Transoral endocrine surgery: Considerations for adopting a new technique

Abstract

Transoral endocrine surgery encompasses a group of operations whereby the thyroid or parathyroid gland is removed through the oral vestibule. This operation has the advantage of leaving no cutaneous scar and a risk profile similar to open surgery. Adoption of this technique has increased dramatically over the last several years. It is of paramount importance for surgeons to undergo adequate training before adopting this technique. K E Y W O R D S endoscopic parathyroidectomy, endoscopic thyroidectomy, minimally invasive surgery, remote access surgery, transoral endocrine surgery, transoral parathyroid surgery, transoral thyroid surgery 1 | INTRODUCTION In the early 1900s, Kocher documented the open surgical approach to thyroidectomy using a transverse cervical incision. 1 This approach persisted as the gold standard operation for thyroidectomy for more than a century. However, over the last two decades, there has been a dramatic rise in alternatives to the conventional transcervical Kocher approach with the goal to avoid leaving a visible scar on the neck. Broadly speaking, these approaches include remote access through axillary incisions, periariolar incisions, and retroauricular incisions and more recently, incisions in the lower lip. Transoral endocrine surgery (TES) encompasses a group of operations that can be performed using the Transoral Endoscopic Vestibular Approach. While the former three remote access approaches have been present for over two decades, they have failed to gain general popularity for several reasons. First, all three earlier remote access sites are associated with morbidity not seen in the standard open approach, such as axillary abscesses and possible paresthesia along with the dissection flaps. Second, axillary, periareolar and retroauricular approaches all require extensive flap dissection far greater than those created in open thyroid and parathyroid surgery. Finally, they still require a cutaneous incision which leaves a scar, albeit in less visible locations. 2,3 In 2011, Richmond et al, 4 published the first report of removing the thyroid gland via the oral vestibule in two cadavers. 4 Five years later, Anuwong published the first series of 60 consecutive endoscopic thyroidectomies via the vestibular approach in humans. 5 A subsequent landmark article from Anuwong in 2018 showed that endoscopic vestibular approach outcomes were equivalent to the standard open operation. 6 Anuwong termed this approach TransoralEndoscopic Thyroidectomy Vestibular Approach (TOETVA). The approach has since been used for parathyroidectomies, lymph node dissections, and has also been done with robotic assistance. TES is an all-encompassing term that describes any of these neck operations being done via the oral vestibule. Since the first case series by Anuwong was published, there has been a rapid rise in attention to this new approach in the endocrine surgery community and has been explored and adopted throughout the world with enthusiasm not seen with previous remote access techniques. There are sever...

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

“…Other exclusion criteria contain ongoing oral infection and poorly differentiated cancer. Operation in patients with prior neck surgery, previous head and neck irradiation, or extensive thyroiditis are technically demanding and are relatively contraindicated [ 15 , 16 ].…”

“…Hence, some surgeons prefer deeper dissection at the periosteum level of the mandible ( Figure 4 ) [ 16 , 39 , 43 ]. Dissection through this layer goes underneath the mentalis muscle, and the muscle can be mostly preserved, decreasing the associated risk of muscle bleeding [ 43 ].…”

“…The commonly used dissectors in transoral thyroidectomy are blunt tip straight rods [ 18 , 48 ] or Hegar dilator [ 16 , 49 ]. Hegar dilator is a slightly curved metal rod, which may be easier to apply when passing through the concave surface between the chin and neck.…”

Novel Approaches for Treating Autonomously Functioning Thyroid Nodules

“…Surgical removal of AFTN is a recognized indication for TOETVA ( 31 ). Due to the novelty of this approach and low incidence of AFTN, the data regarding resection for AFTN is limited.…”

NOTES revisited

“…Endocrine surgeons have been performing laparoscopic and robotic transoral thyroidectomy, and the main benefit of the approach is the absence of a neck scar. 10 Yet, the new approach also brings about new risks, including a higher risk of mental nerve injury, chin flap perforation, and oral commissure or inferior labial frenulum tear. Thus, to translate flexible endoscopic transoral thyroidectomy into human application, the endoscopist will need to become familiar with the neck anatomy to avoid potential adverse events.…”