First case report of benign subcutaneous thyroid tissue implantation following transoral endoscopic thyroidectomy vestibular approach (TOETVA).

Background: Following the era of remote access thyroid surgery in the 1990s, several techniques were developed including transoral endoscopic thyroidectomy vestibular approach (TOETVA), which was invented in 2016. TOETVA has gained acceptance and proven comparable results to the conventional open thyroidectomy. Despite the potential complications that may occur as a result of remote access thyroid surgery, such as nerve, vascular, and tracheal injury, seroma, and hypoparathyroidism, there was an extremely rare late complication of a benign subcutaneous thyroid implantation, which have not been reported following TOETVA. Case Description: A 28-year-old female was developed multiple subcutaneous nodules after undergoing right lobe TOETVA for 2 years due to a 3.1 cm benign nodular goiter. The nodules were excised via submandibular incision and the pathological results were shown as benign. Conclusions: Thyroid tissue implantation may result from intracorporeal thyroid tissue rupture, as reported in this research. Extending the vestibular incision to 2-2.5 cm and partially cutting the specimen within the retrieval bag were options to prevent further tissue damage or spillage during specimen extraction. Meanwhile, a separate incision, such as the axillary or submandibular incision, may be required to retrieve the larger nodules. Even though there were no absolute guidelines or contraindications for patient selection in TOETVA, an awareness of tissue breakage should always be considered. The optimal size of the nodule for vestibular removal, which would minimize the risk of tissue breakage, still required additional research.

Seeding recurrence of follicular thyroid carcinoma after transoral endoscopic thyroidectomy vestibular approach: a case report.

Background: While track recurrence of thyroid cancer following endoscopic and robotic transaxillary surgeries has been reported previously, no such cases have been reported for transoral endoscopic thyroidectomy vestibular approach (TOETVA). This case report describes the first documented case of recurrence of thyroid cancer along the surgical track after TOETVA. Case Description: The patient underwent right lobectomy via TOETVA for a 4 cm follicular thyroid carcinoma (FTC) initially diagnosed as benign follicular nodule on preoperative gun biopsy. The thyroid capsule partially ruptured within the surgical field during surgery. Ultrasonography and computed tomography conducted 27 months after surgery revealed seeding recurrence in the postsurgical thyroid bed, and subcutaneous layers of the right lower lip, submental area, and mid to right upper neck levels I, IIA, and VI. Two-stage re-operation was done to perform completion thyroidectomy, lymph node dissection, and excision of recurrent nodules, which were pathologically confirmed as metastatic FTC. The patient underwent two treatments of radioactive iodine therapy, and post-therapeutic whole-body scintigraphy and computed tomography showed no residual disease. Conclusions: Careful monitoring after TOETVA is essential due to the rare but potential risk of seeding recurrence, especially when the thyroid gland ruptures during surgery. Surgeons should be aware of this atypical complication and be prepared to recommend surgical and/or medical strategies to manage any local seeding of thyroid tissue that may occur.

Aesthetic Perceptions Regarding a Thyroidectomy Scar and Transvestibular Approach in Brazil.

OBJECTIVE: We investigated motivation levels across the general Brazilian population and subgroups and their willingness to spend for surgery without a cervical scar. METHODS: This random-sample survey was performed by a specialized third-party research institute. In this study, we created a hypothetical thyroidectomy scenario, and the transcervical and transoral endoscopic thyroidectomy vestibular approach (TOETVA) were used. The survey included sociocultural data and questions regarding participants' surgical preferences. RESULTS: Data were obtained from 1250 participants; 42.4% were of the opinion that a cervical scar affects social or professional life. Young and childless women were most likely to be affected (p <0.001). All respondents accepted the transoral approach to avoid cervical scarring. However, 30.7% and 31.9% of respondents maintained their preference for TOETVA despite understanding the risks of a hypothetical increase in complications and unfavorable oncological outcomes and 98.6% were of the opinion that this approach was likely associated with greater postoperative pain. Only 16.2% were unwilling to spend for TOETVA. The variable that most affected patients' willingness to spend was a salary greater than 10 Brazilian minimum wages (odds ratio 9.797, 95% confidence interval, p <0.005). Upper class respondents were 10 times more likely to spend for TOETVA than lower class patients. CONCLUSION: This study highlights patients' interest in TOETVA. Cervical scar perception is affected by concerned about appearance, particularly in certain societal subgroups. Our study population showed significant motivation to undergo TOETVA, which was emphasized by their acceptance of the complication rate, poor postoperative outcomes, greater postoperative pain, and willingness to spend on surgery with an invisible scar. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3862-3867, 2024.

Comparison of postoperative pain between transoral and conventional thyroidectomy: a propensity score-matched analysis.

BACKGROUND: The extent of postoperative pain following transoral thyroidectomy is not well-understood and remains a subject of debate. This study aims to analyze and compare postoperative pain levels between patients undergoing transoral and conventional transcervical thyroidectomy. METHODS: A prospective evaluation on postoperative pain was conducted in 310 patients undergoing conventional thyroidectomy and 194 undergoing transoral thyroidectomy. Pain levels were evaluated using the numerical rating scale (NRS, ranging from 0 to 10) through preoperative and postoperative questionnaires at specified time points: 1, 3, and 6 days, and 1 and 3 months following surgery. Propensity score-matched analysis was carried out based on six covariates: sex, age, body mass index, extent of thyroidectomy, tumor size, and central neck dissection. RESULTS: After propensity score matching based on the six covariates, 121 patient pairs were identified from each group. Within this matched cohort, postoperative pain scores significantly worsened 1 day after surgery but showed progressive recovery up to 3 months post-surgery in both groups. The transoral group exhibited higher postoperative pain scores than the conventional group from day 1 (4.43 ± 2.6 vs. 3.11 ± 2.5, p < 0.001) to day 6 (1.76 ± 1.9 vs. 1.13 ± 1.6, p = 0.016) post-surgery, with no significant difference noted at 1 month. Among transoral procedures, pain scores were significantly higher for the endoscopic approach compared to the robotic approach on days 1 (5.52 ± 2.3 vs. 4.29 ± 2.3, p = 0.028) and 3 (3.52 ± 2.5 vs. 2.64 ± 2.0, p = 0.047) post-surgery. CONCLUSIONS: Postoperative pain was significantly higher in transoral thyroidectomy compared to conventional thyroidectomy up to 6 days post-surgery. Within the transoral group, the robotic procedure resulted in lower pain levels than the endoscopic approach during the early postoperative period.

Patient-reported swallowing outcomes after transoral robotic thyroidectomy: Comparison with conventional transcervical thyroidectomy.

BACKGROUND: This study aimed to evaluate the swallowing outcomes after transoral robotic thyroidectomy (TORT) and compare them with those of conventional transcervical thyroidectomy. METHOD: We enrolled 146 patients who underwent thyroidectomy (73 TORT; 73 conventional approach). We prospectively analyzed swallowing outcomes using the Swallowing Impairment Index-6 (SIS-6) questionnaire, a patient-reported measure, before and 1, 3, and 6 days; 1, 3, and 6 months; and 1 year after surgery. Propensity score-matched analysis was performed using three covariates: age, sex, and extent of thyroidectomy. RESULTS: SIS-6 scores worsened significantly immediately after surgery and progressively recovered 1 year postoperatively in both groups. Propensity score matching generated two matched groups of 22 patients each. In the propensity score-matched samples, the SIS-6 scores did not differ between the TORT and conventional groups, except at 1 day postoperatively. CONCLUSION: Patient-reported swallowing outcomes of TORT were comparable to those of the conventional transcervical procedure.

Tiroidectomía y paratiroidectomía endoscópica transoral con abordaje vestibular(TOETVA TOEPVA): Experiencia inicial en el Hospital Universitario Austral / Transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA TOEPVA): intial experience in Hospital Universitario Austral

RESUMEN Antecedentes: la cervicotomía de Kocher ha sido el abordaje clásico para la cirugía tiroidea y paratiroidea. El aumento en la preocupación por la cicatriz cervical ha generado un interés creciente por disminuir su tamaño o trasladarla a lugares menos visibles. Anuwong publica 60 casos de TOETVA/TOEPVA en 2016, con resultados óptimos. Objetivos: comunicar la experiencia con la tiroidectomía y paratiroidectomía transoral endoscópica con abordaje vestibular en el Hospital Universitario Austral. Material y métodos: análisis retrospetivo, sobre base prospectiva, de 18 procedimientos, entre mayo de 2019 y marzo de 2020. Se realizaron 2 paratiroidectomías, 13 lobectomías, 4 tiroidectomías totales, una con linfadenectomía central; una paciente presentó 2 patologías (adenoma paratiroideo y nódulo tiroideo). Citología según Bethesda: categoría II: 7; indeterminada: 1 y categoría VI: 9. Resultados: 18 pacientes femeninas. Mediana de edad: 41 años. Media del tamaño nodular: 30 mm. Volumen glandular medio: 24 mL. Conversión: 1 caso. Promedio de tiempo quirúrgico: lobectomía, 260 minutos; tiroidectomía total, 262 minutos. Histología definitiva: carcinoma papilar, 11; bocio nodular, 6; adenoma paratiroideo, 2. Complicaciones: equimosis leve, 12 pacientes; hipoparatiroidismo transitorio, 1 caso; paresia recurrencial transitoria, 1 caso; hiposensibilidad mentoniana transitoria, 1 caso. Dos casos de tiroidectomía total por cáncer: tiroglobulina a las 6 semanas < 0,1 μUI/mL. Conclusiones: 1) Es un abordaje seguro y ofrece resultados cosméticos excelentes. 2) Puede implementarse con equipamiento endoscópico convencional, con curva de aprendizaje corta y escasa morbilidad. 3) Alternativa para el tratamiento del carcinoma papilar de bajo riesgo. 4) Es prioritario garantizar la seguridad del paciente.

ABSTRACT Background: Kocher's cervicotomy has been the classic approach for thyroid and parathyroid surgery. The greater concern about neck scarring has generated an increasing interest in reducing scar size or leaving the scar in less visible places. In 2016 Anuwong published 60 cases of TOETVA/TOEPVA with optimal outcomes. Objectives: The aim of this study is to report the initial experience with transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach in Hospital Universitario Austral. Material and methods: We conducted a retrospective analysis of 18 prospective procedures performed between May 2019 and March 2020. The procedures performed were 2 parathyroidectomies, 13 lobectomies, 4 total thyroidectomies, 1 with central lymph node dissection; one patient presented a parathyroid adenoma and a benign thyroid nodule. Cytology report according to the Bethesda system: category II in 7 cases, VI in 9 and indeterminate in 1. Results: 18 female patients. Median age: 41 years. Mean nodule size: 30 mm. Mean gland volume: 24 mL. Conversion. 1 case. Mean operative time: lobectomy, 260 minutes; total thyroidectomy, 262 minutes. Definite histology: papillary thyroid carcinoma,11; benign nodular goiter, 6; parathyroid adenoma, 2. Complications: mild ecchymosis, 12 patients; temporary hyperparathyroidism, 1 case; temporary recurrent laryngeal palsy, 1 case; temporary numbness of the mental region in 1 case. In the two cases undergoing total thyroidectomy due to cancer, thyroglobulin level 6 weeks after surgery was < 0.1 μIU/mL. Conclusions: 1) The transoral approach is a safe and feasible procedure that offers excellent cosmetic results. 2) It can be implemented using conventional endoscopic equipment, has a short learning curve and low morbidity rate. 3)It constitutes an alternative for the treatment of low-risk papillary thyroid carcinoma. 4) Patient's safety should be guaranteed.

Tiroidectomía transoral endoscópica por abordaje vestibular (TOETVA): primer caso en Perú / Transoral endoscopic thyroidectomy via vestibular approach (TOETVA): first case in Peru

RESUMEN La calidad de vida luego de la cirugía de la glándula tiroides es tan importante como el control de la enfermedad. Para mejorar los resultados cosméticos y la satisfacción del paciente se usan abordajes endoscópicos usando incisiones fuera de la región cervical. La tiroidectomía transoral endoscópica no deja ninguna cicatriz visible en la piel y es una técnica quirúrgica segura. Se presenta el caso de una paciente mujer de 29 años con una tumoración benigna de la glándula tiroides con síntomas compresivos y preocupaciones estéticas, sometida a hemitiroidectomia derecha mediante abordaje transoral vestibular endoscópico en un tiempo de 150 minutos y sangrado mínimo. Los resultados son comparables con la técnica quirúrgica abierta, con un mejor resultado estético y mejora en la calidad de vida.

ABSTRACT Quality of life after thyroid gland surgery is as important as disease control. To improve cosmetic results and patient satisfaction, endoscopic approaches are used using incisions outside the cervical region. Endoscopic transoral thyroidectomy does not leave any visible scarring on the skin. We present the case of a 29-year-old female patient with a benign thyroid gland tumor with compressive symptoms and aesthetic concerns, who underwent a right hemithyroidectomy by means of an endoscopic transoral vestibular approach in a time of 150 minutes and minimal bleeding, without complications in the postoperative period. The transoral endoscopic vestibular approach for endoscopic resection of the thyroid gland is safe and the results are comparable with the open surgical technique, with a better cosmetic result and improved quality of life.

Primera tiroidectomía transoral vestibular endoscópica (TOETVA) en la Argentina / First transoral endoscopic thyroidectomy vestibular approach in Argentina

Se realizó una lobectomía transoral vestibular endoscópica (TOETVA) en una paciente femenina de 53 años interesada particularmente en su resultado cosmético, que presentaba un nódulo de 40 mm en el lóbulo tiroideo izquierdo. Mostró una excelente evolución posoperatoria. Se realizó la revisión de la bibliografía acerca de este abordaje y se informa el primer caso del país.

A 53-year-old female patient with a 40-mm nodule in the left thyroid lobe underwent surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA) because she was particularly interested in the cosmetic results. She evolved with excellent postoperative outcome. We review the literature dealing with this approach and report the first case in our country.

Robotic Transoral Thyroidectomy: Right Thyroidectomy and Ipsilateral Central Neck Dissection with da Vinci Si Surgical System

Transoral approach for thyroidectomy recently gains a lot of attention among the thyroid surgeons, with the merits of cosmetic outcomes and minimal flap dissection. We've successfully introduced the robotic surgical system to the transoral approach for thyroidectomy. For transoral robotic thyroidectomy, we made 3 incisions in the gingival-buccal sulcus for three intraoral ports. An additional axilla port was inserted for counter-traction and later drain insertion. Herein, our unique procedures of transoral robotic thyroidectomy (TORT) are described in the treatment of a patient with papillary thyroid carcinoma.

Robotic transoral thyroidectomy for papillary thyroid carcinoma

Transoral robotic thyroidectomy (TORT) is well consistent with the primary goal of remote-access thyroid surgery, which is to avoid a visible cervical scar. Additionally, the extent of transoral thyroidectomy dissection is less than that of other remote-access surgical procedures. Owing to these merits of the transoral approach, several institutions around the world are now performing this procedure. Since transoral thyroidectomy is performed in a confined, narrow space, and is characterized by a close distance from the ports to the working space, more benefits can be derived from multiarticulation of robotic instruments. Especially when performing left lobectomy by TORT, the surgeon can use right-handed robotic instruments over the thyroid cartilage with the merits of multiarticulation. In this study, we present our unique procedure of left lobectomy by TORT in detail.

Transoral Robotic Thyroidectomy

Transoral approach for thyroidectomy recently gains a lot of attention among the thyroid surgeons, with definite merits over previously developed remote-access approaches. The approach not only resulted in the ideal cosmetic outcome but less postoperative pain with smaller dissection plane in comparison with other approaches. We have successfully introduced the robotic surgical system and its related techniques to this transoral surgical approach for thyroidectomy, which enables the surgeon to have the three-dimentional operative vision and to use the articulating instruments to enhance th eoptimal surgical outcomes. Herein, our unique procedures of transoral robotic thyroidectomy (TORT) are described, and possible advantages and disadvantages of the operation are discussed.

Transoral Endoscopic Thyroid Surgery: Indication, Preparation and Surgical Technique / 대한이비인후과학회지

Natural orifice transluminal endoscopic surgery (NOTES) is the latest surgical technique for inserting an endoscope through the mouth, anus, vagina etc., and for performing surgery with mucosal incision only, i.e., without skin incision. Recently, a number of researchers have applied NOTES to thyroid surgery in several trials, with the aim of removing the thyroid gland through oral cavity. The transoral endoscopic thyroid surgery became widely known after Anuwong et al. reported successful results for their first 60 patients and it has become increasingly recognized as a feasible novel surgical procedure. The purpose of this article is to review and summarize the existing literature, and describe in detail the preoperative considerations, rationale for patient selection, surgical method and postoperative management for transoral thyroid surgery.