Commentary on transoral access for endoscopic thyroid resection : Witzel K, von Rahden BH, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22(8):1871-1875

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy

INTRODUCTION

Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA).

MATERIALS AND METHODS

Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab.

RESULTS

The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34).

CONCLUSIONS

TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Robotic versus endoscopic transoral thyroidectomy in papillary thyroid cancer: A comparative analysis of surgical outcomes in 240 consecutive patients

BACKGROUND

This study compared the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) in papillary thyroid cancer (PTC).

METHODS

The TOETVA and TORT groups comprised 119 and 121 patients between November 2016 and May 2022. Clinico-surgical outcomes and operation times were retrospectively reviewed.

RESULTS

The TORT group showed a higher number of retrieved central compartment lymph nodes, shorter hospital stays, and lower pain score after 48 h than the TOETVA group. No significant difference was observed in the other postoperative complications, including permanent vocal cord palsy. Total operation, working space creation, and endoscopic or robotic surgery times of the TORT group were longer than those of the TOETVA group.

CONCLUSIONS

TORT and TOETVA are feasible and safe. TORT may have some advantages, such as central compartment node dissection, shorter hospital stays, and pain score after 48 h in PTC, despite a longer operative time.

Recent Trends in Surgical Approach to Thyroid Cancer

Over the past decade, the incidence of thyroid cancer has rapidly increased worldwide, and thyroid surgery has become one of the most common performed surgical procedure. Even though conventional open thyroidectomy remains the gold standard, this approach leaves a neck scar which could be worrying mainly for young women. The recent progress in surgical technology, as well as patient cosmetic requests, have led to the development of alternative access to the thyroid lodge. Thus, alternative techniques have been established in order to potentially provide a more appealing cosmetic result, both with a minimally-invasive cervical or remote-access approach. However, the introduction of these new techniques was initially approached with caution due to technical challenges, the introduction of new complications and, above all, skepticism about the oncologic effectiveness. Among several alternative approaches proposed, the minimally invasive video-assisted thyroidectomy and the robot-assisted transaxillary thyroidectomy became popular and obtained the favor of the scientific community. Moreover, the recent introduction of the trans-oral endoscopic thyroidectomy with vestibular approach, although the safety and the efficacy are still under discussion, deserves particular attention since it represents the only technique truly scarless and provides the best cometic result. The purpose of this article is to provide an overview of the current main alternative approaches for the treatment of thyroid cancer with particular focus on the oncological effectiveness of the procedures.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Our outcomes from Turkey

OBJECTIVES

The Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) was described in 2016 and had its case series published. This study aimed to present the largest TOETVA case series performed in Turkey.

MATERIAL AND METHODS

Data from 52 patients who underwent TOETVA procedure between February 2018 and October 2019 were analyzed retrospectively. Demographic data, duration of operation, blood loss, rate of conversion to open surgery, radiological findings, pathological outcomes, and complications were analyzed.

RESULTS

All patients were female. Mean duration of the operation was 192 ± 45 minutes, mean blood loss was 39 ± 47 mL, and the ratio of surgical site infection was 6% (3/50). In two (4%) patients, TOETVA was converted to open surgery. Temporary and permanent recurrent laryngeal nerve (RLN) paralysis was observed in 2 (4%) and 0 patients, respectively. Temporary and permanent hypoparathyroidism was observed in 10 (20%) and 0 patients, respectively.

CONCLUSION

TOETVA procedure is the most recently defined NOTES technique for endocrine surgery. In experienced healthcare centers, TOETVA can achieve outcomes similar and even better than the ones obtained with open surgery. The complication rates, durations of operation, surgical site infection, and blood loss parameters that we observed in our experience are similar to the ones reported in the literature.

Evaluation of the efficacy of postoperative antibiotic treatment in transoral endoscopic thyroidectomy: a prospective randomised controlled trial

Transoral endoscopic thyroid surgery (TOET) is a new, minimally-invasive approach that does not result in a scar in the anterior neck. To prevent infection of the surgical site from oral cavity flora into the thyroidectomy area, postoperative antibiotics are generally given orally for 3-7 days. However, there is no clinical evidence to support this approach. This study was an open-label, randomised, controlled trial to evaluate the clinical usefulness of postoperative antibiotics given orally to patients having TOET. Patients were randomly assigned to receive amoxicillin-clavulanate 625mg orally three times a day for a week after operation (treated group) or no antibiotics (untreated group). Fifty patients - 25 treated and 25 untreated - were enrolled. Maximum body temperature, pulse rate, white blood cell count, and C-reactive protein concentrations did not differ between the two groups. Evaluation of the surgical site showed no significant differences between them. Seven patients in the treated group developed nausea, vomiting, and diarrhoea compared with none in the untreated group. The results suggest that postoperative oral antibiotics are not essential after TOET. Large-scale prospective series are required to confirm this finding.

Transoral Thyroidectomy Using A Flexible Robotic System: A Preclinical Cadaver Feasibility Study

OBJECTIVES/HYPOTHESIS

Traditionally, most thyroid surgery utilizes a curvilinear cervical incision with a resulting permanent scar. Minimally invasive and remote access thyroid surgery techniques continue to evolve. Transoral approaches through a vestibular incision have been developed at several centers throughout the world, obviating the need for a cutaneous incision and optimizing aesthetics. To date this technique has been performed using rigid endoscopes or a linear robotic platform. The goal of this study was to test the feasibility of a novel flexible robotic system to perform a transvestibular thyroidectomy in a preclinical cadaver model.

STUDY DESIGN

Preclinical feasibility study.

METHODS

Right and left thyroid lobectomies were successfully performed via a transvestibular approach in four cadavers.

RESULTS

A single vestibular incision between bilateral mental nerves allowed entrance of the flexible robot in a subplatysmal plane in both male and female cadavers. The recurrent laryngeal nerves and parathyroids were identified and preserved. The flexible three-dimensional camera allowed excellent visualization and could be easily repositioned for optimal visualization of right and left structures. The flexible and wristed instruments enabled an atraumatic approach and allowed for precise surgical technique.

CONCLUSIONS

The transoral vestibular approach to the central neck is a promising technique for thyroidectomy with optimal cosmesis and can be successfully accomplished using this novel flexible robotic system. Improvements in visualization and access offered by this system may improve application of this technique.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1482-1487, 2019.

Transoral endoscopic thyroidectomy via a vestibular approach: why and how?

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel, scar-free surgical procedure that does not require visible incisions. Indications for TOETVA are as follows: predicted gland width on diagnostic imaging ≤10 cm; a thyroid volume outline of <45 mL or dominant nodule dimension of ≤50 mm; three or four Bethesda lesions; a primary papillary microcarcinoma without local or distant metastasis; and patient request for optimal esthetic results. Contraindications are as follows: patients unfit for general anesthesia; precedent radiation in the head, neck, upper mediastinum; antecedent neck surgery; recurrent goiter; a gland volume of >45 mL or main nodule diameter of >50 mm; and documentation of lymph node or distant metastases, tracheal/esophageal infiltration, preoperative laryngeal nerve palsy, hyperthyroidism, mediastinal goiter, or an oral abscess. Patients with poorly differentiated or un-differentiated cancer, dorsal extrathyroidal radius, and/or lateral neck metastasis are not suitable for TOETVA. Following the introduction of a robotic surgical system, enabling a three-dimensional surgical view and the use of articulating instruments, TOETVA became suitable for most differentiated thyroid cancers without evidence of extensive extrathyroidal invasion or lateral neck metastasis. The procedure is performed using a vestibular approach and three-port technique; a 10-mm port is used for the 30° endoscope, two 5-mm ports are used for the dissecting and coagulating instruments, and an 8-mm port is placed in the axillary fold during the robotic procedure to enhance fine countertraction of tissue for radical oncological dissection. TOETVA follows surgical planes and is probably the best scar-free approach to the thyroid, given the short distance between the gland and intraoral incisions.

Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe

This video aimed to describe the role of intraoperative neuromonitoring (IONM) during transoral endoscopic thyroidectomy vestibular approach (TOETVA) with emphasis given to IONM technical and technological notes, the identification of recurrent laryngeal nerve (RLN). Standardized technique of IONM consist in identifying and monitoring both the vagus nerve and the RLNs before and after resection (V1, V2, R1, R2). According to this report, IONM during TOETVA is feasible and safe in providing identification and function of laryngeal nerves. IONM enable surgeons to feel more comfortable with their initial approach to TOETVA or extended indications. Larger series are needed for appropriated evaluation of IONM in reduction of the rates for RLN complications.

Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences

Recently, natural orifice transluminal endoscopic surgery (NOTES) has been applied in thyroid surgery with transoral access. The benefit of transoral endoscopic thyroidectomy is the potential for scar-free surgery. However, there are many concerns over some aspects, such as infection, recurrent laryngeal nerve injury, and oncological outcome. In this paper, we have reviewed the development history and the current clinical evidence of this innovative surgery. We conclude that the transoral endoscopic thyroidectomy vestibular approach (TOETVA) is feasible and can be considered no longer an experimental operation.

The Novel Transvestibule Approach for Endoscopic Thyroidectomy: A Case Series

Object:

To evaluate the feasibility of NOTES for thyroid by the transvestibule approach.

Methods:

Six patients diagnosed with benign thyroid diseases were enrolled and underwent transvestibule endoscopic thyroidectomy in our hospital from October 2013 to September 2014.

Results:

All 6 patients completed transvestibule endoscopic thyroidectomy successfully with no conversion to open surgery. The mean operation time was 122 minutes (100 to 150 min). The average blood loss during surgery was 30 mL (10 to 40 mL). The pathologic diagnosis coincided with the preoperative diagnosis, which was 1 case of thyroid adenoma and 5 cases of thyroid goiters. The mean length of hospital stay was 8.2 days (8 to 10 d). No severe complications were reported during the 3 to 13 months’ follow-up.

Conclusions:

Transvestibule endoscopic thyroidectomy is feasible, with a satisfactory cosmetic effect; yet, further improvement of surgical techniques are required on account of the complexity of the surgical procedure and the prolonged operation time.

Transoral robotic thyroid surgery

There is currently significant demand for minimally invasive thyroid surgery; however the majority of proposed surgical approaches necessitate a compromise between minimal tissue dissection with a visible cervical scar or extensive tissue dissection with a remote, hidden scar. The development of transoral endoscopic thyroid surgery however provides an approach which is truly minimally invasive, as it conceals the incision within the oral cavity without significantly increasing the amount of required dissection. The transoral endoscopic approach however presents multiple technical challenges, which could be overcome with the incorporation of a robotic operating system. This manuscript summarizes the literature on the feasibility and current clinical experience with transoral robotic thyroid surgery.

Minimally invasive thyroid and parathyroid operations: surgical techniques and pearls

With advances in technology and greater demand for minimally invasive procedures, novel minimally invasive approaches to thyroid and parathyroid glands increasingly have been described and practiced worldwide. For the MIT approaches, the direct/cervical approaches truly can be considered minimally invasive, as they require less surgical dissection than the conventional thyroidectomy. The indirect/extracervical approaches, however, only can be considered endoscopic, however, because they generally do require greater surgical dissection. Still, among the indirect/extracervical approaches, the axillary approach appears the preferred choice, as it requires the least amount of dissection while offering the advantage of being scarless in the neck. The addition of the robot such as the de Vinci surgical system could make some of the extracervical approaches technically less challenging and improve patient outcomes. Unlike MIT, MIP has become the standard approach for surgical management of primary hyperparathyroidism caused by localized solitary parathyroid adenoma.