
- Choi YS, Choi JH, Jeon MS, Yu MJ, Lee HM, Shin AY, Yi JW. First Experience of Single-Port Robotic Areolar Approach Thyroidectomy. Clin Exp Otorhinolaryngol. 2023 Aug;16(3):275-281. doi: 10.21053/ceo.2023.00682.
- Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg. 2018;153:21-7. doi: 10.1001/jamasurg.2017.3366
