Hidden in Plain Sight: Transoral and Submental Thyroidectomy as a Compelling Alternative to “Scarless” Thyroidectomy

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.

Transoral and submental endoscopic thyroidectomy (TOaST) for early stage papillary thyroid carcinoma: a real-world data retrospective cohort study

INTRODUCTION

Although transoral endoscopic thyroidectomy (TOETVA) is widely utilized in clinical practice, some problems and restrictions still remain. Our study compared the perioperative features and early surgical efficacy of TOETVA and a modified transoral and submental endoscopic thyroidectomy (TOaST) in early stage papillary thyroid carcinoma (PTC).

METHODS

The clinical data of PTC patients who underwent endoscopic thyroidectomy, including 42 modified TOaST patients and 114 traditional TOETVA patients, were retrospectively collected. Propensity score matching was employed to reduce patient selection bias. The perioperative features and early surgical efficacy data of two groups were compared.

RESULTS

The operation time of the TOaST group was significantly shorter than that of the TOETVA group (150.00 ± 35.47 min vs. 168.75 ± 44.49 min; P = 0.030). Furthermore, the TOaST group required shorter days for a normal diet (3.38 ± 0.93 days vs. 4.04 ± 1.03 days; P = 0.000) and a shorter hospital stay than the TOETVA group (5.85 ± 2.17 days vs. 6.12 ± 2.01 days; P = 0.003). There was no statistical difference in complications between the two groups, but the probability of numbness of the lower lip and chin in the TOaST group was lower than that in the TOETVA group(5.12% vs. 13.04%, P = 0.321). The symptoms of mandibular numbness and hoarseness of most patients were relieved in both groups 6 months after surgery, and no abnormalities and recurrence were found in the thyroid ultrasound. All the patients were satisfied with the appearance of their surgical incision.

CONCLUSION

In early stage PTC patients, TOaST had the same surgical effectiveness as traditional TOETVA but can minimize the probability of mandibular numbness and improve the perioperative quality of life.

Clinical efficacy and inflammatory reaction of submental endoscopic thyroidectomy versus conventional thyroidectomy: A prospective randomized study

OBJECTIVES

This prospective study aimed to explore the clinical efficacy and inflammatory reaction of submental endoscopic thyroidectomy versus conventional thyroidectomy.

METHODS

We prospectively recruited 45 patients (total 90 patients) who met the eligibility criteria to undergo conventional open thyroidectomy or submental endoscopic thyroidectomy from January 2021 to July 2022 in the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. These patients were evaluated using the following indices: number of lymph nodes dissected, complications, pain severity, inflammatory indicators, cosmetic satisfaction, and economic cost. All data were analyzed by the t-test or chi-squared test.

RESULTS

Ninety patients were enrolled. The two groups did not significantly differ regarding baseline characteristics. All patients who underwent thyroidectomy had a similar trauma index and increased level of inflammation. There were no significant differences between the open thyroidectomy and submental endoscopic thyroidectomy groups in the total number of lymph nodes dissected, number of positive lymph nodes, drainage volume, and complications. The Vancouver scar score and cosmetic satisfaction score were significantly better in the submental endoscopic thyroidectomy group than the open thyroidectomy group. The submental endoscopic thyroidectomy group had a significantly lower pain scores on postoperative days 1 and 2, less downtime, and cheaper medical and esthetic costs than the open thyroidectomy group.

CONCLUSION

Compared with conventional open thyroidectomy, submental endoscopic thyroidectomy did not increase the degree of trauma, had superior clinical efficacy, caused less pain, required a shorter downtime, achieved a better cosmetic effect, and was associated with lower healthcare costs.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique

Background

The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO₂)-related complications. Herein, we proposed a new technique without CO₂ called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA.

Methods

We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded.

Results

Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery.

Conclusions

Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.

Transoral thyroid surgery vestibular approach

Objectives

Transoral thyroid surgery vestibular approach (TOETVA) is a novel and feasible surgical technique that allows for cervical surgery without visible incisions. TOETVA represents a new frontier in endocrine surgery since aesthetic results play a more and more decisive role in elective surgery. However, acceptance is different around the world with widespread prevalence in Asian countries and some high-volume centres in the US. While inclusion criteria for TOETVA are limited regarding size and volume a combination with other extracervical techniques like the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) approach or transaxillary access is an option.

Methods

TOETVA is carried out through a three-port technique placed at the oral vestibule. Originally one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments are used. Alternatively, one 5-mm and one or two 3 mm ports can be used. CO2 insufflation pressure is set at 6 mmHg. An additional device to optimize gas outflow for optimum view might be helpful. An anterior cervical subplatysmal space is created by hydrodissection from the oral vestibule to the sternal notch, laterally to the sternocleidomastoid muscle. Conventional endoscopic instruments are used. Combination of TOETVA with a modified retroauricular access includes insertion of a 10-12 mm trocar placed subcutaneously via a skin incision on the scalp, behind the ear by blunt dissection.

Results

Since Anuwong published the first case series of 60 patients who underwent scarless thyroidectomy via the lower vestibule of the mouth with excellent results in 2016 almost 1,000 cases are reported in literature to date with comparable results especially regarding traditional complications. In contrast to other extracervical approaches, areolar or axillary for example, the transoral access route is short and the dissection planes are rather like transcervical surgery. Surgical indications and contraindications have been modified since its first description and are partly institution specific to date. To amend indications combination with other extracervical techniques is an option. In addition, patients must carefully be selected for and surgeons` candidacy is of utmost importance in transoral surgery.

Conclusions

Transoral surgery will likely continue to gain attraction as surgeons become more experienced with the technique. With increased operative use and surgeon experience the gap in conventional outcomes between transoral surgery and the transcervical approach will narrow, with both operative time and the incidence of specific complications diminishing. Experience in thyroid and endoscopic surgery is required to achieve excellent results with low complication rates. However, the new transoral technique is related to novel complications that must be evaluated.

Clinical application of transoral and submental thyroidectomy (TOaST): a series of 54 human cases

Objective

A new endoscopic thyroidectomy approach—transoral and submental endoscopic thyroidectomy (TOaST)—was applied in clinical practice and considered an improved approach for endoscopic thyroid surgery via the oral approach. This paper discusses the feasibility and effectiveness of this surgical method.

Methods

A retrospective analysis was performed on the clinical data of 54 patients who had undergone TOaST in the thyroid disease center of the First Affiliated Hospital of Nanchang University between December 2020 and December 2021. The surgical data and techniques, complications, and cosmetic outcomes of these patients were studied.

Results

Among the total 54 patients, 23 underwent unilateral subtotal thyroidectomy, 3 patients underwent bilateral subtotal thyroidectomy, 27 with unilateral thyroid cancer underwent affected thyroid + isthmus + central lymph node resection, and only 1 patient underwent total thyroidectomy. The mean operative time was 88.06 ± 12.03 min (range: 65–135 min), the mean intraoperative blood loss was 8.61 ± 4.60 ml (range: 5–20 ml), the mean postoperative drainage volume was 49.96 ± 9.88 ml (range: 30–60 ml), the mean drainage time was 36.61 ± 2.65 h (range: 32–50 h), and the mean length of hospital stay was 46.63 ± 3.28 h (range 45–70 h). One patient experienced transient recurrent laryngeal nerve injury, and another patient experienced transient parathyroid dysfunction; there was no superior laryngeal nerve injury and other complications, such as postoperative subcutaneous hematoma, hypercapnia, mental nerve injury, tracheoesophageal injury, infection, or lymphatic leakage.

Conclusion

TOaST cannot only achieve a good therapeutic effect but also avoid mental nerve injury, reduce the discomfort of the patient’s jaw, obtain a good cosmetic effect, and facilitate the operation of the operator. It is an endoscopic thyroidectomy technique with a certain clinical value.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02663-w.

Comparison of Quality of Life between Patients Undergoing Submental Endoscopic Thyroidectomy and Conventional Thyroidectomy: A Prospective Controlled Clinical Trial

The objectives of this study were to compare the surgical outcomes and quality of life between patients undergoing submental endoscopic thyroidectomy and those undergoing conventional thyroidectomy. The surgical outcomes and quality of life were recorded. Forty-eight patients were included in the study. Their ages ranged from 20 to 60 years. All patients underwent lobectomy, isthmectomy, or the combination of lobectomy and isthmectomy. Most histological diagnoses were benign (85.42%). The submental endoscopic thyroidectomy group showed better scores in the energy/fatigue, emotional wellbeing, and general health domains (p = 0.006, 0.041, and 0.004, respectively). There were no statistically significant differences in surgical outcomes between the submental endoscopic thyroidectomy and conventional thyroidectomy groups (p > 0.05). Submental endoscopic thyroidectomy is feasible, and permits a better quality of life in terms of the energy/fatigue, emotional wellbeing, and general health domains.

Initial Experience With Transoral Endoscopic Thyroidectomy via the Submental and Vestibular Approach for the Treatment of Thyroid Cancer: A Retrospective Cohort Study

Background

Transoral endoscopic thyroidectomy vestibular approach is feasible and safe but has some unavoidable limitations, such as sensory changes in the center of the chin region. We aim to report our initial experience in performing transoral endoscopic thyroidectomy via the submental and vestibular approach for the treatment of thyroid cancer.

Patients and Methods

This retrospective cohort study included patients with thyroid cancer confirmed by fine-needle aspiration who underwent endoscopic thyroidectomy and central lymph node dissection via the submental and vestibular approaches between November 2019 and January 2020. Patients’ clinicopathological characteristics, operation details, and postoperative complications were analyzed.

Results

Fifteen surgeries were performed successfully. The mean ± standard deviation age of the patients was 37 ± 10.8 years, the average duration of surgery was 146.5 ± 34.6 min, and the median intraoperative blood loss was 11.1 ± 6.3 mL. None of the surgeries were converted to open thyroidectomy. According to postoperative pathology, all cases involved papillary thyroid carcinoma or papillary thyroid microcarcinoma. One patient developed transient recurrent laryngeal nerve paralysis. No patient developed skin numbness at the center of the chin region.

Conclusions

Transoral endoscopic thyroidectomy via the submental and vestibular approach is effective and safe in patients with thyroid cancer and does not lead to skin numbness at the center of the chin region. This technique is beneficial for surgeons less experienced in performing transoral thyroid surgery as it involves using a short and direct route to the thyroid gland, which can reduce the difficulty in establishing the first operative space to some extent.

Axillary channel-assisted TOETVA: An effective way to prevent mental nerve from iatrogenic injury?

Aim

To evaluate the protective effect of axillary channel-assisted (ACA) transoral endoscopic thyroidectomy vestibular approach on mental nerve.

Materials and Methods

From August 2018 to December 2020, 126 cases of thyroid micro-carcinoma patients who underwent endoscopic thyroidectomy were recruited retrospectively. Of those, 74 cases were performed with ACA trans-oral endoscopic thyroidectomy vestibular approach (ACA_TOETVA) (V and A group), 52 cases received standard TOETVA (V group). On postoperative day 1 (POD1), nylon monofilament test and numbness visual analogue scale score were conducted to evaluate the severity of numbness within the mental area, facial expression was tested to determine the motor function of lower mandible and the thickness of cutaneous and subcutaneous layers was measured with ultrasound. The other observation parameters including the time for operation and intraoperative blood loss were carefully collected.

Results

On POD1, nylon monofilament test showed that scores in the V and A group (2.9 ± 0.3) were significantly higher than V group (1.7 ± 0.5), P < 0.01, u = 254. The completion percentage of facial expression in the V and A group was 90.5% (67/74) and significantly higher than in V group (21.2%, 11/52), P < 0.01, χ2 = 62.35. The thickness increment of cutaneous and subcutaneous layer was 2.2 ± 1.2 mm in the V and A group, which was significantly less than in the V group (4.0 ± 1.2 mm), P < 0.01, u = 605. Compared with V group, the operation time (113.4 ± 22.3 min vs. 127.7 ± 25.6 min, u = 1262) and intraoperative blood loss (43.5 ± 13.4 ml vs. 51.0 ± 14.1 ml, u = 1355) were also significantly less in the V and A group.

Conclusions

The ACA transoral endoscopic thyroidectomy possesses the protective effect on mental nerve and motor function of lower mandible and facilitates the operative procedures of TOETVA.

Thyroidectomy using a single-port cervico-mental angle approach

Background

Over the last two decades, several endoscopic thyroidectomy methods have been developed. However, there are some limitations in these procedures. To date, the optimal surgical approach for thyroid cancer has not yet been developed. This study reported the surgical operation steps, clinical outcomes, and experience of 30 patients who underwent trans-cervico-mental angle single-port endoscopic thyroidectomy (TCMASPET) at our centre.

Patients and Methods

A total of 30 patients were enrolled in the present study. Patients underwent unilateral or bilateral thyroidectomy through a cervico-mental angle incision of 2.48 ± 0.31 cm, after which the lymphoid adipose tissues in the central region were dissected.

Results

All surgeries were successfully completed. Two patients underwent bilateral thyroid carcinoma resection with bilateral central region lymph node dissection, 23 patients received unilateral thyroid cancer resection with unilateral central region lymph node dissection, four patients underwent unilateral thyroid resection, and one patient received bilateral thyroid resection with unilateral central region lymph node dissection. No permanent post-operative complications were observed.

Conclusions

TCMASPET was a safe and feasible approach that was relatively easy to perform. This approach may expand the indications for endoscopic thyroidectomy while maintaining excellent cosmetic outcomes.

Comparison Between Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and Conventional Open Thyroidectomy for Patients Undergoing Total Thyroidectomy and Central Neck Dissection: A Propensity Score-Matching Analysis

Background

Use of the novel transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasing worldwide. Although several studies have compared safety and efficacy of TOETVA and other approaches, most focused on comparisons in the context of unilateral thyroidectomy. Therefore, the present study aimed to compare the safety and surgical completeness of TOETVA with conventional open thyroidectomy (COT) in patients with papillary thyroid carcinoma (PTC) undergoing total thyroidectomy and central neck dissection.

Methods

The medical records of patients who underwent TOETVA or COT by a single surgeon between June 2017 and October 2021 were retrospectively reviewed. All patients were diagnosed with PTC and underwent total thyroidectomy with central neck dissection. Propensity score-matching (PSM) was used to reduce potential selection bias and to adjust for differences in baseline clinicopathological characteristics.

Results

After PSM, 84 (TOETVA: 28; COT: 56) patients remained in the study population. There were no significant differences in sex, mean age, combined thyroiditis, tumor size, capsule invasion, tumor multifocality in the same lobe, or tumor location between the groups. Operative time was longer (190.54 ± 28.26 vs. 123.93 ± 29.78 min, P<0.001), while postoperative drainage volume (161.07 ± 225.30 vs. 71.16 ± 28.56 ml, P=0.045) was greater, in the TOETVA group than in the COT group. The groups exhibited no significant differences in the mean number of central lymph nodes retrieved (9.39 ± 4.01 vs. 10.71 ± 5.17, P=0.202), mean number of metastatic central lymph nodes (1.36 ± 1.93 vs. 1.77 ± 2.31, P=0.421), postoperative mean thyroglobulin levels (0.08 ± 0.24 vs. 0.10 ± 0.27, P=0.686), rate of transient hypoparathyroidism (TOETVA: 67.9% vs. COT: 66.1%, P=0.870), rate of transient vocal cord palsy (TOETVA: 0% vs. COT: 1.8%, P=1.000), or other complications (TOETVA: 3.6% vs. COT: 0%, P=0.333).

Conclusions

TOETVA is a safe approach in select patients with PTC and exhibits similar efficacy to COT in terms of surgical completeness.

Transoral and submental thyroidectomy using intraoperative nerve stimulation and indocyanin green fluorescence imaging

There is a recent proliferation of clinical studies about the minimally invasive scarless thyroid surgery. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) carries a great potential for being scarless surgery via a short dissection flap. However, TOETVA has limitations in extracting larger thyroid tumours via the transoral vestibular incision and due to its potential damage to the branches of the mental nerve. The rapidly evolving surgical innovations have now introduced transoral and submental thyroidectomy (TOaST) approach that allows extraction of large thyroid tumours with less flap dissection and minimal postoperative pain. We present a 39-year-old man with a large multinodular goitre. The patient was euthyroid with moderate to severe compression symptoms of difficulty in breathing and swallowing. We performed a TOaST procedure using intraoperative neuromonitoring and indocyanin green fluorescence imaging with an uneventful recovery. This is a first case report from the middle east region that will pave the way to large clinical trials to determine the efficacy and safety of TOaST.

The sensorimotor changes of the lower lip and chin after transoral endoscopic thyroidectomy vestibular approach

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) can lead to abnormal sensorimotor changes in the lower lip and chin because of its incision design. This study aimed to explore the surgical outcomes of these changes after TOETVA. A total of 122 patients who underwent TOETVA were reviewed. The original incision design was used for the 39 patients in group A and a modified incision design was used for the 83 patients in group B. The sensorimotor changes in the lower lip and chin were compared. Varying degrees of paresthesia of the lower lip and chin (PoLC) were noted in all group A patients. Approximately 20.5% of group B patients did not suffer from PoLC, and the degree of PoLC in group B was significantly lower (P < 0.001). Abnormal motor function of the lower lip was noted for 23.1% of the patients in group A and 2.4% of those in group B. The incision design plays an important role in the morbidity of sensorimotor changes in the lower lip and chin. Our modified incision design seems minimally invasive and feasible for patients who undergo TOETVA.

Endoscopic parathyroidectomy using a three-port submental approach

PURPOSE

The three-port submental endoscopic approach and its variations were introduced in 2016 and have been used for thyroidectomy since. However, there has been no report of this approach being used for parathyroidectomy [1, 2]. The objective of this paper was thus to report our experience using a three-port submental approach for endoscopic parathyroidectomy in challenging cases such as tertiary parathyroidism.

METHODS

We compared the outcomes before and after endoscopic removal of the parathyroid glands using a three-port submental endoscopic approach.

RESULTS

Endoscopic subtotal parathyroidectomy was performed using submental approach in five patients with tertiary hyperparathyroidism from January 2018 to June 2019. The parathyroid hormone levels of the patients dropped significantly after undergoing subtotal parathyroidectomy (mean difference 2260 pg/ml; 95% CI 1883.74 to 2636.65), as did calcium levels (mean difference 2.84 mg/dl; 95% CI 1.90 to 3.78). No major adverse events occurred in this study.

CONCLUSIONS

Submental approach parathyroidectomy allows for visualization of all parathyroid glands. Surgical scarring was minor and was hidden under the chin. The surgical outcomes were promising, and there were no major complications.