Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Direct trans-vestibular feminization thyroid laryngochondroplasty

“…17,18 Using the DTV approach, we encountered a fair rate of resolving surgical complications that may be partly due to a learning curve and partly to the combination of lower facial feminization with FLC. Some complications (ie, injury to the mental nerves, skin flap perforation, significant blood loss when the mandibular angles and chin are reduced, chin edema, hematoma, seroma) are specific to the transvestibular approach and are similar to those encountered in transoral thyroidectomy, 19 as both procedures involve elevating an extensive cervical skin flap and operating through a long tunnel under the flap. Avoidance of surgical drains, to prevent a neck scar, might have led to the 22.2% rate of hematomas and seromas in our cohort.…”

Cannula Fracture during Transoral Endoscopic Thyroidectomy Vestibular Approach: Causes and Prevention

“…suggest using a 5 mm central trocar to replace the 12 mm one in pediatric patients [14 Indeed, the premandibular space can be dilated to relieve compression, facilitate troca movement, and remove specimens. However, routine space dilatation is not recom mended because it may injure the surrounding mental nerve, which provides sensory in nervation to the lower lip and chin, and/or the mentalis muscle, which elevates the lowe lip and allows it to pout [7,11].…”

“…Indeed, the premandibular space can be dilated to relieve compression, facilitate trocar movement, and remove specimens. However, routine space dilatation is not recommended because it may injure the surrounding mental nerve, which provides sensory innervation to the lower lip and chin, and/or the mentalis muscle, which elevates the lower lip and allows it to pout [7,11]. The movement of the endoscope should be gentle so that the cannula is not forcibly compressed against the mandible.…”

“…The patient underwent transoral endoscopic left thyroidectomy. The operative procedure was similar to Dr. Anuwong’s technique with some refinements, as described in our previous publication [ 10 , 11 ]. One 12 mm trocar (ENDOPATH XCEL Trocar, Ethicon, Cincinnati, OH, USA), and two 5 mm trocars (VersaOne Optical Trocar, Medtronic, Minneapolis, MN, USA) were placed.…”

Updates in Thyroid Cancer Surgery

“…Minimally invasive surgery techniques, robotic surgery, and ablative therapies such as radiofrequency ablation have joined traditional surgery. Notably, transoral thyroidectomy, known as TOEVA, allows the thyroid gland to be removed through a hidden incision in the oral vestibule with excellent aesthetic results and a surgical outcome comparable to open surgery [ 7 ].…”