Balloon Dilators for Fast and Safe Flap Dissection in Transoral Endoscopic Vestibular Approach Thyroidectomy Vestibular Approach (TOETVA)

Abstract

Purpose: Creating working space while performing thyroid surgery via a transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be technically challenging. We describe our experiences using a balloon dilator for easy and rapid flap dissection during TOETVA. Methods: The medical records of patients who underwent surgery for thyroid diseases via a TOETVA were retrospectively reviewed and divided into two groups: the Routine group included patients who underwent routine flap dissection using conventional laparoscopic instruments without the use of a balloon dilator, and the Spacemaker group included patients who underwent flap dissection using a balloon dilator. The working space formation time, defined as the time from first insertion of an instrument into a trocar until the time of the completion of working space formation, and clinical outcomes were analyzed and compared between groups. Results: A total of 39 patients (6 males and 33 females) were included in the study, with 26 patients in the Routine group and 13 patients in the Spacemaker group. There were no differences in patient demographics between groups. Flap dissection time was significantly longer in the Routine group compared to the Spacemaker group (8.0±2.8 minutes vs. 5.3±2.1 minutes, P=0.004). No excessive bleeding events or conversion to open surgery occurred during surgery in either group. There were also no postoperative bleeding events or infections in either group. Conclusion: Balloon dilators can provide a fast, efficient, and safe flap dissection method for working space formation during thyroid surgery with TOETVA.

Comparison of surgical outcomes of transoral robotic and endoscopic thyroidectomy: A systematic review and network meta‐analysis

“…This is consistent with previous studies. 21,22 As is already known, the longer operative time for TORT may be attributed to the time required for placing robotic arms, exchanging robotic devices, and setting up the working space, compared to TOETVA or conventional thyroidectomy. 10,18 In terms of complications, our findings showed that RLN palsy, hypoparathyroidism, and total complication rates of the CTT group did not differ compared to the two transoral approaches, indicating that the transoral approaches using surgical robots or endoscopy seem to be safe and comparable to the conventional approach.…”

“…A recent study employed direct pairwise meta-analyses to compare TOETVA and TORT. 21 However, this meta-analysis was limited in scope, as it included only a small number of original studies and relied solely on direct evidence, potentially leading to estimation bias due to a lack of information from indirect comparisons without necessarily considering all differences. Another study indirectly compared TOETVA and TORT through CTT and nine other remote-access and minimally invasive approaches using a network meta-analysis but did not include direct comparison.…”

Prince and princesses: The current status of robotic surgery in surgical oncology

“…143,146 In a meta-analysis comparing the two approaches, TOETVA was associated with a shorter operative time and a higher rate of transient recurrent laryngeal nerve palsy, but there was no significant difference in LN harvest, postoperative pain, LOS, or other postoperative complications. 147 There remains a need for large scale trials comparing the two approaches to see if improved visualization with the robot provides any advantage to TORT.…”

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

“…In addition, tracheal perforation by a Veress needle puncture has been reported [ 38 ]. Therefore, some surgeons prefer using needles with a small caliber (e.g., 22-gauge spinal needle) for hydrodissection [ 45 , 47 ]. Thin needles are difficult to control when approaching deeper spaces.…”

“…Balloon dilatation with a balloon in the Foley catheter [ 50 ], cuff in the endotracheal tube [ 51 ], and commercialized balloon dilator device [ 47 , 52 ] are also alternative options used by some surgeons. With the balloon inflation pressure, it is easier to create a homogenous space with a clear tissue plane and achieve good hemostasis [ 50 ].…”