Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results

The Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA). Between February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves' disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO2 insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices. TOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 +/- 1.78 cm (1-10 cm). Median operative time was 97 +/- 40.5 min (45-300 min). Median blood loss was 30 +/- 46.25 mL (6-300 mL). Mean visual analog scale measurements were 2.41 +/- 2.04 (2-7), 1.17 +/- 1.4 (0-5), and 0.47 +/- 0.83 (0-3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified. TOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.