Starting a Transoral Thyroid and Parathyroid Surgery Program

Application and advantages of a joystick-controlled robotic scope holder in transoral endoscopic thyroidectomy vestibular approach: a comparative study

Transoral endoscopic thyroidectomy has gained popularity due to its scarless nature, but the use of a handheld endoscope can lead to an unstable visual field. Soloassist II, a robotic scope holder, enables precise control using a joystick, ensuring stable vision. This study aims to evaluate the application and the advantages of Soloassist II in transoral thyroidectomy. Patients who underwent transoral thyroidectomy with Soloassist II or human assistance between June 2019 and May 2021 were reviewed. Patient demographics and surgical outcomes were compared. The ergonomic stress of the assistant in both groups was also measured. A total of 100 consecutive patients were included: 32 were assisted by Soloassist II and 68 by humans. The Soloassist II group demonstrated significantly shorter operation times (median [IQR]) (165 [149,179] vs. 181 [165,204] min, P = 0.004) in unilateral lobectomy and less blood loss (median [IQR]) (2 [2,2] vs. 2 [2,3] ml, P = 0.002) than the human-assisted group. Postoperative course and complication rates were similar. The musculoskeletal pain of the assistant was significantly higher and involved more areas in the human-assisted group. The utilization of Soloassist II in transoral endoscopic thyroidectomy is easy to set up and leads to shorter operation times, reduced blood loss, and decreased musculoskeletal pain compared to human handheld endoscope. These findings support the potential of Soloassist II in improving surgical outcomes and minimizing physical strain during transoral thyroidectomy.

Scarless Surgery: Clinical Indications for Transoral Endocrine Surgery and Implications for Pathologists

Transoral endocrine surgery (TES) is a scarless approach to thyroidectomy and parathyroidectomy for well-selected patients. Criteria for the TES approach to thyroidectomy include thyroid diameter less than or equal to 10 cm, benign nodule less than or equal to 6 cm, or confirmed or suspected malignant nodule less than or equal to 2 cm. Although fragmentation of surgical specimens has been reported in TES, additional studies are needed to evaluate the implications of TES on pathologic examination.

Modified Larssen solution (MLS)-fixed cadaver model for transoral endoscopic thyroidectomy vestibular approach (TOETVA) education: a feasibility study

BACKGROUND

Training formats for transoral endoscopic thyroidectomy vestibular approach (TOETVA) are limited. Our aim was to create and investigate a TOETVA training model for general and ENT surgeons.

METHODS

A total of 15 modified Larssen solution (MLS) human cadavers were used in the study. A day duration TOETVA human cadaver workshops were offered in two years consecutive. Post-training verbal and online questionnaires were applied to all trainers to evaluate course structure and program, organoleptic characteristics of MLS-fixed human cadavers, and TOETVA training effectiveness. Cost assessment is included in the study.

RESULTS

Ninety-eight participants, i.e., 14 trainers and 84 hands-on (HO) and observer (OB) trainees, attended the workshops, completed the tasks assigned, and fulfilled the questionnaires. Implementation of all steps of TOETVA was approved positively by 89.8% of all participants, 94.4% of HO, and 83.3% of OB trainees. Regarding human cadaver and teaching quality, 10.8 ± 0.8 (10-12) human cadavers were "practical" by 13.2 (94.5%) of the trainers, and by 33.3 (92.5%) of the trainees for all steps of TOETVA. The cadavers were stored for 4.53 years and used 6.27 times repeatedly for endoscopic workshops and research studies. TOETVA workshop cost with repeatable use of MLS-fixed human cadaver is half of other performed TOETVA workshops.

CONCLUSIONS

A TOETVA human cadaver workshop model has not been reported yet. Our findings suggest the feasibility of MLS-fixed human cadaver model for training of TOETVA, preserve the organoleptic properties necessary for the implementation of surgical steps, and reduce the cost.

Scarless total thyroidectomy via transoral endoscopic vestibular approach: initial case series in a developing Asian country

Conventional open thyroidectomy may leave a visible scar postoperatively and can lead to impaired quality of life. Since 2016, the transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has gained popularity due to being a true 'scarless' procedure. However, minimally invasive thyroidectomy has not been widely adopted in the Philippines yet. From August 2019 to December 2019, nine patients (mean thyroid nodule size of 3.1 cm) underwent TOETVA with one open conversion due to adherent papillary cancer. Majority had a blood loss of <100 ml, whereas mean operative time was 149.8 ± 20.5 minutes. Five patients developed hypocalcemia (three transient), whereas two patients reported transient lower lip numbness. TOETVA is a safe and feasible novel procedure for both benign and malignant thyroid diseases. Care must be taken in selecting patients who opt for TOETVA, and that surgeons should reassess their limitations before implementing this technique in their surgical practice.

Transoral endoscopic vestibular approach for thyroidectomy and parathyroidectomy - From promise to practice

OBJECTIVES

To describe the evolution and recent series on transoral endoscopic vestibular approach thyroidectomy and parathyroidectomy (TOET/PVA).

DATA SOURCES

PubMed, Google Scholar.

REVIEW METHODS

Review of the available English literature.

RESULTS

TOET/PVA may offer several advantages over other remote access thyroidectomy approaches and has been adopted by many centers worldwide with excellent success rates. Indications include benign disease and early thyroid cancer patients. Complication rate is comparable to the trans-cervical approach. The suggested framework has been validated in recent studies and its feasibility confirmed.

CONCLUSION

TOET/PVA has now been used to treat thousands of patients worldwide due to low cost, short learning curve and excellent cosmetic outcomes. Further studies will be necessary to demonstrate oncologic non-inferiority and also the true value that is added by the approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Public perceptions of transoral endocrine surgery and their influence on choice of operative approach

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

OBJECTIVE

We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches.

STUDY DESIGN

Retrospective analysis.

SETTING

The National Cancer Database (NCDB) was queried between 2010 and 2016.

SUBJECTS AND METHODS

National cohort of patients. Descriptive statistics were performed using χ² test, Mann-Whitney U test, t test and analysis of variance. To investigate complication rates, patient matching was performed with subsequent analysis using simple and multivariable logistic regressions.

RESULTS

We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures (P = .025). Robotic thyroid surgery was associated with increased risk of positive margins (P = .046), while endoscopic thyroid surgery was associated with a higher rate of unplanned hospital readmission (OR, 1.55; 95% CI, 1.09-2.22), longer inpatient stays (OR, 1.55; 95% CI, 1.19-2.02), and higher 90-day postoperative mortality (OR, 4.45; 95% CI, 1.58-12.6).

CONCLUSION

Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open surgery.

The role of surgeon-performed ultrasound in transoral endoscopic thyroidectomy vestibular approach (TOETVA)

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a recently described surgical technique where the thyroid and central neck can be accessed without a cutaneous incision. To date nearly 700 cases have been described within the English literature demonstrating the feasibility, safety, and efficacy of the technique. As more institutions begin to adopt the surgical approach, it is important that surgeons pay close attention to appropriate patient selection and surgical optimization to prevent experience-related complications. A valuable tool to facilitate these considerations is the utilization of surgeon-performed ultrasonography (US). While the merits of surgeon-performed US are well-documented within head & neck endocrine surgery as a whole, its value may be of even greater importance when implementing a novel surgical technique such as TOETVA. Here we highlight and summarize the role of surgeon-performed US within head & neck endocrine surgery, focusing on how it may influence patient selection and surgical planning with TOETVA.

An easier option for "invisible scar" thyroidectomy: hybrid-transoral endoscopic thyroidectomy submental access (H-TOETSA)-experience on twenty-two consecutive patients

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is currently the only "cervical invisible scar" procedure with a surgical access close to the thyroid area. The aim of this technical note was to describe a hybrid technique with a vestibular and a submental access as applied in 22 consecutive patients undergoing lobectomy.

METHODS

Out of 502 thyroidectomies performed from February 1, 2018 to May 31, 2019, feasibility of Hybrid-TransOral Endoscopic Thyroidectomy Submental Access (H-TOETSA) was assessed in 22 patients meeting the inclusion criteria. Differently from TOETVA, a central trocar (≤ 10 mm) for the camera was placed on the natural skin depression immediately under the chin. A left 3 mm and a right 5 mm (or 3 mm if a 3 mm energy device was available) trocars were placed in the vestibulum (as in TOETVA).

RESULTS

Operative time was 74.32 (± 34.16) min. Two temporary recurrent nerve paralysis and three lip/chin dysesthesia were observed. In two patients, an additional 3 cm horizontal access was performed 2 cm above the clavicle to control a persistent bleeding. Patients complained pain only in the first postoperative hours. All patients perceived excellent cosmetic results even at postoperative day 1.

CONCLUSION

H-TOETSA was feasible and resulted to have some technical and clinical advantages maintaining the purpose to avoid a visible scar on the neck.

Simulations and simulators in head and neck endocrine surgery

Simulations and simulators have become an increasingly important tool in trainee education across many surgical disciplines, particularly for robotic and minimally invasive procedures. Thyroidectomy and parathyroidectomy are common procedures performed across multiple surgical disciplines, however, there is limited literature regarding training models/simulators for these operations. This is despite the advent and growing popularity of remote-access thyroidectomy techniques, where simulators may provide significant value in trainee education and safe implementation. Here we review the literature regarding available simulations/simulators in head and neck endocrine surgery for both conventional transcervical approaches and newer remote-access thyroidectomy techniques.