Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update.
ABSTRACT: Transoral endoscopic thyroidectomy and parathyroidectomy via the vestibular approach (TOET/PVA or TOETVA-TOEPVA) is the latest remote-access technique employed in the central neck. As the only approach that does not leave any cutaneous incision, (TOET/PVA) has become popular in both the Far East and Western series since its original description in 2015. More than just a "scarless" surgery, (TOET/PVA) has been associated with a short learning curve, access to the bilateral central neck compartments, few surgical contraindications, minimal complications, and minimal additional instrumentation. To date, more than 2,000 cases have been completed, including more than 400 in North America, demonstrating brisk utilization of a novel technique relative to earlier remote access central neck approaches. Herein, we describe updates that continue to improve the safety and efficacy of the procedure.
Project description: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.
Project description:Data with regard to potential recurrent laryngeal nerve (RLN) compromise caused by intra-neck CO2 insufflation during transoral endoscopic thyroidectomy vestibular approach (TOETVA) are missing. RLN electromyographic (EMG) profiles, metabolic and hemodynamic parameters (oxygen saturation, heart rate, blood pressure, experimental time, CO2 partial pressure, pH, O2 partial pressure), central venous pressure (CVP), airpocket temperature and pressure were recorded in a TOETVA animal model. Twelve pigs were randomly divided into different groups according to increasing CO2 insufflation pressures. Nerves segments were then collected for histopathology. Significant variation of metabolic and hemodynamic parameters were registered when CO2 insufflation pressures increased x3 and x5 the baseline parameters. Combined EMG amplitude drop and latency increase also were documented. There was no significant change in the intraluminal temperature. RLNs structure were preserved with normal axons, no fibrosis, and no vacuolization and without loss of myelinated fibers during the experiment. RLN EMG profiles (but not histology) were altered when CO2 insufflation pressures increased.
Project description:Recently, a transoral robotic-assisted technique to access the thyroid gland has been introduced. Despite the advantages this approach may have over other minimally invasive and robotic-assisted techniques, we found that the placement of the camera through the floor of mouth led to restricted freedom of movement. We describe our modification to this technique to overcome this problem. In a study using two fresh human cadavers, the camera port of the da Vinci robot was placed in the midline oral vestibule instead of the floor of the mouth. A transoral thyroidectomy and central neck dissection was successfully performed. Our modification led to an unfettered view of the central neck and allowed for a total thyroidectomy and central neck dissection. Our modification of transoral robotic-assisted thyroidectomy provides superior access to the central compartment of the neck over other robotic-assisted thyroidectomy techniques.The online version of this article (doi:10.1007/s11701-011-0287-2) contains supplementary material, which is available to authorized users.
Project description:The safety and efficacy of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) continues to be verified with the growing literature in regards to the procedure. While early cases were thyroid lobectomies performed for benign disease, the indications for TOETVA have now expanded to include total thyroidectomy for select small well-differentiated thyroid cancers (DTCs). Oncologic efficacy of this procedure remains unproven at this time, as the procedure was described only recently. Furthermore, as many of the cases completed via TOETVA are often diagnostic lobectomies, the appropriate management for patients requiring or opting for further surgical intervention per American Thyroid Association (ATA) guidelines has not been established. Here we present a case of a diagnostic lobectomy via TOETVA followed by interval completion thyroidectomy via the same approach for minimally invasive Hurthle cell carcinoma. Postoperative ultrasound demonstrated no evidence of thyroid remnant and serum thyroglobulin without circulating anti-thyroid antibodies was 0.3 ng/mL (reference range, 1.5-38.5 ng/mL) following the patient's completion thyroidectomy.
Project description:Transoral robotic thyroidectomy (TORT) is well consistent with the primary goal of remote-access thyroid surgery, which is to avoid a visible cervical scar. Additionally, the extent of transoral thyroidectomy dissection is less than that of other remote-access surgical procedures. Owing to these merits of the transoral approach, several institutions around the world are now performing this procedure. Since transoral thyroidectomy is performed in a confined, narrow space, and is characterized by a close distance from the ports to the working space, more benefits can be derived from multiarticulation of robotic instruments. Especially when performing left lobectomy by TORT, the surgeon can use right-handed robotic instruments over the thyroid cartilage with the merits of multiarticulation. In this study, we present our unique procedure of left lobectomy by TORT in detail.
Project description:Transoral robotic surgery (TORS) has emerged as a technique that allows head and neck surgeons to safely resect large and complex oropharyngeal tumors without dividing the mandible or performing a lip-split incision. These resections provide a reconstructive challenge because the cylinder of the oropharynx remains closed and both physical access and visualization of oropharyngeal anatomy is severely restricted. Transoral robotic reconstruction (TORRS) of such defects allows the reconstructive surgeon to inset free flaps or perform adjacent tissue transfer while seeing what the resecting surgeon sees. Early experience with this technique has proved feasible and effective. Robotic reconstruction has many distinct advantages over conventional surgery, and offers patients a less morbid surgical course. In this review, we discuss the clinical applicability of transoral robotic surgery in head and neck reconstruction, highlighting the benefits and limitations of such an approach, and outlining the guidelines for its utilization.
Project description:Objective To define the learning curve for transoral endoscopic thyroidectomy via the vestibular approach (TOETVA). Study Design Case series with planned data collection. Setting Tertiary care academic hospital. Subjects and Methods Included patients were those who met the 2015 American Thyroid Association guidelines for lobectomy and our group's previously documented indications for TOETVA. Operative time (incision to closure) was used as a surrogate for procedural proficiency and plotted as a function of case number to determine a learning curve. A simple moving average of operative time was then calculated, with the proficiency case defined as the case number where the slope of this curve changed. Demographic/characteristic data, outcomes, and complications were compared between the skill acquisition period (case 1 to proficiency case) and the proficiency period (remaining cases). A linear regression model was then used to calculate and compare the slopes of the skill acquisition and proficiency periods in the "operative time versus case number" plot. Results Thirty cases were attempted, with a procedural success rate of 29 of 30 (94%) and no incidence of permanent mental nerve or recurrent laryngeal nerve injury. The proficiency case was case 11. There was a statistically significant difference between the skill acquisition and proficiency periods in slopes of the linear regressions (-16.7 vs -0.3, respectively; P < .001) and median operative times (191 vs 119 minutes, P < .001). There was no difference in demographics, procedural success rate, or complication rate between the periods. Conclusions The learning curve for TOETVA was 11 cases for the surgeon evaluated in this series.
Project description:The introduction of transoral endoscopic surgery has initiated a fundamental change in the treatment of head and neck cancer. The endoscopic approach minimizes the intraoperative trauma. Due to the lower burden for the patient and the savings potential these methods have gained wide acceptance. These transoral accesses routes allow experienced surgeons to reduce the morbidity of surgical resection with no deterioration of oncologic results. This suggests a further extension of the indication spectrum and a high growth potential for these techniques and equipment in the coming years. For selected patients with selected tumors the minimally invasive transoral surgery offers improved oncological and functional results. In the present paper, different surgical access routes are presented and their indications discussed.
Project description:Background:The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recently introduced method of minimally invasive thyroid surgery. To our knowledge, no studies have compared TOETVA outcomes using different laparoscopic systems. This study compared outcomes of TOETVA using conventional high definition (HD) and ultra-high definition (UHD) equipment. Methods:Medical data and surgery videos of 62 patients who randomized to undergo thyroid lobectomy by TOETVA using an HD or UHD system from August 2018 to April 2019 were retrospectively reviewed. Endoscopic procedures were divided into four phases: flap creation to isthmectomy (phase I); strap muscle division to upper pole ligation (phase II); trimming recurrent laryngeal nerve (phase III); and ligation of Berry's ligament to complete resection (phase IV). Results:Of the 62 patients, 28 underwent TOETVA using an HD device and 34 using a UHD device. The clinical characteristics of the two groups were not different. Mean operating time for lobectomy was similar in the HD and UHD groups (44.19±9.94 versus 43.47±12.19 min, P=0.825). The times required for phases I (15.02±5.33 versus 13.67±5.44 min, P=0.397); II (12.89±2.84 versus 13.17±5.22 min, P=0.816); III (9.85±4.36 versus 9.98±4.55 min, P=0.918); and IV (6.43±3.69 versus 6.65±3.45 min, P=0.840) were also similar in the HD and UHD groups. The numbers of retrieved lymph nodes did not differ significantly in the HD and UHD groups (3.26±2.62 versus 3.45±2.81, P=0.807). Conclusions:Applying a UHD system in TOETVA resulted in outcomes similar to those observed with a conventional HD system. Operation time tended to be lower, especially for flap dissection, and numbers of harvest lymph nodes tended to be higher in the UHD group. Large-scale studies are needed to assess the advantages of the UHD system.
Project description:Background:Transoral endoscopic thyroidectomy provides access via the oral vestibule and gas insufflation to provide reliable remote access surgery to perform a total thyroidectomy. The da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a next generation flexible single port system that offers unique advantages over previous robotic rigid systems. Here we sought to evaluate the feasibility of performing transoral thyroidectomy with this next generation flexible robotic system. Methods:Cadaveric dissection with gas insufflation to test the feasibility of performing transoral thyroidectomy with the da Vinci SP. Results:A 2 cm incision was made in the oral vestibule and the working space created with a 1cm central port and two lateral 5 mm ports. Then an extra small wound protector (Applied Medical, Rancho Santa Margarita, CA) was placed through the central incision after closure of the 5 mm ports. The robotic system was then deployed through the wound protector while insufflation was maintained at ~6 mmHg. Three instrument arms were deployed. A fenestrated bipolar was used to grasp the thyroid gland while Maryland bipolars and monopolar scissors were used to mobilize each hemi lobe of the thyroid. The recurrent laryngeal nerves were seen and preserved bilaterally. After completion of the surgery and removal of the wound protector the vestibular incision was measured to be 3 cm. Further dissection to identify the mental nerves identified each nerve to be >1 cm from the lateral extent of the central incision. Conclusions:In summary, it is feasible to perform a total thyroidectomy with gas insufflation utilizing this next generation flexible robotic system. Further evaluation will be needed to validate the clinical applicability of this technique.