Comprehensive Guide to Transoral Endoscopic Thyroidectomy Vestibular Approach: Step-by-Step Technique

Abstract

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a minimally invasive surgical technique that offers safety comparable to conventional open thyroidectomy, with the added benefit of superior cosmetic outcomes due to the absence of visible scars. This innovative approach is gaining popularity worldwide as an alternative for patients seeking thyroid surgery without postoperative scarring. TOETVA involves positioning the patient supine with slight neck extension under general anesthesia. The procedure uses three trocars placed via midline and lateral incisions, with a 10-mm 30-degree laparoscope for visualization. Preoperative care includes cleaning the surgical area and administering intravenous antibiotics to prevent infection. The technique mirrors conventional thyroidectomy but utilizes standard laparoscopic instruments. It emphasizes the precise identification and preservation of critical anatomical structures, such as the cricoid cartilage, thyroid isthmus, trachea, carotid artery, superior laryngeal nerve, and recurrent laryngeal nerve. The use of an energy device and careful dissection help minimize bleeding and reduce nerve injury risks. Superior pole management and meticulous handling of the thyroid lobe ensures optimal outcomes. The growing popularity of TOETVA indicates a shift toward minimally invasive thyroid surgery, with TOETVA emerging as a leading method. This paper provides a comprehensive overview of the procedure, highlighting its benefits and critical aspects of its successful implementation.

Keywords

endoscopic thyroidectomy - TOETVA - transoral

Publication History

Received: 27 July 2024

Accepted: 30 July 2024

Article published online:
23 August 2024

• References

• 1 Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996; 83 (06) 875
• 2 Miccoli P, Berti P, Bendinelli C, Conte M, Fasolini F, Martino E. Minimally invasive video-assisted surgery of the thyroid: a preliminary report. Langenbecks Arch Surg 2000; 385 (04) 261-264
• 3 Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy and parathyroidectomy by the axillary approach. A preliminary report. Surg Endosc 2002; 16 (01) 92-95
• 4 Sasaki A, Nakajima J, Ikeda K, Otsuka K, Koeda K, Wakabayashi G. Endoscopic thyroidectomy by the breast approach: a single institution's 9-year experience. World J Surg 2008; 32 (03) 381-385
• 5 Choe JH, Kim SW, Chung KW. et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 2007; 31 (03) 601-606
• 6 Lee KE, Kim E, Koo H, Choi JY, Kim KH, Youn YK. Robotic thyroidectomy by bilateral axillo-breast approach: review of 1,026 cases and surgical completeness. Surg Endosc 2013; 27 (08) 2955-2962
• 7 Kang SW, Lee SC, Lee SH. et al. Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 2009; 146 (06) 1048-1055
• 8 Lee DY, Baek SK, Jung KY. Endoscopic thyroidectomy: retroauricular approach. Gland Surg 2016; 5 (03) 327-335
• 9 Terris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: patient selection and technical considerations. Surg Laparosc Endosc Percutan Tech 2011; 21 (04) 237-242
• 10 Anuwong A. Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. World J Surg 2016; 40 (03) 491-497
• 11 Sasanakietkul T, Jitpratoom P, Anuwong A. Transoral endoscopic parathyroidectomy vestibular approach: a novel scarless parathyroid surgery. Surg Endosc 2017; 31 (09) 3755-3763
• 12 Jitpratoom P, Ketwong K, Sasanakietkul T, Anuwong A. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy. Gland Surg 2016; 5 (06) 546-552
• 13 Udelsman R, Anuwong A, Oprea AD. et al. Trans-oral Vestibular Endocrine Surgery: A New Technique in the United States. Ann Surg 2016; 264 (06) e13-e16
• 14 Dionigi G, Bacuzzi A, Lavazza M. et al. Transoral endoscopic thyroidectomy: preliminary experience in Italy. Updates Surg 2017; 69 (02) 225-234
• 15 Russell JO, Clark J, Noureldine SI. et al. Transoral thyroidectomy and parathyroidectomy - a North American series of robotic and endoscopic transoral approaches to the central neck. Oral Oncol 2017; 71: 75-80
• 16 Lira RB, De Cicco R, Rangel LG. et al. Transoral endoscopic thyroidectomy vestibular approach: experience from a multicenter national group with 412 patients. Head Neck 2021; 43 (11) 3468-3475
• 17 Fernandez Ranvier G, Meknat A, Guevara DE. et al. International multi-institutional experience with the transoral endoscopic thyroidectomy vestibular approach. J Laparoendosc Adv Surg Tech A 2020; 30 (03) 278-283
• 18 Deroide G, Honigman I, Berthe A. et al. Trans oral endoscopic thyroidectomy (TOETVA): first French experience in 90 patients. J Visc Surg 2021; 158 (02) 103-110
• 19 Benhidjeb T, Wilhelm T, Harlaar J, Kleinrensink GJ, Schneider TA, Stark M. Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 2009; 23 (05) 1119-1120
• 20 Wilhelm T, Metzig A. Video. Endoscopic minimally invasive thyroidectomy: first clinical experience. Surg Endosc 2010; 24 (07) 1757-1758
• 21 Wilhelm T, Metzig A. Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg 2011; 35 (03) 543-551
• 22 Benhidjeb T, Stark M. Endoscopic minimally invasive thyroidectomy (eMIT): safety first!. World J Surg 2011; 35 (08) 1936-1937 , author reply 1938–1939
• 23 Karakas E, Steinfeldt T, Gockel A. et al. Transoral thyroid and parathyroid surgery–development of a new transoral technique. Surgery 2011; 150 (01) 108-115
• 24 Park JO, Kim CS, Song JN. et al. Transoral endoscopic thyroidectomy via the tri-vestibular routes: results of a preclinical cadaver feasibility study. Eur Arch Otorhinolaryngol 2014; 271 (12) 3269-3275
• 25 Nakajo A, Arima H, Hirata M. et al. Trans-oral video-assisted neck surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc 2013; 27 (04) 1105-1110
• 26 Wang C, Zhai H, Liu W. et al. Thyroidectomy: a novel endoscopic oral vestibular approach. Surgery 2014; 155 (01) 33-38
• 27 Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. JAMA Surg 2018; 153 (01) 21-27
• 28 Zhang D, Sun H, Kim HY. et al. Bacterial colonization on endoscopic materials and surgical field without infections after transoral endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech 2024; 34 (03) 248-258
• 29 Ngo QX, Ngo DQ, Le DT, Nguyen DD, Tran TD, Le QV. Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: a prospective cohort study. J Minim Access Surg 2024; . Online ahead of print
• 30 Oh MY, Chai YJ, Yu HW, Kim SJ, Choi JY, Lee KE. Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis. Int J Surg 2023; 109 (08) 2467-2477
• 31 Arikan M, Riss P. European TOETVA Study Group. Transoral thyroidectomy: initial results of the European TOETVA Study Group. World J Surg 2023; 47 (05) 1201-1208
• 32 Pradhan S, Fernando DT, Tien A, Wong SL, Yew MK. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): initial experience in Australia. ANZ J Surg 2023; 93 (03) 545-549
• 33 Lee JS, Kim HJ, Lee JS. et al. Prophylactic antibiotics may not be necessary for transoral endoscopic thyroidectomy. Front Surg 2022; 9: 940391
• 34 Zhang D, Fu Y, Dionigi G. et al. Human cadaveric model for studying the preservation of mental nerve during transoral endoscopic thyroidectomy. Surg Radiol Anat 2020; 42 (01) 55-62
• 35 Kim WW, Cho J, Jeon YS. et al. Prospective, randomized, comparative, multicenter study of the hybrid ultrasonic advanced bipolar device and the ultrasonic coagulating shears in open thyroidectomy. Surg Innov 2021; 28 (01) 41-47
• 36 Montori G, Botteri E, Ortenzi M. et al. Systematic review and meta-analysis of the use of high-energy devices for thyroid surgery. Langenbecks Arch Surg 2024; 409 (01) 217
• 37 Chen LW, Assadi N, Hefetz-Kirshenbaum L. et al. Preferences for thyroidectomy technique: comparing traditional and transoral approaches. Head Neck 2021; 43 (06) 1747-1758
• 38 Broekhuis JM, Chen HW, Maeda AH, Duncan S, Grogan RH, James BC. Public perceptions of transoral endocrine surgery and their influence on choice of operative approach. J Surg Res 2021; 267: 56-62