Pneumoperitoneum after transoral endoscopic thyroidectomy vestibular approach

A suspension surgical space construction method involving a gasless transoral endoscopic thyroidectomy vestibular approach: a single-center experience

OBJECTIVE

This study aimed to summarize and explore how to establish a good surgical space via a gasless transoral endoscopic thyroidectomy vestibular approach (TOETVA) to facilitate smooth surgical progress.

METHODS

This study was conducted between January 2022 and December 2023. The study involved 281 patients with papillary thyroid carcinoma who underwent gasless TOETVA at The First Affiliated Hospital of the University of Science and Technology of China. The suspension method was used to establish the surgical space during the operation. The key steps and difficulties of surgical space construction were summarized, and the clinicopathological characteristics and surgical complications of the patients were analyzed.

RESULTS

The mean surgical duration was 167.86 ± 25.38 min, and the time needed to create the surgical space (from incision of the lip mucosa to incision of the anterior border of the neck) was 17.82 ± 9.44 min. During the construction of the surgical space, there was 1 case of thermal skin burn and 2 cases of bleeding from the anterior jugular vein, with no permanent injury to the mental nerve.

CONCLUSION

In the gasless TOETVA, the suspension method of surgical space construction was employed to rapidly establish a stable three-dimensional operating space that was less prone to collapse, thus facilitating the smooth implementation of subsequent surgical procedures.

En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma

INTRODUCTION

The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma.

OBJECTIVE

This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma.

METHODS

This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed.

RESULTS

All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51 cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision.

CONCLUSION

The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.

Scarless total thyroidectomy via transoral endoscopic vestibular approach: initial case series in a developing Asian country

Conventional open thyroidectomy may leave a visible scar postoperatively and can lead to impaired quality of life. Since 2016, the transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has gained popularity due to being a true 'scarless' procedure. However, minimally invasive thyroidectomy has not been widely adopted in the Philippines yet. From August 2019 to December 2019, nine patients (mean thyroid nodule size of 3.1 cm) underwent TOETVA with one open conversion due to adherent papillary cancer. Majority had a blood loss of <100 ml, whereas mean operative time was 149.8 ± 20.5 minutes. Five patients developed hypocalcemia (three transient), whereas two patients reported transient lower lip numbness. TOETVA is a safe and feasible novel procedure for both benign and malignant thyroid diseases. Care must be taken in selecting patients who opt for TOETVA, and that surgeons should reassess their limitations before implementing this technique in their surgical practice.

Asymptomatic carbon dioxide embolism during transoral vestibular thyroidectomy: A case report

BACKGROUND

Endoscopic thyroidectomy has obvious advantages over conventional surgical techniques in terms of postoperative cosmetic outcome. Although the incidence of carbon dioxide embolism (CDE) during endoscopic thyroidectomy is very low, it is potentially fatal. The clinical manifestations of CDE vary, and more attention should be paid to this disorder.

CASE SUMMARY

A 27-year-old man was scheduled for thyroidectomy by the transoral vestibular approach. The patient had no other diseases or surgical history. During the operation, he developed a CDE following inadvertent injury of the anterior jugular vein. The clinical manifestation in this patient was a transient sharp rise in end-tidal carbon dioxide, and his remaining vital signs were stable. In addition, loud coarse systolic and diastolic murmurs were heard over the precordium. The patient was discharged on day 4 after surgery without complications.

CONCLUSION

A transient sharp rise in end-tidal carbon dioxide is considered a helpful early sign of CDE during endoscopic thyroidectomy.

Complications of Transoral Thyroidectomy: Overview and Update

Transoral thyroidectomy via the vestibular approach has become popular worldwide, with advantages including less surgical morbidity, excellent postoperative cosmesis, and superior functional voice outcomes. Several studies have reported that the surgical outcomes of the transoral approach were comparable to those of the conventional transcervical approach in selected patients. However, unusual complications, such as CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been noted in transoral thyroidectomy. This paper aims to review and provide updated information on these complications and their management. Routine intraoperative neural monitoring is required to avoid laryngeal nerve palsy in the transoral approach. To prevent CO2 embolism, surgeons need to be careful not to injure the anterior jugular vein, and the CO2 insufflation pressure should be set as low as 4-6 mmHg. To avoid mental nerve injury, vestibular incisions should be placed in the safety zone, and dissection of the vestibular area and chin should be minimized. In conclusion, recognizing the possibility of complications and understanding their prevention and management are important for patient safety and the success of the transoral approach.