Transoral Thyroidectomy: Anatomical Aspects of an Esthetic Access

Abstract

IntroductionClassically, ample dissections expose the indisputable beauty of the human structural topography and offer an unquestionable learning opportunity on the syntropy of anatomical repairs, be they by the Letulle (en masse) technique or by the Virchow (organ by organ) method. Jargon of the type: “great surgeons, great incisions,” in light of technological advances, lack in conceptual revision.The traditional transverse cervicotomy, as an access for thyroidectomy, presents itself as consecrated, yet the disagreeable cosmetic aspect in the form of a scar still persists. Surgeons and Anatomists seek alternative accesses, such as the transoral, which could contemplate the same efficacy, safety and outcomes as the transverse cervicotomy. The objective of this study was to verify the viability of using a cadaver fixed in a modified Larsen solution to perform a transoral thyroidectomy for teaching and training.MethodTwo cadavers were carefully dissected in order to obtain safe anatomical parameters, both by the transoral pathway of the subplastimal space, for the resection of the thyroid. Both cadavers were in horizontal dorsal decubitus with a cushion under the shoulder girdle and with the head in hyperextsion. On the first, relaxing and combined incisions were made, going from the right and left labial commissures in the craniocaudal direction to the mandibular tuberosity, and; on the second, 10‐mm trocar punctures were made on the medial line and two 5‐mm punctures in the projections of the lower canine teeth in the buccal vestibule. Both dissections accomplished the detachment of the superficial fascia of the neck, creating space for the exposure of the pre‐thyroid musculature. In sequence, the linea alba was opened, the laryngeal prominence, trachea, thyroid isthmus, upper and lower vascular pedicles of the thyroid, parathyroid glands and right and left recurrent laryngeal nerves were identified and then the gland was removed. In both cadavers, the thyroid region had been clearly totally approached in a safe manner, preserving adjacent structures (Figure 1).ResultsThe thyroid gland was adequately located, as well as its vasculonervous relations. The neck fascia, trachea and innervation of the platysma, motor and sensory muscles were preserved.Discussion and conclusionThe transoral pathway is possible and topographically adequate for performing a thyroidectomy, but the compulsory hyperextension of the head may be contraindicated for patients with cervical spine disorders. The hyperextension was possible, as the fixation by the modified Larsen solution provides sufficient tissue malleability to perform the maneuver.The use of a cadaver presents a safe and reliable alternative in teaching video‐assisted anatomy and for training the resident surgeon.