Novel Trocars and Suspension System Application in Gasless Transoral Endoscopic Thyroidectomy Vestibular Approach Oral Endoscopic Surgery

Gasless transoral endoscopic thyroidectomy in a primary substernal goitre patient: First case

ABSTRACT

For most primary substernal goitre (SG) surgeries, sternotomy is required because the blood supply vessels of tumours come from the mediastinum. However, sternal dehiscence may lead to several surgical complications. We reported an older patient who underwent simultaneous removal of a primary SG and parathyroid adenoma through a gasless transoral endoscopic approach. The patient recovered well with no hoarseness, post-operative bleeding or other complications after the operation. To the best of our knowledge, this is the first reported case of gasless transoral endoscopic parathyroid adenoma and primary SG resection in the real world. We found that gasless transoral endoscopic surgery is feasible in patients with small primary SG and parathyroid adenoma.

Patient-reported oral function and psychological well-being outcomes of papillary thyroid cancer patients (PTC) after surgery: a cross-sectional study

BACKGROUND

This study was performed to evaluate the differences in oral function and psychological well-being between patients with PTC after the gasless transoral endoscopic thyroidectomy vestibular approach (gasless-TOETVA) and patients with PTC after open surgery.

METHODS

PTC patients who underwent radical surgery from May 2021 to August 2022 were included in this study. Postoperative data on oral function and psychological well-being, including the Oral Health Impact profile-14 (OHIP-14) and State-Trait Anxiety Inventory Form Y, were collected and analyzed.

RESULTS

212 patients were included in the analysis. Among them, 102 patients who received gasless-TOETVA were assigned to the gasless-TOETVA group, while the remaining 110 patients who underwent open surgery were categorized as the open group. Although the OHIP-14 score in the gasless-TOETVA group was higher than that of the open group from 6 months to 1 year after surgery (p = 0.012), the difference in OHIP-14 scores between the two groups disappeared 1 year after surgery (p = 0.155). There were no differences between the gasless-TOETVA group and the open group in state-anxiety scores. However, the gasless-TOETVA group had significantly lower trait-anxiety scores than the open group at all follow-up time periods. Furthermore, within the gasless-TOETVA group, patients who were more than 1 year post-surgery showed significantly increased trait-anxiety scores compared to those of patients who were less than 1 year post-surgery (Δ = 3.4; p = 0.032). In contrast, the open group showed a decreasing trend in trait-anxiety scores, but there was no statistically significant difference between patients who had surgery less than 1 year ago and those who had surgery more than 1 year ago (Δ = - 2.2; p = 0.094).

CONCLUSION

Gasless TOETVA had a temporary impact on oral function, but it did not alleviate the state of anxiety. Furthermore, we observed a significant increase in trait-anxiety scores among PTC patients who underwent gasless-TOETVA after 1 year.

Comparisons of different approaches and incisions of thyroid surgery and selection strategy

To date, the traditional open thyroid surgery via a low collar incision remains the standard approach for patients undergoing thyroidectomy. However, this conventional approach will inevitably leave patients a neck scar and even cause a variety of complications such as paresthesia, hypesthesia, and other uncomfortable sensations. With the progress in surgical techniques, especially in endoscopic surgery, and the increasing desire for cosmetic and functional outcomes, various new approaches for thyroidectomy have been developed to avoid or decrease side effects. Some of these alternative approaches have obvious advantages compared with traditional surgery and have already been widely used in the treatment of thyroid disease, but each has its limitations. This review aims to evaluate and compare the different approaches to thyroidectomy to help surgeons make the proper treatment strategy for different individuals.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique

Background

The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO₂)-related complications. Herein, we proposed a new technique without CO₂ called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA.

Methods

We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded.

Results

Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery.

Conclusions

Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.

Novel suspension system for gasless transoral vestibular thyroidectomy

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is receiving increased attention, frequently due to growing requirements for cosmetic incisions. Here, we report our initial experience and discuss the safety and efficacy of the innovative surgical working space suspension system for gasless TOETVA.

METHODS

We retrospectively analyzed 75 consecutive patients for whom gasless TOETVA with our novel working space suspension system was used. This suspension system included self-developed retractors, a sterile bandage, and an anesthesia stand. We also improved some main surgical instruments in gasless TOETVA.

RESULTS

The study included 75 patients who successfully underwent thyroidectomy and central neck dissection via gasless TOETVA. The mean operating time was 143.27 ± 34.60 min. The mean number of retrieved lymph nodes was 8.00 ± 5.39. Conversion to open surgery did not occur, nor did patients exhibit serious postoperative complications. Postoperative complications included 4 cases of transient recurrent laryngeal nerve (RLN) palsy, 9 of transient hypoparathyroidism, and 3 of transient mental nerve injury. One patient with subcutaneous fluid after surgery recovered after aspiration. Another patient with submental minor perforation recovered well after suturing. There was no evidence of specific complications related to self-designed retractors.

CONCLUSION

The innovative working space suspension system for gasless TOETVA provided enough and stable working space and optimized the clarity of the surgical field without CO₂-related complications.

En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma

INTRODUCTION

The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma.

OBJECTIVE

This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma.

METHODS

This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed.

RESULTS

All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51 cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision.

CONCLUSION

The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.

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.