BACKGROUND: Many remote-access approaches (RAAs) to the thyroid have been described to circumvent anterior neck scarring, including the transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. These techniques have been popularized in Asia, but adoption has been slow in North America. We aimed to examine multi-institutional North American outcomes with RAA thyroidectomy in the context of these institutions' transcervical approach (TCA) outcomes. STUDY DESIGN: Cases of lobectomy and total thyroidectomy via transaxillary, robotic facelift, and transoral endoscopic vestibular approaches were reviewed. Demographic characteristics, outcomes, and complications were compared with the same measures in patients undergoing lobectomy and total thyroidectomy via TCA by the primary RAA surgeons at each institution. Patients who underwent parathyroidectomy or other concomitant neck dissection procedures were excluded. RESULTS: Two hundred and sixteen RAA thyroidectomies were attempted (92 transoral endoscopic vestibular approaches, 70 transaxillary, and 54 robotic facelift) and 410 TCA thyroidectomies were performed. There was no difference in mean index nodule sizes between RAA (2.8 ± 1.6 cm) and TCA (2.9 ± 1.9 cm) cohorts (p = 0.72). Median operative times for

Objective To define the learning curve for transoral endoscopic thyroidectomy via the vestibular approach (TOETVA). Study Design Case series with planned data collection. Setting Tertiary care academic hospital. Subjects and Methods Included patients were those who met the 2015 American Thyroid Association guidelines for lobectomy and our group's previously documented indications for TOETVA. Operative time (incision to closure) was used as a surrogate for procedural proficiency and plotted as a function of case number to determine a learning curve. A simple moving average of operative time was then calculated, with the proficiency case defined as the case number where the slope of this curve changed. Demographic/characteristic data, outcomes, and complications were compared between the skill acquisition period (case 1 to proficiency case) and the proficiency period (remaining cases). A linear regression model was then used to calculate and compare the slopes of the skill acquisition and proficiency periods in the "operative time versus case number" plot. Results Thirty cases were attempted, with a procedural success rate of 29 of 30 (94%) and no incidence of permanent mental nerve or recurrent laryngeal nerve injury. The proficiency case was case 11. There was a statistically significant difference between the skill acquisition and proficiency periods in slopes of the linear regressions (-16.7 vs -0.3, respectively; P < .001) and median operative times (191 vs 119 minutes, P < .001). There was no difference in demographics, procedural success rate, or complication rate between the periods. Conclusions The learning curve for TOETVA was 11 cases for the surgeon evaluated in this series.

Key Points Question What proportion of patients who present for thyroid or parathyroid surgery are eligible for a scarless transoral operation based on currently accepted exclusion criteria? Findings In this cross-sectional study of 1000 surgical patients across 3 US academic medical centers, 558 patients (55.8%) who underwent thyroid or parathyroid surgery would have been eligible for a scarless transoral approach. Meaning Transoral endocrine surgical procedures are more broadly applicable to patients undergoing thyroid and parathyroid surgery than previously thought, and definitive studies on the safety, efficacy, and cost of the transoral approach are warranted.