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

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level 4.

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

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

Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review

This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.

OUP accepted manuscript

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transoral thyroidectomy vestibular approach versus non-transoral endoscopic thyroidectomy: a comprehensive systematic review and meta-analysis

BACKGROUND

To conduct a meta-analysis to compare the short-term outcomes of transoral thyroidectomy vestibular approach (TOTVA) with non-transoral endoscopic thyroidectomy (NTET).

METHODS

MEDLINE, EMBASE, science citation index expanded, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from January 2007 to January 2021 were searched for relevant literature. The evaluated endpoints were intra-operative and post-operative outcomes.

RESULTS

Ten eligible, non-randomized comparative studies involving 1677 patients were included. Meta-analysis results revealed that TOTVA was associated with significantly longer operative time [weighted mean differences (WMD), 22.60; 95%confidence interval (CI), 7.51-37.69; P = 0.003]. No significant differences were found between TOTVA group and NTET group in terms of post-operative outcomes.

CONCLUSION

TOTVA appears to be an equally feasible and safe surgical procedure as NTET for patients with benign thyroid nodules and selected differentiated thyroid carcinomas.

Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients

BACKGROUND

Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques.

METHODS

This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers.

RESULTS

The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%).

DISCUSSION

This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

Objective

The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications.

Methods

Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong.

Results

A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery.

Conclusion

The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Trans oral endoscopic thyroidectomy (TOETVA): First French experience in 90 patients

OBJECTIVE

Thyroidectomy techniques using extracervical approaches have grown in popularity for about 20 years and their feasibility has now been demonstrated. We wanted to evaluate one of these new approaches: the anterior vestibular endoscopic approach (TOETVA). The aim of this study was to evaluate the results of an initial series patients who underwent an anterior trans-vestibular endoscopic oral thyroidectomy.

METHODS

From February 2018 to September 2020, this technique was offered to patients aged 18 to 70, ASA I or II, who presented with an indication for thyroid surgery and who wished to avoid cervical scars. The approach was through the anterior vestibule of the mouth and the specimen was extracted either transorally or via the axilla depending on its size. Apart from the first ten cases, all patients underwent recurrent nerve neuromonitoring. The patients were operated on by two surgeons experienced in thyroid surgery. All the patients had follow-up visits on D15, D30 and at 2 months. The pre- and intra-operative data, length of stay and complications were evaluated.

RESULTS

A total of 90 consecutive patients (87 women) aged 46±12.4 years (18 to 69) with a mean BMI of 24.4±4 were included. The indications for surgery included 11 papillary cancers, 5 oncocytic nodules, 15 toxic nodules, 13 cases of Graves disease and 46 symptomatic goiters and/or nodules. The mean pre-operative diameter of the nodules was 3.61±1.99 (0.44 to 7.3) cm. The interventions performed were 44 lobo-isthmectomies, 41 total thyroidectomies and 5 isthmectomies. The mean operating time was 134±45min (40 to 255). On D1, the post-operative ionized calcium was 1.09±0.11mmol/L (4.3685±0.44mg/dL) (normal 0.8-1.15mmol/L) (3.206-4.609mg/dL)) and the total serum calcium was 2.07±0.11mmol/L 8.296±0.44mg/dL (normal 2.2-2.5mmol/L) (8.817-10.019mg/dL). Five patients underwent conversion from endoscopic to open cervical approach (5.5%). The complications were seven cases of transient recurrent nerve palsy (7.8%), eight cases of hypoparathyroidism (19%) including six transient and two permanent, one skin burn and 26 cases of transient chin numbness related to the electrocautery (29%). Ten patients (11%) presented with transient post-operative skin ecchymosis that resolved within 7-10 days. A spontaneous pneumo-mediastinum was observed on chest CT in three patients and evolved favorably. No hematoma, or surgical site infection, or complications related to axillary extraction were observed. All the patients declared themselves satisfied post-operatively and at the end of the follow-up.

CONCLUSION

The TOETVA route of entry is a safe and reliable technique in well-selected patients wishing to avoid a cervical scar.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3–3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.

Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis

PURPOSE

Conventional thyroidectomy has been standard of care for surgical thyroid nodules. For cosmetic purposes different minimally invasive and remote-access surgical approaches have been developed. At present, the most used robotic and endoscopic thyroidectomy approaches are minimally invasive video assisted thyroidectomy (MIVAT), bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET), bilateral axillo-breast approach robotic thyroidectomy (BABA-RT), transoral endoscopic thyroidectomy via vestibular approach (TOETVA), retro-auricular endoscopic thyroidectomy (RA-ET), retro-auricular robotic thyroidectomy (RA-RT), gasless transaxillary endoscopic thyroidectomy (GTET) and robot assisted transaxillary surgery (RATS). The purpose of this systematic review was to evaluate whether minimally invasive techniques are not inferior to conventional thyroidectomy.

METHODS

A systematic search was conducted in Medline, Embase and Web of Science to identify original articles investigating operating time, length of hospital stay and complication rates regarding recurrent laryngeal nerve injury and hypocalcemia, of the different minimally invasive techniques.

RESULTS

Out of 569 identified manuscripts, 98 studies met the inclusion criteria. Most studies were retrospective in nature. The results of the systematic review varied. Thirty-one articles were included in the meta-analysis. Compared to the standard of care, the meta-analysis showed no significant difference in length of hospital stay, except a longer stay after BABA-ET. No significant difference in incidence of recurrent laryngeal nerve injury and hypocalcemia was seen. As expected, operating time was significantly longer for most minimally invasive techniques.

CONCLUSIONS

This is the first comprehensive systematic review and meta-analysis comparing the eight most commonly used minimally invasive thyroid surgeries individually with standard of care. It can be concluded that minimally invasive techniques do not lead to more complications or longer hospital stay and are, therefore, not inferior to conventional thyroidectomy.

Transoral thyroidectomy (TOETVA): Complications, surgical time and learning curve

BACKGROUND

Since 2018, transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a true scarless thyroid surgery. In this study, we explore early outcomes and learning curve of this new approach.

METHODS

A retrospective cohort including conventional thyroidectomies and TOETVAs performed in a cancer center was designed. Learning curve and early surgical outcomes of TOETVA were assessed and compared to conventional thyroidectomy.

RESULTS

A total of 56 TOETVAs and 745 conventional thyroid procedures were included. In the TOETVA group, we had a 14.4% total complication rate with no permanent vocal cord paresis or hypocalcemia. The mean surgical time dropped from 167 to 117 min (p = 0.0001) after the 15 first cases. Comparing to conventional procedures, we didn't find any significant difference in complications rate. Operative time was longer in the TOETVA group.

CONCLUSIONS

In this study, TOETVA was safe and feasible, with a learning curve of 15 cases.

Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy

INTRODUCTION

The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA).

METHODS

The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued.

RESULTS

Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times.

CONCLUSIONS

The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.

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.