Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Feasibility of completion thyroidectomy via transoral endoscopic vestibular approach

Transoral endoscopic thyroidectomy is widely utilized for treating benign conditions and low-risk thyroid cancers, yet its use for completion thyroidectomy, especially when performed more than 2 weeks after an initial lobectomy, is less understood. In this retrospective study, we assessed patients who underwent endoscopic completion thyroidectomy via the transoral route, examining operative data and complications from both the initial lobectomy and the subsequent completion thyroidectomy, along with the pathological and oncologic outcomes of the latter surgery. Among the ten patients diagnosed with papillary carcinoma following an initial lobectomy who underwent a completion thyroidectomy via the same transoral approach, the median interval between surgeries was 5.4 months, with 80% of cases exceeding 3 months. All procedures were completed endoscopically without necessitating an open conversion. In 40% of these patients, additional microcarcinomas were identified in the contralateral thyroid lobe. Although the median operative time for completion thyroidectomy was longer (249 min) compared to the initial lobectomy (220 min), and postoperative pain scores on days 1 and 2 were slightly higher, and these differences were not statistically significant. Blood loss, drainage amounts, and hospital stay lengths were similar between both surgeries. The only major complication was transient hypoparathyroidism, occurring in 20% of the completion group, with 80% of patients achieving suppressed thyroglobulin levels of < 0.2 ng/mL postoperatively. Our findings demonstrate the practicality of using the transoral endoscopic vestibular approach for completion thyroidectomy, even when conducted more than 3 months after the initial lobectomy.

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.

A novel minimally invasive endoscopic approach of thyroid surgery-endoscopic thyroidectomy via sternocleidomastoid muscle posteroinferior approach

Background

Since the endoscopic thyroidectomy was firstly reported by Hüscher in 1997, there has been an ongoing debate regarding whether mainstream endoscopic thyroidectomy can be classified as minimally invasive surgery. In this study, we innovatively proposed the endoscopic thyroidectomy via sternocleidomastoid muscle posteroinferior approach (ETSPIA), a novel minimally invasive surgical technique, and compared its efficacy with the well-established transoral endoscopic thyroidectomy vestibular approach (TOETVA).

Methods

We retrospectively analyzed 50 patients who underwent ETSPIA and 50 patients who underwent TOETVA at Beijing Tongren Hospital, comparing their clinical characteristics, operative duration, blood loss, postoperative alterations in parathyroid hormone (PTH) and serum calcium, recovery post-surgery, complications, and follow-up data.

Results

The ETSPIA group had a shorter operation time compared to the TOETVA group (243.40±58.67 vs. 278.08±78.50 min; P=0.01). The ETSPIA group also had less intraoperative blood loss than the TOETVA group (20.60±10.58 vs. 33.00±11.11 mL; P<0.001). More central lymph nodes were dissected in the ETSPIA group compared to the TOETVA group (5.90±4.72 vs. 3.36±2.80; P=0.002). However, the difference in the number of positive central lymph nodes dissected was not statistically significant (1.38±2.33 for ETSPIA vs. 0.94±1.39 for TOETVA; P=0.26). The ETSPIA group had a shorter length of stay (LOS) compared to the TOETVA group (6.82±2.02 vs. 8.26±2.72 days; P=0.003). The alteration in PTH levels 1 day after surgery was less pronounced in the ETSPIA group compared to the TOETVA group (-26.38%±18.43% vs. -35.75%±22.95%; P=0.04). At the 1-month postoperative mark, the ETSPIA group showed a marginal increase in PTH levels, whereas the TOETVA group exhibited a slight decrease (10.12%±35.43% vs. -11.53%±29.51%; P=0.03). Regarding the average percentage change in serum calcium level 1 day after surgery, the ETSPIA group showed a smaller change, though this difference was not statistically significant (-4.79%±5.47% vs. -5.66%±3.90%; P=0.40). Furthermore, the incidence of hoarseness attributable to transient recurrent laryngeal nerve (RLN) injury in postoperative patients was lower in the ETSPIA group compared to the TOETVA group, but this difference did not reach statistical significance (0% vs. 4%; P=0.15).

Conclusions

Overall, compared to TOETVA, the ETSPIA is characterized by a shorter operative route, enhanced protection of the parathyroid glands, reduced trauma, and expedited postoperative recovery.

Direct Transvestibular Feminization Thyroid Laryngochondroplasty

BACKGROUND

Feminization laryngochondroplasty (FLC) methods have evolved from using a midcervical incision to a submental, less visible incision. The scar may be unacceptable to the patient because it signals gender reassignment surgery. An endoscopic transoral approach to FLC inspired by transoral endoscopic thyroidectomy was recently suggested to avoid the neck scar; however, it requires special equipment and has a long learning curve. A vestibular incision is used to approach the chin in lower-third facial feminization surgery. The authors propose that this incision may be extended to the thyroid cartilage in performing direct FLCs. The authors describe their experience with a novel, minimally invasive, direct transvestibular use of the chin-reshaping incision.

METHODS

The medical records of all patients who underwent direct transvestibular FLC (DTV-FLC) from December of 2019 to September of 2021 were retrieved and reviewed for this retrospective cohort study. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic results were retrieved.

RESULTS

Nine transgender women were included. Seven DTV-FLCs were performed during lower-third facial feminization surgery, and two were isolated DTV-FLCs. One was a revision DTV-FLC. Transient minor complications were encountered and resolved by the postoperative visit at 1 to 2 months. Vocal fold function and voice quality remained intact. Eight available patients were satisfied with the surgical results. A blinded assessment by eight plastic surgeons determined that seven procedures were successful.

CONCLUSION

The novel DTV-FTLC approach either in isolation or as part of lower-third facial feminization surgery facilitated scar-free FLC with satisfactory cosmetic and functional results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Pre-incisional, trans-isthmic injection of indocyanine green for lymph node mapping during the transoral endoscopic thyroidectomy vestibular approach

Indocyanine green (ICG) is a useful tracer for lymph node mapping and retrieval. However, during endoscopic surgery, it is challenging to administer ICG into the thyroid without spillage. We developed a simple technique of delivering ICG, thereby preventing leakage. Patients who underwent the transoral endoscopic thyroidectomy were retrospectively reviewed. In 20 patients, who constituted the ICG group, 0.1 mL ICG was injected into the peri-tumoral space under ultrasound guidance, soon after the patients received general anesthesia. Patients with papillary thyroid carcinoma who did not receive the ICG injection comprised the control group (n = 43). The location, size, and number of harvested lymph nodes were recorded in conjunction with parathyroid-related parameters. No ICG spillage occurred in the ICG group, and 76 ICG-stained lymph nodes were detected in the pretracheal (57.9%), paratracheal (25.0%), and prelaryngeal regions (17.1%). The ICG group demonstrated a significantly higher number of total (5.3 vs 2.1) and metastatic (1.5 vs 0.6) lymph nodes, a larger metastatic deposit in the positive node (3.5 mm vs 1.6 mm), and a higher rate of pathologically node-positive disease (70.0% vs 27.9%) than did the control group. The postoperative calcium level (7.8 mg/dL vs 7.2 mg/dL) was also higher in the ICG group. Pre-incisional, trans-isthmic injection of ICG under ultrasound guidance is a simple technique to prevent the leakage of ICG. Under fluorescence imaging, an adequate number of lymph nodes can be harvested for examination, which may assist in intraoperative decision-making.

Transoral and submental endoscopic thyroidectomy (TOaST) for early stage papillary thyroid carcinoma: a real-world data retrospective cohort study

INTRODUCTION

Although transoral endoscopic thyroidectomy (TOETVA) is widely utilized in clinical practice, some problems and restrictions still remain. Our study compared the perioperative features and early surgical efficacy of TOETVA and a modified transoral and submental endoscopic thyroidectomy (TOaST) in early stage papillary thyroid carcinoma (PTC).

METHODS

The clinical data of PTC patients who underwent endoscopic thyroidectomy, including 42 modified TOaST patients and 114 traditional TOETVA patients, were retrospectively collected. Propensity score matching was employed to reduce patient selection bias. The perioperative features and early surgical efficacy data of two groups were compared.

RESULTS

The operation time of the TOaST group was significantly shorter than that of the TOETVA group (150.00 ± 35.47 min vs. 168.75 ± 44.49 min; P = 0.030). Furthermore, the TOaST group required shorter days for a normal diet (3.38 ± 0.93 days vs. 4.04 ± 1.03 days; P = 0.000) and a shorter hospital stay than the TOETVA group (5.85 ± 2.17 days vs. 6.12 ± 2.01 days; P = 0.003). There was no statistical difference in complications between the two groups, but the probability of numbness of the lower lip and chin in the TOaST group was lower than that in the TOETVA group(5.12% vs. 13.04%, P = 0.321). The symptoms of mandibular numbness and hoarseness of most patients were relieved in both groups 6 months after surgery, and no abnormalities and recurrence were found in the thyroid ultrasound. All the patients were satisfied with the appearance of their surgical incision.

CONCLUSION

In early stage PTC patients, TOaST had the same surgical effectiveness as traditional TOETVA but can minimize the probability of mandibular numbness and improve the perioperative quality of life.

Updates in Thyroid Cancer Surgery

This Special Issue of Cancers entitled "Updates in thyroid surgery" is a collection of nine articles that covers a wide range of topics, providing a comprehensive picture of the latest developments in thyroid surgery [...].

Cannula Fracture during Transoral Endoscopic Thyroidectomy Vestibular Approach: Causes and Prevention

In the transoral endoscopic thyroidectomy vestibular approach (TOETVA), three oral vestibular incisions are used to access the thyroid. This approach leaves no scar on the body surface; however, unexpected complications may occur. Three patients (two women, one man) underwent TOETVA using the standard three-port technique. Broken cannulas of the 12 mm central port were noted in all cases. All cannulas broke on the ventral side of the distal shaft. The fracture lines were 3–4 cm in length, with some fragments scattered throughout the operative field and oral cavity. The fractures were caused by compression against the mandible while tilting the cannula during surgical manipulation. Male sex, short stature, and protruding chin may be risk factors for cannula fracture in TOETVA. Measures should be taken to prevent this complication, particularly in high-risk patients.