Central neck dissection via the transoral approach

Abstract

There has been a strong impetus for the development of remote access approaches to the central neck. The primary motivation for this has been to alleviate the negative impact that some patients may perceive from a central neck scar. Numerous approaches have been described; however the only approach that provides midline access and equivalent visualization of the bilateral thyroid lobes and paratracheal basins is transoral neck surgery (TONS). TONS has been shown to be safe and effective in performing thyroidectomy, parathyroidectomy, and central neck dissection (CND) via both the endoscopic and robotic techniques. In contrast with other remote access techniques, it provides the surgeon with familiar views of the bilateral recurrent laryngeal nerves (RLN) at their insertion site in concert with equivalent access to both paratracheal basins, thus uniquely facilitating safe and comprehensive CND. Though feasible and safe, CND via TONS is not appropriate in all cases. CND via TONS should only be performed with concomitant transoral total thyroidectomy, either prophylactically if the surgeon routinely performs prophylactic CND, or therapeutically if there is newly found evidence of nodal metastasis in the central compartment at the time of surgery. We base these recommendations on both the recent American Head and Neck Society (AHNS) consensus statement for indications for transcervical CND and the baseline indications for TONS.

Remote-Access Thyroidectomy: A Multi-Institutional North American Experience with Transaxillary, Robotic Facelift, and Transoral Endoscopic Vestibular Approaches

“…Previous studies have proposed that characteristics inherent to TOETVA might allow for enhanced visualization and protection of the RLNs. 34 The TOETVA allows for visualization of the bilateral RLNs at their insertion points, a view familiar to experienced thyroid surgeons. In addition, the approach allows for a favorable angle of dissection along the nerve.…”

Robotic transoral vestibular parathyroidectomy: Two case reports and review of literature

“…To our knowledge, our report presents the first pure RTVP cases[ 24 ]. Transoral vestibular approach can also provide convenience in neck dissection and surgery of thyroid malignancies, however there is no data about parathyroid malignancies in the literature[ 24 , 25 ]. The steps of the surgery should be well defined for patient safety before adoption of this technique[ 26 ].…”

Anterior cervical incision‐sparing thyroidectomy: Comparing retroauricular and transoral approaches

“…More recently, Anuwong described the transoral endoscopic thyroidectomy vestibular approach (TOETVA), which similarly, utilizes a familiar dissection plane but provides a midline surgical field with equal access to both thyroid lobes. 10,12,[15][16][17] As early North American adopters of both techniques, our institution wished to compare our initial experience with RFT and TOETVA in terms of outcomes, complications, and learning curve. To our knowledge, this is the first manuscript to compare the experience with TOETVA and RFT at a single institution.…”

“…Our technique for TOETVA was adapted from that of Anuwong and has been previously described by our group. 10,15,17 In brief, the patient is positioned supine and intubated with a 6.0 or 7.0 nerve monitoring tube orotracheally. Three incisions are then made in the oral vestibule to accommodate central and lateral trochars.…”

“…RFT aimed to use dissection planes familiar to head and neck surgeons, approaching the thyroid from a superior and lateral dissection. More recently, Anuwong described the transoral endoscopic thyroidectomy vestibular approach (TOETVA), which similarly, utilizes a familiar dissection plane but provides a midline surgical field with equal access to both thyroid lobes …”