Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update

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.

[Indications and technique for transoral thyroid gland and parathyroid gland surgery]

The conventional Kocher collar incision is the standard access to the thyroid and parathyroid glands. Although the incision length has been significantly shortened in recent years with this approach, there is increasing interest among patients in a surgical technique without visible scars in the décolleté. Transoral endoscopic thyroid gland surgery via the vestibular approach (TOETVA) is a modern technique that can be learned relatively quickly and leaves no visible scars because it is carried out exclusively through a natural orifice (natural orifice transluminal endoscopic surgery, NOTES). For retrieval of larger specimens, the transoral approach can be combined with a retroauricular access and thus covers a larger range of indications. The indications must be strictly followed, analogous to conventional surgery. Once the transoral access has been established, the operation is carried out as in open surgery but strictly from cranial to caudal. The classical complications are comparable to the results of conventional surgery. Specific complications include perioral, mandibular or cervical dysesthesia and hypesthesia.

Redo Thyroidectomy: Updated Insights

The risk of post-operatory hypothyroidism and hypocalcaemia, along with recurrent laryngeal nerve injury, is lower following a less-than-total thyroidectomy; however, a previously unsuspected carcinoma or a disease progression might be detected after initial surgery, hence indicating re-intervention as mandatory (so-called "redo" surgery) with completion. This decision takes into consideration a multidisciplinary approach, but the surgical technique and the actual approach is entirely based on the skills and availability of the surgical team according to the standard protocols regarding a personalised decision. We aimed to introduce a review of the most recently published data, with respect to redo thyroid surgery. For the basis of the discussion, a novel vignette on point was introduced. This was a narrative review. We searched English-language papers according to the key search terms in different combinations such as "redo" and "thyroid", alternatively "thyroidectomy" and "thyroid surgery", across the PubMed database. Inclusion criteria were original articles. The timeframe of publication was between 1 January 2020 and 20 July 2024. Exclusion criteria were non-English papers, reviews, non-human studies, case reports or case series, exclusive data on parathyroid surgery, and cell line experiments. We identified ten studies across the five-year most recent window of PubMed searches that showed a heterogeneous spectrum of complications and applications of different surgeries with respect to redo interventions during thyroid removal (e.g., recurrent laryngeal nerve monitoring during surgery, other types of incision than cervicotomy, the use of parathyroid fluorescence, bleeding risk, etc.). Most studies addressing novel surgical perspectives focused on robotic-assisted re-intervention, and an expansion of this kind of studies is expected. Further studies and multifactorial models of assessment and risk prediction are necessary to decide, assess, and recommend redo interventions and the most adequate surgical techniques.

Long-term Quality of Life After Thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Transcervical Approach

OBJECTIVE

To compare long-term health-related quality of life (HRQOL) after Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and transcervical approach (TCA) thyroidectomy.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

METHODS

A web-based survey was distributed to patients at our institution who met the criteria for TOETVA and underwent thyroidectomy by TOETVA or TCA between August 2017 and October 2021. All survey participants were at least 6 months postsurgery. Minors, non-English speakers, and patients who received concomitant neck dissection or reoperative thyroidectomy were excluded from the study. The survey assessed quality of life through 4 standardized instruments: the Dermatology Life Quality Index (DLQI), the Eating Assessment Tool (EAT-10), the Voice Handicap Index (VHI-10), and the Short Form Health Survey (SF-36).

RESULTS

A total of 108 TOETVA and 129 TCA patients were included in the study. The median age of respondents was 44 (36, 54; 25th, 75th percentile) years and median time from surgery to survey was 35 (22, 45; 25th, 75th percentile) months. TOETVA group DLQI (0.63 vs 0.99; P = .17), VHI-10 (1.94 vs 1.67; P = .35), EAT-10 (2.14 vs 2.32; P = .29), SF-36 physical component (52.25 vs 51.00; P = .25), and SF-36 mental component (47.74 vs 47.29; P = .87) scores were all similar to those of the TCA group. Scrutinizing specific DLQI questions, individuals in the TOETVA group were less self-conscious of their skin as compared to the TCA group (Q2; 0.08 vs 0.26, P = .03).

CONCLUSION

Long-term HRQOL after TOETVA is similar to TCA, with significantly lower skin-related self-consciousness.

Advances in the assessment of cosmetic outcomes, sensory alteration in surgical areas, and health-related quality of life of endoscopic thyroidectomy

BACKGROUND

Endoscopic thyroidectomy has been preliminarily proven effective and safe for thyroid diseases. The cosmetic outcomes and life quality are critical contents of postoperative assessment. This review will primarily focus on the assessment methods and results related to cosmetic outcomes, sensory alteration of surgical area, and quality of life following endoscopic thyroidectomy.

METHODS

A comprehensive search of published articles within the last decade was conducted using the terms "endoscopic/robotic thyroidectomy," "patient satisfaction scores," "questionnaire," "quality of life," and "cosmetic" in PubMed.

RESULTS

Assessment methods for postoperative cosmetic satisfaction and sensory alterations encompassed verbal/visual analog scales, scar evaluations, Semmes-Weinstein monofilament tests, and more. The evaluation of postoperative quality of life in endoscopic thyroidectomy involved tools such as SF-36, SF-12, thyroid-specific questionnaires, thyroid cancer-specific quality of life questionnaires (THYCA-QOL), as well as assessments related to voice and swallow function. The cosmetic results of endoscopic thyroidectomy generally surpassed those of open thyroidectomy, while the quality of life in endoscopic procedures was either superior or equivalent to that in open thyroidectomy, especially with respect to general health, role emotion, and vitality.

CONCLUSIONS

Assessments of cosmetic outcomes and sensory alterations following endoscopic thyroidectomy predominantly relied on patients' subjective feelings. The objective and subjective perspectives of scar assessments remain underutilized. In addition, postoperative laryngoscopy and voice function assessments in endoscopic thyroidectomy procedures require more attention.

Is transoral endoscopic thyroidectomy safe for total thyroidectomy compared to open thyroidectomy? A propensity-score matched cohort study with papillary thyroid carcinoma

BACKGROUND

Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has become increasingly popular in the treatment of papillary thyroid cancer (PTC). This study aimed to describe the safety and feasibility of total thyroidectomy between the TOETVA and open thyroidectomy (OT) approaches for the treatment of patients with PTC.

METHODS

We retrospectively reviewed 780 consecutive patients suffering from PTC that had undergone total thyroidectomy using TOETVA (n = 107) and OT (n = 673) between April 2016 and December 2021 at our institute. Afterward, a total of 101 matched patients' surgical outcomes were compared using propensity score matching (PSM) analysis.

RESULTS

Before PSM, the patients in the TOETVA group were younger (p < 0.001), had a lower body mass index (p < 0.001) and a greater female population (p < 0.001). After PSM, the TOETVA group was associated with significantly longer operative time (p < 0.001), greater blood loss (p < 0.001), total drainage amount (p < 0.001), higher C-reaction protein level (p < 0.001), better cosmetic satisfaction (p < 0.001) and quality of life (p < 0.001) and lower scar self-consciousness (p < 0.001). There was no statistical difference between the groups in the rate of parathyroid autotransplantation and bilateral lymph node dissection, the positivity of lymph node metastasis, number of dissected lymph nodes and positive lymph nodes, multifocality, postoperative level of blood calcium and parathyroid hormone (PTH), rate of PTH < 15 ng/mL, visual analog scale score, duration of hospital stay, complications, mean thyroid stimulating hormone (TSH)-stimulated Tg level before radioactive iodine, mean Tg level without TSH stimulation, and the proportion of serum Tg level of <1.

CONCLUSION

TOETVA is a safe and feasible technique for better cosmetic effects and similar surgical outcomes compared to conventional open surgery for the studied patients that required total thyroidectomy.

Application of carbon nanoparticles combined with refined extracapsular anatomy in endoscopic thyroidectomy

Objective

To evaluate the value of refined extracapsular anatomy combined with carbon nanoparticle suspension tracing technology for protecting parathyroid function and the thoroughness of lymph node dissection in the central region during endoscopic thyroid cancer surgery.

Patients and methods

Retrospective clinical data analysis was performed on 108 patients who underwent endoscopic thyroid cancer surgery at the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from November 2019 to November 2022. Before surgery, thyroid function tests, color Doppler ultrasounds and neck-enhanced CT scans were performed on all patients. Cytopathological diagnosis obtained via ultrasound-guided fine-needle aspiration served as confirmation for the primary diagnosis. It was determined whether to perform a total thyroidectomy or a hemithyroidectomy (HT) together with preventive unilateral (ipsilateral) central neck dissection. Follow-up times were 1 to 34 months.

Results

Transient neuromuscular symptoms were present in 3.70% (4/108) cases, with no permanent neuromuscular symptoms or permanent hypoparathyroidism. Regarding transient hypoparathyroidism, the patients recovered after three months and did not need long-term calcium supplementation. The number of harvested LNs (mean± SD) was 5.54 ± 3.84, with ≤5 in 57.41% (62/108) and >5 in 42.59% (46/108) cases. The number of patients with metastatic LNs was 37.96% (41/108), with ≤2 in 65.85% (27/41) and >2 in 34.15% (14/41) cases.

Conclusions

Fine extracapsular anatomy combined with carbon nanoparticle suspension tracing is effective in endoscopic thyroid cancer surgery. It can improve the thoroughness of prophylactic central neck dissection and recognition of the parathyroid gland and avoid parathyroid injury and other complications to effectively protect parathyroid function.

Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications

Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.

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.

Optimal primary wound closure methods after thyroid and parathyroid surgery: network meta-analysis of randomized clinical trials

BACKGROUND

At present, there is no consensus on optimal neck wound closure methods after thyroid and parathyroid surgery. The aim of this study was to perform a systematic review and network meta-analysis of RCTs evaluating the optimal neck closure method after thyroid and parathyroid surgery.

METHODS

A frequentist random-effects network meta-analysis was performed for RCTs comparing at least two closure methods according to PRISMA-network meta-analysis guidelines. Analysis was performed using R packages and Shiny.

RESULTS

Eighteen RCTs evaluating six closure methods (that is adhesive (28.5 per cent, 404 patients), absorbable subcuticular suture (18.1 per cent, 257 patients), non-absorbable subcuticular suture (16.8 per cent, 238 patients), staples (26.3 per cent, 372 patients), steristrips (8.1 per cent, 115 patients), and conventional suture (2.1 per cent, 30 patients)) in 1416 patients were included. At network meta-analysis, there was no difference in complication, infection, dehiscence, or haematoma rates irrespective of closure method used. Staples reduced closure duration versus absorbable subcuticular suture (mean difference (MD) 8.50, 95 per cent c.i. 6.90 to 10.10) and non-absorbable subcuticular suture (MD 0.30, 95 per cent c.i. 0.23 to 0.37), whereas adhesives (MD -1.05, 95 per cent c.i. -1.31 to -0.79) reduced closure time relative to staples. Cosmesis was improved after non-absorbable subcuticular suture (odds ratio (OR) 3.41, 95 per cent c.i. 1.66 to 7.00) relative to staples. Staples reduced patient satisfaction (OR 0.04, 95 per cent c.i. 0.00 to 0.33) and ability to shower (OR 0.04, 95 per cent c.i. 0.00 to 0.33) relative to adhesives.

CONCLUSION

Despite staples decreasing closure times, this advantage is offset by reduced patient satisfaction, ability to shower, and cosmesis compared with patients with wounds closed using adhesives, absorbable subcuticular suture, and non-absorbable subcuticular suture. Therefore, these closure methods are favourable for closing neck wounds due to more acceptable patient-reported outcomes, without compromising the safety of the procedure.

Advancements in Thyroidectomy: A Mini Review

Demand for minimally invasive surgery has driven the development of new gadgets and surgical techniques. Yet, questions about safety and skeptical views on new technology have prevented proliferation of new modes of surgery. This skepticism is perhaps due to unfamiliarity of new fields. Likewise, there are currently various remote-access techniques available for thyroid surgeons that only few regions in the world have adapted. This review will explore the history of minimally invasive techniques in thyroid surgery and introduce new technology to be implemented.

Transoral thyroid surgery vestibular approach

Objectives

Transoral thyroid surgery vestibular approach (TOETVA) is a novel and feasible surgical technique that allows for cervical surgery without visible incisions. TOETVA represents a new frontier in endocrine surgery since aesthetic results play a more and more decisive role in elective surgery. However, acceptance is different around the world with widespread prevalence in Asian countries and some high-volume centres in the US. While inclusion criteria for TOETVA are limited regarding size and volume a combination with other extracervical techniques like the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) approach or transaxillary access is an option.

Methods

TOETVA is carried out through a three-port technique placed at the oral vestibule. Originally one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments are used. Alternatively, one 5-mm and one or two 3 mm ports can be used. CO2 insufflation pressure is set at 6 mmHg. An additional device to optimize gas outflow for optimum view might be helpful. An anterior cervical subplatysmal space is created by hydrodissection from the oral vestibule to the sternal notch, laterally to the sternocleidomastoid muscle. Conventional endoscopic instruments are used. Combination of TOETVA with a modified retroauricular access includes insertion of a 10-12 mm trocar placed subcutaneously via a skin incision on the scalp, behind the ear by blunt dissection.

Results

Since Anuwong published the first case series of 60 patients who underwent scarless thyroidectomy via the lower vestibule of the mouth with excellent results in 2016 almost 1,000 cases are reported in literature to date with comparable results especially regarding traditional complications. In contrast to other extracervical approaches, areolar or axillary for example, the transoral access route is short and the dissection planes are rather like transcervical surgery. Surgical indications and contraindications have been modified since its first description and are partly institution specific to date. To amend indications combination with other extracervical techniques is an option. In addition, patients must carefully be selected for and surgeons` candidacy is of utmost importance in transoral surgery.

Conclusions

Transoral surgery will likely continue to gain attraction as surgeons become more experienced with the technique. With increased operative use and surgeon experience the gap in conventional outcomes between transoral surgery and the transcervical approach will narrow, with both operative time and the incidence of specific complications diminishing. Experience in thyroid and endoscopic surgery is required to achieve excellent results with low complication rates. However, the new transoral technique is related to novel complications that must be evaluated.

Gasless endoscopic transaxillary thyroid surgery: CUSUM analysis of a single surgeon's experience from 105 preliminary procedures

BACKGROUND

We aimed to evaluate the feasibility and oncologic safety of gasless endoscopic transaxillary thyroidectomy (TAT) in patients with thyroid diseases. Improvements in surgical techniques were also reported, and the learning curves of gasless endoscopic TAT were further studied.

METHODS

An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between TAT and conventional open surgery. A questionnaire was designed to evaluate the quality of life of enrolled patients. A cumulative summation analysis was designed for the quantitative estimation of the learning curves.

RESULTS

A total of 105 consecutive patients who successfully received endoscopic TAT were retrospectively enrolled in the current study. A standard three-step working space making procedure, an approach that does not free the superficial part of the sternal head of the sternocleidomastoid muscle (SCM, NFSSH) and a "point to line to surface" en bloc procedure utilized in lobectomy with ipsilateral central neck dissection (CND), were introduced in our surgical procedures. The mean operation time in the TAT group was significantly longer than that in the conventional open group (86.9 ± 31.3 vs 44.2 ± 8.3, p < 0.001). Significant differences in the complication rate were not found between the two groups. Discomfort in the anterior neck area and SCM was relieved over time in most cases (verbal response scores (VRSs) were gradually decreased over time). The learning curves for working space making, ipsilateral thyroidectomy and the total endoscopic TAT approach were 45 cases, 25 cases and 42 cases, respectively. The operation time in the proficient group was significantly shorter than that in the learning group (67.0 ± 8.4 vs 112.3 ± 35.7, p < 0.001). VRSs in the SCM were significantly lower in the proficient group (for 1 week: 1.25 ± 0.65 vs 2.40 ± 0.63, p < 0.001; for 1 month: 0.81 ± 0.69 vs 1.81 ± 0.40, p < 0.001).

CONCLUSIONS

Gasless endoscopic TAT was safe in a cohort of patients with thyroid diseases, with satisfactory surgical outcomes and cosmetic appearance. The learning curve for endoscopic TAT was approximately 42 cases. The proficiency of the endoscopic TAT approach depended primarily on the proficiency of working space making.

Completion thyroidectomy and lateral neck dissection revealed adhesions in the lateral neck compartment after gasless transaxillary endoscopic thyroidectomy: a case report

BACKGROUND

Endoscopic thyroidectomy is effective and safe surgical option for thyroid surgery while providing satisfactory cosmetic results. Gasless transaxillary endoscopic approaches have been reported to achieve endoscopic thyroidectomy in our center.

CASE DESCRIPTION

We present a patient who previously underwent gasless transaxillary endoscopic lobectomy with ipsilateral central neck dissection who underwent open completion thyroidectomy and lateral neck dissection (LND) (reoperation) in our center. The ultrasound test before the first treatment did not reveal abnormal lymph nodes in the central and lateral neck compartments. Further evaluation of the neck lymph nodes was not performed. Meanwhile, this patient did not participate in the originally planned follow-up at the 3- and 6-month visits. At the one-year visit, imaging tests revealed enlarged and suspicious malignant lymph nodes in levels III and IV of the lateral neck compartments. We believed that reoperation was performed for persistent, rather than truly recurrent disease for this patient. During the second surgery, we found that the surface of internal jugular vein (IJV) was significantly adhered to the surrounding fibroadipose tissue and the omohyoid muscle was adhered to the IJV. After carefully dissected the IJV, the dissection of the lateral neck compartment had been performed successfully.

CONCLUSIONS

Exposure of the lateral neck compartment in the gasless transaxillary procedure, especially exposure of the IJV, causes adhesions of the lateral neck compartment and brings difficulties for possible future LND. Gasless transaxillary endoscopic thyroid surgery should be performed in strictly selected patients with adequate preoperative assessment. The IJV should be carefully dissected to avoid IJV injury, and the lateral neck compartment could be dissected successfully during reoperation.

Scoping review of approaches used for remote-access parathyroidectomy: A contemporary review of techniques, tools, pros and cons

After our coauthors described the first remote-access parathyroidectomy (RAP) series in 2000, several other approaches were developed. No systematic review has been performed to classify and evaluate RAP techniques. We performed a literature search using PubMed and Cochrane Library (CENTRAL). A total of 71 studies met our inclusion/exclusion criteria. RAP can be categorized into five approaches: (1) endoscopic and robotic axillary, (2) anterior chest, (3) transoral, (4) retroauricular, and (5) a combination of these approaches. The limited data in the literature suggest that the cure rates and safety of RAP are in no way inferior to those of open parathyroidectomy. Each approach has its advantages and disadvantages, and the recommendations for the selection of each approach are listed. The selection of approach methods might depend on the surgeon's experience and familiarity and the patient's preference and disease status.

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Simple Summary

Transoral thyroidectomy accesses the thyroid gland through three incisions in the oral vestibule. The cosmetic outcome was excellent since no scar was observed on the body surface. However, it is challenging to create a working space using this new approach. Unconventional but severe complications can also occur. Our review summarizes the tips regarding working space creation in transoral thyroidectomy and tricks for preventing complications.

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

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.

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.

Learning curve for robotic thyroidectomy using BABA: CUSUM analysis of a single surgeon's experience

BACKGROUND

This study assessed the safety and oncologic outcomes of robotic thyroidectomy via the bilateral axillary breast approach (BABA RT) for conventional open procedures. The learning curves of BABA RT were further evaluated.

METHODS

An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between robotic thyroidectomy and conventional open surgery. Learning curves were assessed using cumulative summation analysis.

RESULTS

There was no significant difference in general characteristics, short time outcomes (including transient hypoparathyroidism, transient postoperative hoarseness, hematoma/seroma, mean postoperative hospital stay, and other complications), the number of retrieved central lymph nodes, and recurrence rates between robotic BABA and conventional groups. The mean number of retrieved lateral LNs in the robotic group was significantly less than those in the conventional group. The learning curve for working space making, robotic lobectomy, and total thyroidectomy are approximately 15, 30, and 20 cases, respectively. No differences except for operation time were found between the learning group and the proficient group.

CONCLUSIONS

Robotic thyroidectomy and neck dissection via BABA are feasible in terms of surgical completeness, surgical safety, and oncological safety. Our results provide a criterion for judging whether the surgeon has entered the stable stage of robotic thyroidectomy via BABA in terms of the operative time.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches.

Methods

A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed.

Results

This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed.

Conclusions

Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries - A case series

BACKGROUND

We present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach.

METHODS

Retrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed.

OUTCOMES

All 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma.

CONCLUSION

Transoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.

One hundred and one consecutive transoral endoscopic parathyroidectomies via the vestibular approach for PHPTH: a worldwide multi-institutional experience

IMPORTANCE

The transoral vestibular approach for thyroid and parathyroid surgery is being adopted rapidly world-wide. Currently there is a paucity of information on this approach for primary hyperparathyroidism (PHPTH). If this approach is safe and efficacious it would provide patients a completely scarless option for parathyroidectomy.

OBJECTIVE

To determine whether parathyroidectomy via the transoral vestibular approach can be successfully done in a safe and efficient manner.

DESIGN

Consecutive case series of 101 transoral parathyroidectomies performed over a two-year period.

SETTING

Multi-institutional, academic, high-volume transoral thyroidectomy centers from the USA, Israel, and Thailand.

PARTICIPANTS

A consecutive series of adult patients with a biochemical diagnosis of classic PHPTH and who met criteria for parathyroidectomy based on established international consensus for surgery for PHPTH. All patients also had well-localized single adenomas on at least two preoperative imaging studies.

INTERVENTION

Transoral endoscopic parathyroidectomy vestibular approach.

MAIN OUTCOMES AND MEASURES

Surgical success rate defined by immediate intra or post-operative return to normal PTH values. Surgical complications including recurrent laryngeal nerve injury, permanent hypoparathyroidism, and infection.

RESULTS

Of the 101 consecutive transoral parathyroidectomy patients 84% were female with an average age of 54.23 ± 11.0 years and an average BMI of 27.35 ± 6.19. Ninety-nine out of the 101 patients had immediate return to normal PTH after resection for a surgical success rate of 98%. There were no permanent recurrent laryngeal nerve injuries, one temporary nerve palsy, and no permanent hypoparathyroidism. The median operative time dropped from 130.5 min (IQR 86) to 66.5 min (IQR 56) between the first- and second-half of cases.

CONCLUSION AND RELEVANCE

Transoral endoscopic parathyroidectomy via the vestibular approach is a scarless method of removing parathyroids that is clinically feasible, safe, and efficacious and is a reasonable option for focused minimally invasive parathyroidectomy that can be offered to select patients with PHPTH.

Evaluation of the clinical value of carbon nanoparticles in endoscopic thyroidectomy and prophylactic central neck dissection through total mammary areolas approach for thyroid cancer

Background

Carbon nanoparticles (CNs) are tracers used in thyroid surgery of patients with thyroid cancer (TC) to help remove lymph nodes and protect the parathyroid gland. The facilitative effect of carbon nanoparticles in endoscopic thyroidectomy and prophylactic central neck dissection (pCND) has not been reported.

Methods

The protective effect on parathyroid gland (PG) function and the numbers of identified parathyroid glands and central lymph nodes in endoscopic thyroid surgery through the total mammary areolas approach were compared between the CN and control groups.

Results

All endoscopic thyroidectomies were successfully completed. No difference was found in either group regarding the general characteristics or operative complications. The mean number of superior PGs and inferior PGs identified in situ or in the dissected central lymph tissues was not different between the groups. The mean number of lymph nodes removed by unilateral CND was greater in the CN group than in the control group. However, there was no difference in the number of harvested lymph nodes when excluding the LNs less than 5 mm, which exhibit an extremely low metastatic rate.

Conclusion

Carbon nanoparticles do not improve the protective effect on the parathyroid gland, especially the inferior glands, in endoscopic thyroid surgery through the total mammary areolas approach. There is no need to use CNs to facilitate the lymph node harvest in endoscopic prophylactic unilateral CND.

The Effect of Transoral Endoscopic Thyroidectomy Vestibular Approach on Regional Cerebral Oxygen Saturation: A Prospective Observational Study

BACKGROUND

Decreased regional cerebral oxygen saturation (rSO2) is associated with neurological events. We aimed to investigate the effects of carbon dioxide (CO2) insufflation applied to the neck during transoral endoscopic thyroidectomy vestibular approach (TOETVA) surgery on the rSO2.

MATERIALS AND METHODS

Patients scheduled for TOETVA and open thyroidectomy (OT) were enrolled between October 2019 and November 2020. Alongside hemodynamic parameters, the rSO2 values of the patients were recorded at 5 different times. These were; before anesthesia induction (T0), 10 minutes after anesthesia induction (T1), 5 minutes after the patient was placed in the operation position (T2), 10 minutes after the CO2 insufflation in the TOETVA group, 10 minutes after the platysma incision in the OT group (T3), 10 minutes after the CO2 desufflation in the TOETVA group, 10 minutes after platysma closure in the OT group (T4), at the end of the surgery (T5).

RESULTS

A total of 40 patients, 20 in each group, were included in the study. The surgery duration was 113±26.9 minutes in the OT group, while it was 274.1±78.1 minutes in the TOETVA group (P=0.000). The EtCO2 values during the T3 time interval; group OT 31±2.2, group TOETVA 33.9±2.1 (P=0.000). The rSO2 values of the patients were similar, except for the T3 time interval. While the right rSO2 value we obtained during the T3 time interval in the TOETVA and OT groups were 66.9±9.1 and 73.9±7.8 (P=0.013), the left rSO2 value in the TOETVA and OT groups were 66.3±9.9 and 74.8±6.8 (P=0.003), respectively.

CONCLUSIONS

As long as the patients stay within the limits of normocapnia, the CO2 insufflation applied during TOETVA surgery has no negative effects on rSO2.

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience

AIM

Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey.

MATERIALS AND METHODS

Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020.

RESULTS

Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up.

CONCLUSION

TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

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.

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases

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.

Lateral Vestibular Approach to the Central Neck for Thyroid and Parathyroid Surgery: A Cadaveric Study

Background: The transoral endoscopic approach to the central neck has rapidly become one of the most widely utilized remote-access approaches for thyroid and parathyroid surgery in the world. The approach involves three small incisions inside the lower lip and has an optimal cosmetic outcome with no visible scar. However, the technique is quite difficult and poses several challenges that limit its widespread adoption. To overcome these issues, a novel lateral vestibular approach (LaVA) was explored in cadavers. Methods: Study using 7 fresh human cadavers that were dissected using open and endoscopic techniques to explore the feasibility of a transoral vestibular approach to the central neck without gas insufflation. Results: This novel approach resulted in wide access to the central neck and allowed for a total thyroidectomy and central neck dissection while preserving the marginal mandibular and mental nerves. Conclusions: LaVA permits excellent access to the central neck with a wide working space without the need for gas insufflation and overcomes many of the limitations of current transoral endoscopic approaches to the central neck.

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.