Use of fluorescence imaging and indocyanine green during thyroid and parathyroid surgery: Results of an intercontinental, multidisciplinary Delphi survey.

BACKGROUND: In recent years, fluorescence imaging-relying both on parathyroid gland autofluorescence under near-infrared light and angiography using the fluorescent dye indocyanine green-has been used to reduce risk of iatrogenic parathyroid injury during thyroid and parathyroid resections, but no published guidelines exist regarding its use. In this study, orchestrated by the International Society for Fluorescence Guided Surgery, areas of consensus and nonconsensus were examined among international experts to facilitate future drafting of such guidelines. METHODS: A 2-round, online Delphi survey was conducted of 10 international experts in fluorescence imaging use during endocrine surgery, asking them to vote on 75 statements divided into 5 modules: 1 = patient preparation and contraindications to fluorescence imaging (n = 11 statements); 2 = technical logistics (n = 16); 3 = indications (n = 21); 4 = potential advantages and disadvantages of fluorescence imaging (n = 20); and 5 = training and research (n = 7). Several methodological steps were taken to minimize voter bias. RESULTS: Overall, parathyroid autofluorescence was considered better than indocyanine green angiography for localizing parathyroid glands, whereas indocyanine green angiography was deemed superior assessing parathyroid perfusion. Additional surgical scenarios where indocyanine green angiography was thought to facilitate surgery are (1) when >1 parathyroid gland requires resection; (2) during redo surgeries, (3) facilitating parathyroid autoimplantation; and (4) for the predissection visualization of abnormal glands. Both parathyroid autofluorescence and indocyanine green angiography can be used during the same procedure and employing the same imaging equipment. However, further research is needed to optimize the dose and timing of indocyanine green administration. CONCLUSION: Though further research remains necessary, using fluorescence imaging appears to have uses during thyroid and parathyroid surgery.

Modified Larssen solution (MLS)-fixed cadaver model for transoral endoscopic thyroidectomy vestibular approach (TOETVA) education: a feasibility study.

BACKGROUND: Training formats for transoral endoscopic thyroidectomy vestibular approach (TOETVA) are limited. Our aim was to create and investigate a TOETVA training model for general and ENT surgeons. METHODS: A total of 15 modified Larssen solution (MLS) human cadavers were used in the study. A day duration TOETVA human cadaver workshops were offered in two years consecutive. Post-training verbal and online questionnaires were applied to all trainers to evaluate course structure and program, organoleptic characteristics of MLS-fixed human cadavers, and TOETVA training effectiveness. Cost assessment is included in the study. RESULTS: Ninety-eight participants, i.e., 14 trainers and 84 hands-on (HO) and observer (OB) trainees, attended the workshops, completed the tasks assigned, and fulfilled the questionnaires. Implementation of all steps of TOETVA was approved positively by 89.8% of all participants, 94.4% of HO, and 83.3% of OB trainees. Regarding human cadaver and teaching quality, 10.8 ± 0.8 (10-12) human cadavers were "practical" by 13.2 (94.5%) of the trainers, and by 33.3 (92.5%) of the trainees for all steps of TOETVA. The cadavers were stored for 4.53 years and used 6.27 times repeatedly for endoscopic workshops and research studies. TOETVA workshop cost with repeatable use of MLS-fixed human cadaver is half of other performed TOETVA workshops. CONCLUSIONS: A TOETVA human cadaver workshop model has not been reported yet. Our findings suggest the feasibility of MLS-fixed human cadaver model for training of TOETVA, preserve the organoleptic properties necessary for the implementation of surgical steps, and reduce the cost.

Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series.

INTRODUCTION: A cervical scar has been shown to have an impact on the quality of life of children undergoing thyroid surgery. Transoral endoscopic vestibular thyroidectomy via the vestibular approach (TOETVA) offers the absence of a cutaneous incision, and has not been described to date in the pediatric population. OBJECTIVE: To describe the first series of TOETVA in a pediatric population. PATIENTS AND METHODS: A retrospective, multicenter study, including all patients > 18 years old who underwent TOETVA. Data was prospectively collected and included demographics, preoperative ultrasound, cytology and indications for surgery. Intraoperative parameters included length of surgery and complications, with final pathology and postoperative course also reviewed. TOETVA surgical success was defined as completion of surgery via this approach. RESULTS: Forty-eight children were included. Of these, 43 (89.5%) were girls. The median age was 16 years (range 10-17). The most common indication for surgery was a benign thyroid nodule (n = 26, 54.1%). Eleven patients (22.9%) had papillary thyroid carcinoma on final pathology, of which 90.9% (10/11) were diagnosed pre-operatively based on FNA cytology. Hemithyroidectomy was performed in 36 patients (75%). All surgeries were completed endoscopically. The mean malignant tumor size was 1.4 ± 0.4 cm and all tumors were completely excised with clean margins. No permanent complications were documented. A single patient (2.1%) had transient RLN injury (1.6%, 1/60 nerves at risk). Transient hypocalcemia was documented in 4 of the 12 patients undergoing total thyroidectomy (33.3%). Transient mental nerve injury/chin hypoesthesia was documented in 2 patients (4.2%). CONCLUSIONS: TOETVA appears to be a feasible and safe approach for thyroidectomy in the pediatric population in carefully selected cases, and may be discussed with patients and parents as an alternative for the trans-cervical approach.

One hundred and one consecutive transoral endoscopic parathyroidectomies via the vestibular approach for PHPTH: a worldwide multi-institutional experience.

IMPORTANCE: The transoral vestibular approach for thyroid and parathyroid surgery is being adopted rapidly world-wide. Currently there is a paucity of information on this approach for primary hyperparathyroidism (PHPTH). If this approach is safe and efficacious it would provide patients a completely scarless option for parathyroidectomy. OBJECTIVE: To determine whether parathyroidectomy via the transoral vestibular approach can be successfully done in a safe and efficient manner. DESIGN: Consecutive case series of 101 transoral parathyroidectomies performed over a two-year period. SETTING: Multi-institutional, academic, high-volume transoral thyroidectomy centers from the USA, Israel, and Thailand. PARTICIPANTS: A consecutive series of adult patients with a biochemical diagnosis of classic PHPTH and who met criteria for parathyroidectomy based on established international consensus for surgery for PHPTH. All patients also had well-localized single adenomas on at least two preoperative imaging studies. INTERVENTION: Transoral endoscopic parathyroidectomy vestibular approach. MAIN OUTCOMES AND MEASURES: Surgical success rate defined by immediate intra or post-operative return to normal PTH values. Surgical complications including recurrent laryngeal nerve injury, permanent hypoparathyroidism, and infection. RESULTS: Of the 101 consecutive transoral parathyroidectomy patients 84% were female with an average age of 54.23 ± 11.0 years and an average BMI of 27.35 ± 6.19. Ninety-nine out of the 101 patients had immediate return to normal PTH after resection for a surgical success rate of 98%. There were no permanent recurrent laryngeal nerve injuries, one temporary nerve palsy, and no permanent hypoparathyroidism. The median operative time dropped from 130.5 min (IQR 86) to 66.5 min (IQR 56) between the first- and second-half of cases. CONCLUSION AND RELEVANCE: Transoral endoscopic parathyroidectomy via the vestibular approach is a scarless method of removing parathyroids that is clinically feasible, safe, and efficacious and is a reasonable option for focused minimally invasive parathyroidectomy that can be offered to select patients with PHPTH.

Transoral endoscopic vestibular approach for thyroidectomy and parathyroidectomy - From promise to practice.

OBJECTIVES: To describe the evolution and recent series on transoral endoscopic vestibular approach thyroidectomy and parathyroidectomy (TOET/PVA). DATA SOURCES: PubMed, Google Scholar. REVIEW METHODS: Review of the available English literature. RESULTS: TOET/PVA may offer several advantages over other remote access thyroidectomy approaches and has been adopted by many centers worldwide with excellent success rates. Indications include benign disease and early thyroid cancer patients. Complication rate is comparable to the trans-cervical approach. The suggested framework has been validated in recent studies and its feasibility confirmed. CONCLUSION: TOET/PVA has now been used to treat thousands of patients worldwide due to low cost, short learning curve and excellent cosmetic outcomes. Further studies will be necessary to demonstrate oncologic non-inferiority and also the true value that is added by the approach.

Transoral robotic thyroidectomy versus transoral endoscopic thyroidectomy: a propensity-score-matched analysis of surgical outcomes.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been shown to be safe and has similar outcomes as open thyroidectomy for selected patients. It is not clear if transoral robotic thyroidectomy (TORT) may extend transoral endoscopic thyroidectomy to more complex thyroid operations. The study aimed to compare the safety and outcomes of TORT with those of TOETVA. METHODS: We retrospectively reviewed all patients who had TORT and TOETVA performed by a single surgeon from June 2017 to May 2019. Intrathoracic goiter and combined operations were excluded. Surgical outcomes were compared after propensity score matching. Learning curves, as measured by operating time, were evaluated. RESULTS: A total of 150 patients underwent 154 transoral (55 TORT and 99 TOETVA) thyroidectomy. Of the 154 operations, 28 (18.2%) were bilateral total thyroidectomy and 126 (81.8%) were unilateral thyroid lobectomy. After propensity score matching, we found a longer operative time (median [interquartile range]) for TORT (n = 53) than for the TOETVA (308 [284-388] vs 228 [201-267] min, P < 0.001). Blood loss and visual analog scale scores for pain were not significantly different between the two groups. Central neck lymph node dissection was performed more frequent in the TORT group (28 of 53 [52.8%] vs 10 of 53 [18.9%], P = 0.001), and when performed, the numbers of total and positive lymph nodes did not differ significantly between the two groups. The rates of hypoparathyroidism and recurrent laryngeal nerve injury did not differ significantly between the two groups. There was no conversion to open thyroidectomy, mental nerve injury, or surgical site infection. The learning curve for TORT was 25 cases, but no obvious learning curve was observed for TOETVA. CONCLUSIONS: TORT requires a longer operative time, but is as safe as TOETVA and may be useful for more complex thyroid operations.

The role of surgeon-performed ultrasound in transoral endoscopic thyroidectomy vestibular approach (TOETVA).

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a recently described surgical technique where the thyroid and central neck can be accessed without a cutaneous incision. To date nearly 700 cases have been described within the English literature demonstrating the feasibility, safety, and efficacy of the technique. As more institutions begin to adopt the surgical approach, it is important that surgeons pay close attention to appropriate patient selection and surgical optimization to prevent experience-related complications. A valuable tool to facilitate these considerations is the utilization of surgeon-performed ultrasonography (US). While the merits of surgeon-performed US are well-documented within head & neck endocrine surgery as a whole, its value may be of even greater importance when implementing a novel surgical technique such as TOETVA. Here we highlight and summarize the role of surgeon-performed US within head & neck endocrine surgery, focusing on how it may influence patient selection and surgical planning with TOETVA.

Lessons Learned from the Transoral Endoscopic Thyroidectomy with Vestibular Approach (TOETVA) for the Treatment of Thyroid Carcinoma.

BACKGROUND: Early detection of thyroid carcinoma has become commonplace. Consequently, the endoscopic approach has become a widely used method. OBJECTIVE: Our aim was to report our experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). METHODS: We reviewed the records of 46 patients who underwent TOETVA. Only patients with no regional lymph node metastases (N0) and fine needle aspiration biopsy-confirmed thyroid cancer were included. The surgical technique used was as described by Angkoon Anuwong. RESULTS: Forty-six patients with a mean age of 43.6 years (range 17-71) were included (37 women and 9 men). The mean time of surgery was 207 min (range 95-345), and the conversion to open thyroidectomy rate was 13% (six cases). CONCLUSION: TOETVA is an acceptable approach for thyroid carcinoma. Poorly differentiated cancer, as well as extrathyroidal extension, result in patients being unsuitable for TOETVA. It is imperative to identify the circumstances under which conversion to open thyroidectomy must take place.

Indications, benefits and risks of transoral thyroidectomy.

The advancement of minimally invasive surgery in the field of endocrine surgery over the last 2 decades has fostered the attempt of natural orifice transluminal endoscopic surgery (NOTES) for thyroidectomy and parathyroidectomy via oral incisions. This technically demanding surgery is currently being evaluated in a number of specialised centres. The procedure has gained popularity worldwide and is performed in more than 50 centres. By retrieving information from published or presented articles and direct personal communications, this study reports several issues to enable and optimise correct patient and surgeon candidacy, present the advantages and prevent novel complications under the standards of open thyroid surgery. Not all patients are eligible for the transoral approach. Transoral endoscopic and robotic procedures were described and critically analysed in this study.

Transoral endoscopic thyroid surgery in a Korean population.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach is expected to be a safe alternative to open surgery for certain patients and has been used increasingly by several surgeons around the world for the past 2 years. The purpose of this paper is to review our 2-year experience and describe in detail our preoperative considerations, patient selection, operating room settings, anesthetic considerations, surgical technique, postoperative management, and outcomes. METHODS: We reviewed the medical records of 65 consecutive patients who underwent transoral endoscopic thyroidectomy between July 2016 and May 2018 in our hospital. RESULTS: We have performed 65 thyroid surgeries (54 thyroid lobectomies, 1 completion thyroidectomy, and 10 total thyroidectomies) in 64 patients. Postoperative pathology revealed papillary carcinoma in 55 patients (84.6%), follicular carcinoma in two (3.1%), hyalinizing trabecular tumor in one (1.5%), and other benign tumor in seven (10.8%). All surgical margins were negative. Two (3.1%) patients developed transient vocal cord palsy but recovered within 2 months. One (1.5%) patient with vocal cord palsy had not recovered by 3 months after surgery. Five (7.7%) patients who underwent total thyroidectomy developed transient hypocalcemia but recovered within 2 months. CONCLUSION: Although transoral thyroid surgery is a relatively recent technique requiring further validation, it affords several advantages. Transoral thyroid surgery has not yet been universally accepted, but may be the best choice for thyroid surgery in the future.

Transoral Robotic Thyroidectomy Versus Conventional Open Thyroidectomy: Comparative Analysis of Surgical Outcomes in Thyroid Malignancies.

Background: Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT). Methods: We retrospectively reviewed and compared the medical records of consecutive patients who underwent TORT or OT for thyroid carcinoma from April 2016 to March 2017. Results: The study included 205 patients who underwent TORT (n = 100) or OT (n = 105). Mean tumor size was 0.9 cm in both groups. The two groups showed similar surgical outcomes, except for a longer operative time for TORT. Conclusions: TORT could be performed safely and had comparable surgical outcomes with OT in the selected patients. TORT may be considered a suitable operative alternative for patients who do not want to leave scars on the neck.

Transoral Endoscopic Thyroidectomy for Thyroid Cancer.

The prevalence of low-risk differentiated thyroid cancer (DTC) is dramatically increasing because of superior diagnostic imaging technologies. Remote-access endoscopic thyroidectomy is becoming more popular for the lack of a noticeable neck scar. Transoral endoscopic thyroidectomy, vestibular approach (TOETVA) is the only technique that could be called a true scarless surgery; however, there is a scarcity of long-term studies about its safety and feasibility. Because thyroid cancer is a slow-growing lesion, with adequate follow-up and surveillance, TOETVA is a surgical procedure for the management of low-risk DTC without any difference of surgical and oncological outcome.

Transoral thyroidectomy with a next generation flexible robotic system: A feasibility study in a cadaveric model.

BACKGROUND: Transoral endoscopic thyroidectomy provides access via the oral vestibule and gas insufflation to provide reliable remote access surgery to perform a total thyroidectomy. The da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a next generation flexible single port system that offers unique advantages over previous robotic rigid systems. Here we sought to evaluate the feasibility of performing transoral thyroidectomy with this next generation flexible robotic system. METHODS: Cadaveric dissection with gas insufflation to test the feasibility of performing transoral thyroidectomy with the da Vinci SP. RESULTS: A 2 cm incision was made in the oral vestibule and the working space created with a 1cm central port and two lateral 5 mm ports. Then an extra small wound protector (Applied Medical, Rancho Santa Margarita, CA) was placed through the central incision after closure of the 5 mm ports. The robotic system was then deployed through the wound protector while insufflation was maintained at ~6 mmHg. Three instrument arms were deployed. A fenestrated bipolar was used to grasp the thyroid gland while Maryland bipolars and monopolar scissors were used to mobilize each hemi lobe of the thyroid. The recurrent laryngeal nerves were seen and preserved bilaterally. After completion of the surgery and removal of the wound protector the vestibular incision was measured to be 3 cm. Further dissection to identify the mental nerves identified each nerve to be >1 cm from the lateral extent of the central incision. CONCLUSIONS: In summary, it is feasible to perform a total thyroidectomy with gas insufflation utilizing this next generation flexible robotic system. Further evaluation will be needed to validate the clinical applicability of this technique.

How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach.

BACKGROUND: Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. METHODS: The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. RESULTS: Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. CONCLUSIONS: The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.

Lessons Learned From a Faulty Transoral Endoscopic Thyroidectomy Vestibular Approach.

BACKGROUND: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is currently considered the most promisingly scarless approach to the thyroid and has gained more acceptance. MATERIALS AND METHODS: We described a case of faulty TOETVA. RESULTS: The faulty TOETVA resulted in pneumomediastinum, diffuse subcutaneous emphysema, prolonged surgery, and anesthesia. CONCLUSIONS: The important technical considerations during TOETVA, including the use of external retraction, the identification of the subplatysmal plane of dissection, CO2 insufflation settings, the learning curve, and patient selection, were described and discussed.