Feasibility and Safety of Ambulatory Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)

Abstract

Background In search of an ideal cosmesis, transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has recently been introduced to avoid a visible scar. Although ambulatory thyroid surgery is considered safe in carefully selected patients, this remains unclear for TOETVA. Methods All consecutive adult patients who underwent ambulatory TOETVA or open thyroid surgery at a French university hospital were prospectively enrolled from 12/2020 until 11/2021. The primary outcome was postoperative morbidity (recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, wound morbidity, or hospital readmission). The secondary outcome was quality of life (QoL), measured by a survey including a validated questionnaire (SF-12) and a modified thyroid surgery questionnaire six weeks after surgery. Results Throughout the study period, 374 patients underwent a unilateral lobectomy or isthmectomy in ambulatory setting, of which 34 (9%) as TOETVA (including 21 (62%) for a possible malignancy). In the TOETVA group, younger age (median 40 vs. 51 (40-60) years, P \ 0.001) and lower BMI (median 23.1 (20.9-25.4) vs. 24.9 (22.1-28.9) kg/m 2 , P = 0.001) were noted. No cases were converted to open cervicotomy. TOETVA was at least as good as open cervicotomy with nil versus four (1%) re-interventions for bleeding, one temporary (5%) versus 13 (4%) (temporary) RLN palsies, and one (\1%) wound infection (open cervicotomy group). No hospital readmissions occurred in all ambulatory surgery patients. No differences were found in physical (P = 0.280) and mental (P = 0.569) QoL between TOETVA and open surgery. Conclusions In carefully selected patients, the feasibility and safety of ambulatory TOETVA are comparable to open surgery.

The safety, benefits and future development of overnight and outpatient thyroidectomy

“…A total of 374 patients were recruited and divided into a TOETVA group and an open surgery group. There was no difference in physical and mental scores of QoL or postoperative complications compared with inpatient surgery ( 14 ). Zhang et al.…”

“…There are also subtle differences in preoperative patient selection between different surgical approaches, with TOETVA requiring thyroid nodules volume<45 ml and/or nodule diameter<50 mm. Cytological examination Bethesda grade less than grade 4, or nodules less than 2 cm in the case of Bethesda grade ≥ 5, and no lateral lymph node spread or mediastinal metastasis ( 14 ). The exclusion criteria for patients with ETCBA were lateral lymph node metastasis ( 15 ).…”

“…In addition to routine preoperative preparation for surgery, all patients underwent preoperative neck ultrasound to assess thyroid nodule size and lymph nodes before surgery. Some medical institutions will perform ultrasound-guided fine-needle aspiration and pathological classification of patients with suspicious nodules ( 14 , 15 ). Different approaches of overnight endoscopic thyroidectomy have different requirements for preoperative preparation.…”

Preoperative application of carbon nanoparticles in transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer

“…Due to less scarring in the neck, endoscopic thyroid surgery techniques including the transoral approach and the bilateral axillo-breast approach have been used all over the world ( 13 ). The transoral approach does not cause scarring in the skin and requires a smaller subcutaneous flap elevation than the bilateral axillo-breast approach; therefore, TOETVA attracted the attention of both surgeons and patients ( 3 ). A previous study showed that central lymph node metastasis occurred in nearly half of the patients and prophylactic central lymph node dissection was performed to reduce its recurrence ( 14 ).…”

“…Papillary thyroid carcinoma is the most common endocrine tumor worldwide ( 1 , 2 ). The transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides easy access to the thyroid and central compartment and avoids skin scarring during thyroid surgery, which makes it a widely popular option in thyroidectomy ( 3 ).…”