Transoral Endoscopic Vestibular Approach Sistrunk Procedure: Surgery Video

Abstract

Introduction: Thyroglossal duct cyst (TGDC) is a congenital malformation and it is usually found in children <10 years old (>90%).1–4 It is the most common neck cyst and congenital neck mass in the pediatric population and a smaller number of cases occur in adulthood.1–5 The diagnosis is confirmed with imaging and it can be done with a simple ultrasound scan, CT scan, or MRI. The definitive treatment is surgical removal and the gold standard surgery is called Sistrunk procedure,6 which involves excision of the whole cyst and the body of the hyoid bone, because of the embryologic origin of the malformation. This technique described in 19206 was a game changer in the treatment of TGDC as it reduced recurrence rates from 40% to <3%,7 however, it has not changed since then. More recently, the transoral vestibular approach technique for accessing the central neck made possible a total endoscopic safe technique for thyroid and parathyroid removal—TOETVA/TOEPVA.8,9 As TGDCs are located in the same field, the same technique has been shown to give good access for treating TGDC without leaving a neck scar.1–3 Other authors already published two case reports2,3 and a case series1 about effective excision of TGDC transorally. They named the technique transoral endoscopic vestibular approach Sistrunk (TEVAS) procedure.1 The aim of this video is to describe, step-by-step, a case of TEVAS. Materials and Methods: We recorded this video of TEVAS in a woman. The patient involved in the case gave written informed consent to participate in this study. Case: A 47-year-old woman with no medical history presented with a long-term midline neck mass with recent enlargement associated with neck discomfort and sensation of compression. Clinical examination showed a midline mass located on the level of the hyoid bone measuring ~5 cm. Sistrunk sign was positive. The patient underwent a CT scan that showed a 4.5 cm TGDC. Surgery was indicated and endoscopic approach was chosen. The surgery began with the confection of three endoscopic portals through the oral vestibule. After that, the working space was made with an ultrasonic scalpel while running CO2 insufflation. The midline was opened and TGDC was observed. The soft tissue around the cyst was dissected with an ultrasonic scalpel and the hyoid bone was exposed, cutting the insertions of the strep muscles. The bone was cut using the ultrasonic scalpel with an open jaw, touching it with the active blade and making some pressure. The thyroglossal duct was ligated with hemolocks and after that it was sectioned, releasing the specimen, which was removed through the central port using an endobag. Conclusion: This video illustrates the application of TEVAS for treating TGDC. Experience with TOETVA/TOEPVA made possible the execution of this surgery. The most important aspect to choose this novel approach was the patient's motivation to avoid a neck scar. Cutting the hyoid bone was the most challenging step. Using a harmonic scalpel to do the osteotomies was efficient and we recommend it. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. Runtime of video: 11 mins 58 secs