Endoscopic Thyroid Surgery Research Articles

Feasibility of using minimal incision in thyroidectomy operation

Background: The conventional technique of thyroidectomy requires long skin incision, not satisfying patient and surgeon in terms of cosmesis and endoscopic thyroid surgery requires expertise. The aim of this study was to compare the clinical outcomes of patients undergoing minimal-incision thyroidectomy with those undergoing conventional thyroidectomy for benign thyroid diseases.Methods: Prospective randomized study that was carried on 50 patients who were undergone thyroidectomy at the department of surgery-Menoufia University from June 2018 to June 2019. The patients were divided into two groups. Group A included 25 patients who were operated upon using minimal incision thyroidectomy technique and group B included 25 patients who were undergone traditional thyroidectomy incision.Results: The length of skin incision was significantly shorter in the minimal-incision thyroidectomy than that in the conventional thyroidectomy group. Operative time was shorter in minimal incision technique. The incidence of postoperative complications was higher in conventional thyroidectomy group but didn’t reach to significant level. Patients undergone minimal-incision thyroidectomy experienced significantly less postoperative pain and were more satisfied with the cosmetic result than patients who underwent conventional thyroidectomy.Conclusions: Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible and safe option for selected patients with excellent cosmetic outcome, with minimal learning curve.

Comparison of surgical outcome between conventional open thyroidectomy and endoscopic thyroidectomy through axillo-breast approach.

Objective:Minimally invasive thyroidectomy can be categorized into either video-assisted method or remote access thyroidectomy (RAT). Although RAT provided excellent cosmetic results, some debate about the advantages and disadvantages remains in different countries. Thus, this study aimed to compare the surgical results between endoscopic thyroid surgery and conventional thyroidectomy.Materials and Methods:The study retrospectively reviewed the conventional and endoscopic thyroidectomy performed at our institution from September 2011 to July 2012. Overall, 30 patients were recruited for this study. The patients were divided into two groups: Group O (open group, n = 15) and Group E (endoscopic group, n = 15). Postoperative outcomes (including wound pain, swallowing disturbance, and chest wall paresthesia) and complications were analyzed and assessed.Results:The endoscopic group was associated with longer operation time and hospital stay. The visual analog scale (VAS) score of surgical wound pain was significantly higher in the open group in 1-week postoperation. However, the VAS score of swallowing disturbance was significantly higher in the endoscopic group in 1-week postoperation. More than half of the patients (53%) had chest wall paresthesia within 1-month postoperation in the endoscopic group. No surgical complications occurred in both groups.Conclusion:Although endoscopic thyroidectomy provides excellent cosmetic results in thyroid surgery, higher immediate postoperative pain, and prolonged chest wall paresthesia compared with those in conventional surgery are a concern and warrant careful patient selection.

The Learning Curve for Transoral Endoscopic Thyroid Surgery: A Single Surgeon's 204 Case Experience.

Background: Endoscopic intervention through the natural foramen is becoming more and more interesting because of surgical treatment without any incision of the skin. In our center, transoral endoscopic thyroid surgery through vestibular approach (TOETVA) thyroid surgery may provide excellent results from a cosmetic viewpoint, which requires a learning curve. Generally, learning curve research for TOETVA could be benefit for investigating the surgical outcome for thyroid operation. Methods: This retrospective study investigated 204 consecutive patients, who underwent TOETVA performed by a single thyroid surgeon from November 2014 to June 2017. We divided the patients into hemithyroidectomy and total thyroidectomy, benign and malignant group. These groups were analyzed in terms of cut-suture time (CST) and cumulative sum (CUSUM) analysis, while accompanied with patient characteristics, perioperative clinical results, and operation-related complications. Results and Conclusions: The average CST of 204 cases was 147.99 ± 43.67 minutes. We observed that TOETVA enables a rapidly decreasing mean operative time after 40-50 cases to reach stabilized CST. Also, we compared the learning curve and CUSUM of the hemithyroidectomy and total thyroidectomy group, benign and malignant group, respectively.

Patient and Surgeon Candidacy for Transoral Endoscopic Thyroid Surgery.

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments.

Modern technologies in thyroid surgery – an overview of the benefits

Utilization of modern technologies in thyroid surgery is increasing. The aim of this paper was to present the up-to-data use of modern technologies in thyroid surgery with special emphasis put on their potential influence on minimized risk of surgeryrelated morbidity and improved quality of surgery. Authors searched PubMed database using the following search terms: modern technologies AND/OR thyroid surgery AND/ OR transoral endoscopic thyroidectomy AND/OR neuromonitoring AND/OR parathyroid preservation AND/OR energybased hemostasis. Of 1678 publications identified 826 were found to be consistent with the aim of this review. The relevant papers addressed the following issues: neuromonitoring in minimization of risk of laryngeal nerves injury (62%), intraoperative iPTH monitoring in preselection of patients for early discharge or onset of substitution with calcium (21.5%), narrow-band and near infrared imaging for identification of parathyroids (5.7%), parathyroids angiography with indcyianine green for parathyroids vascularity assessment (5.5%), transoral endoscopic thyroid surgery via vestibular approach for improvement of cosmetic effects (4.1%), energy-based devices for surgical hemostasis (1.2%). Modern technologies are primarily designed to improve the safety and quality of thyroid surgery, and only then to optimize the cosmetic effects and reduce the time of surgery.

Transoral endoscopic thyroidectomy for thyroid carcinoma: outcomes and surgical completeness in 150 single-surgeon cases.

Transoral endoscopic thyroid surgery vestibular approach (TOETVA) is a promising technique involving no skin incision. Since its first use in 60 patients in 2015, TOETVA has been adopted by several hospitals worldwide. However, reports of TOETVA for thyroid cancer are scarce. Between August 2016 and March 2019, 150 and 125 thyroid cancer patients underwent TOETVA and open thyroidectomy (OT), respectively, by a single endocrine surgeon. Comparative analyses were performed on clinical and pathological findings, complications, and surgical completeness in total thyroidectomy cases, as indicated by the serum thyroglobulin (Tg) level. Data were collected prospectively and analyzed retrospectively. Mean age was younger in the TOETVA than in the OT group (43.06 ± 10.90 vs. 51.02 ± 12.42). The percentage of females was 96.7% in the TOETVA group. Total thyroidectomy was higher in the OT group (26.7% vs. 65.0%). Operation time (min) was longer in the TOETVA group for lobectomy (102.12 ± 32.59 vs. 76.38 ± 21.24) and total thyroidectomy (132.65 ± 34.79 vs. 90.71 ± 25.09). The largest tumor diameter was 0.91 (± 1.00) in the TOETVA group and 1.19 (± 1.07) in the OT group. The harvested lymph node number was not significantly different between the two groups for lobectomy (3.19 ± 2.89 vs. 3.49 ± 2.41, p = 0.319) and total thyroidectomy (4.98 ± 3.12 vs. 5.70 ± 4.35, p = 0.714). The thyroid-stimulating hormone stimulated Tg level before administration of the first dose of radioactive iodine was also not different (3.38 ± 10.87 vs. 3.44 ± 11.51, p = 0.595). Percentage of stimulated Tg below 1.0ng/ml was 80.0% in the TOETVA group. TOETVA is feasible in selected thyroid cancer patients, not only because it is cosmetically advantageous but also because it is oncologically safe. A large prospective cohort study including recurrence surveillance is needed to consolidate the feasibility of TOETVA.

Transoral endoscopic thyroid surgery in a Korean population.

Transoral endoscopic thyroidectomy vestibular approach is expected to be a safe alternative to open surgery for certain patients and has been used increasingly by several surgeons around the world for the past 2years. The purpose of this paper is to review our 2-year experience and describe in detail our preoperative considerations, patient selection, operating room settings, anesthetic considerations, surgical technique, postoperative management, and outcomes. We reviewed the medical records of 65 consecutive patients who underwent transoral endoscopic thyroidectomy between July 2016 and May 2018 in our hospital. We have performed 65 thyroid surgeries (54 thyroid lobectomies, 1 completion thyroidectomy, and 10 total thyroidectomies) in 64 patients. Postoperative pathology revealed papillary carcinoma in 55 patients (84.6%), follicular carcinoma in two (3.1%), hyalinizing trabecular tumor in one (1.5%), and other benign tumor in seven (10.8%). All surgical margins were negative. Two (3.1%) patients developed transient vocal cord palsy but recovered within 2 months. One (1.5%) patient with vocal cord palsy had not recovered by 3 months after surgery. Five (7.7%) patients who underwent total thyroidectomy developed transient hypocalcemia but recovered within 2 months. Although transoral thyroid surgery is a relatively recent technique requiring further validation, it affords several advantages. Transoral thyroid surgery has not yet been universally accepted, but may be the best choice for thyroid surgery in the future.

Endoscopic Thyroid Surgery: Initial Experience of More than 100 Cases from a Tertiary Care Centre in India

The demand for cosmetic procedures is stronger than ever and women who comprise the majority of patients with thyroid tumours drive this demand the world over. The goal of endoscopic thyroidectomy (ET) is to avoid visible scarring on the neck without compromising treatment safety and efficacy. At our institute, we are performing ET since 2014. The size limitation for ET usually ranges from 4 to 6 cm; however, being in an endemic goitre region, most of our patients usually present with long-standing goitres and majority are larger than the recommended size for ET. However, the patient’s demand for better cosmesis is only increasing. The aim of this study is to analyse our initial experience of endoscopic thyroidectomy and various approaches used and determine the feasibility in Indian patients.

Transoral endoscopic thyroid surgery

To analyze own initial experience of transoral thyroid surgery. There were 7 patients thyroid nodules who underwent surgery for the period from March 2018 to May 2019. All patients signed an informed consent to be included in the study. Surgical approach was performed through three incisions in the lower arch of the vestibule of the mouth with deployment of 10 mm endoscope and two 5 mm tools. Gas insufflation was used. All patients were females aged 43.3±11.8 years. Thyroidectomy was performed in 2 cases, hemithyroidectomy - in 5 patients. Dimensions of nodules varied from 10 to 42 mm. Mean time of hemithyroidectomy and thyroidectomy was 206.4±63.8 and 232±37.5 min, respectively. Papillary carcinoma was histologically verified in 1 case. Injuries of recurrent laryngeal nerve, postoperative hypocalcemia and local complications were absent. Drainage was not applied. Postoperative hospital-stay was 3.7±1.1 days. Transoral approach to the thyroid gland is technically feasible with standard endoscopic instruments, safe for important anatomical structures and more precise due to the optical capabilities of endoscopic equipment. Any types of procedures are possible. Undoubtedly, aesthetic outcome is also favorable.

The evolution and progress of the application of intraoperative monitoring in endoscopic thyroid surgery

Intraoperative nerve monitoring (IONM) is a validated and well accepted technology in open thyroid surgery. Intermittent and continuous neuromonitoring are the current technologies that are available. The International Neural Monitoring Group has established standards for the use of nerve monitoring in open surgery. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is becoming common in high volume endocrine surgery centers. To be widely accepted the safety benchmarks set by open surgery for neuromonitoring have to be met. The evolution of use of IONM in endoscopic thyroid surgery, the current technique of IONM use in TOETVA, equipment used, advantages and disadvantages are discussed in this review.

Subplatysmal or subfascial approach in totally endoscopic thyroidectomy has better postoperative efficacy for voice, sensory, swallowing symptoms and cosmetic result. Cohort study

BackgroundAfter totally endoscopic thyroidectomy (TET), patients usually suffer from voice, sensory, swallowing symptoms and they are also concerned with the postoperative cosmetic result. We compared the effects of subfascial dissection method with the subplatysmal method in TET on postoperative symptoms and cervical appearance. Methods143 female patients who underwent totally endoscopic thyroid surgery were assigned to the subplatysmal approach group and subfascial approach group. The patient's voice symptoms were assessed using the Voice Handicap Index (VHI) questionnaire. Sensory function was assessed with subjective pain and light touch sensation. Swallowing symptoms were assessed using the Swallow Impairment Score (SIS) questionnaire and the 3 oz water swallow test. Neck cosmetic effect was assessed by postoperative recovery time of the suprasternal fossa and subjective satisfaction questionnaire. Each variable was measured preoperatively, at 2 weeks, 3 months and 6 months after operation. ResultsIn both groups, the subjective voice, sensory and swallowing symptoms deteriorated at 2 weeks and improved at 3 months postoperatively. Indicators of VHI, SIS and 3 oz water swallow test returned to the preoperative level at 6 months after operation. In the subfascial group, SIS was significantly better than that of the subplatysmal group (p = 0.005) at 2 weeks after operation. The recovery time of the suprasternal fossa in the subfascial group was delayed (p = 0.158), compared with the subplatysmal group. ConclusionThe subfascial approach may have certain advantages in swallowing symptoms basing on the swallowing impairment test. However, the subplatysmal approach and the subfascial approach may have the same cosmetic effect.

Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America.

Since its introduction nine years ago, gasless transaxillary thyroidectomy with robotic assistance (RT) has achieved a relatively limited application in North America. This study aimed to assess the outcomes of RT in a recent large, diverse North American population. Consenting patients were selected for the RT approach from November 2010 to July 2015 based on patient preference, and their perioperative data were retrospectively reviewed. Of 301 robotic thyroidectomies completed in 281 patients, 160 were total thyroidectomy and 141 were lobectomy. Women predominated (98.9%), with a mean age of 41 years (range 17-74 years) and a mean follow-up of 24 months (range 3-71 months). The mean body mass index (BMI) was 25.7 kg/m2 (range 17-44 kg/m2). However, 33.3% of patients had a BMI 25-29.9 kg/m2, 12.4% had a BMI 30-34.9 kg/m2, 3.5% had a BMI 35-39.9 kg/m2, and 0.7% had a BMI ≥40 kg/m2. Excluding 20 completion lobectomy, the indications for surgery were indeterminate cytology (53%), malignant cytology (10%), growth (18%), Graves' disease (12%), and other (5%). The mean size of the largest resected nodule was 2.5 cm (range 0.7-6.4 cm). Mean operating time for robotic lobectomy and total thyroidectomy was 81 and 109 minutes, respectively. One patient was converted to standard cervicotomy for failure to progress endoscopically. Complications included temporary dysphonia (6.0%), permanent recurrent laryngeal nerve deficit (1.3%), hypocalcemia (temporary 8.2%, permanent 1.1%), seroma (0.7%), and hematoma requiring reoperation (0.3%). Complications did not differ in patients with a BMI ≥25 kg/m2 compared to those with a BMI <25 kg/m2 or with respect to nodules >3 cm or surgery for Graves' thyroiditis. One patient developed grade II arm lymphedema ipsilateral to the axillary incision at two years, which resolved with conservative management. No patient had a surgical site infection or brachial plexopathy. Cancer was present histologically in 133 (48%) patients. Among 91 patients with cancer of the index nodule, 48.4% had papillary, 44.0% follicular variant papillary, 2.2% minimally invasive follicular carcinoma, and 5.5% minimally invasive Hürthle cell carcinoma. One patient had sclerosing variant thyroid paraganglioma. To date, all patients are without evidence of tumor recurrence. At a high-volume center, gasless transaxillary endoscopic thyroid surgery done with robotic assistance is a safe, efficient, and effective approach in a diverse North American patient population.

The learning curve of endoscopic thyroid surgery for papillary thyroid microcarcinoma: CUSUM analysis of a single surgeon\u2019s experience

BackgroundWith the development of surgical technics, endoscopic thyroid surgery has been gradually accepted and utilized in thyroid disease treatment, including thyroid carcinoma. This study aimed to evaluate the learning curve for endoscopic hemithyroidectomy (EHT) with ipsilateral central neck dissection (CND) and investigate how many cases must be performed before a surgeon becomes competent and proficient in this approach.MethodsNinety-nine consecutive patients who underwent EHT with ipsilateral CND for papillary thyroid microcarcinoma by a single surgeon between June 2015 and October 2017 were analyzed. Multidimensional cumulative summation (CUSUM) analysis was performed to evaluate the learning curve.ResultsThe CUSUM graph showed the learning curve ascended in the first 31 cases and declined in the following cases. The number of lymph nodes removed in phase 2 (the following 68 cases) was significantly more than that in phase 1 (the first 31 cases) (5.06 ± 1.44 vs. 4.19 ± 1.51, P = 0.001). The operation time in phase 2 was shorter than that in phase 1 (123.38 ± 12.71 min vs. 132.90 ± 13.95 min, P = 0.008) and the rate of accidental removal of parathyroid gland decreased from 35.5% in phase 1 to 16.2% in phase 2 (P = 0.040). There was a declining trend but no significant difference in the rate of postoperative complications (9.7% in phase 2 vs. 4.4% in phase 1, P = 0.309).ConclusionEHT with ipsilateral CND performed by surgeons was mastered after 31 cases, and the safety and feasibility of this endoscopic approach can also be demonstrated.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances.

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach.

Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.

Clinical Study of Three Dimensional Endoscopic Technique in the Treatment of Thyroid Neoplasm.

To evaluate the safety and efficacy of three-dimensional (3D) endoscopic technique in clinical practice. A retrospective analysis of the clinical data of 180 cases of endoscopic thyroid surgery, 88 cases by umbrella 3D endoscopic technique (observation group), 92 cases with common endoscopic technique (control group), comparing two groups of patients with age, surgery related indicators, postoperative complications, recovery condition and others. There was no significant difference in the average age, tumor diameter, intraoperative bleeding, postoperative drainage, hospitalization time, and pain scores after surgery between the to groups (P > .05); the operation time of the observation group was shorter than the control group [(93.8 + 33.7) minutes versus (135.5 + 37.5) minutes, P < .05]. There was no hoarseness in the observation group, and 2 cases in the control group had transient hoarseness and no permanent hoarseness. The surgical application of 3D endoscopic technique can shorten the time of endoscopic thyroid surgery, reduce the risk of recurrent laryngeal nerve injury, reduce the operation difficulty and operation pressure, greatly reduce the risk of surgical patients, and increase the safety of surgery.

Endoscopic Thyroid Surgeries via Areola Approach: Experience and Outcomes of 500 Cases in a Single Institute

With the growing popularity of endoscopic thyroid surgery for treatment of thyroid diseases, this study aimed to summarize our experience of endoscopic thyroidectomy (ETE), and evaluate the feasibility and safety of ETE, in our institute. Five hundred patients underwent ETE via the areola approach. The learning curve, clinicopathologic characteristics, cosmetic satisfaction, complications, and so on were analyzed. Among the 500 cases, 497 were successfully managed with ETE, and 3 were converted to open procedure. The score of cosmetic satisfaction, average operation time, tumor diameter, mean total intra-operative blood loss, hospital stay, drainage time, and age were 9.4 ± 0.5, 142 ± 20 min, 2.6 ± 1.2 cm, 34 ± 12 ml, 11.4 ± 3.6 days, 3.3 ± 0.7 days, and 44.2 ± 11.9 years, respectively. Pathological types of the tumor included papillary thyroid carcinoma (PTC; n = 87), nodular goiters (n = 283), follicular adenoma (n = 84), and others (n = 46). The complications included transient recurrent laryngeal nerve (RLN) palsy (n = 15, 3.0%), transient superior laryngeal nerve (SLN) palsy (n = 3, 0.6%), transient hypoparathyroidism (n = 32, 6.4%), tracheal injury (n = 1, 0.2%), swallowing discomfort (n = 20, 4.0%), infection (n = 7, 1.4%), and others (n = 15, 3.0%). No patients experienced permanent RLN injury or SLN injury, asphyxia/dyspnea, esophagus injury, bleeding, chylous fistula, or death. Among the cases of PTC, 76 (87.4%) cases underwent the central lymph node dissection. The mean number of retrieved lymph nodes was 6.4 ± 2.1, while the mean number of metastatic central lymph nodes was 1.2 ± 2.3. The ratios of capsule invasion, central lymph node metastasis, and extrathyroidal extension were 10.3, 26.4, and 3.4%. ETE via areola approach is safe, feasible, and cosmetic, with good operative results and low complication rates. It provides an effective choice for treating patients.

Transoral endoscopic thyroid surgery via the tri-vestibular approach with a hybrid space-maintaining method: A preliminary report.

Transoral endoscopic thyroid surgery has been introduced in a few institutions. The purpose of this study was to present an innovative hybrid space-maintaining method for the tri-vestibular approach. Eighteen consecutive patients underwent transoral endoscopic thyroidectomy. Three incisions were made in the vestibule. The surgical space was maintained with CO2 insufflation along with a suspension device. Thyroidectomy and central neck dissection (CND) were performed safely and effectively. The mean operation time was 124 minutes for a simple lobectomy, subtotal thyroidectomy, and isthmectomy in 8 patients, 172 minutes for hemithyroidectomy with ipsilateral CND in 8 patients, and 205 minutes for total thyroidectomy with ipsilateral CND in 7 patients. Transient superior laryngeal nerve (SLN) injury occurred in 3 patients and transient mental nerve injury was found in 1 patient. No evidence of recurrence or metastasis was found at follow-up. This approach brings satisfactory cosmetic effect along with minimal invasion. Further study is needed to verify its validity.

Transoral Endoscopic Thyroid Surgery: Indication, Preparation and Surgical Technique

Natural orifice transluminal endoscopic surgery (NOTES) is the latest surgical technique for inserting an endoscope through the mouth, anus, vagina etc., and for performing surgery with mucosal incision only, i.e., without skin incision. Recently, a number of researchers have applied NOTES to thyroid surgery in several trials, with the aim of removing the thyroid gland through oral cavity. The transoral endoscopic thyroid surgery became widely known after Anuwong et al. reported successful results for their first 60 patients and it has become increasingly recognized as a feasible novel surgical procedure. The purpose of this article is to review and summarize the existing literature, and describe in detail the preoperative considerations, rationale for patient selection, surgical method and postoperative management for transoral thyroid surgery. Key words: Endoscopic thyroidectomy ㆍ Minimally invasive ㆍ Thyroidectomy ㆍ Transoral endoscopic thyroidectomy ㆍ Transoral thyroidectomy

Hybrid techniques and patients' safety in implementing transoral sublingual thyroidectomy.

Cosmetic advantages and minimally invasive aspects become more and more important for patients undergoing thyroidectomy. We report on our personal experience and conceptual design in dealing with approaches to the thyroid gland, which we were the first to describe. We report on ideas and experiences concerning its implementation. Our own experiences and considerations in the process of finding an endoscopic minimally invasive access in thyroidectomy are compared in a systematic review with the available literature on minimally invasive or endoscopic thyroid surgery. We describe our failures and risk assessment. Our analysis of the literature on minimally invasive thyroidectomy and our own experiences lead us to the conclusion that using different hybrid technologies during the implementation of endoscopic procedures in thyroid surgery can be helpful and could improve patients' safety. A combination of transoral endoscopic and non-transoral techniques might be a useful safer, but more traumatizing alternative for implementation. Several studies show the feasibility of the transoral access in thyroid surgery. We believe that the implementation of these new procedures as routine surgery in specialized centers must be carefully considered and discussed. The transoral access seems to be less invasive than other extracollar endoscopic accesses in thyroid surgery. For a sublingual single-access routine surgery, better instruments are needed. The vestibular access is possible with standard instruments. Using hybrid technologies for implementation should not be considered as a failure. The transoral thyroidectomy can be a safe method in the hand of experienced surgeons. We expect this hybrid technique to play a major part in further spreading endoscopic transoral thyroid surgery.