Anterior cervical incision-sparing thyroidectomy: Comparing retroauricular and transoral approaches

Complication and conversion outcomes in transoral endoscopic thyroidectomy vestibular approach (TOETVA): a retrospective multicenter propensity score-matched cohort study

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a scarless thyroid surgery used as an alternative to open conventional surgery. Our aim was to investigate possible risk factors for complications and conversion during TOETVA. The study was conducted internationally by centres from Turkiye, the Republic of Korea, Italy, and Peru. A total of 406 patients who underwent TOETVA and were ≥ 18 years of age were included in the study. Demographic, pre-, intra-, and postoperative data were collected and compared between the groups with/without complication/conversion to identify possible predictors of complication/conversion. Subsequently, patients with complication/conversion were matched by the hospital, age, sex, and American Society of Anesthesiologists classification score using a propensity score (PSM) of 1:3 to eliminate confounding differences. Results were reported for the un-matched and matched groups. Complications occurred in 11 (2.7%) patients. High body mass index (26.4 ± 3.4 vs. 23.3 ± 3.7, p = 0.007), larger tumor size (1.7 ± 1.3 cm. vs. 1.1 ± 1.0 cm, p = 0.012), larger thyroid volume (20.0 ± 9.2 vs. 12.8 ± 8.5, p = 0.007) and long operation time (127.8 ± 45.0 min. vs. 97.7 ± 38.5 min., p = 0.008) were significantly associated with complications in un-matched analyses. Older age (42.7 ± 8.0 vs. 34.9 ± 9.2, p = 0.023), high BMI (26.7 ± 3.2 vs. 23.3 ± 3.7, p = 0.012), and longer operation time (160.1 ± 54.1 min. vs. 97.4 ± 37.8, p = 0.001) were significantly related to conversion in un-matched analyses. However, significance was lost after PSM for both complication and conversion. The data from this study conducted on TOETVA cases do not suggest a risk factor for complications and conversion with PSM.

Facelift thyroid surgery: a systematic review of indications, surgical and functional outcomes

OBJECTIVE

To investigate indications, surgical and functional outcomes of robotic or endoscopic facelift thyroid surgery (FTS) and whether FTS reported comparable outcomes of other surgical approaches.

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

REVIEW METHODS

A literature search was conducted about indications, clinical and surgical outcomes of patients who underwent FTS using PICOTS and PRISMA Statements. Outcomes reviewed included age; gender; indications; pathology; functional evaluations; surgical outcomes and complications.

RESULTS

Fifteen papers met our inclusion criteria, accounting for 394 patients. Endoscopic or robotic FTS was carried out for benign and malignant thyroid lesions, with or without central neck dissection. Nodule size and thyroid lobe volume did not exceed 6, 10 cm, respectively. FTS reported comparable outcome with transaxillary or oral approaches about operative time, complication rates or drainage features. The mean operative time ranged from 88 to 220 min, depending on the type of surgery (endoscopic vs robotic hemi- or total thyroidectomy). Conversion to open surgery was rare, occurring in 0-6.3% of cases. The most common complications were earlobe hypoesthesia, hematoma, seroma, transient hypocalcemia and transient recurrent nerve palsy. There was an important disparity between studies about the inclusion/exclusion criteria, surgical and functional outcomes.

CONCLUSION

FTS is a safe and effective approach for thyroid benign and malignant lesions. FTS reports similar complications to conventional thyroidectomy and excellent cosmetic satisfaction.

Evaluation of Preference and Utility Measures for Transoral Thyroidectomy

BACKGROUND

Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy.

METHODS

In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises.

RESULTS

Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics.

CONCLUSION

Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients-in keeping with the current findings of this study.

The Role of High-Resolution Ultrasound in the Assessment of Surgical Candidates for Transoral Endoscopic Thyroidectomy Via Vestibular Approach (TOETVA)

The approach of surgical techniques has evolved significantly over the last decade, with natural orifice surgeries replacing traditional open approaches. In 2016, Angkoon Anuwong, in Thailand, demonstrated it was possible to perform thyroidectomies in a series of patients by a transoral endoscopic ap-proach - transoral endoscopy thyroidectomy vestibular approach (TOETVA) - with similar complication rates when compared to conventional surgeries. This transoral surgery has become a safe alternative with better cosmetic results, compared to conventional open-route procedures, like Kocher cervi-cotomy. Indeed, it is an option to surgically treat neoplastic and functional thyroid diseases. The technique is performed through a median incision in the oral vestibule, plus two bilateral incisions, followed by the insertion of three trocars, one centrally for a camera, and two laterally for working instruments. Although revolutionary, TOETVA has its technical limitations. Therefore, it is important to precisely define the preoperative eligibility criteria for this type of surgical approach. High-resolution ultrasound is the first imaging modality for the assessment of thyroid nodules, lymph node metastases and surgical field. The aim of this article is to outline the sonographic technique and the role of high-resolution ultrasound in the presurgical evaluation of TOETVA.

Review: Improving quality of life in patients with differentiated thyroid cancer

Well differentiated thyroid cancer is a common malignancy diagnosed in young patients. The prognosis tends to be excellent, so years of survivorship is expected with low risk disease. When making treatment decisions, physicians should consider long-term quality of life outcomes when guiding patients. The implications for treating indolent, slow growing tumors are immense and warrant careful consideration for the functioning years ahead. Surgery is the standard of care for most patients, however for a subset of patients, active surveillance is appropriate. For those wishing to treat their cancer in a more active way, novel remote access approaches have emerged to avoid a cervical incision. In the era of "doing less", options have further expanded to include minimally invasive approaches, such as radiofrequency ablation that avoids an incision, time off work, a general anesthetic, and the possibility of post-treatment hypothyroidism. In this narrative review, we examine the health related quality of life effects that surgery has on patients with thyroid cancer, including some of the newer innovations that have been developed to address patient concerns. We also review the impact that less aggressive treatment has on patient care and overall wellbeing in terms of active surveillance, reduced doses of radioactive iodine (RAI) treatment, or minimally invasive techniques such as radiofrequency ablation (RFA) for low risk thyroid disease.

Surgical treatment of thyroid cancer: Established and novel approaches

Thyroid surgery is one of the most common head and neck procedures. The thyroid can be accessed through an anterior cervical incision, or by remote access techniques such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA) which is favored for its ease, safety and direct plane to the thyroid gland. Other novel approaches for targeting small-localized well-differentiated thyroid cancer are by thermal ablation, namely ultrasound guided radiofrequency ablation. These innovative techniques for minimizing a cutaneous scar or for targeting small cancers directly without removal of the gland have developed alongside our realization that low risk well-differentiated thyroid cancer tends to be slow growing and indolent. Up to date, the most robust data supports offering these therapies primarily to patients who would be eligible for active surveillance protocols. In this paper, we review the traditional surgical approaches for removing well-differentiated thyroid cancer, as well as innovative remote access techniques (namely TOETVA), and minimally invasive thermal ablation (namely RFA).

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Simple Summary

Transoral thyroidectomy accesses the thyroid gland through three incisions in the oral vestibule. The cosmetic outcome was excellent since no scar was observed on the body surface. However, it is challenging to create a working space using this new approach. Unconventional but severe complications can also occur. Our review summarizes the tips regarding working space creation in transoral thyroidectomy and tricks for preventing complications.

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Intraoperative Neuromonitoring: Evaluating the Role of Continuous IONM and IONM Techniques for Emerging Surgical and Percutaneous Procedures

Continuous and intermittent intraoperative nerve monitoring (IONM) has become an important asset for endocrine surgeons over the past few decades. The ability to determine neurophysiologic integrity of the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) on top of identification and meticulous dissection of the nerve in the surgical field, has allowed for advances in technology and improved outcomes when it comes to prevention of vocal fold immobility. This article aims to compare in review continuous and intermittent nerve monitoring (CIONM, IIONM), as well as review the current paradigms of their use. This article will also discuss the future of intraoperative nerve monitoring technologies in scarless thyroid surgery and percutaneous approaches to thyroid pathology in form of radiofrequency ablation (RFA).

Transoral versus gasless transaxillary endoscopic thyroidectomy: a comparative study

This study aimed to compare the surgical safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless endoscopic thyroidectomy transaxillary approach (GETTA). This retrospective study assessed 150 patients managed with the TOETVA at the Yantai Yuhuangding hospital and 150 patients managed via the GETTA at the Zhenjiang Provincial People's Hospital. The procedures were compared in terms of workspace creation time, operating time, complications, post-operative complaints, cosmetic satisfaction, and the efficacy of central neck lymph-node dissection. There was no significant between-group difference in terms of post-operative complications. The average workspace creation and operating times were significantly shorter for GETTA than for TOETVA (P values for both < 0.001). The average number of lymph nodes dissected from the central compartment of the neck was higher in the TOETVA group than in the GETTA group (7.2 ± 4.6 vs. 3.9 ± 3.0, P < 0.001). The mean swallowing impairment index-6 scores at 1 month were significantly lower in the GETTA group than in the TOETVA group (1.5 ± 1.2 vs 2.6 ± 1.4, P < 0.001). Over 97% of all patients (both groups) were either satisfied or very satisfied with the cervical cosmetic outcomes at 3 months post-surgery (P = 0.099). TOETVA and GETTA are both safe procedures with good cervical cosmetic outcomes for well-selected patients. Although TOETVA is more efficacious in terms of central lymph nodes dissection, GETTA has a greater time-cost advantage.

Preferences for thyroidectomy technique: Comparing traditional and transoral approaches

BACKGROUND

We investigated preferences between the transcervical and transoral thyroidectomy approach in the United States and Israel.

METHODS

An online survey assessing scar attitudes and surgical preferences, in English and Hebrew, was distributed on ThyCa.com and other platforms.

RESULTS

928 and 339 responses from the United States and Israel cohorts, respectively, were analyzed. In both countries, individuals without prior thyroidectomy preferred a scarless approach when hypothetical risks equaled those of traditional thyroidectomy (77% United States, 76% Israel, p = 0.61). U.S. respondents without thyroidectomy had greater preference to avoid a scar and would pay more to do so than those with thyroidectomy (both p < 0.001). Many respondents with prior thyroidectomy still expressed interest in scarless alternatives (57% United States).

CONCLUSIONS

Populations in Israel and the United States prefer scarless thyroidectomy when risks equal the traditional approach. While individuals without prior thyroidectomy are more likely to favor a scarless option, former thyroidectomy patients may have preferred avoiding a scar.

The variable direct cost and cost drivers of transoral endoscopic thyroidectomy vestibular approach

Background

As transoral endoscopic thyroidectomy vestibular approach grows in popularity, there is a need for data on cost in order to better characterize its value to patients. To this end, we compared the variable direct cost of transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy and determined which factors drive the increased cost for the transoral approach.

Methods

Patients undergoing thyroid lobectomy and total thyroidectomy that met inclusion criteria for transoral endoscopic thyroidectomy vestibular approach, including those patients that opted for management via the transcervical approach, between 8/2016 and 4/2019 were reviewed. The variable direct cost for the surgical encounter was collected and means were compared between the transoral and transcervical cohorts for lobectomy and total thyroidectomy respectively. The operative time independent variable direct cost was similarly compared between cohorts.

Results

Out of 238 patients, 118 (50%) were managed via transoral endoscopic thyroidectomy vestibular approach and 120 (50%) were managed via transcervical approach thyroidectomy. Mean variable direct cost, our primary outcome, was $4,455 (SD 1,129, 95% CI: 4,204-4,706) for transoral lobectomy and $3,179 (SD 687, 95% CI: 2,990-3,369) for transcervical lobectomy [t(132.05)=8.09, P<0.001] representing a difference in cost of $1,276 (SD 158, 95% CI: 964-1,587). Mean variable direct cost was $4,681 (SD 829, 95% CI: 4,405-4,957) for transoral total thyroidectomy and $3,645 (SD 876, 95% CI: 3,431-3,858) for transcervical total thyroidectomy [t(79.92)=5.98, P<0.001], representing a difference in cost of $1,036 (SD 173, 95% CI: 691-1,381). Differences in energy devices alone account for $487.53 and $447.96 of the cost differences, respectively.

Conclusions

The differences in mean variable direct cost between transoral endoscopic vestibular approach and transcervical approach for lobectomy and total thyroidectomy were $1276 and $1036 respectively, amounts far less than some believe them to be. This data will be invaluable as we ultimately aim to define the value of transoral endoscopic thyroidectomy vestibular approach.

Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy

BACKGROUND

Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods.

METHODS

A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve.

RESULTS

Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2.

CONCLUSIONS

The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.

Appearance characteristics of incision, satisfaction with the aesthetic effect, and quality of life in of thyroid cancer patients after thyroidectomy

OBJECTIVE

This study aimed to assess the correlation between satisfaction with aesthetic effect (SAE) and quality of life (QoL) in thyroid cancer patients after thyroidectomy and identify the impact of appearance characteristics of scars on SAE.

METHODS

This prospective, single-centre, cross-sectional study from November 2018 to June 2019 enrolled 285 thyroid cancer patients three months after their thyroidectomy. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 was used to assess QoL 3 months after thyroidectomy, while the Patient Scar Assessment Scale (PSAS) was used to assess the SAE of patients.

RESULTS

The mean PSAS score was 35.00, and the mean QoL score was 69.96. Correlation analysis demonstrated that PSAS was negatively correlated with QoL score. Multivariate logistic regression analysis demonstrated that age, marital status, radiotherapy, surgery type, neurological deficits, and PSAS were independent risk factors with decreased QoL. Furthermore, correlation analysis showed that scar colour, stiffness, thickness, irregularity and length were positively correlated with poor PSAS. Scar irregularity and length were independent risk factors with poor PSAS.

CONCLUSION

This study demonstrated that scar irregularity and length were independent risk factors with SAE, and poor SAE was correlated with decreased QoL in thyroid cancer patients after thyroidectomy.

Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA)

The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.

Endoscopic cephalic access thyroid surgery (EndoCATS) using the retroauricular approach - a single centre retrospective data analysis

BACKGROUND

Due to improvements in endoscopic as well as robotic technology, and a request for better cosmetic results, there was a significant increase in thyroid surgery using these methods during the past decade.

METHODS

The aim of our study is to evaluate the perioperative short- and long-term outcome as well as the learning curve of EndoCATS and the Quality of Life (QoL).

RESULTS

A total of 150 patients with 152 hemithyroidectomies who underwent endoscopic thyroid surgery by EndoCATS between 2010 and 2016 were enrolled in this study. The mean specimen volume was 15.04 g ± 7.89 g. The mean operation time was 132.79 ± 50.52 min. There is a significant reduction of the operation time after the 53th case. (p < 0.05) There was no acute rebleeding or permanent hypoparathyroidism. Permanent RLN palsy occurred in 3 nerves at risk (NAR) 1.97%. There were no cases of pneumothorax, postoperative infections or skin flap ischemia. 94.11% of the patients describe their state of general health as good as or better than before the surgery.

CONCLUSIONS

EndoCATS is a safe and effective, but a demanding single port access procedure; therefore, extensive training is required. An advantage is the near ideal visualization of the RLN and the parathyroid glands as well as the ability to recover even large specimens without difficulties.

Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach

BACKGROUND

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure.

METHODS

Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT.

RESULTS

A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R² of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001).

CONCLUSIONS

We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases

BACKGROUND

North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA).

STUDY DESIGN

Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m², overweight 25-29.9 kg/m², and obese ≥ 30 kg/m² for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication.

RESULTS

Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively.

CONCLUSION

TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.

Transoral thyroidectomy (TOETVA): Complications, surgical time and learning curve

BACKGROUND

Since 2018, transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a true scarless thyroid surgery. In this study, we explore early outcomes and learning curve of this new approach.

METHODS

A retrospective cohort including conventional thyroidectomies and TOETVAs performed in a cancer center was designed. Learning curve and early surgical outcomes of TOETVA were assessed and compared to conventional thyroidectomy.

RESULTS

A total of 56 TOETVAs and 745 conventional thyroid procedures were included. In the TOETVA group, we had a 14.4% total complication rate with no permanent vocal cord paresis or hypocalcemia. The mean surgical time dropped from 167 to 117 min (p = 0.0001) after the 15 first cases. Comparing to conventional procedures, we didn't find any significant difference in complications rate. Operative time was longer in the TOETVA group.

CONCLUSIONS

In this study, TOETVA was safe and feasible, with a learning curve of 15 cases.

Minimally Invasive Approaches for Thyroid Surgery-Pitfalls and Promises

PURPOSE OF REVIEW

To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies.

RECENT FINDINGS

Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

The role of surgeon-performed ultrasound in transoral endoscopic thyroidectomy vestibular approach (TOETVA)

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a recently described surgical technique where the thyroid and central neck can be accessed without a cutaneous incision. To date nearly 700 cases have been described within the English literature demonstrating the feasibility, safety, and efficacy of the technique. As more institutions begin to adopt the surgical approach, it is important that surgeons pay close attention to appropriate patient selection and surgical optimization to prevent experience-related complications. A valuable tool to facilitate these considerations is the utilization of surgeon-performed ultrasonography (US). While the merits of surgeon-performed US are well-documented within head & neck endocrine surgery as a whole, its value may be of even greater importance when implementing a novel surgical technique such as TOETVA. Here we highlight and summarize the role of surgeon-performed US within head & neck endocrine surgery, focusing on how it may influence patient selection and surgical planning with TOETVA.

Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy

INTRODUCTION

The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA).

METHODS

The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued.

RESULTS

Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times.

CONCLUSIONS

The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.

Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update

Transoral endoscopic thyroidectomy and parathyroidectomy via the vestibular approach (TOET/PVA or TOETVA-TOEPVA) is the latest remote-access technique employed in the central neck. As the only approach that does not leave any cutaneous incision, (TOET/PVA) has become popular in both the Far East and Western series since its original description in 2015. More than just a "scarless" surgery, (TOET/PVA) has been associated with a short learning curve, access to the bilateral central neck compartments, few surgical contraindications, minimal complications, and minimal additional instrumentation. To date, more than 2,000 cases have been completed, including more than 400 in North America, demonstrating brisk utilization of a novel technique relative to earlier remote access central neck approaches. Herein, we describe updates that continue to improve the safety and efficacy of the procedure.

Simulations and simulators in head and neck endocrine surgery

Simulations and simulators have become an increasingly important tool in trainee education across many surgical disciplines, particularly for robotic and minimally invasive procedures. Thyroidectomy and parathyroidectomy are common procedures performed across multiple surgical disciplines, however, there is limited literature regarding training models/simulators for these operations. This is despite the advent and growing popularity of remote-access thyroidectomy techniques, where simulators may provide significant value in trainee education and safe implementation. Here we review the literature regarding available simulations/simulators in head and neck endocrine surgery for both conventional transcervical approaches and newer remote-access thyroidectomy techniques.

Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery

OBJECTIVE

Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.

METHODS

Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.

RESULTS

One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T² = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T² = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T² = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.

CONCLUSION

Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1603-1608, 2020.

Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy

Objectives:

The objectives of the study were to investigate the improvement in operation time for thyroid surgery gained using a modified endobag and suture and to accelerate the learning process for novice endoscopic surgeons.

Materials and Methods:

A retrospective study was conducted between 2 June 2015 and 1 November 2018. Medical records of patients who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) were retrieved and analysed. Comparisons of operative time with or without the use of modified equipment were calculated by the unequal variance t-test in lobectomy and isthmectomy groups.

Results:

Medical records of 102 patients (mean age: 39.1 years) were analysed. The size of thyroid nodule averaged 4.0 cm (range: 1.0–13.0 cm). TOETVA was applied for right lobectomy (57.8%), left lobectomy (34.3%), isthmectomy (3.9%) and total thyroidectomy (3.9%). Early in our experience, TOETVA required 168 min, whereas following the introduction of the modified endobag and extracorporeal suture, operative time was reduced to 30 min (P > 0.05).

Conclusions:

The use of modified equipment permitted shorter operation times. The time difference was not statistically significant but does represent a significant time-saving. The use of the modified equipment will simplify and speed up the learning process for novice endoscopic surgeons.

Starting a Transoral Thyroid and Parathyroid Surgery Program

Purpose of Review

To describe the necessary steps to facilitate safe implementation of a transoral thyroid and parathyroid surgery program.

Recent Findings

Transoral vestibular approaches to the central neck have been demonstrated to be safe and feasible, while avoiding the morbidity of a cutaneous scar. As operative volume expands from a select few high-volume centers, a framework for implementation has been recommended to allow the evidence-based outcomes to translate into clinical practice for new adopters of these techniques. These include securing institutional support, choosing the appropriate candidate (both patient and surgeon), appropriate case observation and instruction (live and cadaver), and adequate first-case preparation and knowledge of the learning curve(s) for the techniques.

Summary

The recommendations in this article provide a foundation from which a transoral thyroid and parathyroid program may be successfully built. An intricate understanding of conventional transcervical central neck surgery and institutional support are absolute prerequisites to safe and successful implementation of these transoral vestibular techniques.

Transoral Vestibular Thyroidectomy: Current State of Affairs and Considerations for the Future

CONTEXT

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a recently described procedure for surgical management of select thyroid pathology without the need for a cutaneous scar. TOETVA is far from the first described remote-access approach to the thyroid. In fact, numerous such techniques have been described over the past 20 years, although none have gained wide-spread implementation in North America or Europe. TOETVA, with its rapid growth worldwide and excellent outcomes to date, however, may succeed where these prior described techniques have failed.

EVIDENCE ACQUISITION

The English literature was reviewed using the following keywords: transoral thyroidectomy, remote-access thyroidectomy, minimally-invasive thyroidectomy, and TOETVA. As three recent systematic reviews have been performed in regards to the technique, this manuscript does not seek to provide a fourth such text. Rather, here we summarize salient findings from these reviews and focus on candidates for the procedure, technique-specific characteristics which have led to TOETVA's early success, and prospects for the future.

EVIDENCE SYNTHESIS

TOETVA is the only thyroidectomy approach obviating the need for a cutaneous incision, and offers several advantages over prior described remote-access thyroidectomy techniques. These include a favorable anatomic surgical perspective, a comparatively short learning curve, no requirement for expensive instrumentation, and a broad inclusion criterion. These characteristics have facilitated the excellent surgical outcomes to date.

CONCLUSIONS

TOETVA is a suitable surgical option for a carefully selected patient population with proven safety and feasibility. The potential value of the procedure outside enhanced cosmesis continues to be defined.

Remote-Access Thyroidectomy: A Multi-Institutional North American Experience with Transaxillary, Robotic Facelift, and Transoral Endoscopic Vestibular Approaches

BACKGROUND

Many remote-access approaches (RAAs) to the thyroid have been described to circumvent anterior neck scarring, including the transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. These techniques have been popularized in Asia, but adoption has been slow in North America. We aimed to examine multi-institutional North American outcomes with RAA thyroidectomy in the context of these institutions' transcervical approach (TCA) outcomes.

STUDY DESIGN

Cases of lobectomy and total thyroidectomy via transaxillary, robotic facelift, and transoral endoscopic vestibular approaches were reviewed. Demographic characteristics, outcomes, and complications were compared with the same measures in patients undergoing lobectomy and total thyroidectomy via TCA by the primary RAA surgeons at each institution. Patients who underwent parathyroidectomy or other concomitant neck dissection procedures were excluded.

RESULTS

Two hundred and sixteen RAA thyroidectomies were attempted (92 transoral endoscopic vestibular approaches, 70 transaxillary, and 54 robotic facelift) and 410 TCA thyroidectomies were performed. There was no difference in mean index nodule sizes between RAA (2.8 ± 1.6 cm) and TCA (2.9 ± 1.9 cm) cohorts (p = 0.72). Median operative times for lobectomy were 146 minutes (range 60 to 343 minutes) and 90 minutes (range 25 to 247 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). Median operative time for total thyroidectomy was 170 minutes (range 100 to 398 minutes) vs 126.5 minutes (range 51 to 260 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). There was no difference in the rates of permanent recurrent laryngeal nerve injury between the RAA (0 of 216 [0%]) and TCA (0 of 410 [0%]) cohorts (p = 0.99).

CONCLUSIONS

Remote-access approach thyroidectomy can be performed in a select North American patient population with outcomes comparable with TCA.