Abstract
Introduction
The Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA).
Methods
Between February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves’ disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO2 insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices.
Results
TOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1–10 cm). Median operative time was 97 ± 40.5 min (45–300 min). Median blood loss was 30 ± 46.25 mL (6–300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2–7), 1.17 ± 1.4 (0–5), and 0.47 ± 0.83 (0–3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified.
Conclusion
TOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.
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References
Ferzli GS, Sayad P, Abdo Z, Cacchione RN (2001) Minimally-invasive, non-endoscopic thyroid surgery. J Am Coll Surg 192:665–668
Rafferty M, Miller I, Timon C (2006) Minimal incision for open thyroidectomy. Otolaryngol Head Neck Surg 135:295–298
Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C (1999) Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest 22:849–851
Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J (2001) Endoscopic thyroidectomy by the axillary approach. Surg Endosc 15:1362–1364
Choe J (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31:601–606
Wang C, Feng Z, Li J, Yang W, Zhai H, Choi N, Yang J, Hu Y, Pan Y, Cao G (2015) Endoscopic thyroidectomy via areola approach: summary of 1,250 cases in a single institution. Surg Endosc 29:192–201
Park JO, Kim SY, Chun BJ, Joo YH, Cho KJ, Park YH, Kim MS, Sun DI (2015) Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique. Surg Endosc 29:1469–1475
Witzel K, von Rahden BH, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22:1871–1875
Benhidjeb T, Wilhelm T, Harlaar J, Kleinrensink GJ, Schneider TA, Stark M (2009) Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 23:1119–1120
Karakas E, Steinfeldt T, Gockel A, Westermann R, Kiefer A, Bartsch DK (2010) Transoral thyroid and parathyroid surgery. Surg Endosc 24:1261–1267
Wilhelm T, Metzig A (2011) Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg 35:543–551
Woo SH (2014) Endoscope-assisted transoral thyroidectomy using a frenotomy incision. J Laparoendosc Adv Surg Tech A 24:345–349
Nakajo A, Arima H, Hirata M, Mizoguchi T, Kijima Y, Mori S, Ishigami S, Ueno S, Yoshinaka H, Natsugoe S (2013) Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc 27:1105–1110
Wang C, Zhai H, Liu W, Li J, Yang J, Hu Y, Huang J, Yang W, Pan Y, Ding H (2014) Thyroidectomy: a novel endoscopic oral vestibular approach. Surgery 155:33–38
Anuwong A (2016) Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. World J Surg 40:491–497
Koo DH, Kim DM, Choi JY, Lee KE, Cho SH, Youn YK (2015) In-depth survey of scarring and distress in patients undergoing bilateral axillo-breast approach robotic thyroidectomy or conventional open thyroidectomy. Surg Laparosc Endosc Percutan Tech 25:436–439
Arora A, Swords C, Garas G, Chaidas K, Prichard A, Budge J, Davies DC, Tolley N (2016) The perception of scar cosmesis following thyroid and parathyroid surgery: a prospective cohort study. Int J Surg 25:38–43
Lee MC, Park H, Lee BC, Lee GH, Choi IJ (2016) Comparison of quality of life between open and endoscopic thyroidectomy for papillary thyroid cancer. Head Neck 38(Suppl 1):E827–E831
Richmon JD, Holsinger FC, Kandil E, Moore MW, Garcia JA, Tufano RP (2011) Transoral robotic-assisted thyroidectomy with central neck dissection: preclinical cadaver feasibility study and proposed surgical technique. J Robot Surg 5:279–282
Lee HY, Richmon JD, Walvekar RR, Holsinger C, Kim HY (2015) Robotic transoral periosteal thyroidectomy (TOPOT): experience in two cadavers. J Laparoendosc Adv Surg Tech A 25:139–142
Lee HY, You JY, Woo SU, Son GS, Lee JB, Bae JW, Kim HY (2015) Transoral periosteal thyroidectomy: cadaver to human. Surg Endosc 29:898–904
Clark JH, Kim HY, Richmon JD (2015) Transoral robotic thyroid surgery. Gland Surg 4:429–434
Cai C, Huang Y, Zhang T, Chai L, Wang G, Shi L, Wiegand S, Güldner C, Günzel T, Wilhelm T (2015) Anatomical study of surgical approaches for minimally invasive transoral thyroidectomy: eMIT and TOPP. Minim Invasive Ther Allied Technol 24:340–344
McHenry CR (2011) Endoscopic minimally invasive thyroidectomy: a prospective proof-of-concept study in humans. World J Surg 35:552
Yang J, Wang C, Li J, Yang W, Cao G, Wong HM, Zhai H, Liu W (2015) Complete endoscopic thyroidectomy via oral vestibular approach versus areola approach for treatment of thyroid diseases. J Laparoendosc Adv Surg Tech A 25:470–476
Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L (2016) 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid 26:1–133
Song CM, Jung JH, Ji YB, Min HJ, Ahn YH, Tae K (2014) Relationship between hypoparathyroidism and the number of parathyroid glands preserved during thyroidectomy. World J Surg Oncol 12:200. doi:10.1186/1477-7819-12-200
Ywata de Carvalho A, Chulam TC, Kowalski LP (2015) Long-term results of observation vs prophylactic selective level vi neck dissection for papillary thyroid carcinoma at a cancer center. JAMA Otolaryngol Head Neck Surg 141:599–606
Calò PG, Pisano G, Medas F, Pittau MR, Gordini L, Demontis R, Nicolosi A (2014) Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients. J Otolaryngol Head Neck Surg 43:16. doi:10.1186/1916-0216-43-16
Selberherr A, Scheuba C, Riss P, Niederle B (2015) Postoperative hypoparathyroidism after thyroidectomy: efficient and cost-effective diagnosis and treatment. Surgery 157:349–353
Seo GH, Chai YJ, Choi HJ, Lee KE (2016) Incidence of permanent hypocalcaemia after total thyroidectomy with or without central neck dissection for thyroid carcinoma: a nationwide claim study. Clin Endocrinol 85:483–487
Yang CH, Chew KY, Solomkin JS, Lin PY, Chiang YC, Kuo YR (2013) Surgical site infections among high-risk patients in clean-contaminated head and neck reconstructive surgery: concordance with preoperative oral flora. Ann Plast Surg 71(Suppl 1):S55–S60
Shan CX, Zhang W, Jiang DZ, Zheng XM, Liu S, Qiu M (2010) Prevalence, risk factors, and management of seroma formation after breast approach endoscopic thyroidectomy. World J Surg 34:1817–1822
Udelsman R, Anuwong A, Oprea AD, Rhodes A, Prasad M, Sansone M, Brooks C, Donovan PI, Jannitto C, Carling T (2016) Trans-oral vestibular endocrine surgery: a new technique in the United States. Ann Surg 264:e13–e16
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Dr. Angkoon Anuwong, Dr. Thanyawat Sasanakietkul, Dr. Pornpeera Jitpratoom, Dr. Khwannara Kantha, Dr. Hoon Yub Kim, Dr. Gianlorenzo Dionigi and Dr. Jeremy Richmon have no conflicts of interest or financial ties to disclose related to the work herein.
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Anuwong, A., Sasanakietkul, T., Jitpratoom, P. et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc 32, 456–465 (2018). https://doi.org/10.1007/s00464-017-5705-8
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DOI: https://doi.org/10.1007/s00464-017-5705-8