Transoral endoscopic thyroidectomy via the tri-vestibular routes: results of a preclinical cadaver feasibility study

Outcome of isolated and combined direct feminization laryngochondroplasty: Our first 20 cases

This retrospective study describes the surgical outcomes of our first 20 transgender women to undergo feminization thyroid laryngochondroplasty (FLC) by a direct transvestibular FLC (DTV-FLC) approach from December 2019 to October 2023. The medical records of all patients were retrieved and reviewed. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic outcomes were retrieved. The cosmetic results were evaluated by four independent facial plastic surgeons. Thirteen patients underwent DTV-FLC combined with genioplasty or genioplasty with mandibular angle reduction and seven underwent isolated DTV-FLC. DTV-FLC was feasible in all planned cases. Complications (skin flap perforation, thyroid cartilage fracture, mental hypoesthesia, hematoma, dehiscence of the vestibular incision, vestibular scar adhesions, and anemia) were minor and resolved spontaneously. The preoperative grade of thyroid cartilage protrusion was 1.9 ± 0.9 on a scale from 1 to 3. The postoperative cosmetic results of 18 patients were judged as having improved (a score of 2.1 ± 0.8 on a scale from -1 to 3). Eighteen patients were satisfied with the cosmetic result, one was dissatisfied (the revision surgery patient), and one was lost to follow-up. In conclusion, DTV-FTLC is a valid surgical approach for FLC, yielding high patient satisfaction and good cosmetic results.

Direct Transvestibular Feminization Thyroid Laryngochondroplasty

BACKGROUND

Feminization laryngochondroplasty (FLC) methods have evolved from using a midcervical incision to a submental, less visible incision. The scar may be unacceptable to the patient because it signals gender reassignment surgery. An endoscopic transoral approach to FLC inspired by transoral endoscopic thyroidectomy was recently suggested to avoid the neck scar; however, it requires special equipment and has a long learning curve. A vestibular incision is used to approach the chin in lower-third facial feminization surgery. The authors propose that this incision may be extended to the thyroid cartilage in performing direct FLCs. The authors describe their experience with a novel, minimally invasive, direct transvestibular use of the chin-reshaping incision.

METHODS

The medical records of all patients who underwent direct transvestibular FLC (DTV-FLC) from December of 2019 to September of 2021 were retrieved and reviewed for this retrospective cohort study. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic results were retrieved.

RESULTS

Nine transgender women were included. Seven DTV-FLCs were performed during lower-third facial feminization surgery, and two were isolated DTV-FLCs. One was a revision DTV-FLC. Transient minor complications were encountered and resolved by the postoperative visit at 1 to 2 months. Vocal fold function and voice quality remained intact. Eight available patients were satisfied with the surgical results. A blinded assessment by eight plastic surgeons determined that seven procedures were successful.

CONCLUSION

The novel DTV-FTLC approach either in isolation or as part of lower-third facial feminization surgery facilitated scar-free FLC with satisfactory cosmetic and functional results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Cadaver Study on Transoral Thyroid Chondrolaryngoplasty and Transoral Sistrunk Operation, Possibility from Transoral Thyroidectomy

OBJECTIVE

Transoral approaches in surgery are gaining global popularity. Transoral endoscopic and robotic thyroidectomies are well established due to the benefit of being truly scarless. Thyroid chondrolaryngoplasty reduces protrusion of the thyroid notch in transgender patients. The Sistrunk operation involves removal of the thyroglossal cyst and the central portion of the hyoid bone. In this cadaveric study, we developed a transoral thyroidectomy approach and assessed the feasibility of applying this technique to thyroid chondrolaryngoplasty and Sistrunk operation with the proper usage of a special endoscopic burr.

METHODS

We performed surgery using the transoral vestibular approach with 13 fresh-frozen human cadavers. Unlike transoral thyroid surgery, which requires high-resolution detailed anatomical view, this technique uses a 5-mm 30-degree endoscope with a 5-mm central port. A smaller central port can reduce the risk of mental nerve paresthesia. A special endoscopic burr for functional endoscopic sinus surgery is used to thin the thyroid notch cartilage and cut the central portion of the hyoid bone.

RESULTS

We successfully performed transoral thyroid chondrolaryngoplasty and transoral Sistrunk operation in 13 cadavers.

CONCLUSION

Transoral chondrolaryngoplasty and transoral Sistrunk operation are feasible for transgender or thyroglossal cyst patients. It offers the additional benefit of being a scarless surgery and could play a promising role in minimally invasive thyroid surgeries. Proper use of an endoscopic drilling burr to thin thyroid notch cartilage and cutting the central portion of the hyoid bone can make transoral thyroid chondrolaryngoplasty and transoral Sistrunk operation safe and feasible .

Transoral thyroidectomy implemented by a novice surgeon: Efforts for safe implementation

Background

This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon.

Methods

We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy.

Results

Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome.

Conclusions

Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework.

Level of Evidence

Level 4.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): A novel surgical technique for scarless thyroidectomy in pediatric surgery

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel surgical technique in thyroid surgery that provides a feasible opportunity to avoid a visible neck scar. In recent years, TOETVA became popular in the thyroid surgery of selected adult patients with cosmetic concerns. We conducted a right lobectomy with the TOETVA technique in a 17-year-old adolescent with a suspicious thyroid nodule the present report aimed to describe the details of the operative technique step by step. Level of evidence: LEVEL IV, case series with no comparison group.

OUP accepted manuscript

BACKGROUND

The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework.

METHODS

A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework.

RESULTS

Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration).

CONCLUSION

There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.

Current concepts in thyroid gland surgery: transoral endoscopic and robotic surgical procedures

The increased incidence of thyroid cancer in young females may raise concerns about visible hypertrophic scarring on the center of the neck after thyroid gland surgery. Therefore, endoscopic surgical procedures have attracted significant interest from patients with thyroid cancer, leading to the development of various endoscopic and robotic approaches. Although the cosmetic outcomes of current endoscopic and robotic thyroid surgeries have been excellent, all the procedures still require a large incision and extensive flap elevation. Transoral endoscopic thyroid surgery is a newly developed surgical method performed by inserting an endoscope through a mucosal opening created in the mouth, obviating the need for a skin incision. Additionally, the dissection area is relatively small and no dressings are required. Showering or shaving may resume the day after surgery and the port created within the oral mucous membrane generally heals within one week. Importantly, this approach is markedly less invasive than other endoscopic approaches. Although transoral endoscopic thyroid surgery has not yet been universally accepted, it may emerge as the preferred method for thyroid surgery in the near future.

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.

Safety of central compartment neck dissection for transoral endoscopic thyroid surgery in papillary thyroid carcinoma

Background

Remote access and endoscopic thyroid surgery has been gaining popularity because it allows patients to avoid a visible scar in the neck. There is limited data on transoral endoscopic thyroidectomy when it relates to patients with papillary thyroid carcinoma. We aim to evaluate the safety of ipsilateral central compartment dissection for patients who undergo transoral thyroidectomy (thyroidectomy vestibular approach–compartment lymph node dissection).

Patients and Methods

A total of 80 patients who underwent thyroidectomy vestibular approach–compartment lymph node dissection for papillary thyroid carcinoma from June 2015 to September 2016 were identified. Over the same period, a matched cohort of 80 patients who underwent open thyroidectomy with routine ipsilateral central compartment dissection was also identified (Open-compartment lymph node dissection). The two groups were analyzed in terms of patient characteristics, perioperative clinical results and post-operative outcomes.

Results

All patients were female with a mean age of 32-year. There was no difference in mean maximum tumor size and number of lymph nodes dissected. Moreover, there was no difference in average positive lymph nodes between thyroidectomy vestibular approach–compartment lymph node dissection and Open-compartment lymph node dissection (1.48 vs 1.08, P = 0.647). Operative time was longer in the thyroidectomy vestibular approach–compartment lymph node dissection group (193 vs 102 min, P < 0.001). Thyroidectomy specific complications were similar with rates of temporary recurrent laryngeal nerve palsy of 6.3 vs 8.8% and temporary hypocalcemia rates of 2.5 vs 5% in the thyroidectomy vestibular approach–compartment lymph node dissection and Open-compartment lymph node dissection groups, respectively.

Conclusions

Thyroidectomy vestibular approach–compartment lymph node dissection is a feasible and safe option for select patients with papillary thyroid carcinoma who require central node dissection compared with Open-compartment lymph node dissection, and can be a viable alternative for patients wishing to avoid a visible scar.

Extracervical Approaches to Thyroid Surgery: Evolution and Review

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.

Indications, benefits and risks of transoral thyroidectomy

The advancement of minimally invasive surgery in the field of endocrine surgery over the last 2 decades has fostered the attempt of natural orifice transluminal endoscopic surgery (NOTES) for thyroidectomy and parathyroidectomy via oral incisions. This technically demanding surgery is currently being evaluated in a number of specialised centres. The procedure has gained popularity worldwide and is performed in more than 50 centres. By retrieving information from published or presented articles and direct personal communications, this study reports several issues to enable and optimise correct patient and surgeon candidacy, present the advantages and prevent novel complications under the standards of open thyroid surgery. Not all patients are eligible for the transoral approach. Transoral endoscopic and robotic procedures were described and critically analysed in this study.

Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA): experiência inicial no Brasil

RESUMO Objetivo: apresentar a experiência inicial no Brasil com a tireoidectomia transoral endoscópica por abordagem vestibular (TOETVA). Métodos: estudo prospectivo de pacientes submetidos à TOETVA no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Regional do Oeste, Chapecó, Santa Catarina. Foram candidatos para o estudo os pacientes entre 18 e 65 anos de idade, ASA I e II, com volume glandular de até 35cm3e nódulos de até de 4cm. Dados dos pacientes, dos nódulos, tempo cirúrgico, complicações, e tempo de internação foram registrados. Resultados: nove pacientes foram operados entre maio de 2017 e abril de 2018. Todos eram mulheres, com idades entre 33 e 64 anos. O tamanho do nódulo variou de 1cm a 4cm. Dois pacientes eram portadores de neoplasia maligna e a tireoidectomia total foi feita em oito casos. Sete pacientes tiveram uma internação de apenas um dia. Um paciente sofreu uma complicação menor na pele, mas não ocorreram lesões dos nervos laríngeos recorrentes ou hipoparatireoidismo definitivo. Conclusão: a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos.

Complete endoscopic radical resection of thyroid cancer via an oral vestibule approach

The aim of the present study was to explore the feasibility, safety and effectiveness of complete endoscopic radical resection of thyroid cancer via an oral vestibule approach. A total of 60 patients with unilateral thyroid papillary carcinoma were divided into two groups. Half of them underwent complete endoscopic surgeries via an oral vestibule approach at the Department of Head and Neck Surgery of Fujian Cancer Hospital between November 2014 and December 2016. The other 30 patients underwent traditional open surgeries. All the patients underwent unilateral lobectomy and central neck dissection. Tumor diameter, surgery duration, intraoperative inflation pressure and end-tidal CO₂ flow rate, intraoperative peak value of the partial pressure of end-tidal CO₂, postoperative extubation time, the number of lymph nodes in the specimens of central neck dissection and postoperative complications were noted. From this data, tumor diameter (T stage of tumor), surgery duration, postoperative extubation time, the number of lymph nodes in the specimens of central neck dissection and postoperative complications were compared between the two groups. In the endoscopic group, 1 patient had a tracheal injury, and 1 patient had a submental skin perforation. Furthermore, 17 patients experienced transient numbness of the lower lip, 5 patients experienced an abnormal increase in the partial pressure of end-tidal CO₂, and 2 patients experienced postoperative headache. No recurrent laryngeal nerve injury, postoperative bleeding, or infection was determined. There were no significant differences in all items of the indexes, compared with those patients who underwent open radical surgery. The lymph nodes from region VI may be well exposed and completely removed through this novel procedure with no visible scars, which not only ensured the surgery criterion was met, but also met the cosmetic requirements of the patients. The present study conducted procedures safely by surgeons highly skilled in performing laparoscopic surgery.

Transoral Endoscopic Thyroidectomy: A Systematic Review of the Practice So Far

Background and Objectives

Thyroid disease largely affects young females, but the incidence is also increasing among males. In an effort to avoid the scarring of the neck that is synonymous with conventional thyroidectomy, endoscopic techniques have been developed over the years. The transoral endoscopic approach is the latest of these innovations that promises a scarless surgical outcome. This review evaluates whether this technique is safe and feasible in live patients and outlines the outcomes in published literature so far.

Database

PubMed, Medline, BioMed Central, Cochrane Library, OVID and Web of Science were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting strict inclusion and exclusion criteria. Sixteen studies were included in the final analysis.

Discussion

This systematic review presents cases of 785 patients. Surgeons in 15 of the studies used a completely vestibular approach, whereas those in the remaining 2 used the floor of the mouth for primary access. Conversion to open surgery took place in 1.3%. In total, 4.3% of patients experienced transient laryngeal nerve palsy, whereas 0.1% had permanent recurrent incidences of the condition. Transient hypocalcemia occurred in 7.4% of cases, with no recorded permanent cases. Carbon dioxide embolism occurred in 0.6% of cases, and another 0.6% had a deep-seated neck infection. The complication rates within the review were deemed acceptable and the overall technique feasible. A prospective randomized controlled trial was proposed to compare this technique with conventional thyroidectomy.

Robotic and endoscopic transoral thyroidectomy: feasibility and description of the technique in the cadaveric model

Background

Numerous new approaches have been described over the years to improve the cosmetic outcomes of thyroid surgery. Transoral approach is a new technique that aims to achieve superior cosmetic outcomes by concealing the incision in the oral cavity.

Methods

Transoral thyroidectomy through vestibular approach was performed in two institutions on cadaveric models. Procedure was performed endoscopically in one institution, while the robotic technique was utilized at the other.

Results

Transoral thyroidectomy was successfully performed at both institutions with robotic and endoscopic techniques. All vital structures were identified and preserved.

Conclusions

Transoral thyroidectomy has been performed in animal and cadaveric models, as well as in some clinical studies. Our initial experience indicates the feasibility of this approach. More clinical studies are required to elucidate its full utility.

Transoral endoscopic total thyroidectomy vestibular approach: A case series and literature review

Conventional open thyroidectomy is often associated with post-operative complications including nerve damage, voice disturbances, paraesthesias, adhesions and prominent scarring. Several endoscopic surgical techniques have been reported as alternatives to conventional thyroidectomy. Natural orifice transluminal endoscopic surgery is a promising approach which leaves no scar, produces few complications and affords faster discharge from care. Several studies have explored its utility in total thyroidectomy in patients with benign or malignant thyroid disease. Herein, we present a case series on the successful application of transoral endoscopic total thyroidectomy vestibular approach (TOETVA) in benign and malignant diseases of the thyroid. We performed TOETVA in 11 patients presenting with benign or malignant thyroid nodules in our hospital, between 1^st January 2015 and 30^th June 2016. The surgery was completed successfully in all patients with a pre-operative diagnosis of multinodular goitre. The surgery was performed under general anaesthesia and the mean operative time was 130 min. The mean blood loss was 2–3 cc. No incidence of recurrent laryngeal nerve injury, damage to mental nerve, parathyroid damage or peri-incisional adhesion occurred in the study participants. No visible scarring occurred in the patients following surgery. The patients had an uneventful recovery after the surgery and were discharged after 4 days. TOETVA is safe and effective in the surgical management of multinodular goitre and offers a scar-free alternative to conventional surgery.

Indications and contraindications to transoral thyroidectomy

Patient motivation to avoid neck scarring has been a strong impetus in the development of remote access approaches to the thyroid, including transoral robotic or endoscopic thyroidectomy vestibular approach (TOR/ETVA). TOR/ETVA continues to become more prevalent given its early success in North America and the demonstration of its safety and efficacy in Asia. As more surgeons perform this procedure, it is important that specific and uniform indications and contraindications exist to prevent surgical complications due to poor patient selection. In this article, we review the existing English literature regarding TOR/ETVA and compile the inclusion and exclusion criteria of individual authors for both robotic and endoscopic techniques to date. We then resolve differences in the existing literature to provide recommended indications and contraindications to TOR/ETVA based on both our review and our own experience with TOR/ETVA to date. The following are our resultant recommended indications for TOR/ETVA: patient history of hypertrophic scarring or motivation to avoid a cervical neck incision with a maximal thyroid diameter ≤ 10 cm and dominant nodule ≤6 cm, with one of the following pathologic criteria; benign lesion, multinodular goiter, indeterminate nodule, or suspicious lesions/well-differentiated thyroid carcinomas ≤ 2 cm. Recommended contraindications to TOR/ETVA are as follows: history of head & neck surgery, history of head, neck, or upper mediastinal irradiation, inability to tolerate general anesthesia, evidence of clinical hyperthyroidism, preoperative recurrent laryngeal nerve palsy, lymph node metastasis, extrathyroidal extension including tracheal or esophageal invasion, oral abscesses, substernal thyroidal extension, or failure to meet inclusion criteria as above. Relative contraindications include smoking and other oral pathology, and surgeons should be aware that morbid obesity may make it difficult to raise skin flaps.

Transoral thyroidectomy and parathyroidectomy - A North American series of robotic and endoscopic transoral approaches to the central neck

OBJECTIVE

Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma.

MATERIALS AND METHODS

Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017.

RESULTS

Fifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life.

CONCLUSION

The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Transoral thyroidectomy: limitations, patients' safety, and own experiences

For patients undergoing thyroidectomy, the minimally invasive aspect and the cosmetic advantage of the procedure seem to be important factors in surgery. Studies in cadaver and animals have shown that different endoscopic techniques can be performed in a safe and successful way. In the evolution of thyroid surgery, for many endocrine surgeons, the transoral approach seems to be the next step. Even if such procedures are more and more frequently applied in patients, these procedures are far from being generally implemented in routine surgery. In this study, we report on our own experience and considerations in the process of finding a sublingual endoscopic transoral way to the endoscopic transoral thyroidectomy. We describe our failures, risk assessment and compare that with the available literature on transoral sublingual and vestibular thyroid surgery. The access itself needs to be further refined, and even more suitable and better adapted instruments need to be developed, so that optimal and safe results that meet all requirements on endocrine surgery can be achieved. A learning curve at the risk of patients' lives should be avoided. Furthermore, a combination of transoral endoscopic non-transoral techniques might be a useful safer, but more traumatising alternative for implementation. The sublingual access seems to be less invasive than the vestibular access. For a sublingual single-access routine surgery, better instruments are needed. Only in highly specialized centres for endocrine and endoscopic surgery, transoral thyroidectomy should be performed.

Transoral endoscopic thyroidectomy: our initial experience using a new endoscopic technique

BACKGROUND

A transoral approach has been experimentally introduced to the field of thyroid surgery and several groups in Asia have recently used the technique to treat patients. We performed transoral endoscopic thyroidectomies on patients with thyroid cancer or a benign tumor.

METHODS

We reviewed the medical records of patients who underwent transoral endoscopic thyroid surgery between July 2016 and January 2017. A midline incision was made in the vestibule, and a 10 mm cannula was placed; then, the working space was widened by insufflating CO₂ at a pressure of 5-6 mmHg. Two lateral incisions were made in the vestibule near the first molars, and 5-mm-diameter cannulas were inserted. A 10-mm 30° telescope was inserted through the midline cannula and instruments were positioned through the lateral cannulas. Thyroid surgery was endoscopically performed using conventional endoscopic instruments.

RESULTS

We performed 18 thyroid surgeries (15 thyroid lobectomies, one completion thyroidectomy, and two total thyroidectomies) in 17 patients. The postoperative pathology was papillary thyroid cancer in 11 cases (61.1%), a follicular carcinoma in two cases (one patient) (11.1%) and benign in five cases (27.8%). The average tumor diameter was 1.75 cm (range 0.5-7.5 cm). No patient reported sensory changes around the lower lip. No patient developed permanent recurrent laryngeal nerve palsy or hypocalcemia. No patient developed a wound infection or a fistula between the oral incision and anterior neck.

CONCLUSIONS

The transoral endoscopic approach provides a short, direct route to the thyroid gland and seems to be safe and feasible. It is important to further develop and refine the surgical techniques. The approach is optimal, and will become widely used for thyroid surgery in the near future.

Transoral endoscopic thyroidectomy via the trivestibular route

We recently experienced a case of transoral endoscopic thyroidectomy via the trivestibular approach. We identified and preserved all neighboring critical structures during surgery. The patient was discharged on postoperative day 3. There were no complications in thyroid function, vocal cord function, or lower lip sense. Transoral endoscopic thyroidectomy via a trivestibular approach provides a short and direct route to the thyroid and an adequate workspace without a skin incision. Therefore, it is worthwhile to develop and refine the surgical techniques of this promising new surgical approach.

Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases

BACKGROUND

Natural orifice transluminal endoscopic surgery has been adopted for thyroid surgery because of its potential for scar-free operation. However, the previous technique still has some limitations. Thus, we present our initial experience in transoral endoscopic thyroidectomy vestibular approach (TOETVA).

METHODS

From April 2014 to January 2015, we used a three-port technique through the oral vestibule, one 10-mm port for laparoscope and two additional 5-mm ports for instruments. The CO2 insufflation pressure was set at 6 mm Hg. An anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device.

RESULTS

A series of 60 procedures were accomplished successfully. 42 patients had single-thyroid nodules, and a lobectomy was performed. 22 patients had multinodular goiters and two patients had Graves' disease, with total thyroidectomy or Hartley-Dunhill procedures performed. Two had papillary thyroid carcinoma, and total thyroidectomy with central node dissection was performed. The median operative time was 115.5 min (range 75-300 min). The median blood loss was 30 mL (range 8-130 mL). Two patients experienced a transient hoarseness, which was resolved within 2 months. One patient experienced a late postoperative hematoma, which was treated conservatively. No mental nerve injury or infections were found. The patients were discharged in an average of 3.6 days (range 2-7 days) postoperatively.

CONCLUSION

TOETVA is safe and feasible, resulting in no visible scarring. This technique may provide a method for ideal cosmetic results.

Endoscopic thyroidectomy: the transoral approach

Transoral endoscopic thyroid surgery seems to be the logical consequence in the evolution of thyroid surgery. Animal and cadaver studies have shown that different endoscopic techniques can be performed in a safe and successful way. Presently, the minimally invasive aspect and cosmetic advantage seem to be the most important factor for the patients. However, even if these procedures are feasible in patients, the transoral access must still be considered as experimental. In this study then we aim at comparing the available literature on transoral thyroid surgery with our own experience in this field. The access itself needs to be further refined, and even more suitable and better adapted instruments need to be developed so that optimal and safe results that meet all requirements on endocrine surgery can be achieved and all requirements for endocrine surgery are met. The transoral thyroidectomy should only be performed in highly specialized centres for endocrine and endoscopic surgery. As an alternative, a combination with endoscopic non-transoral techniques-so called hybrid techniques-might be useful for our patients.