Transoral Endoscopic Thyroidectomy Vestibular Approach: An Initial Experience in Vietnam

Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: A prospective cohort study

INTRODUCTION

Thyroid tumours are a common condition and open surgery is a conventional method for treating benign thyroid tumours when surgery is indicated. In this study, we evaluate the outcomes of benign thyroid tumour treatment using transoral endoscopic thyroidectomy via vestibular approach (TOETVA) and compare the results with those of conventional open thyroidectomy (COT).

PATIENTS AND METHODS

We conducted a prospective cohort study between 100 patients who underwent TOETVA and 100 who underwent COT surgery for benign diseases from June 2018 to December 2021 in our hospital. Outcomes between the two groups, including post-operative complications, operative time and length of stay, were compared.

RESULTS

The surgical time in the TOETVA group was significantly longer than in the COT group. The operative time of lobectomy in the TOETVA and COT groups was 77.5 ± 13.3 and 51.5 ± 4.2 min, respectively, with a P < 0.001. The operative time of total thyroidectomy in the TOETVA and COT groups was 108.1 ± 7.0 and 65.0 ± 4.1 min, respectively, with a P < 0.001. There was no difference in post-operative length of stay between the two groups. In TOETVA group, there were no patients who converted to open surgery. Amongst all 200 patients in the study, there were no cases of post-operative bleeding. The transient hypoparathyroidism rate after surgery in the TOETVA and COT groups was 3% and 2%, respectively, with no statistically significant difference ( P = 0.651). Similarly, the transient recurrent laryngeal nerve injury rate showed no difference between the two groups, with rates of 5% and 4% in the TOETVA and COT groups, respectively ( P = 0.733). There were no cases of post-operative infection in either group in our study. At 3 months postoperatively, the cosmetic satisfaction were significantly higher in the endoscopic groups than in the conventional group ( P < 0.001).

CONCLUSIONS

TOETVA is a safe and effective method, with a low complication rate and optimal aesthetic results compared to traditional surgery to treat benign thyroid tumours.

Transoral endoscopic thyroidectomy vestibular approach as a novel technique for pediatric populations: Results from a single surgeon

Background

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasingly being adopted worldwide because of its many advantages. However, there are few reports on the effectiveness and safety of TOETVA in children. In this study, we report the results of the application of TOETVA on 27 pediatric patients in Vietnam. To the best of our knowledge, this is also the largest sample size of the TOETVA technique performed by a single surgeon on pediatric patients worldwide. Patients and methods: From June 2020 to February 2022, we performed TOETVA on 27 pediatric patients (≤ 18 years old). The outcomes of the procedure were retrospectively reviewed.

Results

Our study was conducted on 27 pediatric patients, of whom 24 were female (88.9%). The mean age was 16.3 ± 2 (range 10-18). Fifteen patients had benign thyroid nodules with a mean nodule size of 31.6 ± 7.1 (range 20-50mm), and 12 patients had papillary thyroid carcinoma with a mean nodule size of 10.2 ± 5.6 (range 4-19mm). All 27 patients underwent successful TOETVA without any conversion to open surgery. The 15 patients with benign thyroid nodules had lobectomies with a mean operative time of 83.3 ± 10.5 (range 60-105 minutes). Among the 12 patients diagnosed with thyroid cancer, ten had a lobectomy, isthmusectomy, and central neck dissection, with a mean operative time of 89.8 ± 5.7 (range 80-100 minutes). The other two underwent total thyroidectomy with central lymph node dissection with a mean operative time of 132.5 minutes. The mean hospital stay was 4.7 ± 0.9 (range 3-7 days). No patient had permanent complications, such as hypocalcemia, recurrent laryngeal nerve injury, or mental nerve injury. The rates of temporary recurrent laryngeal nerve injury and mental nerve injury were 3.7% and 11.1% respectively.

Conclusions

TOETVA may be a feasible and safe surgical method for children with thyroid disease. However, we recommend that only high-volume thyroid surgeons with experience in TOETVA should perform TOETVA on the pediatric population.

Three-port transoral robotic thyroidectomy without axillary incision: A preliminary report on a case series from Vietnam

BACKGROUND

Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. Here, we present our preliminary data from the initial 5 consecutive patients to explore the feasibility of three-port TORT without axillary incision.

METHODS

From August 2022 to December 2022, we performed TORT using three ports via the da Vinci Xi system with three robotic arms.

RESULTS

All 5 patients had cT1aN0M0 papillary thyroid carcinomas with a mean tumour size of 6 mm. All patients underwent lobectomy with ipsilateral central neck dissection. The mean surgical time was 170 ± 15,8 min; the average length of hospital stay is 4.2 days. The number of retrieved central lymph nodes was 4.2 ± 0.8. All patients were discharged uneventfully without complications and completely satisfied with the cosmetic results.

CONCLUSIONS

TORT is feasible and safe when performed on carefully selected patients by experienced surgeons.

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

INTRODUCTION

Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars.

METHODS

Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021.

RESULTS

Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity.

CONCLUSTIONS

Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

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

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

OUP accepted manuscript

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bilateral Central Neck Dissection via Transoral Approach in Papillary Thyroid Carcinoma

BACKGROUND

The transoral endoscopic vestibular approach (TOETVA) for thyroidectomy is gaining popularity (Russell et al. in Thyroid 28(7):825-829, 2018; Le et al. in Surg Laparosc Endosc Percutan Tech 30(3):209-213, 2020; Liao et al. in Laryngoscope 130(6):1603-1608, 2020). TOETVA has been utilized successfully in performing thyroidectomy, parathyroidectomy, and neck dissection, via both endoscopic and robotic techniques (Razavi et al. in Head Neck 40(10):2246-2253, 2018; Otolaryngol Head Neck Surg 159(4):625-629, 2018; Ngo et al. in J ENT, 2020. https://doi.org/10.1177/0145561320943358 ; Ann Surg Oncol 28(5):2766, 2021). In this video, we show bilateral central neck dissection via transoral approach in papillary thyroid carcinoma.

PATIENT AND METHODS

A 37-year-old female with no significant medical history was diagnosed pT3bN0M0 intraoperatively with the tumor having slightly invaded the strap muscle. Thus, we decided to perform total thyroidectomy with bilateral central neck dissection via transoral approach.

METHODS

Prelaryngeal dissection: in the prelaryngeal compartment, soft tissue containing these lymph nodes was intimately associated with the pyramidal lobe. Right paratracheal dissection: fibrofatty tissue was dissected off the prevertebral fascia and the trachea with preservation of right parathyroid glands. Pretracheal lymph nodes were removed with paratracheal dissection. Left paratracheal dissection: the lymphatic tissue was then dissected off the prevertebral and esophageal musculature and the trachea after identifying the left parathyroid glands. Finally, bilateral central neck dissection was finished with preservation of the nerve and parathyroid glands.

RESULTS

The operation was completed successfully without conversion to open surgery. The operative time for central neck dissection was 20 min. There were nine harvested lymph nodes in the central compartments, while there were two metastatic lymph nodes of papillary thyroid carcinoma with 3 × 3 mm maximal dimension. There were no major postoperative complications.

CONCLUSION

Central neck dissection via TOETVA is a safe and feasible method in selected patients.

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

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

Transoral Endoscopic Modified Radical Neck Dissection for Papillary Thyroid Carcinoma

BACKGROUND

Recently, transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) has become popular worldwide.1-3 After controlling for the technique, the authors used the transoral endoscopic approach to modified radical neck dissection (MRND) for papillary thyroid carcinoma with clinically positive lymph nodes in the lateral compartments. To the best of their knowledge, the authors report the first case of TOETVA for MRND.

PATIENT

A 27-year-old woman had a diagnosis of cT1aN1bM0 right papillary thyroid carcinoma (metastatic to a small right level 4 lymph node). Therefore, total thyroidectomy, bilateral central neck dissection, and MRND of right levels 2, 3, and 4 were performed via the transoral endoscopic approach.

METHODS

Total thyroidectomy and bilateral central lymph node dissections were performed based on the three-trocar Anuwong technique.4 Then, the fourth incision was made near the sixth teeth in the right oral vestibular area for insertion of the fourth 5-mm trocar, which was used to expose the lateral lymph compartment and to perform right MRND easily.

RESULTS

The operation was completed successfully without conversion to open surgery. The total operative time was 170 min, and the operating time for MRND was 55 min. The numbers of harvested lymph nodes were 7 and 8 in the central and right lateral compartments, respectively. The numbers of metastatic lymph nodes were 2 and 1 in the central and lateral compartments, respectively. No major postoperative complications occurred.

CONCLUSION

Transoral endoscopic MRND of levels 2, 3, and 4 can be feasible and safe for highly selected patients.

Case Report: Transoral Endoscopic Thyroidectomy via Vestibular Approach in Pediatric Thyroid Cancer

Background: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is a new technique that has become more popular worldwide because of its many advantages. However, this novel approach for thyroid cancer treatment in children is highly challenging, even for high-volume surgeons. In our study, we report our experiences with TOETVA for pediatric patients with thyroid cancer. Patients and Methods: This study included four pediatric patients who underwent TOETVA performed by a single surgeon between June and December 2020. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated. Results: Four patients successfully underwent TOETVA with no complications. All patients were girls, aged from 13 to 18. Three patients underwent lobectomy and isthmusectomy, plus prophylactic unilateral central neck dissection. One patient had a total thyroidectomy, plus prophylactic bilateral central neck dissection. The mean operative time was 85 min for the lobectomy and 120 min for total thyroidectomy plus central neck dissection. The median hospital stay was 4.1 days. No drains were used. The histological examination showed four cases of malignant disease (papillary thyroid carcinoma). The mean number of harvested lymph nodes was 4.2 (ranged 3 to 8). Conclusion: In the hands of a high-volume surgeon, TOETVA is a novel, feasible, and safe approach for treating selected pediatric patients with thyroid cancer.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Thyroiditis

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.

Transoral Endoscopic Thyroidectomy via Vestibular Approach With 4 Trocars: A New Technique

OBJECTIVES

The objective of this study was to report the feasibility and safety of a novel 4-trocar approach for transoral endoscopic thyroidectomy via the vestibular.

METHODS

In this study, we first used 4 trocars via vestibular area to perform transoral endoscopic thyroidectomy. We reported the safety and surgical feasibility of transoral endoscopic thyroidectomy using a 4-trocar technique in our institute from February 1, 2020, to May 10, 2020.

RESULTS

Transoral endoscopic thyroidectomy via the vestibular approach using 4 trocars was carried out in 5 patients. No complications such as bleeding, mental nerve injury, recurrent laryngeal nerve injury, or hypoparathyroidism were reported. All patients were completely satisfied with the cosmetic results.

CONCLUSIONS

Transoral endoscopic thyroidectomy with 4 trocars via vestibular approach is an effective and feasible method. Markedly, this technique can assist surgeons to expose and preserve both parathyroid glands and recurrent laryngeal nerve easily when performing transoral endoscopic thyroidectomy.

Novel Approaches for Treating Autonomously Functioning Thyroid Nodules

Benign thyroid nodules are exceedingly common in the adult population. Only a small percentage of nodules are toxic or autonomously functioning thyroid nodules (AFTNs). The options clinicians have for treating the symptoms of hyperthyroidism include anti-thyroidal medications, radioactive iodine, or surgery. Depending on the patient population treated, these options may not be suitable or have inherent risks that are undesirable to the patient. On the other hand, untreated hyperthyroidism can lead to osteoporosis, atrial fibrillation, emotional lability, and neurological consequences. Thus, we present a review of two novel safe and effective approaches for treating AFTN; one surgical (transoral endoscopic thyroid surgery) and one non-surgical (radiofrequency ablation), as a means for expanding our treatment armamentarium.