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Bertelli AA, Lira RB, Gonçalves AJ, Kowalski LP. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) and complications. Rev Col Bras Cir 2021; 48:e20213084. [PMID: 34468504 PMCID: PMC10683466 DOI: 10.1590/0100-6991e-20213084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Antonio Augusto Bertelli
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Renan Bezerra Lira
- - AC Camargo Cancer Center, Departamento de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
- - Hospital Israelita Albert Einstein, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Antonio José Gonçalves
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Luiz Paulo Kowalski
- - AC Camargo Cancer Center, Departamento de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
- - Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
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152
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Indocyanine Green Angiography for Parathyroid Gland Evaluation during Transoral Endoscopic Thyroidectomy. J Pers Med 2021; 11:jpm11090843. [PMID: 34575620 PMCID: PMC8468084 DOI: 10.3390/jpm11090843] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 12/15/2022] Open
Abstract
Indocyanine green (ICG) angiography, a real-time intraoperative imaging technique, is associated with better parathyroid identification and functional evaluation during open thyroidectomy. However, the benefits of ICG fluorescence imaging application in transoral endoscopic thyroidectomy are not well-documented. Consecutive patients who underwent transoral endoscopic thyroidectomy were retrospectively reviewed. Parathyroid glands were assessed with visual inspection followed by ICG angiography. The fluorescence intensity of all parathyroid glands was recorded. In total, 158 parathyroid glands from 60 patients (41 underwent lobectomy and 19 underwent total thyroidectomy) were eligible for evaluation. A total of 135 parathyroid glands (85.4%) were identified, including nine glands (5.7%) that were solely localized because of ICG angiography. Incidental parathyroidectomy occurred in 12 patients with predominant inferior gland (83.3%) and associated with central neck dissection (66.7%). Among patients receiving total thyroidectomy, patients who retained at least one well-perfused parathyroid gland had higher parathyroid hormone (PTH) level and were less likely to develop hypoparathyroidism on postoperative day one than those without any well-perfused ICG-enhanced parathyroid gland (p = 0.038). In addition, the duration of calcium supplementation to maintain normocalcemia was also shorter. ICG angiography is a feasible adjunct procedure for parathyroid identification and postoperative functional prediction in transoral endoscopic thyroidectomy.
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153
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Alnehlaoui F, Guraya SY. Transoral and submental thyroidectomy using intraoperative nerve stimulation and indocyanin green fluorescence imaging. BMJ Case Rep 2021; 14:e243306. [PMID: 34426423 PMCID: PMC8383884 DOI: 10.1136/bcr-2021-243306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, UAE
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154
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Kim H, Woo SH. Endoscopically-Assisted Scar-Free Midline Neck Mass Excision. Clin Exp Otorhinolaryngol 2021; 14:251-258. [PMID: 34407369 PMCID: PMC8373841 DOI: 10.21053/ceo.2020.02446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 06/25/2021] [Indexed: 11/22/2022] Open
Abstract
Traditional open surgery is indicated for the treatment of selected tumor subsites in the head and neck. However, it can cause major cosmetic problems and functional pathologies. The endoscopically-assisted transoral approach is increasingly preferred in some surgical fields due to its superior cosmetic and functional outcomes. Nonetheless, endoscopically-assisted transoral approach is not yet standard in the head and neck due to their anatomical complexity. The transoral surgical approach has been used for head and neck masses since the 1960s, and its application continues to evolve with changing disease conditions and recent innovations in surgical instruments. The potential for wide application of transoral surgery continues to be investigated, with a focus on minimizing occurrence of the complications. This review presents details of the surgical procedure and postoperative clinical outcomes, as well as endoscopically-assisted scar-free techniques for the resection of midline neck masses.
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Affiliation(s)
- Hyoyeon Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Seung Hoon Woo
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
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155
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Lira RB, De Cicco R, Rangel LG, Bertelli AA, Duque Silva G, de Medeiros Vanderlei JP, Kowalski LP. Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients. Head Neck 2021; 43:3468-3475. [PMID: 34382715 DOI: 10.1002/hed.26846] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/05/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Renan Bezerra Lira
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil.,Post-Graduate in Robotic Head and Neck Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rafael De Cicco
- Instituto de Câncer Dr. Arnaldo Vieira de Carvalho, São Paulo, Brazil
| | - Leonardo Guimarães Rangel
- Head and Neck Surgery Division, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Antônio Augusto Bertelli
- Head and Neck Surgery Division, Department of Surgery, Santa Casa Medical School, São Paulo, Brazil
| | - Guilherme Duque Silva
- Head and Neck Surgery Division, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | | | - Luiz Paulo Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil.,Head and Neck Surgery Department and LIM 28, University of São Paulo Medical School, São Paulo, Brazil
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156
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Zhang D, Li S, Dionigi G, Wang T, Zhang J, Xue G, Sun H. Consequences of Trocar Dynamics on Mental Nerve in Transoral Thyroidectomy. Surg Laparosc Endosc Percutan Tech 2021; 30:305-311. [PMID: 32459705 DOI: 10.1097/sle.0000000000000795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mental nerve (MN) injuries are reported during transoral endoscopic thyroidectomy vestibular approach. Effect of trocar insertion and position on MN are examined in the present study. MATERIALS AND METHODS Ten millimeter incision was made at the center of the lower lip oral vestibule. Two 5 mm lateral incisions of the lower lip oral vestibule were made at the junction between the incisor and the canine. These 2 lateral incisions were high, just below the edge of lower lip. Nine pigs (18 MN) were randomly divided into 3 groups and MN dissection was performed. The angle between the lateral ports and median line were changed between 15 and 45 degrees among 3 groups and effect on MN was examined. RESULTS During dissection when insertion and other ports are in neutral position visual inspection of MNs did not reveal any compression bilaterally. The distance between MN and the ports was 18.2±2.1 mm (16.3 to 21.2 mm). In group I and group II, MNs have no compression by the lateral trocars. In group III (45 degrees), left MNs were all compressed. Two MNs (66.7%) were compressed on the right side. The MN was compressed at its ramification. CONCLUSIONS The results of the present experimental study, endorse the suggested medial and lateral vestibular incisions for transoral endoscopic thyroidectomy vestibular approach. However, during dynamic modification of the lateral port position/angle, MN compression was observed when the angle was >45 degrees.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Shijie Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", Division for Endocrine and Minimally Invasive Surgery, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Jiao Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Gaofeng Xue
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
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157
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Park JO, Lee DH, Kim MR, Kim SY, Han JH, Sun DI. Transoral endoscopic thyroidectomy using a self-retaining retractor as an alternative to carbon dioxide gas insufflation: A comparative analysis of 131 cases. Oral Oncol 2021; 121:105463. [PMID: 34343782 DOI: 10.1016/j.oraloncology.2021.105463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jun-Ook Park
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Dong-Hyun Lee
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Mi Ra Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Inje University of Korea, Republic of Korea
| | - Sang-Yeon Kim
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, Inje University of Korea, Republic of Korea
| | - Jae Hong Han
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Dong-Il Sun
- Department of Otolaryngology Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea.
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158
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The sensorimotor changes of the lower lip and chin after transoral endoscopic thyroidectomy vestibular approach. Updates Surg 2021; 73:2283-2291. [PMID: 34287761 DOI: 10.1007/s13304-021-01133-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
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.
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159
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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. Surgery 2021; 170:1680-1686. [PMID: 34284897 DOI: 10.1016/j.surg.2021.06.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/10/2021] [Accepted: 06/21/2021] [Indexed: 12/11/2022]
Abstract
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.
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160
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Liang TJ, Wang NY, Liu SI, Chen IS. Vocal cord granuloma after transoral thyroidectomy using oral endotracheal intubation: two case reports. BMC Anesthesiol 2021; 21:170. [PMID: 34126924 PMCID: PMC8201730 DOI: 10.1186/s12871-021-01393-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background Transoral thyroidectomy can be performed using nasal or oral intubation. Recently, we encountered two cases of vocal cord granuloma that were suspected to result from intraoperative compression by the oral endotracheal tube. Cases presentation Two women underwent transoral endoscopic thyroidectomy with oral endotracheal tubes fixed at the mouth angle. Their initial postoperative recovery was uneventful, but they developed hoarseness 2 months after the surgery. Subsequent strobolaryngoscopy revealed vocal cord granulomas at the side of contact of the endotracheal tube. One patient received medication and voice therapy, and her granuloma shrank significantly one month later. The other patient underwent granuloma resection. Thereafter, the symptoms improved in both the patients. Conclusions Oral intubation with tube placement at the mouth angle might result in the formation of vocal cord granulomas. Therefore, we suggest positioning the tube at the midline to avoid excessive irritation on one side of the vocal cord.
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Affiliation(s)
- Tsung-Jung Liang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Zuoying District, 81362, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, 11221, Taipei, Taiwan
| | - Nai-Yu Wang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Zuoying District, 81362, Kaohsiung, Taiwan
| | - Shiuh-Inn Liu
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Zuoying District, 81362, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, 11221, Taipei, Taiwan
| | - I-Shu Chen
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Zuoying District, 81362, Kaohsiung, Taiwan.
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161
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Broekhuis JM, Chen HW, Maeda AH, Duncan S, Grogan RH, James BC. Public perceptions of transoral endocrine surgery and their influence on choice of operative approach. J Surg Res 2021; 267:56-62. [PMID: 34130239 DOI: 10.1016/j.jss.2021.04.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Transoral Endocrine Surgery (TES) represents an alternative to the open approach with no visible scar. Studies have shown TES has a safety profile similar to the open approach, but adoption has been limited. Public perception and preference for TES are factors associated with adoption that have not been explored. Here we aim to understand the perception of TES by the public and factors which influence decision making. MATERIALS AND METHODS A 38-question survey was designed to assess factors which influence willingness to pursue TES. The survey was distributed utilizing Amazon Mechanical Turk (MTurk), a crowdsourcing marketplace in which individuals perform tasks virtually based on interest. Descriptive analyses, Pearson chi-squared tests, Student's t-tests, and multivariate logistic regression were performed to evaluate theoretical decision to pursue TES. RESULTS Respondents (n = 795) were 47% female, 78% white, 70% held a college degree or higher, and had a mean age of 37. The majority (69%) preferred a mouth incision over a neck incision. Respondents were willing to pursue TES for a theoretical cancer despite increased cost (52%) and longer operative time (70%). Respondents top two most important surgical factors were safety and experience. CONCLUSIONS Our data suggest the general public is willing to pursue TES and factors thought to be barriers to choosing TES may not deter the public. An informed discussion with appropriately-selected patients should be had between the patient and surgeon regarding specific surgical and postoperative differences including risks, safety, and experience.
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Affiliation(s)
- Jordan M Broekhuis
- Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Hao Wei Chen
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Anthony H Maeda
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah Duncan
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Raymon H Grogan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Benjamin C James
- Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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162
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Prevention of transoral thyroidectomy complications: An analysis of surgical outcomes in 423 consecutive series. Surgery 2021; 170:1155-1159. [PMID: 34090673 DOI: 10.1016/j.surg.2021.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although there are several publications on the new transoral robotic thyroidectomy technique, few have thoroughly reviewed its associated complications. This study analyzed the causes and prevention of transoral robotic thyroidectomy-specific complications and presented preventive measures. METHODS The medical records of patients who underwent transoral robotic thyroidectomy performed by a single surgeon between March 1, 2009 and April 30, 2019 were retrospectively analyzed. Patient demographic, clinical, and operative data were analyzed using descriptive statistics. We describe the transoral robotic thyroidectomy-related complications experienced at our institution and how to overcome them. RESULTS This study included a total of 423 patients who underwent transoral robotic thyroidectomy. The general surgical complications included immediate postoperative bleeding (2 cases) and delayed hematoma (3 cases). Chyle leakage and localized wound infection were found in 1 case each. Transient vocal cord palsy occurred in 4 cases, and 1 case developed transient hypoparathyroidism. The transoral robotic thyroidectomy-specific complications included zygoma bruise (2 cases), flap bruise (3 cases), chin flap perforation (2 cases), and oral commissure tearing (2 cases). The complications occurring when creating the flap included flap burns (4 cases), skin dimpling in the midline of the lower chin (2 cases), and hematomas in the intraoral trocar insertion sites (3 cases). CONCLUSION Surgeons familiar with thyroid surgery and experienced in robotic surgery can perform transoral robotic thyroidectomy without causing more complications than those seen with traditional surgery.
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163
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Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series. Surg Endosc 2021; 36:2507-2513. [PMID: 34031742 DOI: 10.1007/s00464-021-08537-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A cervical scar has been shown to have an impact on the quality of life of children undergoing thyroid surgery. Transoral endoscopic vestibular thyroidectomy via the vestibular approach (TOETVA) offers the absence of a cutaneous incision, and has not been described to date in the pediatric population. OBJECTIVE To describe the first series of TOETVA in a pediatric population. PATIENTS AND METHODS A retrospective, multicenter study, including all patients > 18 years old who underwent TOETVA. Data was prospectively collected and included demographics, preoperative ultrasound, cytology and indications for surgery. Intraoperative parameters included length of surgery and complications, with final pathology and postoperative course also reviewed. TOETVA surgical success was defined as completion of surgery via this approach. RESULTS Forty-eight children were included. Of these, 43 (89.5%) were girls. The median age was 16 years (range 10-17). The most common indication for surgery was a benign thyroid nodule (n = 26, 54.1%). Eleven patients (22.9%) had papillary thyroid carcinoma on final pathology, of which 90.9% (10/11) were diagnosed pre-operatively based on FNA cytology. Hemithyroidectomy was performed in 36 patients (75%). All surgeries were completed endoscopically. The mean malignant tumor size was 1.4 ± 0.4 cm and all tumors were completely excised with clean margins. No permanent complications were documented. A single patient (2.1%) had transient RLN injury (1.6%, 1/60 nerves at risk). Transient hypocalcemia was documented in 4 of the 12 patients undergoing total thyroidectomy (33.3%). Transient mental nerve injury/chin hypoesthesia was documented in 2 patients (4.2%). CONCLUSIONS TOETVA appears to be a feasible and safe approach for thyroidectomy in the pediatric population in carefully selected cases, and may be discussed with patients and parents as an alternative for the trans-cervical approach.
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164
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Transoral Endoscopic Thyroidectomy Vestibular Approach: An Initial Experience in Vietnam. Surg Laparosc Endosc Percutan Tech 2021; 30:209-213. [PMID: 32032330 DOI: 10.1097/sle.0000000000000764] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be applied to many health facilities worldwide, even in places whose medical facilities have not developed yet. To that end, our hospital is the first hospital to deploy this novel technique in Vietnam. In the study, the authors will evaluate the safety and efficacy of TOETVA, which was initially performed on patients in Vietnam. MATERIALS AND METHODS A TOETVA research was conducted on 28 patients in hospital K from January 1, 2018 to May 31, 2019. The surgical outcomes, cosmetic results, and complications were evaluated. RESULTS The mean operative time was 91 minutes (70 to 130 min). There were no cases with temporary and permanent hypoparathyroidism in the patients. One patient had temporary mental nerve injury recovered completely after 14-day surgery. No case used drains in patients. All patients were highly satisfied with the surgical outcome, especially, cosmetic results. CONCLUSIONS TOETVA is a safe and feasible technique with acceptable complication rates and good outcomes. The authors will carry on this procedure for selected patients. TOETVA should not only be performed in some countries with well-developed health care systems but also be done in other developing countries worldwide.
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Transoral versus gasless transaxillary endoscopic thyroidectomy: a comparative study. Updates Surg 2021; 74:295-302. [PMID: 33914272 DOI: 10.1007/s13304-021-01062-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
This study aimed to compare the surgical safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless endoscopic thyroidectomy transaxillary approach (GETTA). This retrospective study assessed 150 patients managed with the TOETVA at the Yantai Yuhuangding hospital and 150 patients managed via the GETTA at the Zhenjiang Provincial People's Hospital. The procedures were compared in terms of workspace creation time, operating time, complications, post-operative complaints, cosmetic satisfaction, and the efficacy of central neck lymph-node dissection. There was no significant between-group difference in terms of post-operative complications. The average workspace creation and operating times were significantly shorter for GETTA than for TOETVA (P values for both < 0.001). The average number of lymph nodes dissected from the central compartment of the neck was higher in the TOETVA group than in the GETTA group (7.2 ± 4.6 vs. 3.9 ± 3.0, P < 0.001). The mean swallowing impairment index-6 scores at 1 month were significantly lower in the GETTA group than in the TOETVA group (1.5 ± 1.2 vs 2.6 ± 1.4, P < 0.001). Over 97% of all patients (both groups) were either satisfied or very satisfied with the cervical cosmetic outcomes at 3 months post-surgery (P = 0.099). TOETVA and GETTA are both safe procedures with good cervical cosmetic outcomes for well-selected patients. Although TOETVA is more efficacious in terms of central lymph nodes dissection, GETTA has a greater time-cost advantage.
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Wu YJ, Chi SY, Chan YC, Chou FF, Wee SY, Wu KT. Scarless Completion Thyroidectomy After Initial Transoral Approach for Differentiated Thyroid Cancer: How and When to Start? Surg Laparosc Endosc Percutan Tech 2021; 31:554-557. [PMID: 33788820 DOI: 10.1097/sle.0000000000000933] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND With growing literature, the feasibility of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been confirmed as a valid method for managing differentiated thyroid cancer. Completion thyroidectomy (CT) is recommended in patients who have been diagnosed with differentiated thyroid cancer after unilateral lobectomy by TOETVA. In this retrospective study, the authors addressed the critical questions of how and when to do the second operation of CT to avoid a neck scar. MATERIALS AND METHODS The authors retrospectively reviewed our patients who had received TOETVA in our hospital from August 2016 to December 2019. Those who received CT after initial TOETVA as cTOETVA were further separated according to the approaching methods. Demographic data, operative variables, and postoperative variables were collected and analyzed. RESULTS A total of 97 patients were enrolled using TOETVA. Malignancies were present in 42 patients (43.3%) using TOETVA. There were 3 approaching methods of cTOETVA and separated into reopen transcervical approach (re-TCA), retransoral TOETVA (re-TOETVA), and transaxillary approach (TAA) groups. There were no significant complications among patients for cTOETVA. Of the 8 patients for the cTOETVA, 3 received re-TCA, 3 re-TOETVA, and 2 TAA. CONCLUSIONS The outcomes are encouraging and demonstrate the feasibility of scarless completion thyroidectomy after initial TOETVA. The re-TOETVA procedure should be completed within 14 days after the initial TOETVA procedure, TAA beyond 14 days, and re-TCA may be completed at any time. The cTOETVA techniques using re-TOETVA or TAA have better cosmetic results than re-TCA in oncological equivalency.
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Affiliation(s)
- Yi-Ju Wu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Zhang WD, Dai L, Wang YC, Xie YY, Guo JY, Li JJ, Wu XJ. Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Endoscopic Thyroidectomy Via Areola Approach for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study. Surg Laparosc Endosc Percutan Tech 2021; 31:550-553. [PMID: 33734209 DOI: 10.1097/sle.0000000000000932] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic thyroidectomy via areola approach (ETA) has been widely used in thyroidectomy for many years as it can effectively avoid a scar in the neck. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied and has gained popularity quickly. This study is to compare the safety and effectiveness of TOETVA and ETA. MATERIALS AND METHODS A total of 95 patients who underwent TOETVA or ETA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2020. The basic information (such as gender, age), intraoperative hemorrhage, postoperative drainage volume, hospital durations, intraoperative and postoperative complications, operative time, central lymph node dissection time, total number of central lymph nodes, and number of metastatic central lymph nodes were compared. RESULTS The operative time of the TOETVA group was significantly longer than the ETA group (148.11±19.78 vs. 135.90±12.77 min, P<0.05). However, the result was opposite when central lymph node dissection time was compared (10.31±2.93 vs. 12.48±3.55, P<0.05). TOETVA had an advantage on total number of central lymph nodes over ETA (7.82±3.35 vs. 5.26±2.45, P<0.05). No differences were found between the 2 groups on other data. CONCLUSION TOETVA and ETA have the similarity on surgical safety and effectiveness. TOETVA has its advantage on central lymph node dissection and might be a reasonable alternative for ETA and open surgery in the future.
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Affiliation(s)
- Wei-Dong Zhang
- Department of Thyroid Surgery, Hwa Mei Hospital
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences
| | - Lei Dai
- Department of Thyroid Surgery, Hwa Mei Hospital
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences
| | | | | | - Jian-Yao Guo
- Department of surgery, Ningbo Hangzhou Bay Hospital
| | - Jian-Jun Li
- Department of Thyroid Surgery, Hwa Mei Hospital
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences
| | - Xian-Jiang Wu
- Department of Thyroid Surgery, Hwa Mei Hospital
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors, Zhejiang Province, Ningbo, China
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Zhang D, Fu Y, Zhou L, Wang T, Liang N, Zhang J, Xue G, Dionigi G, Sun H. Pictorial essay of vestibular incision outcomes from transoral endoscopic thyroidectomy. Langenbecks Arch Surg 2021; 406:2869-2877. [PMID: 33719000 DOI: 10.1007/s00423-021-02124-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a new treatment option for patients with selected thyroid disease requiring surgery. The aim of this pictorial essay is to illustrate the healing outcomes of the vestibular incisions. METHODS TOETVA patients were recruited at two Centers in China and Italy. TOETVA is initiated with one 10-20-mm median incision in the center of the oral vestibule 10 mm above the inferior labial frenulum, and two 5-mm lateral incisions, just below the lower lip near the labial commissure. Healing of the vestibular incision was monitored through serial photographs 1, 3, 7, 30, and 90 days after surgery. Outcomes were evaluated by Landry's score, time to healing, issues affecting wound outcomes, scar, fibrin, granulation, necrotic tissue formation, and infections. RESULTS Results of TOETVA were monitored in 52 patients. There were no postoperative infections. All lateral incisions demonstrated favorable surgical outcomes. Landry's criteria scores indicated worse outcomes for the median incisions vs. the lateral ones (p<0.05). Median incisions healed well in 65.4% of patients, but 34.6% of patients had visible scars from the median incision 90 days after surgery. Eight (15.4%) had cicatricial diathesis, seven (13.5%) experienced displacement of the stitches, and three (5.8%) developed synechia with gingiva. When the central vestibular incision was <10mm from the gingiva, patients tended to form synechia (60%). There were no significant differences in wound healing between the Chinese and Italian patients. CONCLUSIONS Knowledge of vestibular incision healing is essential to provide practical TOETVA clinical guide and to define optimal outcomes evaluation for transoral surgeons. Vestibular wound problems were confined only to the central incision.
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Affiliation(s)
- Daqi Zhang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Yantao Fu
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Le Zhou
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Tie Wang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Nan Liang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Jiao Zhang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Gaofeng Xue
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Hui Sun
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China.
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169
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Park JO. Current concepts in thyroid gland surgery: transoral endoscopic and robotic surgical procedures. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.3.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The increased incidence of thyroid cancer in young females may raise concerns about visible hypertrophic scarring on the center of the neck after thyroid gland surgery. Therefore, endoscopic surgical procedures have attracted significant interest from patients with thyroid cancer, leading to the development of various endoscopic and robotic approaches. Although the cosmetic outcomes of current endoscopic and robotic thyroid surgeries have been excellent, all the procedures still require a large incision and extensive flap elevation. Transoral endoscopic thyroid surgery is a newly developed surgical method performed by inserting an endoscope through a mucosal opening created in the mouth, obviating the need for a skin incision. Additionally, the dissection area is relatively small and no dressings are required. Showering or shaving may resume the day after surgery and the port created within the oral mucous membrane generally heals within one week. Importantly, this approach is markedly less invasive than other endoscopic approaches. Although transoral endoscopic thyroid surgery has not yet been universally accepted, it may emerge as the preferred method for thyroid surgery in the near future.
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170
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Deroide G, Honigman I, Berthe A, Branger F, Cussac-Pillegand C, Richa H, Anuwong A. Trans oral endoscopic thyroidectomy (TOETVA): First French experience in 90 patients. J Visc Surg 2021; 158:103-110. [PMID: 33676861 DOI: 10.1016/j.jviscsurg.2021.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- G Deroide
- Franco-British Hospital Institute, 4, Rue Kleber Hôpital Franco-Britannique, 92300 Levallois, France; Clinique Lambert Ramsay, La garenne Colombes, France.
| | - I Honigman
- Polyclinique de Saint-Jean-de-Luz, Saint-Jean-de-Luz, France
| | - A Berthe
- Clinique Lambert Ramsay, La garenne Colombes, France
| | - F Branger
- Franco-British Hospital Institute, 4, Rue Kleber Hôpital Franco-Britannique, 92300 Levallois, France; Clinique Lambert Ramsay, La garenne Colombes, France
| | - C Cussac-Pillegand
- Franco-British Hospital Institute, 4, Rue Kleber Hôpital Franco-Britannique, 92300 Levallois, France
| | - H Richa
- Franco-British Hospital Institute, 4, Rue Kleber Hôpital Franco-Britannique, 92300 Levallois, France
| | - A Anuwong
- Police General Hospital, Bangkok, Thailand
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Bermúdez-Triano M, Fernández-Castellano G, Guerrero-Domínguez R, López-Romero JL, Benítez-Linero I. Anaesthetic management of transoral endoscopic thyroidectomy. A case report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:149-152. [PMID: 32622475 DOI: 10.1016/j.redar.2020.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/19/2019] [Accepted: 01/14/2020] [Indexed: 06/11/2023]
Abstract
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel and minimally invasive procedure, free of visible scars and showing encouraging results in terms of rapid recovery and less postoperative pain. It consists of performing the thyroidectomy through its natural orifice, using three ports in the oral vestibular area and carrying out a careful dissection to the sternal notch and the edges of both sternocleidomastoid muscles. The objective of this article is to describe the different anesthetic implications that this surgical technique entails, given that the evidence published to date in the literature is very limited. It is considered essential to control the recurrent laryngeal nerve using an endotracheal tube with electromyography to ensure its identification and integrity, as well as the use of other monitors such as the TOF watch or the bispectral index to ensure adequate anesthetic depth and an optimal level of muscle relaxation.
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Affiliation(s)
- M Bermúdez-Triano
- Anestesiología y Reanimación, Hospitales Universitarios Virgen del Rocío, Sevilla, España. , Sevilla, España.
| | - G Fernández-Castellano
- Anestesiología y Reanimación, Hospitales Universitarios Virgen del Rocío, Sevilla, España. , Sevilla, España
| | - R Guerrero-Domínguez
- Anestesiología y Reanimación, Hospitales Universitarios Virgen del Rocío, Sevilla, España. , Sevilla, España
| | - J L López-Romero
- Unidad de Gestión Clínica de Anestesiología y Reanimación, Hospital General Virgen del Rocío, Sevilla, España
| | - I Benítez-Linero
- Anestesiología y Reanimación, Hospitales Universitarios Virgen del Rocío, Sevilla, España. , Sevilla, España
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172
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And now… thyroidectomy through a transoral approach! J Visc Surg 2021; 158:101-102. [PMID: 33632645 DOI: 10.1016/j.jviscsurg.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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173
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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve. J Clin Med 2021; 10:jcm10040863. [PMID: 33669741 PMCID: PMC7922263 DOI: 10.3390/jcm10040863] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Chen LW, Assadi N, Hefetz-Kirshenbaum L, Hong H, Razavi CR, Grogan RH, Tufano RP, Khafif A, Russell JO. Preferences for thyroidectomy technique: Comparing traditional and transoral approaches. Head Neck 2021; 43:1747-1758. [PMID: 33555089 DOI: 10.1002/hed.26627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/14/2020] [Accepted: 01/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND We investigated preferences between the transcervical and transoral thyroidectomy approach in the United States and Israel. METHODS An online survey assessing scar attitudes and surgical preferences, in English and Hebrew, was distributed on ThyCa.com and other platforms. RESULTS 928 and 339 responses from the United States and Israel cohorts, respectively, were analyzed. In both countries, individuals without prior thyroidectomy preferred a scarless approach when hypothetical risks equaled those of traditional thyroidectomy (77% United States, 76% Israel, p = 0.61). U.S. respondents without thyroidectomy had greater preference to avoid a scar and would pay more to do so than those with thyroidectomy (both p < 0.001). Many respondents with prior thyroidectomy still expressed interest in scarless alternatives (57% United States). CONCLUSIONS Populations in Israel and the United States prefer scarless thyroidectomy when risks equal the traditional approach. While individuals without prior thyroidectomy are more likely to favor a scarless option, former thyroidectomy patients may have preferred avoiding a scar.
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Affiliation(s)
- Lena W Chen
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niddal Assadi
- A.R.M. Otolaryngology - Head and Neck, Maxillofacial Clinics, Assuta Medical Center, Tel Aviv, Israel
| | - Lior Hefetz-Kirshenbaum
- A.R.M. Otolaryngology - Head and Neck, Maxillofacial Clinics, Assuta Medical Center, Tel Aviv, Israel
| | - Hanna Hong
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher R Razavi
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raymon H Grogan
- Endocrine Surgery Program, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Avi Khafif
- A.R.M. Otolaryngology - Head and Neck, Maxillofacial Clinics, Assuta Medical Center, Tel Aviv, Israel
| | - Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Zheng G, Ma C, Sun H, Wu G, Guo Y, Wu G, Zheng H. Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study. Eur J Surg Oncol 2021; 47:1346-1351. [PMID: 33558121 DOI: 10.1016/j.ejso.2021.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC. MATERIALS AND METHODS This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%). RESULTS The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up. CONCLUSION TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.
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Affiliation(s)
- Guibin Zheng
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Chi Ma
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Haiqing Sun
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Guochang Wu
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Yawen Guo
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Guoyang Wu
- Department of General Surgery, Zhongshan Hospital Xiamen University, Xiamen, 361004, China.
| | - Haitao Zheng
- Department of Thyroid Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China.
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176
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Razavi CR, Tanavde VA, Kim AS, Shaear M, Tufano RP, Russell JO. The variable direct cost and cost drivers of transoral endoscopic thyroidectomy vestibular approach. Gland Surg 2021; 10:521-528. [PMID: 33708535 DOI: 10.21037/gs-20-653] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background As transoral endoscopic thyroidectomy vestibular approach grows in popularity, there is a need for data on cost in order to better characterize its value to patients. To this end, we compared the variable direct cost of transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy and determined which factors drive the increased cost for the transoral approach. Methods Patients undergoing thyroid lobectomy and total thyroidectomy that met inclusion criteria for transoral endoscopic thyroidectomy vestibular approach, including those patients that opted for management via the transcervical approach, between 8/2016 and 4/2019 were reviewed. The variable direct cost for the surgical encounter was collected and means were compared between the transoral and transcervical cohorts for lobectomy and total thyroidectomy respectively. The operative time independent variable direct cost was similarly compared between cohorts. Results Out of 238 patients, 118 (50%) were managed via transoral endoscopic thyroidectomy vestibular approach and 120 (50%) were managed via transcervical approach thyroidectomy. Mean variable direct cost, our primary outcome, was $4,455 (SD 1,129, 95% CI: 4,204-4,706) for transoral lobectomy and $3,179 (SD 687, 95% CI: 2,990-3,369) for transcervical lobectomy [t(132.05)=8.09, P<0.001] representing a difference in cost of $1,276 (SD 158, 95% CI: 964-1,587). Mean variable direct cost was $4,681 (SD 829, 95% CI: 4,405-4,957) for transoral total thyroidectomy and $3,645 (SD 876, 95% CI: 3,431-3,858) for transcervical total thyroidectomy [t(79.92)=5.98, P<0.001], representing a difference in cost of $1,036 (SD 173, 95% CI: 691-1,381). Differences in energy devices alone account for $487.53 and $447.96 of the cost differences, respectively. Conclusions The differences in mean variable direct cost between transoral endoscopic vestibular approach and transcervical approach for lobectomy and total thyroidectomy were $1276 and $1036 respectively, amounts far less than some believe them to be. This data will be invaluable as we ultimately aim to define the value of transoral endoscopic thyroidectomy vestibular approach.
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Affiliation(s)
- Christopher R Razavi
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ved A Tanavde
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander S Kim
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohammad Shaear
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph P Tufano
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathon O Russell
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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177
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Liang TJ, Tsai CY, Liu SI, Chen IS. Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy. World J Surg 2021; 45:1446-1456. [PMID: 33512565 DOI: 10.1007/s00268-021-05953-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods. METHODS A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve. RESULTS Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2. CONCLUSIONS The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.
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Affiliation(s)
- Tsung-Jung Liang
- Division of General Surgery, Department of Surgery, Zuoying District, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Kaohsiung, 81362, Taiwan.,School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
| | - Chung-Yu Tsai
- Division of General Surgery, Department of Surgery, Zuoying District, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Kaohsiung, 81362, Taiwan
| | - Shiuh-Inn Liu
- Division of General Surgery, Department of Surgery, Zuoying District, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Kaohsiung, 81362, Taiwan.,School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
| | - I-Shu Chen
- Division of General Surgery, Department of Surgery, Zuoying District, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Kaohsiung, 81362, Taiwan.
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178
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Menderico GM, Weissenberg AL, Borba CM, Sallani GM, Poy JDEO. Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA). Rev Col Bras Cir 2021; 48:e20202557. [PMID: 33503138 PMCID: PMC10846390 DOI: 10.1590/0100-6991e-20202557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/27/2020] [Indexed: 11/21/2022] Open
Abstract
The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.
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Affiliation(s)
- Gilberto Mendes Menderico
- - Centro Universitário Lusíada, Disciplina de Clínica Cirúrgica do Curso de Medicina - Santos - São Paulo - Brasil
- - Colégio Brasileiro de Cirurgiões, Membro Adjunto - São Paulo - SP - Brasil
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179
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Lee DW, Kim JK, Tae K. Application of the transoral endoscopic vestibular approach for a benign upper neck mass: A case report. Medicine (Baltimore) 2021; 100:e24087. [PMID: 33466169 PMCID: PMC7808487 DOI: 10.1097/md.0000000000024087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 12/08/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Excision of a benign neck mass is traditionally performed via the transcervical approach. In order to avoid visible scars in the neck, various remote access surgical approaches have been developed. The aim of this report is to present the technique of a transoral endoscopic vestibular approach for treatment of a benign upper neck mass. PATIENT CONCERNS A 47-year-old female with an anterior upper neck mass and throat discomfort visited our institution. DIAGNOSIS The computed tomography (CT) scans and ultrasound (US) images demonstrated a benign-appearing mass on the anterior upper neck area. INTERVENTIONS The benign upper neck mass was successfully removed via the transoral endoscopic vestibular approach, without any complication. OUTCOMES The final pathologic report indicated that the lesion was an epidermal cyst. The cosmetic result was excellent. LESSONS From this case study, we can learn to apply a transoral endoscopic vestibular approach for removal of a benign upper neck mass. Based on the outcomes, endoscopic removal of the benign upper neck mass via a transoral vestibular approach can be useful for patients who wish to hide any anterior neck scar.
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Affiliation(s)
- Dong Won Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Catholic University of Daegu, Daegu
| | - Jeong Kyu Kim
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Catholic University of Daegu, Daegu
| | - Kyung Tae
- Department of Otolaryngology – Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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180
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Kumar C, Lohani KR, Kataria K, Ranjan P, Dhar A, Srivastava A. Endoscopic thyroidectomy: Which one is the better technique for the beginners? J Minim Access Surg 2021; 17:337-341. [PMID: 32964885 PMCID: PMC8270042 DOI: 10.4103/jmas.jmas_184_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Endoscopic thyroidectomy is an advanced procedure and has a long learning curve. Most commonly employed approach is combined axillary-breast approach (ABA). Recently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) is being popularised as a scarless procedure. However, it is not established whether TOETVA or ABA approach is better to begin with. Purpose: The purpose of the study was to compare the initial experience of TOETVA and ABA with respect to difficulties and outcomes. Methodology: A prospective non-randomised interventional study was conducted including the initial ten patients in each group who underwent hemithyroidectomy for benign solitary thyroid nodule. Sigma plot version 12.3 was used for the statistical analysis. Results: All the patients were female and comparable with respect to age (33.2 vs. 28.2 years) and size of nodule (2.7 vs. 3 cm) (TOETVA vs. ABA). The operative time (121 vs. 138.5 min, P = 0.34) and blood loss (50 vs. 60 ml, P = 0.9) were similar in both the groups. Even though the flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001), it was associated with more difficulty in approaching upper pole (P = 0.02) and lower pole (P < 0.001), more intra-operative events (30% vs. 10%, P = 0.58) and conversions to open (20% vs. 10%, P = 1). Similarly, post-operative pain scoring was more with TOETVA (3 vs. 2, P = 0.04). Hospital stay was similar in both the groups (2.5 vs. 3 days, P = 1). Patients in both the groups had both overall and cosmetic satisfaction. Conclusions: Axillary-breast approach should be preferred to start learning the endoscopic thyroidectomy, as it is easier and safer than transoral endoscopic vestibular approach.
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Affiliation(s)
- Chitresh Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Kush Raj Lohani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Anurag Srivastava
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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181
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Kuo TC, Duh QY, Wang YC, Lai CW, Chen KY, Lin MT, Wu MH. Practice Patterns and Learning Curve in Transoral Endoscopic Thyroidectomy Vestibular Approach With Neuromonitoring. Front Endocrinol (Lausanne) 2021; 12:744359. [PMID: 34795638 PMCID: PMC8594485 DOI: 10.3389/fendo.2021.744359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Intraoperative neuromonitoring has not been routinely applied in early experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Because the preparation and surgical interventions are much different from conventional thyroidectomies, most endocrine surgeons willing to adapt to TOETVA lack access to information regarding the practice pattern and proficiency in the learning curve. We aimed to investigate the outcomes and to define the learning curve for TOETVA in this study. METHODS A retrospective analysis was used on patients who underwent TOETVA at our hospital between December 2016 and July 2019. The cumulative sum graphic model was used to implement the learning curve as a surrogate for procedural proficiency. RESULTS The 119 patients had a mean age of 44.65 years and a mean body mass index of 22.49 k/m2, including 107 women, 20 thyroiditis, and 106 hemithyroidectomy. The learning curve revealed two phases, an initial (35 cases) and a mature (84 cases) phase, for surgeons based on operation time (144.2 vs. 114.2 min, p = 0.0001). There were more bilateral thyroidectomies (15.5% vs. 0, p = 0.0100), larger indicated nodules (6.06 cm3vs. 3.32 cm3, p = 0.0468), or larger thyroids to resect (16.38 cm3vs. 8.75 cm3, p = 0.0001) in the mature phase. Procedure-related complications decreased significantly in the mature phase in comparison to the initial phase (3.57% vs. 31.43%, p = 0.0001). CONCLUSIONS The learning curve of TOETVA with neuromonitoring is 35 cases. With the accumulation of proficiency, the indications will expand. Step-by-step improvements from the experience of each case can reduce procedure-related complications.
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Affiliation(s)
- Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Quan-Yang Duh
- Department of Surgery, Section of Endocrine Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chieh-Wen Lai
- Department of Surgery, Buddhist Tzu Chi General Hospital, Taipei, Taiwan
| | - Kuen-Yuan Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Hsun Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
- *Correspondence: Ming-Hsun Wu,
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182
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Rossi L, Materazzi G, Bakkar S, Miccoli P. Recent Trends in Surgical Approach to Thyroid Cancer. Front Endocrinol (Lausanne) 2021; 12:699805. [PMID: 34149628 PMCID: PMC8206549 DOI: 10.3389/fendo.2021.699805] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
Over the past decade, the incidence of thyroid cancer has rapidly increased worldwide, and thyroid surgery has become one of the most common performed surgical procedure. Even though conventional open thyroidectomy remains the gold standard, this approach leaves a neck scar which could be worrying mainly for young women. The recent progress in surgical technology, as well as patient cosmetic requests, have led to the development of alternative access to the thyroid lodge. Thus, alternative techniques have been established in order to potentially provide a more appealing cosmetic result, both with a minimally-invasive cervical or remote-access approach. However, the introduction of these new techniques was initially approached with caution due to technical challenges, the introduction of new complications and, above all, skepticism about the oncologic effectiveness. Among several alternative approaches proposed, the minimally invasive video-assisted thyroidectomy and the robot-assisted transaxillary thyroidectomy became popular and obtained the favor of the scientific community. Moreover, the recent introduction of the trans-oral endoscopic thyroidectomy with vestibular approach, although the safety and the efficacy are still under discussion, deserves particular attention since it represents the only technique truly scarless and provides the best cometic result. The purpose of this article is to provide an overview of the current main alternative approaches for the treatment of thyroid cancer with particular focus on the oncological effectiveness of the procedures.
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Affiliation(s)
- Leonardo Rossi
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Sohail Bakkar
- Department of Surgery, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Paolo Miccoli
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
- *Correspondence: Paolo Miccoli,
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183
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Liu BR, Qiu XG, Li DL, Kong LJ, Ullah S, Li-Xia Z, Fu LJ. Flexible endoscopic transoral thyroidectomy: a pilot study in a porcine model (with video). Gastrointest Endosc 2021; 93:224-228. [PMID: 32858003 DOI: 10.1016/j.gie.2020.07.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Bing-Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; State Key Laboratory of Esophageal Cancer Prevention and Treatment, Zhengzhou University, Zhengzhou, China
| | - Xin-Guang Qiu
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - De-Linag Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ling-Jian Kong
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhao Li-Xia
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li-Jun Fu
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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184
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Tanavde VA, Razavi CR, Chen LW, Ranganath R, Tufano RP, Russell JO. Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach. Head Neck 2020; 43:1220-1228. [PMID: 33377212 DOI: 10.1002/hed.26581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Ved A Tanavde
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher R Razavi
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lena W Chen
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rohit Ranganath
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathon O Russell
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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185
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Dinç B, İlker Turan M, Rıza Gündüz U, Haluk Belen N. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Our outcomes from Turkey. Turk J Surg 2020; 36:340-346. [PMID: 33778392 PMCID: PMC7963300 DOI: 10.47717/turkjsurg.2020.4765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/25/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) was described in 2016 and had its case series published. This study aimed to present the largest TOETVA case series performed in Turkey. MATERIAL AND METHODS Data from 52 patients who underwent TOETVA procedure between February 2018 and October 2019 were analyzed retrospectively. Demographic data, duration of operation, blood loss, rate of conversion to open surgery, radiological findings, pathological outcomes, and complications were analyzed. RESULTS All patients were female. Mean duration of the operation was 192 ± 45 minutes, mean blood loss was 39 ± 47 mL, and the ratio of surgical site infection was 6% (3/50). In two (4%) patients, TOETVA was converted to open surgery. Temporary and permanent recurrent laryngeal nerve (RLN) paralysis was observed in 2 (4%) and 0 patients, respectively. Temporary and permanent hypoparathyroidism was observed in 10 (20%) and 0 patients, respectively. CONCLUSION TOETVA procedure is the most recently defined NOTES technique for endocrine surgery. In experienced healthcare centers, TOETVA can achieve outcomes similar and even better than the ones obtained with open surgery. The complication rates, durations of operation, surgical site infection, and blood loss parameters that we observed in our experience are similar to the ones reported in the literature.
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Affiliation(s)
- Bülent Dinç
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | | | - Umut Rıza Gündüz
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | - Nurhan Haluk Belen
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
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186
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Anatomic Variations From 120 Mental Nerve Dissections: Lessons for Transoral Thyroidectomy. J Surg Res 2020; 256:543-548. [DOI: 10.1016/j.jss.2020.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/20/2020] [Accepted: 07/11/2020] [Indexed: 01/19/2023]
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187
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Fu Y, Wu M, Fu J, Lin S, Song Z, Chen J, Yan W, Kuang P, Lin F, Luo Y, Lin E, Hong X, Wu G. TransOral Endoscopic Thyroidectomy via Submental and Vestibular Approach: A Preliminary Report. Front Surg 2020; 7:591522. [PMID: 33330608 PMCID: PMC7719628 DOI: 10.3389/fsurg.2020.591522] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/28/2020] [Indexed: 12/30/2022] Open
Abstract
Purpose: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA), with its excellent cosmetic effect, has become increasingly popular worldwide. Nonetheless, anatomic obstacles have limited its development to a certain extent. Here, we present our preliminary outcomes of transoral endoscopic thyroidectomy via submental and vestibular approach (TOETSMVA), which can overcome those limitations. Methods: From November 2019 to March 2020, we performed TOETSMVA in 21 consecutive patients with thyroid carcinoma at Zhongshan Hospital, Xiamen University. A 1.5-cm lateral incision was made at two fingers below the mandible; two 5-mm incisions were made in the vestibule near the first molars; TOETSMVA was completed through these incisions. The demographic data and surgical outcomes of the patients were retrospectively reviewed. Results: Twenty-one patients with a mean age of 37.5 ± 10.4 years were incorporated into this study. Fourteen patients had papillary thyroid micro-carcinomas, two had papillary thyroid carcinomas, and five had benign nodules. Eight patients had lymph node metastases. All surgeries were performed successfully without conversion to open thyroidectomy. The mean operation time was 138.8 ± 33.2 min; the average hospital stay was 3.3 ± 0.8 days. No patients developed cutaneous paralysis in the midline chin region. Transient recurrent laryngeal nerve paralysis was observed in one patient. There was no evidence of postoperative bleeding, infection, tetany, or other complications. Conclusion: TOETSMVA was shown to be a safe and advisable alternative for selected patients. This approach can overcome the limitations of TOETVA without sacrificing cosmetic results.
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Affiliation(s)
- Yilong Fu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Mengwei Wu
- Depatment of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinbo Fu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Suqiong Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Zhengfu Song
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jiyu Chen
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Wei Yan
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Penghao Kuang
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Fusheng Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Yezhe Luo
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Ende Lin
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xiaoquan Hong
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Guoyang Wu
- Department of General Surgery, Zhongshan Hospital, Xiamen University, Xiamen, China
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188
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Tae K. Complications of Transoral Thyroidectomy: Overview and Update. Clin Exp Otorhinolaryngol 2020; 14:169-178. [PMID: 33211953 PMCID: PMC8111399 DOI: 10.21053/ceo.2020.02110] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/15/2020] [Indexed: 11/22/2022] Open
Abstract
Transoral thyroidectomy via the vestibular approach has become popular worldwide, with advantages including less surgical morbidity, excellent postoperative cosmesis, and superior functional voice outcomes. Several studies have reported that the surgical outcomes of the transoral approach were comparable to those of the conventional transcervical approach in selected patients. However, unusual complications, such as CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been noted in transoral thyroidectomy. This paper aims to review and provide updated information on these complications and their management. Routine intraoperative neural monitoring is required to avoid laryngeal nerve palsy in the transoral approach. To prevent CO2 embolism, surgeons need to be careful not to injure the anterior jugular vein, and the CO2 insufflation pressure should be set as low as 4-6 mmHg. To avoid mental nerve injury, vestibular incisions should be placed in the safety zone, and dissection of the vestibular area and chin should be minimized. In conclusion, recognizing the possibility of complications and understanding their prevention and management are important for patient safety and the success of the transoral approach.
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Affiliation(s)
- Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
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189
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Russell JO, Razavi CR, Shaear M, Liu RH, Chen LW, Pace-Asciak P, Tanavde V, Tai KY, Ali K, Fondong A, Kim HY, Tufano RP. Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases. World J Surg 2020; 45:774-781. [PMID: 33205227 DOI: 10.1007/s00268-020-05874-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA). STUDY DESIGN Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m2, overweight 25-29.9 kg/m2, and obese ≥ 30 kg/m2 for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication. RESULTS Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively. CONCLUSION TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.
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Affiliation(s)
- Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA.
| | - Christopher R Razavi
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Mohammad Shaear
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Rui H Liu
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Lena W Chen
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Pia Pace-Asciak
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Ved Tanavde
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Katherine Y Tai
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Khalid Ali
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Akeweh Fondong
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, South Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
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190
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Chen YH, Kim HY, Anuwong A, Huang TS, Duh QY. Transoral robotic thyroidectomy versus transoral endoscopic thyroidectomy: a propensity-score-matched analysis of surgical outcomes. Surg Endosc 2020; 35:6179-6189. [DOI: 10.1007/s00464-020-08114-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/16/2020] [Indexed: 12/14/2022]
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191
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Souza KPD, Rahal A, Volpi EM, Falsarella PM, Hidal JT, Andreoni DM, Francisco-Neto MJ, Queiroz MRGD, Garcia RG. Hydrodissection and programmed stop sedation in 100 % of benign thyroid nodules treated with radiofrequency ablation. Eur J Radiol 2020; 133:109354. [PMID: 33099221 DOI: 10.1016/j.ejrad.2020.109354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE To describe our group experience in treatment of benign symptomatic thyroid nodules using radiofrequency ablation technique always associated to routine pre-procedure hydrodissection and under sedation with programmed stop. METHODS Dual-center, retrospective study conducted between April 2018 and January 2020. A total of 52 symptomatic benign thyroid nodules were treated in 34 patients with ultrasound-guided percutaneous radiofrequency ablation. The technique of choice was moving-shot technique and 100 % patients underwent pre-procedural hydrodissection with 5% glucose solution, plus conscious sedation with programmed stop during procedure. RESULTS Most nodules were solid or almost completely solid (n = 45, 88.3 % of nodules), followed by cystic composition (n = 4, 7.8 %) and mixed (n = 2, 3.9 %). As for location, most were on the right lobe (n = 29, 56.9 %), followed by the left lobe (n = 17, 33.3 %) and isthmus (n = 5, 9.8 %). The average volume of nodules before ablation was 18.2 ± 20.5 mL. Volumetric reduction rates at one, three, six and twelve months after ablation were 46.6 %, 64.5 %, 76.1 % and 88.8 %, respectively. No complications strictly related to procedure were reported. No more than 5 min were added to total time of ablative treatment considering routine hydrodissection and stop programmed sedation. CONCLUSIONS Minimally invasive therapies applied to thyroid allow the preservation of healthy thyroid parenchyma and provide a very effective volumetric reduction of symptomatic benign thyroid nodules. Hydrodissection with 5 % glucose solution, conscious sedation and patient stimulation with programmed stop during procedure may provide greater safety to procedure, and, in our experience, could be done routinely in all patients.
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Affiliation(s)
- Katia Pinheiro de Souza
- Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo, 05652-000 Brazil.
| | - Antonio Rahal
- Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo, 05652-000 Brazil; Department of Radiology, Hospital Israelita Albert Einstein. São Paulo, 05652-000 Brazil.
| | - Erivelto Martinho Volpi
- Head and Neck Surgery, Amato - Instituto de Medicina Avançada. São Paulo, 01431-001 Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, 01323-020 Brazil.
| | - Priscila Mina Falsarella
- Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo, 05652-000 Brazil.
| | - Jairo Tabacow Hidal
- Department of Endocrinology, Hospital Israelita Albert Einstein. São Paulo, 05652-000 Brazil.
| | | | - Miguel Jose Francisco-Neto
- Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo, 05652-000 Brazil.
| | - Marcos Roberto Gomes de Queiroz
- Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo, 05652-000 Brazil; Department of Radiology, Hospital Israelita Albert Einstein. São Paulo, 05652-000 Brazil.
| | - Rodrigo Gobbo Garcia
- Department of Radiology, Hospital Israelita Albert Einstein. São Paulo, 05652-000 Brazil.
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192
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Moreno Llorente P, A Gonzales Laguado E, Alberich Prats M, Francos Martínez JM, García Barrasa A. Surgical approaches to thyroid. Cir Esp 2020; 99:267-275. [PMID: 33069356 DOI: 10.1016/j.ciresp.2020.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 01/03/2023]
Abstract
Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIXth century, has become the "gold standard". It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed "new approaches" to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these "new approaches" have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España.
| | - Erick A Gonzales Laguado
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
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193
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Wang Y, Zhou S, Liu X, Rui S, Li Z, Zhu J, Wei T. Transoral endoscopic thyroidectomy vestibular approach vs conventional open thyroidectomy: Meta‐analysis. Head Neck 2020; 43:345-353. [PMID: 33043571 DOI: 10.1002/hed.26486] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/24/2020] [Accepted: 09/21/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yichao Wang
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Shengliang Zhou
- West China School of Medicine, West China Hospital, Sichuan University Chengdu China
| | - Xueting Liu
- Department of Evidence‐Based Medicine and Clinical Epidemiology West China Hospital, Sichuan University Chengdu China
| | - Shu Rui
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Zhihui Li
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Jingqiang Zhu
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Tao Wei
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
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194
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Liu Z, Li Z, Peng X, Zhou B, Lv C, Yi L, Li H, Peng W, Wang Z, Li J. Transoral endoscopic thyroidectomy vestibular approach in a patient with Class III goitre (operative steps and video). Gland Surg 2020; 9:1605-1613. [PMID: 33224838 DOI: 10.21037/gs-20-147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has recently become a hot research topic due to the advantage of leaving no scar, but, according to most centers, its indication is restricted to the size of thyroid gland. Here we report a case of a female patient with Class III goitre who successfully underwent TOETVA (video attached). A 53-year-old woman with a previous history of chest keloidosis presented with a history of neck swelling for 3 years and was diagnosed as Hashimoto's thyroiditis with no nodules. The patient insisted that she undergo a TOETVA procedure in our hospital. Compared to the traditional TOETVA, several techniques were applied in this operation to ensure the resection and removal of the thyroid gland: with the dissection of the mental nerve and using the lateral approach to the thyroid gland. The total volume of thyroid gland was 205 mL. The operating time was 195 min. No complications were incurred. The numbness of the lip and chin was measured by the "two-points discrimination" method with several aspects (touch, pain, temperature) at different times to evaluate mental nerve injury. She felt the numbness during the first operative day but it was almost completely relieved in the third postoperative month. To our knowledge, this is the largest thyroid gland reported removed with TOETVA procedure. By carefully designing the operative steps, it is feasible to use the transoral approach in patients who have a benign thyroid disease with a Class III goitre if the patient strongly desires that operation.
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Affiliation(s)
- Zeyang Liu
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Zan Li
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Xiaowei Peng
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Bo Zhou
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Chunliu Lv
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Liang Yi
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Hui Li
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Wen Peng
- Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Zhiyuan Wang
- Department of Ultrasound, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
| | - Jigang Li
- Department of Pathology, Hunan Cancer Hospital/the Affiliated Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
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195
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Khafif A, Cohen O, Masalha M, Yaish I, Hod K, Assadi N. Adoption of the transoral endoscopic vestibular approach by head and neck surgeons without prior laparoscopic/robotic experience. Head Neck 2020; 43:496-504. [PMID: 33006207 DOI: 10.1002/hed.26503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/12/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Avi Khafif
- ARM - Center for Otolaryngology - Head and Neck Surgery and Oncology, Assuta Medical Center, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel
| | - Oded Cohen
- ARM - Center for Otolaryngology - Head and Neck Surgery and Oncology, Assuta Medical Center, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel
| | - Muhamed Masalha
- ARM - Center for Otolaryngology - Head and Neck Surgery and Oncology, Assuta Medical Center, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel.,Department of Otolaryngology, Head and Neck Surgery, Emek Medical Center, Technion University, Haifa, Israel
| | - Iris Yaish
- ARM - Center for Otolaryngology - Head and Neck Surgery and Oncology, Assuta Medical Center, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel.,Endocrine Institute, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Hod
- Department of Academy and Research, Assuta Medical Centers, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel
| | - Niddal Assadi
- ARM - Center for Otolaryngology - Head and Neck Surgery and Oncology, Assuta Medical Center, Tel Aviv, Affiliated with Ben Gurion University, Beer Sheva, Israel
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196
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Turan MI, Celik M, Ertürk MS. Indocyanine green fluorescence angiography-guided transoral endoscopic thyroidectomy and parathyroidectomy: First clinical report. Photodiagnosis Photodyn Ther 2020; 32:102028. [PMID: 32979545 DOI: 10.1016/j.pdpdt.2020.102028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/05/2020] [Accepted: 09/14/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Indocyanine green fluorescence (ICG) angiography has been used for many purposes including as part of a focused parathyroidectomy technique. Concomitant fluorescence of thyroid tissue may cause challenges defining parathyroid tissue during surgery, since ICG is not a selective fluorescent agent. On the other hand, cosmesis is still a big problem for patients due to the visible neck scars produced by the standard surgical technique. In this study, we described a novel technique to solve both these handicaps. MATERIALS AND METHODS Seven patients who underwent ICG fluorescence angiography-guided transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach between February 2018 and July 2019 were included. Serum parathyroid hormone (PTH) levels were measured intraoperatively and on postoperative day 1. Fluorescent images were confirmed with intraoperative quick-PTH levels. RESULTS All operations were done successfully without conversion to open surgery. Intense and isolated parathyroid fluorescent images were achieved in all operations. All patients had a 50 % decrease between the baseline and final quick-PTH levels and the final quick-PTH levels were in the normal range in all. One of 7 patients had epistaxis due to nasotracheal intubation. One of 7 patients had seroma on post-operative day 5. None of patients had mental nerve injury, permanent hypocalcemia and temporary or permanent recurrent laryngeal nerve injury. CONCLUSION ICG-guided transoral endoscopic thyroid and parathyroid surgery can be used in select patients to increase operative success in focused parathyroidectomy with excellent cosmetic outcome also noted.
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Affiliation(s)
| | - Mehmet Celik
- Trakya University Medical Faculty, Department of Endocrinology and Metabolism, Edirne, Turkey
| | - Mehmet Sercan Ertürk
- University of Health Sciences Antalya Training and Research Hospital, Department of Endocrinology and Metabolism, Antalya, Turkey
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197
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Tartaglia F, Giuliani A, Sorrenti S, Ulisse S. Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews. J Minim Access Surg 2020; 16:315-322. [PMID: 32978350 PMCID: PMC7597888 DOI: 10.4103/jmas.jmas_123_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure. Materials and Methods: PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test. Results: The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups. Conclusions: TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.
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Affiliation(s)
| | - Alessandro Giuliani
- Department of Environment and Health, Superior Institute of Health, Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
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198
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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Thyroiditis. Surg Laparosc Endosc Percutan Tech 2020; 31:188-192. [PMID: 32956332 DOI: 10.1097/sle.0000000000000864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parenchymal fibrosis, which develops in the case of thyroiditis, makes thyroidectomy difficult and increases complication rates. Similar concerns exist within minimally invasive thyroid surgery. This study aimed to evaluate the outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) procedure in patients with thyroiditis. MATERIALS AND METHODS The data of 56 patients who underwent TOETVA between February 2018 and March 2020 were analyzed retrospectively. The patients were classified as those who had lymphocytic or Hashimoto thyroiditis (group T) and those who did not (group NT) in the postoperative pathology results. Results were evaluated in terms of intraoperative, postoperative findings, and complications. RESULTS All patients were female individuals with a median age of 43 (21-76). There were 21 (37%) patients in group T and 35 (63%) patients in group NT. Mean operation times were 174.2±37.4 and 201.4±45.6 minutes in groups T and NT (P=0.025), respectively, and were statistically shorter in group T. Blood loss was 37.9±44.5 and 34.6±46.8 mL (P=0.811) in groups T and NT, respectively. Transient recurrent laryngeal nerve palsy occurred in 1 patient (5%) in group T, 1 (3%) in group NT (P=0.712), and transient hypoparathyroidism occurred in 3 patients (14%) in group T and in 7 (20%) in group NT. There was no difference in terms of intraoperative and postoperative complications. CONCLUSION Although thyroiditis is a condition that complicates thyroidectomy, TOETVA can be applied with similar complication rates in patients with thyroiditis.
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199
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Transoral Thyroidectomy: Advantages and Disadvantages. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2020; 23:112-113. [PMID: 35602384 PMCID: PMC8985635 DOI: 10.7602/jmis.2020.23.3.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/22/2022]
Abstract
To date, many remote-access thyroid surgery techniques using endoscopic or robotic instruments have been developed. Transoral thyroidectomy has attracted great attention as a scarless thyroidectomy and is performed worldwide. Each surgical method has its advantages and disadvantages: selecting the optimal surgical method according to each patient's condition and preferences will possibly result in obtaining the best results and achieving patient satisfaction while minimizing complications after surgery.
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200
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Initial Experience of Endoscopic Thyroidectomy Using Bilateral Axillary Breast and Transoral Vestibular Approach in Georgia. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2020; 23:126-133. [PMID: 35602379 PMCID: PMC8985649 DOI: 10.7602/jmis.2020.23.3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/09/2022]
Abstract
Purpose Remote access thyroid surgery using a bilateral axillary breast approach (BABA) or a transoral endoscopic thyroidectomy vestibular approach (TOETVA) are increasingly performed worldwide. In the Caucasus, these methods were first applied in the Republic of Georgia. This study compares these two methods of endoscopic thyroid surgery performed on patients in a tertiary hospital in Tbilisi, Georgia. Methods Between December 2015 and January 2018, 41 patients underwent endoscopic thyroid surgery at the Aversi Clinic, including 32 who underwent BABA endoscopic thyroidectomy for benign nodules and nine who underwent TOETVA for thyroid cancers. Patients’ medical records were retrospectively reviewed. Results Tumors were significantly larger (2.38±0.38 cm versus 1.70±0.31 cm, p value <0.001), operation time was significantly longer (177.66±21.02 min versus 116.66±5.59 min, p value <0.001), and blood loss was significantly greater (149.07±28.10 ml versus 102.22±8.33 ml, p value <0.001) in patients who underwent BABA than TOETVA. There were no significant differences in postoperative complications between the two groups. Conclusion Remote access thyroid surgery, either BABA or TOETVA, was successfully started, without harmful complications, at the Aversi Clinic in Tbilisi, Georgia. BABA is suitable for large sized benign nodules and TOETVA for thyroid cancers with central lymph node dissection.
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