Multicavity gas migration following da Vinci 5 transoral robotic thyroidectomy in a 50-year-old male: a case report of successful conservative management

Background: Transoral robotic thyroidectomy (TORT) relies on continuous carbon dioxide (CO₂) insufflation to maintain the operative workspace, introducing a spectrum of gas-related complications. The newly introduced da Vinci 5 (DV5) system features an integrated, actively regulated insufflation and smoke evacuation system that differs fundamentally from prior-generation platforms. The platform-specific safety profile of the DV5 in TORT remains largely uncharacterized.

Case Description: A 50-year-old male with papillary thyroid carcinoma (PTC) of the left thyroid lobe underwent transoral robotic left hemithyroidectomy with central lymph node dissection using the DV5 system. Insufflation was maintained at 8 mmHg with a flow rate of 20 L/min; the procedure was uneventful. Upon post-anesthesia care unit (PACU) admission, the patient was stable (SpO₂ 99%), but developed acute chest pain and oxygen desaturation (SpO₂ <90%) approximately 20 minutes later. Emergency chest radiography demonstrated bilateral pneumothorax requiring immediate bilateral chest tube insertion. Subsequent computed tomography (CT) confirmed pneumoretroperitoneum and pneumoperitoneum along the perirenal spaces without visceral injury, consistent with extensive CO₂ migration along cervicofascial planes. The patient recovered with conservative management and was discharged without sequelae on postoperative day four. Final pathology confirmed pT1N0M0 PTC.

Conclusions: Extensive multicavitary gas migration can occur following TORT even under standard insufflation settings and without direct organ injury. The DV5’s integrated airflow regulation may alter intraoperative pressure gradients in way that differ from prior platforms. Surgeons adopting DV5 for TORT should consider reducing insufflation pressure to 6 mmHg, restricting automated smoke evacuation during deep dissection, and extending PACU monitoring for at least 60 minutes post-extubation. Multidisciplinary collaboration with system specialists is essential during platform adoption.