Transoral thyroidectomy: advantages and limitations

Abstract

In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, "transoral thyroidectomy" (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10 cm; (b) US-estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conventional endoscopic instruments and is probably the best scarless approach to the thyroid because of the short distance between the thyroid and the incisions placed intra-orally that do not result in any cutaneous scar and upon following the surgical planes. Experts in TOT organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologist to develop the standards for practicing this emerging technique.

A comparison study of the transoral and bilateral axillo‐breast approaches in robotic thyroidectomy

“…The transoral approach is the most minimally invasive surgery through the closest access, and it is the most cosmetically perfect with real scarless operation among remote access surgeries. The midline approach facilitates total thyroidectomy easily with excellent access to both entire lobes and provides an operative view with the craniocaudal approach, which facilitates CCND completely . The purpose of this study is to report the early experiences of transoral robotic thyroidectomy (TORT) and compare it with the existing BABA method.…”

Indications and contraindications to transoral thyroidectomy

“…define a maximum allowable thyroid diameter as 10 cm, while Wang et al . utilize an 8-cm maximum thyroid diameter value in addition to a 2-cm maximum nodule size (22,28,38,39). Dionigi et al .…”

“…Dionigi et al . additionally limit the size of the dominant nodule to no larger than 5 cm, and the total thyroid volume to no more than 45 mL as per preoperative ultrasonography (28). Other authors have used only maximum diameter of the tumor/nodule as a size indication, with Yang et al .…”

“…(21) and modifications of this technique have gained favor with refinement of incision placement via both robotic and endoscopic approaches (22–25). Transoral robotic or endoscopic thyroidectomy vestibular approach (TOR/ ETVA) offers access to the bilateral thyroid beds via a gingivobuccal incision without a permanent cutaneous scar (22–28). As such, the frequency at which this approach is being utilized continues to increase (22–36).…”

Central neck dissection via the transoral approach

“…Furthermore, TONS provides excellent visualization of the bilateral RLN’s near their insertion into the larynx. This view is familiar to most experienced endocrine surgeons, and provides a favorable angle of dissection along the plane of the nerve (Figure 3), and allows for optimal visualization when transposing the nerve on the right, thus facilitating a true comprehensive CND (19–26,34,35,37). Finally, we have found that there is enhanced visualization and magnification of the parathyroid glands with TONS, aiding in their preservations and prevention of hypoparathyroidism, which is of particular concern, given the reported incidence of temporary hypoparathyroidism of 14–40% after CND (38–40).…”