Transoral thyroidectomy: advantages and limitations

Comparison of learning curves and related postoperative indicators between endoscopic and robotic thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) yield similar perioperative outcomes. This study investigated how the learning curve (LC) affects perioperative outcomes between ET and RT, identifying factors that influence the LC.

MATERIALS AND METHODS

Two researchers individually searched PubMed, EMBASE, Web of Science, and Cochrane Library for relevant studies published until February 2024. The Newcastle-Ottawa Scale assessed study quality. A random-effects model was used to compute the odds ratio and weighted mean difference (WMD). Poisson regression comparison of the number of surgeries (N LC ) was required for ET and RT to reach the stable stage of the LC. Heterogeneity was measured using Cochran's Q. Publication bias was tested using funnel plots, and sensitivity analysis assessed findings robustness. Subgroup analysis was done by operation type and patient characteristics.

RESULTS

This meta-analysis involved 33 studies. The drainage volume of ET was higher than that of RT (WMD=-17.56 [30.22, -4.49]). After reaching the N LC , the operation time of ET and RT was shortened (ET: WMD=28.15 [18.04-38.26]; RT: WMD=38.53 [29.20-47.86]). Other perioperative outcomes also improved to varying degrees. Notably, RT showed more refined central lymph node resection (5.67 vs. 4.71), less intraoperative bleeding (16.56 ml vs. 42.30 ml), and incidence of transient recurrent laryngeal nerve injury (24.59 vs. 26.77). The N LC of RT was smaller than that of ET (incidence-rate ratios [IRR]=0.64 [0.57-0.72]). CUSUM analysis (ET: IRR=0.84 [0.72-0.99]; RT: IRR=0.55 [0.44-0.69]) or a smaller number of respondents (ET: IRR=0.26 [0.15-0.46]; RT: IRR=0.51 [0.41-0.63]) was associated with smaller N LC . In RT, transoral approach (IRR=2.73 [1.96-4.50]; IRR=2.48 [1.61-3.84]) and retroauricular approach (RAA) (IRR=2.13 [1.26-3.60]; IRR=1.78 [1.04-3.05]) had smaller N LC compared to bilateral axillo-breast and transaxillary approach (TAA). In ET, the N LC of RAA was smaller than that of TAA (IRR=1.61 [1.04-2.51]), breast approach (IRR=1.67 [1.06-2.64]), and subclavian approach (IRR=1.80 [1.03-3.14]).

CONCLUSIONS

Rich surgical experience can improve surgical results of ET and RT. After reaching the N LC , the perioperative outcomes of RT are better than those of ET. Study subjects, surgical approaches, and analysis methods can affect N LC .

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.

Future Directions in the Treatment of Thyroid and Parathyroid Disease

The surgical management of thyroid and parathyroid disease has evolved considerably since the era of Theodor Kocher. We review the current trends in thyroid and parathyroid surgery concerning robotic surgery for remote access, the use of parathyroid autofluorescence detection technology to aid in the prevention of hypocalcemia as well as the use of thermal ablation to target thyroid nodules in a minimally invasive way. We also discuss how artificial intelligence is being used to improve the workflow and diagnostics preoperatively as well as for intraoperative decision-making. We also discuss potential areas where future research may enhance outcomes.

Robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach

BACKGROUND

We conducted this study to report our novel robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach and compare it with a conventional transaxillary (CTA) approach using a retraction method for intraoperative and postoperative outcomes.

METHODS

We retrospectively analyzed 354 patients who underwent robotic thyroidectomy between January 2019 and April 2023. Of these patients, 143 underwent the procedure through the GOSTA approach, which involves a small incision of 3 cm along the axillary folds with both arms down and a gas-insufflation, from skin flap creation to the completion of thyroidectomy as a one-step single-port procedure without the need for a retractor. The remaining 211 patients underwent the CTA approach. We analyzed the GOSTA approach and compared the surgical outcomes of the GOSTA (n = 100) and CTA (n = 167) approaches in patients with differentiated thyroid cancer who underwent thyroid lobectomy.

RESULTS

Out of the 143 patients who underwent the GOSTA approach, 12 underwent total thyroidectomy and 9 underwent lateral neck lymph node dissection with total thyroidectomy. GOSTA-thyroid lobectomy was performed on 122 patients; of these, 100 were diagnosed with differentiated thyroid carcinoma. A comparative study with the CTA approach was only conducted in patients who underwent thyroid lobectomy. No significant differences were found in operative time, hospital stay, or complications between the two groups.

CONCLUSIONS

Despite proceeding in one-step with a single smaller incision, from skin flap creation to the completion of thyroidectomy, the GOSTA approach is as feasible and safe as the CTA approach. Additionally, the GOSTA approach allows for thyroidectomy without using a retractor and reduces the workload for the surgeon and assistants.

Comparison of health-related quality of life and cosmetic outcome between traditional gasless trans-axillary endoscopic thyroidectomy and modified gasless trans-axillary endoscopic thyroidectomy for patients with papillary thyroid microcarcinoma

BACKGROUND

Gasless trans-axillary endoscopic thyroidectomy (GTET) has been proved to provide better cosmetic results; however, it has limitations as dissection of central neck lymph nodes is difficult. We developed a modified approach (MGTET-modified GTET) and compared it with the traditional one in terms of patients' health-related quality of life (HRQoL) and cosmetic results in order to provide more convincing therapeutic results.

METHODS

Between January 2021 and June 2021, 100 cN0 patients who had a confirmed diagnosis of papillary thyroid microcarcinoma were randomized to undergo either MGTET (n = 50) or GTET (n = 50). These two groups' baseline characteristics, intraoperative and postoperative findings, were compared. The Patient and Observer Scar Assessment Scale (POSAS) was determined 6 months after surgery. Thyroid Cancer-Specific Quality of Life Questionnaire was used to assess HRQoL at 1, 3, 6, and 12 months after surgery.

RESULTS

M-GTET was associated with a larger number of lymph nodes dissected (p < 0.001), lower drainage volume (p < 0.001), shorter hospital stay (p < 0.001), and shorter axillary incision (p < 0.001). POSAS was more favorable in M-GTET. HRQoL was significantly better for MGTET in terms of less problems with scar (p < 0.001).

CONCLUSION

Our study suggests that MGTET provides better therapeutic, cosmetic, and HRQoL outcomes.

Endoscopic Thyroidectomy: A 6-Year Experience from a Tertiary Care Teaching Hospital in Western India

Background: Minimally invasive and endoscopic surgical techniques have surpassed the conventional open thyroidectomy for the treatment of thyroid nodules. Trans-axillary, Unilateral Axillo-Breast Approach (UABA), Bilateral Axillo-Breast Approach, and Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) are the most common endoscopic procedures performed currently. This article highlights our experiences with UABA and TOETVA over a period of 6 years. Materials and Methods: Between January 2015 and December 2020, we retrospectively analyzed our experience in Endoscopic thyroidectomy with 119 patients using UABA (n = 72) and TOETVA (n = 47) in our tertiary care teaching hospital. Both approaches used the standard three-port technique. Real time angiography was performed intraoperatively using Indocyanine Green dye to delineate the vessels in all patients. Results: The mean operative time for UABA and TOETVA was 90 and 110 minutes, respectively. Estimated blood loss was 18 mL in the former and 20 mL in the latter. Temporary Recurrent Laryngeal Nerve palsy and Hypoparathyroidism were minimal with TOETVA (5 patients versus 4 patients and 7 patients versus 2 patients). Shorter duration of hospital stay was observed with UABA (3 days versus 5 days). Cosmetic satisfaction was better with TOETVA. Conclusion: Based on our 6-year experience, we propose "JJ Hospital Criteria," which we currently follow to decide which surgical approach will yield best results. UABA and TOETVA are safe, feasible, and give exceptional cosmetic satisfaction. Both approaches should be seen as complementary rather than competitive.

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.

Novel suspension system for gasless transoral vestibular thyroidectomy

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is receiving increased attention, frequently due to growing requirements for cosmetic incisions. Here, we report our initial experience and discuss the safety and efficacy of the innovative surgical working space suspension system for gasless TOETVA.

METHODS

We retrospectively analyzed 75 consecutive patients for whom gasless TOETVA with our novel working space suspension system was used. This suspension system included self-developed retractors, a sterile bandage, and an anesthesia stand. We also improved some main surgical instruments in gasless TOETVA.

RESULTS

The study included 75 patients who successfully underwent thyroidectomy and central neck dissection via gasless TOETVA. The mean operating time was 143.27 ± 34.60 min. The mean number of retrieved lymph nodes was 8.00 ± 5.39. Conversion to open surgery did not occur, nor did patients exhibit serious postoperative complications. Postoperative complications included 4 cases of transient recurrent laryngeal nerve (RLN) palsy, 9 of transient hypoparathyroidism, and 3 of transient mental nerve injury. One patient with subcutaneous fluid after surgery recovered after aspiration. Another patient with submental minor perforation recovered well after suturing. There was no evidence of specific complications related to self-designed retractors.

CONCLUSION

The innovative working space suspension system for gasless TOETVA provided enough and stable working space and optimized the clarity of the surgical field without CO₂-related complications.

Comparative surgical outcomes of transoral endoscopic and robotic thyroidectomy for thyroid carcinoma: a propensity score-matched analysis

BACKGROUND

Surgical outcomes of patients with thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus transoral robotic thyroidectomy (TORT) were compared.

METHODS

Patients who underwent TOETVA or TORT between July 2016 and February 2022 were retrospectively analyzed. TOETVA and TORT groups were propensity score-matched (1:1) based on age, sex, body mass index, surgical extent, tumor size, and presence of thyroiditis.

RESULTS

A total of 185 patients underwent transoral thyroidectomy (142 TOETVA and 43 TORT). Final diagnoses consisted of 135 papillary and seven follicular thyroid carcinomas in the TOETVA group and 43 papillary thyroid carcinomas in the TORT group (p = 0.138). Mean operative time was shorter for the TOETVA group than the TORT group (106.3 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer for the TOETVA group than the TORT group (2.2 vs. 1.9 days, p = 0.031). After 1:1 propensity score matching, each group included 43 patients. Mean operative time was shorter in the TOETVA group than the TORT group (106.2 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer in the TOETVA group (2.3 vs. 1.9 days, p = 0.031). There was no significant difference in vocal cord palsy incidences between the groups (one transient, one permanent in the TOETVA group vs. none in the TORT group, p = 0.359). The learning curve was 71 cases for TOETVA and 25 cases for TORT.

CONCLUSION

TOETVA had shorter mean operative time, and TORT had shorter learning curve and shorter mean hospital stay. Surgeons should be familiar with the advantages and disadvantages of each procedure.

The long-term impact of neck scar satisfaction among thyroid surgery patients

This study evaluated scar satisfaction in Arabic patients who underwent thyroidectomy surgery using validated assessment tools. We aimed to assess the relationship between scar length and scar satisfaction, and validate Arabic versions of the universally used scar satisfaction questionnaires. In this retrospective cohort study, 60 patients who underwent thyroidectomy at King Abdulaziz University Hospital were enrolled. Scars were evaluated in two stages: firstly, by a clinician, and secondly, by a naïve observer. Ratings of disfigurement were measured using the validated Patient and Observer Scar Assessment Scale (POSAS) that was translated into Arabic. Results: The Arabic version of the POSAS showed good or excellent reliability. Average POSAS scores were 12.88, 18.02, and 7.53, respectively, indicating that most patients were satisfied. Incision size and POSAS scores (but not Patient and Naïve Observer scores) were positively correlated, and larger incisions resulted in greater dissatisfaction. Fitzpatrick Skin Type score and Observer scores were positively correlated, but there were no significant correlations between Patient and Naïve Observer scores with skin type. In conclusion, this study validated the Arabic version of universally used questionnaires for scar satisfaction. Most patients were satisfied with their neck scars regardless of scar length. Our findings pave the way for further research into patient postoperative scar satisfaction in Arabic-speaking populations.

Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach in an Endemic Region

Objective

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless method that enables thyroidectomyusing natural orifice of the body. The opinion which is even common among TOETVA performing surgeons is that this surgery involves a small percentage of thyroidectomy applied patients. In this study, based on the currently accepted exclusion criteria, we aimed to determine what percentage of patients, who underwent thyroidectomy in an endemic area are actually suitable for TOETVA.

Methods

Between January 2017 and December 2019, 1197 consecutive patients who underwent surgery for thyroid pathology in our clinic were analyzed retrospectively. Pre-operative evaluations were made according to the current exclusion criteria and as a result, patients with no previous neck surgery, no history of radiotherapy, no retrosternal thyroid extension, and none lymph node dissection operation been made and whose thyroid gland diameter is <10 cm and gland volume is not more than 45 ml, malignant nodule diameter is <2 cm, and benign nodule diameter is <4 cm are involved to this study by being considered appropriate for TOETVA procedure.

Results

According to the criteria, 513 patients (42.8%) were found suitable for TOETVA. A total of 421 (82%) of these patients were female and 92 (18%) were male. The mean age was 46.2±13.2. A total of 192 (37%) of these patients were operated due to the benign reasons, and 321 (63%) of these patients operated due to the malignancy or suspicion of malignancy. Average nodule size was 1.9 cm, and the average thyroid volume was 23.8 ml among benign patients. Whereas among malignant patients, the average nodule size was 1.7 cm and the average thyroid volume was 21.8 ml. A total of 462 (90.1%) of the patients were applied to the total thyroidectomy and 51 (9.9%) of the patients were applied to the hemithyroidectomy. In the same period, 29 patients operated through TOETVA and 4 patients operated through bilateral axillary breast approach thyroidectomy. When the final pathology, results of the patients were examined, papillary thyroid carcinoma was seen in 301 (58.7%) patients, benign pathologies were seen in 192 (37.4%) patients, and 20 (3.9%) patients were diagnosed with other pathologies (follicular thyroid carcinoma, poorly differentiated carcinoma and Hürthle cell neoplasia, etc.).

Conclusion

Although "patient willingness" factor could not be included in the study, TOETVA eligible patient repository is wider contrary to popular belief. In our humble opinion, TOETVA method is going to pursue its spread and become a part of the routine surgical training session due to its effectiveness in terms of credibility in today's world where cosmetic concerns gradually gain prominence.

Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to carbon dioxide gas insufflation: A comparative analysis of 131 cases

Although transoral endoscopic thyroid surgery affords several advantages, the use of carbon dioxide (CO2) gas to create and maintain the working space may cause complications such as subcutaneous emphysema and a CO2 embolism. We have used a self-retaining retractor as an alternative to CO2 gas insufflation for some time; we here report its feasibility and safety. We reviewed the medical records of 131 patients who underwent transoral endoscopic thyroid lobectomy; we compared the "CO2 group" and the "retractor" group. All thyroid tumors were completely removed with negative surgical margins. No major complication occurred in the retractor group. Two major events occurred in the CO2 group: one case of permanent vocal cord palsy and one CO2 embolism. Significant subcutaneous emphysema of the neck and chest were noted in 17.7% of CO2 group patients, but in no retractor group patient. Wound infection occurred in one patient in each group but improved after appropriate management. The total operation times from incision to suture did not differ significantly between the two groups (p = 0.514). Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to CO2 gas insufflation is feasible and safe. The superiority of transoral endoscopic thyroidectomy would be emphasized by avoiding CO2 gas insufflation, thus eliminating the risk of CO2 gas-related complications.

Comparison of the transoral endoscopic thyroidectomy vestibular approach and open thyroidectomy: A propensity score-matched analysis of surgical outcomes and safety in the treatment of papillary thyroid carcinoma

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach has been demonstrated to have similar surgical outcomes as open thyroidectomy for selected papillary thyroid carcinomas. This study aimed to evaluate and compare the surgical outcomes and safety of the transoral endoscopic thyroidectomy vestibular approach with those of open thyroidectomy in the treatment of papillary thyroid carcinoma with a diameter between >1 cm and ≤3.5cm.

METHODS

We retrospectively reviewed all patients who had papillary thyroid carcinoma that was between >1 cm and ≤3.5 cm in diameter and who had undergone the transoral endoscopic thyroidectomy vestibular approach (n = 96) or an open thyroidectomy (n = 425) from January 2017 to June 2020. We then performed 1:1 propensity score matching, yielding 78 matched pairs. Afterward, surgical outcomes and follow-up data were compared between the 2 matched groups.

RESULTS

Compared with the matched open thyroidectomy group, the papillary thyroid carcinoma group had a significantly longer operative time (P < .001), more blood loss (P < .05), higher postoperative white blood cell count (P < .05), higher C-reactive protein (P < .001), more total drainage volume (P < .001), increased surgical cost (P < .05), better cosmetic satisfaction (P <.001), lower scar self-consciousness (P < .001), and better quality of life (P < .001). We observed no significant differences in the incidence of other outcomes, including the number of retrieved lymph nodes and metastatic central lymph nodes, the rate of intraoperative recurrent laryngeal nerve signal weakened and parathyroid autotransplantation, visual analog scale scores for pain, drainage duration, postoperative hospital stay, rate of complications, and oncologic completeness. We observed no conversion to open thyroidectomy and no intraoperative capsular disruption in the transoral endoscopic thyroidectomy vestibular approach group. There was 1 case of persistent nodal disease in the transoral endoscopic thyroidectomy vestibular approach group. No recurrence was observed in the 2 groups during the follow-up period.

CONCLUSION

The transoral endoscopic thyroidectomy vestibular approach is feasible in selected patients with papillary thyroid carcinoma, not only because it is cosmetically advantageous but also because it is surgical and oncologically safe and may be an optional surgical method for treating papillary thyroid carcinomas having a diameter between >1 cm and ≤3.5 cm.

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.

Adoption of the transoral endoscopic vestibular approach by head and neck surgeons without prior laparoscopic/robotic experience

BACKGROUND

Transoral endoscopic vestibular approach (TOEVA) for thyroidectomy (TOETVA) and parathyroidectomy (TOEPVA) is gaining popularity, yet knowledge is based on a limited number of studies, mostly performed by surgeons experienced in laparoscopic\robotic surgery.

METHODS

All patients who underwent TOEVA at our institution between February 2018 and October 2019 were followed prospectively. Main outcomes were ability to accomplish surgery endoscopically (failure defined as conversion to open approach) and complications.

RESULTS

Seventy-one patients (52 TOETVA and 19 TOEPVA) were included. 98% (51/52) and 100% (19/19) of TOETVA and TOEPVA surgeries were accomplished endoscopically, respectively. Transient vocal cord and mental nerve injuries rates were 8.4% (6/71) and 2.8% (2/71), respectively. Thyroid carcinoma was diagnosed in 27 patients (51.9%), all completely excised with clean margins.

CONCLUSIONS

Adoption of the TOEVA suggested framework by head and neck surgeons without prior experience in laparoscopic/robotic techniques is feasible resulting in nearly 100% of surgeries accomplished endoscopically.

The role of carbon nanoparticles in guiding central neck dissection and protecting the parathyroid in transoral vestibular endoscopic thyroidectomy for thyroid cancer

Introduction

Transoral vestibular endoscopic thyroidectomy (TOET) is sometimes used in young and middle-aged patients with papillary thyroid microcarcinoma (PTMC), but it is still difficult to identify lymph nodes (LNs) and parathyroid glands (PGs). Carbon nanoparticle (CN) is a novel lymph node tracer and has been widely used in open thyroid surgery.

Aim

To evaluate the efficacy of CN in identifying LNs and preserving PGs in TOET with central neck dissection (CND).

Material and methods

A total of 72 PTMC patients undergoing TOET with CND were retrospectively enrolled from January 2017 to January 2019. Patients were divided into a CN group (n = 38) and a control group (n = 34). The parameters including pathological characteristics, surgery related indicators, serum Ca²⁺ and parathyroid hormone (PTH) levels were compared.

Results

No significant differences were found in patient characteristics, operative complications and superior PGs preserved in situ (all p > 0.05). Total LNs and number of LNs less than 5 mm were significantly higher in the CN group than in the control group (p = 0.021, p < 0.01). The number of superior PGs preserved in situ discovered in the CN group was greater than the control group (p = 0.038). Serum PTH and Ca²⁺ levels dropped markedly in each group after surgery and gradually recovered in time. The CN group recovered faster than the control group.

Conclusions

CN may be a good choice for TOET for PTMC because of better protection and faster recovery of parathyroid function, and more LNs removed.

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.

Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide

BACKGROUND

The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket.

METHODS

In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures.

RESULTS

Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches.

CONCLUSION

Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.

Transoral thyroid surgery vestibular approach: does size matter anymore?

BACKGROUND

Various approaches for endoscopic and minimally invasive thyroid operations have been reported, with some becoming popular to date. The aim of these procedures is to reduce and prevent visible scars in the neck. This led to the transoral endoscopic thyroidectomy vestibular approach (TOETVA) technique applicable in small thyroid specimen. To amend TOETVA and to broaden the indication for transoral thyroid surgery, our aim was to combine the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach.

METHODS

After successful implementation of the TOETVA technique in 2017, we evaluated the transoral technique regarding feasibility and safety in well-selected patients in Germany and Austria. With the combination of TOETVA and EndoCATS, we were able to optimize the extraction process of the specimen by avoiding damage to the thyroid capsule and to broaden the indication of transoral surgery by operating on thyroid glands with higher volume. Patients' characteristics, surgical outcome and complications were determined.

RESULTS

Seventy-one transoral procedures were performed in 70 patients. The TOETVA procedure was performed in 60 patients, and 10 female patients underwent TOVARA with transoral thyroid lobe mobilization and removal of the specimen via the retroauricular access. Overall, median operation time was 205 min (range 96-370 min) and permanent RLNP rate was 1% accordant to 99 nerves at risk (39 hemithyroidectomies, 29 total thyroidectomies, 2 parathyroid resections, and 1 thyroglossal cyst resection). No conversion to conventional open surgery was necessary. Long-term mental nerve injury occurred in two patients. No infection was identified.

CONCLUSIONS

Transoral thyroid and parathyroid surgery via the vestibular approach is both feasible and safe in Western Europe. The combination of the TOETVA with the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) facelift approach, called TOVARA, is a promising opportunity to allow for thyroid surgery without a visible scar in specimen with volume of more than 40 ml also.

Real Scarless Transoral Robotic Thyroidectomy Using Three Ports Without Axillary Incision

Introduction: Conventional transoral robotic thyroidectomy (TORT) requires an axillary incision and additional flap dissection. This study aimed to outline the first ever experiences with TORT using three ports without axillary incision and compare the results between three-port and four-port TORT. Materials and Methods: A total of 100 consecutive patients were enrolled. The study sample comprised 47 patients who underwent four-port TORT from November 2016 to June 2017, and 53 patients who underwent three-port TORT from September 2018 to June 2019. The indication of the three-port TORT was the anterior/posterior length of the thyroid <1.8 cm and mass size <1.5 cm. Results: Operative time (minutes) was shorter in the three-port group (166.3 ± 35.4 versus 138.5 ± 34.4, P = .005). Hospital stay (days) was also shorter in the three-port group (3.8 ± 0.4 versus 2.4 ± 0.6, P = .003). TORT using three ports yielded a higher cosmetic satisfaction (3.68 ± 0.52 versus 3.89 ± 0.30, P = .002). Postoperative complications, level of calcium, parathyroid hormone, and pain were not significantly different between the groups. Conclusions: Our study showed that three-port TORT was associated with a shorter operative time, hospital stay, and excellent cosmesis than the conventional four-port option. In conclusion, TORT using three ports is a comparable and an effective operation method as a real scarless operation.

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.

A comparison of transoral vestibular and bilateral areolar endoscopic thyroidectomy approaches for unilateral papillary thyroid microcarcinomas

Introduction

A transoral (TO) vestibular approach is a new remote access approach to avoid cutaneous scars in an endoscopic thyroidectomy (ET). And transoral endoscopic thyroidectomy (TOET) has been widely used in papillary thyroid microcarcinomas (PTMCs).

Aim

To evaluate and compare endoscopic thyroidectomies with central neck dissection using a bilateral areolar (BA) approach and TO approach in patients with unilateral PTMCs.

Material and methods

In total, 92 papillary thyroid cancer (PTC) patients undergoing an endoscopic unilateral thyroidectomy with central neck dissection via a TO (n = 48) or BA (n = 44) approach were retrospectively enrolled from August 2017 to December 2018. Differences in various factors, such as clinical characteristics, surgery-related parameters, including operative complications, and hospital durations and costs, were compared.

Results

No significant between-group differences in the age and sex of the patients or the side, body mass index, total operative time, operative bleeding, superior parathyroid preservation in situ, operative complications, and postoperative day of discharge were found (all p > 0.05). The mean central neck dissection time, amount of postoperative drainage, extubation time, and inferior parathyroid preservation in situ were lower in the TO group as compared with these parameters in the BA group (all p < 0.05). The number of central lymph nodes resected and hospitalization costs were higher in the TO group as compared with those in the BA group (all p < 0.05).

Conclusions

An ET via the TO approach may be a good choice for unilateral PTMCs because of the shorter central neck dissection time, reduced postoperative drainage, better cosmetic satisfaction, and higher number of lymph nodes removed.

Video-assisted neck surgery (VANS) using a gasless lifting procedure for thyroid and parathyroid diseases: "The VANS method from A to Z"

Purpose

To describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases.

Methods

We describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves’ disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available.

Results

The working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected.

Conclusions

The VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

Classifying pain in transoral endoscopic thyroidectomy

PURPOSES

Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy.

METHODS

Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach-OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology.

RESULTS

41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups.

CONCLUSIONS

VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.

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.

Human cadaveric model for studying the preservation of mental nerve during transoral endoscopic thyroidectomy

PURPOSE

Mental nerve (MN) injury can be caused by transoral endoscopic thyroidectomy vestibular approach (TOETVA). The purpose of this experimental study was to determine the location and distribution pattern of MN structures in relation to oral vestibular incisions.

METHODS

Ten cadaver specimens were included, yielding a total of 20 MNs. The difference between standard 10-mm TOETVA median incision and modified incision (i.e. lower and perpendicular) was compared.

RESULTS

All 20 MNs were successfully dissected and presented as bifid (100%), lateral toward medial direction. The branches of MNs were equally distributed into both right and left sides. Standard lateral 5-mm vestibular incisions did not determine any division of MN branches. Two left MNs (25%) and one right MN (12.5%) were injured by standard median vestibular incision. Using a more inferiorly positioned and a vertical median incision, the integrity of MN branches was preserved.

CONCLUSIONS

Standard lateral 5-mm vestibular incisions are safe for determining MN integrity. The 10-mm median vestibular incision divided the medial ramifications of MN at a rate of 12-25%. These may result in MN ipsilateral or bilateral paralysis. Hence, it is recommended to locate the median incision more inferiorly or vertically.

The dawn of robotic surgery in otolaryngology-head and neck surgery

Transoral robotic surgery (TORS) utilizing the da Vinci robotic system has opened a new era for minimally-invasive surgery (MIS) in Otolaryngology-Head and Neck Surgery. Awareness of the historical steps in developing robotic surgery (RS) and understanding its current application within our field can help open our imaginations to future of the surgical robotics. We compiled a historical perspective on the evolution of surgical robotics, the road to the da Vinci surgical system, and conducted a review of TORS regarding clinical applications and limitations, prospective clinical trials and current status in Japan. We also provided commentary on the future of surgical robotics within our field. Surgical robotics grew out of the pursuit of telerobotics and the advances in robotics for non-medical applications. Today in our field, cancers and diseases of oropharynx and supraglottis are the most common indications for RS. It has proved capable of preserving the laryngopharyngeal function without compromising oncologic outcomes, and reducing the intensity of adjuvant therapy. TORS has become a standard modality for MIS, and will continue to evolve in the future. As robotic surgical systems evolve with improved capabilities in visual augmentation, spatial navigation, miniaturization, force-feedback and cost-effectiveness, we will see further advances in the current indications, and an expansion of indications. By promoting borderless international collaborations that put 'patients first', the bright future of surgical robotics will synergistically expand to the limits of our imaginations.

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.

Patient and Surgeon Candidacy for Transoral Endoscopic Thyroid Surgery

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments.

Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Perioperative Outcomes of 100 Consecutive Patients

BACKGROUND

Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC).

METHODS

This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed.

RESULTS

There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8 years, and a mean tumor size of 0.8 ± 0.5 cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9 min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery.

CONCLUSION

In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.

Gasless transoral endoscopic thyroidectomy vestibular approach (gasless TOETVA)

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been the subject of increasing interest from several institutions around the world over the last 2 years. Recently, we successfully performed TOETVA in live human patients without CO₂ gas using our newly designed retractable blade.

METHODS

We reviewed the medical records of 15 consecutive patients who underwent gasless TOETVA using a self-retaining retractor.

RESULTS

We successfully performed 13 thyroid lobectomies and 2 total thyroidectomies in 15 patients. No patient exhibited serious postoperative complications such as recurrent laryngeal nerve palsy and permanent hypocalcemia. One patient developed transient hypocalcemia but recovered within 2 months. No patient developed a wound infection; furthermore, no visible scar or dimpling was evident on the neck of any patient.

CONCLUSION

Gasless TOETVA provides enough working space and good visibility to perform thyroid surgery without any risk of CO₂ gas-related complications.

Transoral Robotic Thyroidectomy: The Overview and Suggestions for Future Research in New Minimally Invasive Thyroid Surgery

Purpose of review

This journal introduces a overview in depth about the evolution of transoral robotic thyroidectomy, which has been encountering major confrontations in expanding its indications.

Recent findings

Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. The major advantage of TORT is comparatively smaller flap dissection area than other remote-access methods. The other advantage of TORT is that the wounds of lips fades out over time, and leaves concealed scar near axilla.

Summary

TORT can be done safely to the appropriately selected patients by surgeon expertise in robotic thyroidectomy. It might be a potential alternative surgical approach for thyroidectomy to surgeons who are experienced in remote-access robotic surgery.

Lessons Learned From a Faulty Transoral Endoscopic Thyroidectomy Vestibular Approach

BACKGROUND

Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is currently considered the most promisingly scarless approach to the thyroid and has gained more acceptance.

MATERIALS AND METHODS

We described a case of faulty TOETVA.

RESULTS

The faulty TOETVA resulted in pneumomediastinum, diffuse subcutaneous emphysema, prolonged surgery, and anesthesia.

CONCLUSIONS

The important technical considerations during TOETVA, including the use of external retraction, the identification of the subplatysmal plane of dissection, CO2 insufflation settings, the learning curve, and patient selection, were described and discussed.

Intraoperative Neural Monitoring in Endoscopic Thyroidectomy Via Bilateral Areola Approach

OBJECTIVE

The aim of this report was dual: (a) to describe the step by step standardized intraoperative neural monitoring (IONM) procedure for recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve focusing on percutaneous IONM method, and (b) evaluation and outcomes of intermittent IONM in 237 endoscopic thyroidectomy via bilateral areolar approach cases.

MATERIALS AND METHODS

A 10-mm curved incision is made along the margin of the right areola at the 2 to 4 o'clock position for the 30-degree endoscope. Bilaterally 5-mm incisions are required on the edges of the areola at the 11 to 12 o'clock positions as accessory operating ports. Ball-tip, monopolar, single-use, standard stimulating probe with a 10-cm handle and 9-cm shaft is adopted percutaneously for IONM. As reference, on the dominant thyroid lesion side, a 0.5-cm circle is drawn with the center at the intersection of a line 2-cm lateral to the anterior median line and a line 2-cm above the line connecting the bilateral clavicular heads. After ensuring with ultrasonography that no vessels are within the puncture passage, the skin is pierced with an 18-G syringe needle. After withdrawing the needle, the probe is carefully inserted through the tract. IONM is performed according to standards of equipment set up, anesthesia, tube positioning verification tests, and electromyography determinations.

RESULTS

A total of 277 nerves at risk were favorably monitored with percutaneous probe stimulation. RLN, vagus nerve, and external branch of the superior laryngeal nerve were successfully determined. There were no instances of IONM malfunction, equipment displacement, or interference with the other endoscopic instruments. IONM probe insertion incision determined no scarring or morbidity in the neck. The incidence of RLN monolateral temporary palsy was 6%.

CONCLUSIONS

Standardized monitoring in endoscopic thyroidectomy via bilateral areolar approach is feasible. IONM was implemented by means of percutaneous stimulating probe.

A comparison study of the transoral and bilateral axillo-breast approaches in robotic thyroidectomy

OBJECTIVES

Transoral robotic thyroidectomy (TORT) is a new remote access approach to avoid cervical incision. The purpose of this study is to compare two approaches used to avoid cervical incision: transoral approach and bilateral axillo-breast approach (BABA) in robotic thyroidectomy.

METHODS

A total of 90 patients were enrolled prospectively between September 2016 and April 2017. The BABA group had 43 and the TORT group had 47 patients, respectively. Parameters including clinicopathologic data, operative time, complications, laboratory data, hospital stay, postoperative pain, and cosmetic satisfaction were analyzed.

RESULTS

Complications were not different among the two groups. The operative time of TORT was longer than BABA until 15 cases of TORT were completed, but there was no difference after that. The Visual Analogue Scale score in TORT was lower than BABA in all the periods. TORT showed a higher cosmetic satisfaction after surgery. There was no infection or permanent mental nerve hypoesthesia in TORT.

CONCLUSION

Our study showed that TORT had less postoperative pain and a greater cosmetic satisfaction than the BABA. There were no significant differences in the postoperative surgical results between the two groups. TORT was comparable to the BABA in outcome with higher cosmetic satisfaction and less pain.