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

Drainless thyroid surgeries including goiter or central neck dissection: a case-control study

BACKGROUND

Despite ample of evidence regarding feasibility of simple drainless thyroid surgeries, the evidence of feasibility of such procedures in goiters and central neck dissections remains limited.

METHODS

Patients undergoing total thyroidectomy (TT) between January 2017 and July 2022 were included. The study included two study groups: drainless TT with central neck dissection (CND) and drainless TT due to goiter, which were compared to two controls: non-goiter drainless TT and drained TT for goiter or with CND. Main outcome was post-operative seroma rate.

RESULTS

156 patients met the inclusion criteria for each of the group. No significant differences between groups were found for permanent hypocalcemia, and other complications. Post-operative seroma was found in nine patients (5.8%), all from study groups. No significant differences between groups were found for local infections, aspirations, post-discharge drain insertion.

CONCLUSIONS

Complex drainless thyroid surgeries, including goiter and CND, are feasible and do not seem to significantly increase rate of post-operative seromas or infections.

Scarless Neck Feminization by Transoral Endoscopic Vestibular Approach Chondrolaryngoplasty: A Prospective Cohort

OBJECTIVE

Chondrolaryngoplasty (laryngeal-prominence reduction) is a gender affirmation surgery for transgender women, or for cisgender people desiring an esthetic correction. Up until recently, chondrolaryngoplasty required a visible neck scar. The transoral endoscopic vestibular approach (TOEVA) is gaining widespread use as a scarless alternative for thyroid/parathyroid surgeries. This study aims to describe the feasibility, safety, and outcomes of TOEVA-chondrolaryngoplasty, based on the first-ever performed cases.

STUDY DESIGN

A prospective cohort.

SETTING

An academic referral center.

METHODS

Adult patients interested in chondrolaryngoplasty underwent scarless TOEVA-chondrolaryngoplasty between 2019 and 2022, according to the described protocol. Video stroboscopy was recorded pre-and postoperatively. Surgical data, adverse events, and complications were recorded. Patients' satisfaction was measured using an outcome instrument for esthetic chondrolaryngoplasty.

RESULTS

Twelve patients (10 transgender women, a cisgender man, and a woman) were included. The mean age was 26.7 ± 6.5 years, ranging from 19 to 37. The average operative time was 3:01 ± 0:51 hours. The thyroid cartilage and laryngeal prominence were easily and safely approached and reduced, with no adverse events or major complications. All patients were discharged on postoperative day 1. A single patient had a temporary mental nerve hypoesthesia that resolved spontaneously. Otherwise, no other complications were encountered. Vocal folds' function remained unchanged in all patients. Patients were very much to completely satisfied with the surgical results as measured by the outcome instrument; median (interquartile range), 25 (21-27.75).

CONCLUSION

In this first reported cohort of scarless TOEVA-chondrolaryngoplasty, this approach was proven to be safe and feasible, with no adverse events or major complications, and with high patient satisfaction.

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

Background

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level 4.

OUP accepted manuscript

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary hyperparathyroidism: Disease of diverse genetic, symptomatic, and biochemical phenotypes

Genetic, symptomatic, and biochemical heterogeneity of patients with primary hyperparathyroidism (PHPT) has become apparent in recent years. An in-depth, evidence-based review of the phenotypes of PHPT was conducted. This review was intended to provide the resulting information to surgeons who operate on patients with hyperparathyroidism. This review revealed that the once relatively clear distinction between familial and sporadic PHPT has become more challenging by the finding of various germline mutations in patients with seemingly sporadic PHPT. On the one hand, the genetic and clinical characteristics of some syndromes in which PHPT is an important component are now better understood. On the other hand, knowledge is emerging about novel syndromes, such as the rare multiple endocrine neoplasia type IV (MEN4), in which PHPT occurs frequently. It also revealed that, currently, the classical array of symptoms of PHPT is seen rarely upon initial presentation for evaluation. More common are nonspecific, nonclassical symptoms and signs of PHPT. In areas of the world where serum calcium levels are checked routinely, most patients today are "asymptomatic" and they are diagnosed after an incidental finding of hypercalcemia; however, some of them have subclinical involvement of bones and kidneys, which is demonstrated on radiographs, ultrasound, and modern imaging techniques. Last, the review points out that there are three distinct biochemical phenotypes of PHPT. The classical phenotype in which calcium and parathyroid hormone levels are both elevated, and other disease presentations in which the serum levels of calcium or intact parathyroid hormone are normal. Today several, distinct phenotypes of the disease can be identified, and they have implications in the diagnostic evaluation and treatment of patients, as well as possible screening of relatives.

Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series

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.