Transoral endoscopic thyroidectomy using vestibular approach

Abstract

Background: Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique. Materials and Methods: We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel. Results: From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline. Conclusion: Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

Transoral thyroidectomy - Breaking new grounds??

“…Transoral thyroidectomy is the latest natural orifice approach to the thyroid which espouses cosmesis. The present issue of the journal has published an article which is a single-center initial experience in the Indian setting[ 1 ] using the standard three-port transvestibular technique with CO 2 insufflation.…”

“…The thyroidectomy saga has also advanced similarly. These surgeons[ 1 ] are early adopters of technology and from a tertiary referral centre; which augers well for teaching and training of future surgeons.…”

“…The concept of transoral thyroidectomy popularized by Dr. Angkoon Anuwong from Thailand[ 6 ] began with sublingual access but has now evolved into the safer transvestibular oral route, which the authors[ 1 ] have implemented in their series of 10 patients. There is a need to be judicious in case selection as can be seen in selection of thyroid lobes less than 4 cm in this case series.…”

“…The main issue in any thyroid surgery is the preservation of recurrent laryngeal nerve (RLN) and parathyroid glands and duration of the procedure. The authors[ 1 ] have shown surgical time to be an average of 75 min without damage to the recurrent laryngeal nerve or parathyroids. Although the authors[ 1 ] failed to identify the RLN in two of their patients; luckily, their surgical outcome was uneventful.…”

“…The authors[ 1 ] have shown surgical time to be an average of 75 min without damage to the recurrent laryngeal nerve or parathyroids. Although the authors[ 1 ] failed to identify the RLN in two of their patients; luckily, their surgical outcome was uneventful. This highlights the importance of adequate training before heading into this type of specialised surgery.…”