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Transoral endoscopic thyroid surgery seems to be the logical consequence in the evolution of thyroid surgery. Animal and cadaver studies have shown that different endoscopic techniques can be performed in a safe and successful way. Presently, the minimally invasive aspect and cosmetic advantage seem to be the most important factor for the patients....
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Citations
... RFA has demonstrated safety and efficacy, making it a viable alternative for treating bilateral benign TNs [25] . Recent studies have also indicated the effectiveness of the TOETVA with low complication rates [2] , establishing it as a scarless procedure due to its shorter access to the thyroid gland compared to other endoscopic thyroidectomy approaches [26] . ...
Background
Thyroid nodules (TNs) often require intervention due to symptomatic or cosmetic concerns. Radiofrequency ablation (RFA) has shown promise as a treatment option, offering potential advantages without neck scars. Recently, the scarless treatment alternative of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged. When surgery can be performed in a scarless manner, it remains unclear whether ablation is still the preferred treatment choice. This study aims to compare the safety, efficacy, and patient satisfaction of RFA and TOETVA.
Study Design
A retrospective data analysis was conducted on patients treated with RFA or TOETVA for unilateral benign TNs between December 2016 and September 2021. Propensity score matching was employed to create comparable groups. Various clinicopathologic parameters, treatment outcomes, and costs were assessed.
Results
Of the 2,814 nonfunctional thyroid nodules treated during this period, 642 were benign and unilateral. A total of 121 and 100 patients underwent thermal ablation and transoral endoscopic thyroidectomy, respectively. After matching, 84 patients were selected for each group. Both RFA and TOETVA demonstrated low complication rates, with unique complications associated with each procedure. Treatment time (30.8±13.6 minutes vs. 120.7±36.5 minutes, P <0.0001) was shorter in the RFA group. Patient satisfaction (significant improvement: 89.3% vs. 61.9%, P <0.0001) and cosmetic results (cosmetic score 1-2: 100.0% vs. 54.76%, P <0.0001) favored TOETVA. RFA was found to be less costly for a single treatment, but the cost of retreatment should be considered. The histological diagnoses post-TOETVA revealed malignancies in 9 out of 84 cases, underscoring the significance of follow-up assessments.
Conclusion
Scarless procedures, RFA and TOETVA, are effective for treating unilateral benign TNs, each with unique advantages and drawbacks. While RFA is cheaper for a single treatment, TOETVA offers superior cosmetic results and patient satisfaction. Further research is needed to evaluate long-term safety and cost-effectiveness. It is crucial to remain vigilant about the possibility of malignancy despite benign cytology pre-treatment.
... TOVET is less invasive in creating a dissection space, with less pain, a faster recovery, lower morbidity outcome, and better cosmetic results achieved by invisible neck scars. 7,8 This study aims to evaluate the utilization of endoscopic vestibular approach in thyroid surgery for benign nodules. ...
... 1,2 Concern about the neck cosmesis has led to adoption of endoscopic thyroidectomy at many centers across the world. 3,4 The safety and outcomes of Transoral endoscopic thyroidectomy vestibular approach (TOETVA) in comparison to conventional/ open surgery has been well established. 5,6 As the TOETVA is rapidly being adopted, multiple studies focusing on the quality of life between TOETVA and OTx have been published recently showing superior outcomes with TOETVA. ...
Introduction
It is important for the endoscopic thyroid surgeon to understand the pros and cons of trans‐oral endoscopic thyroidectomy‐vestibular approach (TOETVA) vis‐à‐vis, open conventional thyroidectomy (OTx) so he/she can help patients in making informed choices regarding the type of procedure to opt for. Swallowing related quality of life (SWAL‐QoL) has not been compared between the two approaches. Using a rigorous qualitative methodology and validated reliable tool, this study set out to compare the swallowing related quality of life in patients undergoing TOETVA versus OTx.
Methods
Prospective study at 3 time points in patients planned for hemithyroidectomy (Preoperative, 1 week and 12 weeks). Data were collected on patients at a tertiary teaching institute in India. Participants ranged from age 18–60 years with a diagnosis of benign euthyroid nodule undergoing hemithyroidectomy. Exclusion criteria were—(1) pre‐existing vocal cord abnormalities, (2) undergoing surgery for recurrent nodules, and (3) any neuro‐muscular disease affecting swallowing ability. Main outcome measure was comparison of swallowing related quality of life domain scores between patients undergoing hemithyroidectomy via either endoscopic trans‐oral or open approach.
Results
Of the 82 included patients, 40 underwent TOETVA and 42 OTx. Both the groups were comparable in terms of demographic and clinicopathological profile. The mean preoperative SWAL‐QOL scores were comparable in all domains. Mean SWAL‐QoL scores for all domains on postoperative day 7 were significantly better in TOETVA group with domains burden, eating desire, mental health and communication having medium effect sizes. Physical symptom domain was better in the OTx group but had a small effect size. The difference in SWAL‐QoL domains between the two groups persisted for 3 months also.
Conclusion
Swallowing related quality of life after trans‐oral endoscopic thyroidectomy compared to conventional open surgery has not been reported in the literature. Our findings suggest that trans‐oral endoscopic thyroidectomy results in significant superior swallowing related quality of life in the majority of domains.
... Более сорока лет прошло с тех пор, когда была выполнена первая эндоскопическая операция. В настоящее время это направление стало стандартом почти во всех областях онкологии [1]. Однако в хирургии щитовидной железы (ЩЖ) эндоскопические доступы появились позже. ...
Актуальность. Трансоральная эндоскопическая хирургия щитовидной железы с вестибулярным доступом (TOETVA) является одной из новейших методик, которая не приводит к образованию рубца на передней поверхности шеи. Цель. Мы сообщаем здесь о нашем первоначальном опыте с TOETVA и его краткосрочных результатах у пациентов с новообразованиями щитовидной железы. Материалы и методы. Эта серия случаев состояла из 60 пациентов с новообразованиями щитовидной железы, перенесших TOETVA в МРНЦ им.А.Ф.Цыба в период с июня 2022 г. по август 2022 г. У 36 пациентов новообразование представлено фолликулярной опухолью щитовидной железы, размером от 1 до 5 см, у 24 – папиллярный рак щитовидной железы, распространенностью сT1a – 20 пациентов, cT1b – 4 пациента. Мы ретроспективно рассмотрели клинико-патологические данные и краткосрочные послеоперационные результаты. Полученные результаты. Среди 60 случаев TOETVA 15 были тиреоидэктомя, 45 — гемитиреодэктомия. Средний возраст составил 32,1 года, среднее время операции — 110 ± 21,4 минуты. Размер опухоли варьировал от 0,5 до 5 см. У одного пациента был транзиторный парез голосовых связок. Среди 15 пациентов с тиреоидэктомией у 3 развилась транзиторная гипокальциемия. Не было отмечено ни повреждения ментального нерва, ни инфекции области хирургического вмешательства, ни серомы. Вывод. Трансоральная хирургия щитовидной железы может быть альтернативным хирургическим вариантом для тщательного отобранных пациентов с новообразованиями щитовидной железы, в том числе с раком щитовидной железы.
... Compared with others, the gasless unilateral axillary approach (GUA) can establish a surgical space without carbon dioxide (CO2) insufflation and gas-related complications such as gas embolism and acidosis (6). Furthermore, the learning curve is relatively short for skilled surgeons to obtain, and surgical efficacy and cosmetic outcomes are as well as other techniques (7)(8)(9). However, the surgical space separation was achieved with a dedicated surgical retractor, which, together with the limited operating space, would increase the difficulty of guaranteeing the visual field and disturb the surgeon's manipulation. ...
Introduction:
Gasless unilateral trans-axillary approach (GUA) thyroidectomy has witnessed rapid development in technologies and applications. However, the existence of surgical retractors and limited space would increase the difficulty of guaranteeing the visual field and disturb safe surgical manipulation. We aimed to develop a novel zero-line method for incision design to access optimal surgical manipulation and outcomes.
Methods:
A total of 217 patients with thyroid cancer who underwent GUA were enrolled in the study. Patients were randomly classified into two groups (classical incision and zero-line incision), and their operative data were collected and reviewed.
Results:
216 enrolled patients underwent and completed GUA; among them, 111 patients were classified into the classical group, and 105 patients were classified into the zero-line group, respectively. Demographic data, including age, gender, and the primary tumor side, were similar between the two groups. The duration of surgery in the classical group was longer (2.66 ± 0.68 h) than in the zero-line group (1.40 ± 0.47 h) (p < 0.001). The counts of central compartment lymph node dissection were higher in the zero-line group (5.03 ± 3.02 nodes) than that in the classical group (3.05 ± 2.68 nodes) (p < 0.001). The score of postoperative neck pain was lower in the zero-line group (1.0 ± 0.36) than that in the classical group (3.3 ± 0.54) (p < 0.05). The difference in cosmetic achievement was not statistically significant (p > 0.05).
Conclusion:
The "zero-line" method for GUA surgery incision design was simple but effective for GUA surgery manipulation and worth promoting.
... The increased incidence of thyroid pathology among young women and the increasing attention to the cosmetic outcome brought to the development of alternative surgical approaches [11][12][13][14][15][16][17] . Transoral approach represents a technological advancement in minimally invasive endocrine surgery. ...
... 3) The subplatysmal layer is elevated off the strap muscles and subplatysmal space is enlarged 1 . 4) Three trocars are positioned 14,15 . 5) A working space below the subplatysmal layer is obtained and maintained thanks to CO2 insufflation 12 . ...
Conventional open thyroidectomy is still considered the gold standard for thyroid surgery. Transoral endoscopic thyroidectomy vestibular approach (also known as TOETVA) is often considered to be more advantageous than the other approaches, such as minimally invasive video assisted thyroidectomy, thyroidectomy via breast/axillary/retroauricular access, bilateral axillo-breast approach and axillo-bilateral breast approach. In this scoping review, we discuss the risks and the benefits of this surgical approach and its medico-legal and ethical implications, particularly focusing on the importance of practice on cadavers. Currently, there is little scientific evidence supporting TOETVA, since there are few papers on the comparison with the traditional open thyroidectomy that have been published and thus little data on the long-term outcomes of TOETVA are available. Since the better cosmetic outcome currently represents the main indication for this surgical technique, substantial medico-legal and ethical issues arise. Moreover, practice on cadavers can help surgeons to develop the technical and non-technical skills required to perform efficiently and safely this new surgical procedure.
... These techniques require continuous carbon dioxide insufflation or manual external retraction to maintain the operative space. They are technically demanding and have a steep learning curve [23]. Surgeons in India have reported difficulty in port placement and dissection in male patients due to prominent chins and a bulky thyroid cartilage [24,25]. ...
Background
Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP).Methods
Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection.ResultsEleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids.Conclusion
Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.
... insertion of an optical instrument through a native orifice, such as the mouth [9]. This technique could retain the advantages of minimally invasive surgery and improve the aesthetic aspect as the scars are perfectly hidden from view and heal without leaving scars on the skin. ...
... The average postoperative hospital stay was 6.8 ± 1.3 (5-10) days. The mean number of removed nodes was 7.4 ± 2.5 (4)(5)(6)(7)(8)(9)(10)(11)(12) in the central neck and 10.9 ± 2.8 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) in the lateral neck, and the positive yield amounts were mean values of 2.0 ± 1.2 (0-4) and 2.7 ± 1.9 (0-6), respectively. No major complications occurred, but one case of transient unilateral RLN palsy and 2 cases of effusion in the operative area occurred ( Table 2). ...
... The average postoperative hospital stay was 6.8 ± 1.3 (5-10) days. The mean number of removed nodes was 7.4 ± 2.5 (4)(5)(6)(7)(8)(9)(10)(11)(12) in the central neck and 10.9 ± 2.8 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) in the lateral neck, and the positive yield amounts were mean values of 2.0 ± 1.2 (0-4) and 2.7 ± 1.9 (0-6), respectively. No major complications occurred, but one case of transient unilateral RLN palsy and 2 cases of effusion in the operative area occurred ( Table 2). ...
Background
Transoral endoscopic thyroid surgery via the vestibular approach (TOETVA) has been gradually accepted worldwide due to its scar-free effect on the neck. Even central cervical lymphadenectomy has been performed in some cases of papillary thyroid carcinoma (PTC). However, there are few reports involving lateral neck dissection with TOETVA. In this study, we attempted to perform selective lateral neck dissection (SLND) for PTC via a transoral vestibular approach.
Methods
This prospective study was conducted from January 2016 to December 2018 in twenty PTC patients with unilateral T1 tumors without capsular invasion and patients with abnormal level III and IV lymph nodes who underwent SLND via a transoral vestibular approach.
Results
Endoscopic surgery was successfully accomplished in all 20 PTC patients. The mean age was 29.2 ± 5.5 (20–41) years. The mean operation time was 146.0 ± 18.7 (114–193) min. The average postoperative hospital stay was 6.8 ± 1.3 (5–10) days. The mean number of removed nodes was 7.4 ± 2.5 (4–12) in the central neck and 10.9 ± 2.8 (6–16) in the lateral neck, and the positive yield amounts were 2.0 ± 1.2 (0–4) and 2.7 ± 1.9 (0–6), respectively. No major complications occurred except for 1 case of transient unilateral recurrent laryngeal nerve palsy and two cases of effusion in the operative area. No evidence of persistent or recurrent disease was observed in these patients during a mean follow-up of 24.3 ± 9.1 (6–36) months. The cosmetic results and protection of personal privacy of this procedure were excellent.
Conclusion
Endoscopic SLND via the transoral vestibular approach is feasible, safe, and effective for selected PTCs. A multicenter large comparative study is necessary.
... (9) The transoral endoscopic technique is one of those approaches; it is an adaptation of the concept of natural orifice transluminal endoscopic surgery to the neck, and it is a technique that promises to improve the aesthetic aspect by offering a scar-less operation while retaining the advantages of minimally invasive surgery. (9,10,(12)(13)(14) Endoscopic thyroidectomy approaches are yet to be widely employed in clinical practice; however, the drive to improve cosmesis is still important in some patients. ...
Introduction
There has been increased interest in applying the principles of minimally invasive surgery in thyroid surgery which was promoted by Miccoli and his colleagues in 1999. Different surgical techniques since then were introduced, transcervical and extracervical approaches.
Presentation of case
A 33-year-old Saudi female presented with a swelling over the left side of her neck and dysphagia for three years. The patient underwent transoral endoscopic left thyroid lobectomy, isthmusectomy and sampling of the central compartment via vestibular approach (TOETVA). To the best of our knowledge, this is the first case underwent TOETVA successfully in Saudi Arabia and gulf cooperation council countries.
Discussion
TOETVA is a novel promising procedure, an adaptation of the concept of natural orifice transluminal endoscopic surgery (NOTES) with advantages of scar-less result in excellent cosmesis while retaining the advantages of minimally invasive surgery and the potential value of the procedure outside the enhanced cosmesis continuous to be defined.
The cosmetic superiority in avoiding visible scarring must be balanced against operative time, post-operative hospital stays, increased expense, surgical training, and steep learning curve required.
The technique is novel, some thyroid surgeons opted for longer postoperative observation to exclude complications. As experience and confidence in the procedure increase, the length of stay should decrease dramatically.
Conclusion
This procedure is feasible and safe with excellent cosmetic result. It is in its initial stage in Saudi Arabia, gulf cooperation council countries and it has a potential to be performed more frequently in near future.
... Of the currently available endoscopic techniques, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides a truly scarless approach with relatively direct access to the thyroid and reduced tissue dissection. As such, there has been an increase in the number of TOETVA procedures reported worldwide (2)(3)(4). ...
Background:
Remote access and endoscopic thyroid surgery has been gaining popularity because it allows patients to avoid a visible scar in the neck. There is limited data on transoral endoscopic thyroidectomy when it relates to patients with papillary thyroid carcinoma. We aim to evaluate the safety of ipsilateral central compartment dissection for patients who undergo transoral thyroidectomy (thyroidectomy vestibular approach-compartment lymph node dissection).
Patients and methods:
A total of 80 patients who underwent thyroidectomy vestibular approach-compartment lymph node dissection for papillary thyroid carcinoma from June 2015 to September 2016 were identified. Over the same period, a matched cohort of 80 patients who underwent open thyroidectomy with routine ipsilateral central compartment dissection was also identified (Open-compartment lymph node dissection). The two groups were analyzed in terms of patient characteristics, perioperative clinical results and post-operative outcomes.
Results:
All patients were female with a mean age of 32-year. There was no difference in mean maximum tumor size and number of lymph nodes dissected. Moreover, there was no difference in average positive lymph nodes between thyroidectomy vestibular approach-compartment lymph node dissection and Open-compartment lymph node dissection (1.48 vs 1.08, P = 0.647). Operative time was longer in the thyroidectomy vestibular approach-compartment lymph node dissection group (193 vs 102 min, P < 0.001). Thyroidectomy specific complications were similar with rates of temporary recurrent laryngeal nerve palsy of 6.3 vs 8.8% and temporary hypocalcemia rates of 2.5 vs 5% in the thyroidectomy vestibular approach-compartment lymph node dissection and Open-compartment lymph node dissection groups, respectively.
Conclusions:
Thyroidectomy vestibular approach-compartment lymph node dissection is a feasible and safe option for select patients with papillary thyroid carcinoma who require central node dissection compared with Open-compartment lymph node dissection, and can be a viable alternative for patients wishing to avoid a visible scar.
