Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review

Abstract

This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.

Standardized Intraoperative Neuromonitoring Procedure is Feasible in Transoral Endoscopic Thyroidectomy

“…We showed that 2 of the 43 nerves at risk (4.65%) experienced transient RLN injuries without permanent injuries. This is within the lower range of transient RLN injury incidences reported by a recent systematic review (transient RLN injury range: 0.94 to 22.2%; permanent RLN injury range, 0.59 to 1.42%) 20…”

“…This is within the lower range of transient RLN injury incidences reported by a recent systematic review (transient RLN injury range: 0.94 to 22.2%; permanent RLN injury range, 0.59 to 1.42%). 20 The transient injuries in the present study were caused by the 2 most prevalent causes of RLN injury: thermal and traction injury. 21 Thermal injury of the RLN occurs due to lateral thermal spread or direct contact with electrocautery or energy-based devices.…”

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

“…While sensory changes in the lower lip and chin can be attributed to mental nerve injury, the sensation of the neck is not innervated by the mental nerve, and its alteration is more likely caused by damage that occurs during working space creation. Some patients would feel tightness along the surgical tract that clench their neck and make them unable to raise their heads [ 7 , 41 ]. This so-called pulling sensation is probably caused by fibrosis and adhesion formation of the skin flap.…”

“…In transoral thyroidectomy, developing a working space through three small incisions in the oral vestibule is the core feature of this procedure and is the most challenging part for beginner surgeons who are trying to learn this technique. Many complications that occur during this step are rare or unprecedented in open thyroidectomy, such as carbon dioxide (CO 2 ) embolism, mental nerve injury, drooling, and skin flap perforation [ 7 , 8 ].…”

Management of haematoma after transoral endoscopic thyroidectomy via vestibular approach

“…Intra‐operative use of indocyanine green may assist in identifying the parathyroid glands and assess their viability and blood supply [3, 4]. A meta‐analysis reported an overall surgical trauma‐related complication rate of 2.91% (most commonly emphysema (n = 11), haematoma (n = 10) and seroma (n = 36)) [5], and although findings were limited by the relatively low number of patients included in the available studies (n = 1776), no fatality was reported. Because TOETVA uses an oral vestibular approach, the recommendations by Illif et al.…”