Transoral Endoscopic Thyroidectomy Vestibular Approach: A Single-institution Experience of the First 50 Cases

Abstract

Background. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has evolved from a novel procedure to a cosmetically appealing alternative to the traditional open thyroidectomy. TOETVA is limited to only high-volume centers with the hope to expand and demonstrate the safety, reproducibility, and application for the correct patient with thyroid disease. We present our experience with the first 50 TOETVA procedures performed at our institution. Methods. From September 2016 to June 2018, we performed 50 transoral endoscopic thyroidectomies via the vestibular approach for a variety of thyroid pathologies. Outcomes were analyzed from a prospectively maintained database. Patients were treated for a different range of thyroid pathologies. Results. A total of 12 (24%) patients underwent total thyroidectomy, whereas 38 (76%) patients underwent a subtotal thyroidectomy or thyroid lobectomy. The mean surgical time was 149 ± 40.0 (90-256) minutes for lobectomy and 217.6 ± 33.3 (175-276) minutes for total thyroidectomy. Of our 50 patients, 16 (32%) had postoperative transient lower lip numbness with an average time to recovery of 23.8 (.43-48) weeks, with 1 (2%) patient having persistent, but improving, lower lip numbness beyond the 6-month follow-up. There were 13 (26%) patients with transient chin numbness with an average time to recovery of 15.7 (2-48) weeks. Two (4%) patients had transient recurrent laryngeal nerve (RLN) injury with hoarseness, whereas 1 (2%) patient had permanent injury. Conclusion. The TOETVA is a safe and reproducible procedure. For selected patients, this technique is a viable alternative to conventional thyroidectomy.

Complications of Transoral Thyroidectomy: Overview and Update

“…However, RLN injury might be more frequent in the transoral approach, especially for surgeons who are initially learning the procedure or perform a low volume of procedures. The RLN palsy rate reported in previous studies ranged from 0% to 20% for transient palsy and from 0% to 12.5% for permanent palsy (Table 1) [4,5,[7][8][9][10]13,[16][17][18][19][20]22,[24][25][26][27][28][29][30][31][32][33][34][35]39]. Studies performed during the initial introduction period of the transoral approach reported a higher rate of RLN palsy, ranging from 12.5% to 20% [4,16,39].…”

“…During the initial introduction period of the transoral thyroidectomy procedure, the rate of mental nerve injury was reported to be very high, ranging from 75% to 100%, probably due to the learning curve [4,10,39]. However, recent studies have shown relatively lower rates of mental nerve injury, ranging from 0% to 56.7%, although it is still high in some papers reporting early experiences (Table 2) [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Fernandez-Ranvier et al [33] recently reported that the incidence of numbness of the lower lip and chin were 32% and 26%, respectively, with 2% of patients sustaining a permanent injury.…”

“…Skin flap perforation in the anterior neck area, lower lip, and chin can occur in transoral thyroidectomy [8,10,19,26,29,32,33]. Perforation of the lower lip or chin might occur if the central vestibular incision is placed at the upper part of the oral vestibule near the vermilion border and dissection of the soft tissue is carried out superficially using a monopolar Bovie instrument.…”

“…However, further studies are necessary to determine the safety and efficacy of gasless transoral endoscopic thyroidectomy and the robotic transoral procedure using the da Vinci SP robot [15]. The transoral vestibular approach with CO2 insufflation is currently the most popular procedure in transoral thyroidectomy [7][8][9][10][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Its most significant advantages are low surgical morbidity, superior postoperative cosmesis, and good functional short-term voice outcomes [1,2,36].…”

“…Confirmation of its long-term oncologic safety and efficacy is required. The rate of traditional complications in the transoral approach, such as vocal fold paralysis, hypoparathyroidism/hypocalcemia, hematoma, and seroma, has been shown to be similar to that of conventional thyroidectomy (Table 1) [4,5,[7][8][9][10]13,[16][17][18][19][20]22,[24][25][26][27][28][29][30][31][32][33][34][35]39]. However, unusual complications of the transoral approach, including CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been reported (Table 2) [4,5,[7][8][9][10]13,[16][17][18][19][20]22,[24][25][26][27][28][29]…”