Extracervical Approaches Research Articles

Extracervical Approaches to Substernal Thyroid Goiter Resection: A Systematic Review and Meta-Analysis.

To evaluate the prevalence of extracervical approaches (ECAs) for substernal goiter (SSG) excision. Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021. Participants included adults ages >18 years undergoing SSG excision. The primary outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), ≥50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the Methodological Index for Non-Randomized Studies criteria. Of the 551 studies identified, 69 studies were included for analysis. Definition 1 included 3441 patients from 31 studies; definition 2 included 2957 patients from 26 studies; and definition 3 included 2921 patients from 12 studies. A random-effect model estimating the pooled prevalence of ECA using definition 1 resulted in prevalence of 6.12% (95% confidence interval: 3.48-9.34, I 2 = 90.72%). Extension below the thoracic inlet is the most widely used definition of SSG. Approximately 6% of patients with a SSG undergo an ECA. Patients with SSG undergoing surgery should be counseled on the prevalence, risks, and morbidity of an ECA in the rare occurrence it is needed.

Transoral thyroid surgery vestibular approach.

Transoral thyroid surgery vestibular approach (TOETVA) is a novel and feasible surgical technique that allows for cervical surgery without visible incisions. TOETVA represents a new frontier in endocrine surgery since aesthetic results play a more and more decisive role in elective surgery. However, acceptance is different around the world with widespread prevalence in Asian countries and some high-volume centres in the US. While inclusion criteria for TOETVA are limited regarding size and volume a combination with other extracervical techniques like the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) approach or transaxillary access is an option. TOETVA is carried out through a three-port technique placed at the oral vestibule. Originally one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments are used. Alternatively, one 5-mm and one or two 3mm ports can be used. CO2 insufflation pressure is set at 6mmHg. An additional device to optimize gas outflow for optimum view might be helpful. An anterior cervical subplatysmal space is created by hydrodissection from the oral vestibule to the sternal notch, laterally to the sternocleidomastoid muscle. Conventional endoscopic instruments are used. Combination of TOETVA with a modified retroauricular access includes insertion of a 10-12mm trocar placed subcutaneously via a skin incision on the scalp, behind the ear by blunt dissection. Since Anuwong published the first case series of 60 patients who underwent scarless thyroidectomy via the lower vestibule of the mouth with excellent results in 2016almost 1,000 cases are reported in literature to date with comparable results especially regarding traditional complications. In contrast to other extracervical approaches, areolar or axillary for example, the transoral access route is short and the dissection planes are rather like transcervical surgery. Surgical indications and contraindications have been modified since its first description and are partly institution specific to date. To amend indications combination with other extracervical techniques is an option. In addition, patients must carefully be selected for and surgeons` candidacy is of utmost importance in transoral surgery. Transoral surgery will likely continue to gain attraction as surgeons become more experienced with the technique. With increased operative use and surgeon experience the gap in conventional outcomes between transoral surgery and the transcervical approach will narrow, with both operative time and the incidence of specific complications diminishing. Experience in thyroid and endoscopic surgery is required to achieve excellent results with low complication rates. However, the new transoral technique is related to novel complications that must be evaluated.

Comparison of cosmetic outcomes between remote-access and conventional thyroidectomy: A review of the current literature.

The pursuit of an esthetically pleasing scar following open thyroid surgery has led to the development of endoscopic thyroidectomy through remote incisions placed in several locations outside the neck. The objective of this study is to review the recent literature and compare the incision site appearance and patient satisfaction with the cosmetic outcome after extracervical and conventional thyroidectomy. The English literature published since 2010 was searched through the PubMed/Medline database for studies comparing the cosmetic outcomes between remote-access endoscopic and conventional thyroidectomy using a form of scar assessment scale. A total of 9 relevant papers fulfilled the eligibility criteria including 1486 patients. Among them, 595 patients underwent endoscopic thyroidectomy through several remote-access approaches and 891 patients were assigned to the conventional group. Only one randomized-controlled trial was identified, whereas among the rest, four were prospective and four were retrospective nonrandomized cohorts. Regarding the extracervical modifications performed in the endoscopic groups, the axillary approach was performed in three studies and the breast approach in four studies, while the retroauricular facelift technique and the transoral vestibular method were applied in one study, respectively. Evaluation of the wound appearance and patient satisfaction with the cosmetic outcome at various time points during the follow-up highlighted the superiority of the extracervical approaches over the conventional cervicotomy. Considering these findings, remote-access techniques could possibly be the ideal surgical method for patients with high esthetic requirements, providing an excellent appearance of the thoroughly exposed neck.

Surgical Treatment of Substernal Goiter Part 2: Cervical and Extracervical Approaches, Complications.

The most appropriate treatment of substernal goiter (SG) is surgery. These patients should be evaluated carefully and multidisciplinary in pre-operative period and surgical management should be planned preoperatively. Although most of the SGs can be resected by the cervical approach, an extracervical approach may be required in a small proportion of patients. Surgical complications of SG related to thyroidectomy are higher than other thyroidectomies. In addition to the complications related to thyroidectomy, complications related to the type of surgical intervention may also occur in SG. The patients who may be needed extracervical approaches should be consulted with thorax surgeons, cardiovascular surgeons, and anesthesiologists preoperatively; the surgical management should be planned together. In this part, we aimed to evaluate the cervical approach methods, extracervical approach methods, technical details, and complications in detail.

Different Approaches for Thyroid Surgery.

Surgery remains main treatment of choice for thyroid nodule for diagnosis and treatment. Conventional thyroid surgery gives scar in the neck so many young patients particularly unmarried females demand thyroid surgery without visible scar in the neck for cosmetic reason. Extra cervical approaches have continued to evolve with an increasing body of research (Sarda AK, Bal S, Kapoor MM (1989) Near-total thyroidectomy for carcinoma of thyroid. Br J surg 76(90):2).majority of them presenting in 21-30 age So, here there is evaluation of minimally invasive or endoscopic thyroid techniques. Here, we have studied endoscopic approach and utilize it to minimize scar and scarless thyroid surgery. To evaluate optimal patient selection criteria. To study various surgical approaches and outcomes. To decide surgical approach according to size. To study patients satisfaction. It was a prospective study of 50 patients with a duration of 3years. All the Euthyroid cases with clinically palpable thyroid swelling in age group 15-60, after a detailed clinical history and examination, who required surgery and concern for visible neck scar are councelled and included in our study. In our study 45 patients were females and 5 were males with majority of them presenting in 21-30 age group. All the patients in our study are presented with neck swelling. In most patients FNAC is suggestive of colloid goiter. Endoscopic thyroid surgery is mainly indicated for young patients having benign thyroid tumor less than 3cm in size. Transaxillary and retroauricular are common approaches and is selected as per patient choice and surgeon expertise. Transaxillary thyroidectomy can be performed safely as conventional thyroidectomy.

Trans oral endoscopic thyroidectomy (TOETVA): First French experience in 90 patients.

Thyroidectomy techniques using extracervical approaches have grown in popularity for about 20 years and their feasibility has now been demonstrated. We wanted to evaluate one of these new approaches: the anterior vestibular endoscopic approach (TOETVA). The aim of this study was to evaluate the results of an initial series patients who underwent an anterior trans-vestibular endoscopic oral thyroidectomy. From February 2018 to September 2020, this technique was offered to patients aged 18 to 70, ASA I or II, who presented with an indication for thyroid surgery and who wished to avoid cervical scars. The approach was through the anterior vestibule of the mouth and the specimen was extracted either transorally or via the axilla depending on its size. Apart from the first ten cases, all patients underwent recurrent nerve neuromonitoring. The patients were operated on by two surgeons experienced in thyroid surgery. All the patients had follow-up visits on D15, D30 and at 2 months. The pre- and intra-operative data, length of stay and complications were evaluated. A total of 90 consecutive patients (87 women) aged 46±12.4 years (18 to 69) with a mean BMI of 24.4±4 were included. The indications for surgery included 11 papillary cancers, 5 oncocytic nodules, 15 toxic nodules, 13 cases of Graves disease and 46 symptomatic goiters and/or nodules. The mean pre-operative diameter of the nodules was 3.61±1.99 (0.44 to 7.3) cm. The interventions performed were 44 lobo-isthmectomies, 41 total thyroidectomies and 5 isthmectomies. The mean operating time was 134±45min (40 to 255). On D1, the post-operative ionized calcium was 1.09±0.11mmol/L (4.3685±0.44mg/dL) (normal 0.8-1.15mmol/L) (3.206-4.609mg/dL)) and the total serum calcium was 2.07±0.11mmol/L 8.296±0.44mg/dL (normal 2.2-2.5mmol/L) (8.817-10.019mg/dL). Five patients underwent conversion from endoscopic to open cervical approach (5.5%). The complications were seven cases of transient recurrent nerve palsy (7.8%), eight cases of hypoparathyroidism (19%) including six transient and two permanent, one skin burn and 26 cases of transient chin numbness related to the electrocautery (29%). Ten patients (11%) presented with transient post-operative skin ecchymosis that resolved within 7-10 days. A spontaneous pneumo-mediastinum was observed on chest CT in three patients and evolved favorably. No hematoma, or surgical site infection, or complications related to axillary extraction were observed. All the patients declared themselves satisfied post-operatively and at the end of the follow-up. The TOETVA route of entry is a safe and reliable technique in well-selected patients wishing to avoid a cervical scar.

R35 Early Experiences of Thoracoscopic Parathyroid Gland Resection in New Zealand

Surgical treatment of primary hyperparathyroidism can be complicated by the presence of ectopic mediastinal parathyroid adenomas, which occurs in up to 25% of cases. The majority of mediastinal parathyroid glands can be removed through a cervical incision. However, when this approach is inadequate for access to deeper glands, traditional approaches such as mediastinoscopy, sternotomy or thoracotomy are required. Historically, extracervical approaches to ectopic glands can be associated with increased surgical risk and complications.

Evaluation of endoscopic thyroid surgery with extra-cervical approaches

Evaluation of endoscopic thyroid surgery with extra-cervical approaches

Extracervical Approaches to Thyroid Surgery: Evolution and Review.

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.

Scarless Neck Thyroidectomy Using Bilateral Axillo-breast Approach: Initial Impressions After Introduction in a Specialized Unit and a Review of the Literature

IntroductionThe extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature. MethodsBetween June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4). ResultsAll 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285min and 210min for hemithyroidectomy. The average hospital stay was 1.67 days. With a mean follow-up of 7.73 months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high. ConclusionOur experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Tiroidectomía sin incisión cervical por abordaje endoscópico biaxilo-biareolar. Primeras impresiones tras su introducción en una unidad especializada. Revisión de la literatura

IntroductionThe extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature. MethodsBetween June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4). ResultsAll 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high. ConclusionOur experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Transforming Head and Neck Surgeon Into Thyroid Expert

With the rapid rise in the incidence of thyroid cancer, the number of thyroidectomies has increased remarkably in the last 10 years. Thyroidectomy accounts for approximately 40% of the workload in head and neck fellowship. The decision making in thyroid surgery is quite complex, especially when patients present with recurrent or advanced thyroid cancer. The complications of thyroid surgery can be very serious in relation to quality of life. Some of these complications can be avoided with meticulous surgical technique. Thyroid surgery continues to span various specialties, and surgical volume continues to be an important parameter in outcomes. Technological advances have made a significant impact in thyroid surgery; however, these need to be carefully evaluated before their routine implementation and for extracervical approaches to thyroidectomy. The use of external radiation therapy and targeted therapies has expanded in recent years for patients with recurrent thyroid cancer. In a specialized and tertiary care center, the thyroid expert should be well-trained to make appropriate complex decisions. Thyroid experts should be part of the multidisciplinary team managing thyroid cancer from A to Z.

Robot-assisted parathyroidectomy

Various methods of minimally invasive parathyroid surgery have been introduced over the last 2 decades. Recently, robotic approaches for thyroid and parathyroid surgery had gained increased interest in Asia as well as in the Western countries. These novel approaches did overcome the limitations of the prior described endoscopic approaches through several dexterities of the robotic system such as magnified, high-resolution vision, and precise movement of the instruments. Furthermore, robotic approaches facilitated complete remote extracervical approaches to target these organs with safety. Remote access approaches provides higher cosmetic satisfaction compared with the traditional cervical approach, especially in young women with history of healing with keloids or hypertrophic scars, which would have a significant influence on their quality of life. In this article, we discuss different approaches using remote access robot-assisted parathyroid surgery.

Endoscopic thyroidectomy: retroauricular approach.

The incidence of thyroid cancer has abruptly increased recently, with a female predominance. Conventional thyroidectomy using transcervical incision inevitably leaves an unfavorable neck scar; therefore, various extracervical approaches have been introduced to improve cosmetic satisfaction after thyroidectomy. Several reports demonstrated that these extracervical approaches have advantages not only in terms of cosmesis but also in terms of surgical outcomes and postoperative functional preservation. The retroauricular approach has advantages as the dissection area is smaller than that in the transaxillary approach (TA) and surgical anatomy is familiar to the head and neck surgeons. In addition, there is no concern about paresthesia around the nipple or anterior chest, and surgical direction makes central neck dissection easier than with the other extracervical approaches. Herein, we aim to introduce the surgical procedure of retroauricular approach thyroidectomy and present our experiences of postoperative outcomes.

Intrathyroidal parathyroid carcinoma. A case report and review of the literature

Surgery for substernal goiters can be technically demanding. Extensive mediastinal extension brings the thyroid gland into close quarters with vital intrathoracic structures. Proper preoperative planning is required to determine the potential need for an extracervical approach. Assessing the risk of requiring an extracervical approach is typically based on findings from cross-sectional imaging of the neck and chest. This article addresses the important anatomical considerations when resecting a large substernal goiter and also reviews various extracervical approaches.

The perception of scar cosmesis following thyroid and parathyroid surgery: A prospective cohort study

IntroductionVarious “scarless” approaches have been described for thyroid and parathyroid surgery. The objective of the current study was to investigate patients' perception of neck scar cosmesis, its impact on quality of life (QoL) and evaluate patient preference with regards to scar location. Methods120 patients undergoing thyroid or parathyroid surgery were followed-up over a 5-year period (2008–2013). Validated tools were used to assess scar perception and its impact on QoL. These were evaluated against sex, age, ethnicity, operation type, histopathology, time following surgery and scar length. ResultsMean follow-up was 2.6 ± 3.8 years. One of the most common post-operative problems was scar-related (n = 18). Caucasian patients and those with benign histology expressed a lower impact on QoL (p < 0.001, p = 0.038). Sex and scar length did not significantly affect patients' perception for scar cosmesis (p > 0.05). Clinicians tended to score scar cosmesis higher than patients (p = 0.02). Most participants (75%) expressed a clear preference for an extracervical “scar-less in the neck” approach. DiscussionScar-related issues are frequently reported following thyroid and parathyroid surgery. The negative impact, often underestimated by clinicians, is more apparent amongst Asian and Afro-Caribbean patients and can significantly impact on their QoL. This, combined with the lack of correlation between scar length and patient satisfaction, indicates the need to divert research from miniaturising neck scars to concealing them in extracervical sites. ConclusionPatients prefer a scar-less in the neck approach when given the option. A prospective comparative study is required to compare the cervical and extracervical approaches.

Reply to: Evolution of endoscopic thyroidectomy (10.1007/s00464-011-1763-5)

I would like to thank Dr. Dionigi et al. for their interest in our paper entitled ‘‘Robotic Thyroidectomy by Gasless Unilateral Axillo-Breast or Axillary Approach: Our Early Experiences’’ [1]. I agree with their commentary. Endoscopic or robotic thyroidectomy by gasless unilateral axillo-breast or axillary approach is not minimally invasive thyroid surgery [2, 3]. It is more invasive than conventional open thyroidectomy. The area dissected to expose the thyroid gland, the amount of drainage, and postoperative pain were more than with open thyroidectomy [1, 3]. The complication rate is similar with conventional open thyroidectomy in experienced surgeons [3–5]. However for the learning curve, the rate of recurrent laryngeal nerve palsy might be higher than open thyroid surgery due to the difficulty of the technique and the need for a period of learning. The most significant advantage of robotic or endoscopic thyroidectomy is the excellent postoperative cosmesis [1–3]. The cosmesis might be not an important concern for certain patients. However, thyroid nodules are common in young women who are very concerned about the aesthetic results of thyroidectomy. Hence, endoscopic or robotic thyroidectomy by extracervical approach is clearly indicated for the subset of patients who are very interested in the postoperative cosmesis. The indication of endoscopic or robotic thyroidectomy can be expanded to more advanced thyroid lesions with more experience. Another advantage of robotic or endoscopic thyroid surgery is that the identification and preservation of the recurrent laryngeal nerve and parathyroid gland is subjectively easy due to the magnified view. As Dr. Dionigi’s comments, endoscopic or robotic thyroidectomy by extracervical approaches is less advantageous and effective than endoscopic abdominal and thoracic surgery. The further refinement of procedure and more advanced technology is necessary to minimize the surgical morbidity and invasiveness of robotic and endoscopic thyroid surgery.

Extracervical approaches to endoscopic thyroid surgery

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).

Minimal access surgery — thyroid and parathyroid

The concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, MIT or MIP should properly be defined as operations through a short and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection.Parathyroid glands are particularly suitable for minimally invasive surgery as most parathyroid tumors are small and benign. MIP are performed through a limited or discrete incision when compared to classic open transverse cervical incision and are targeted on one specific parathyroid gland. The concept of these limited explorations is based on the fact that 85% of patients will have single-gland disease. MIP must be proposed only for patients with sporadic hyperparathyroidism in whom a single adenoma has been clearly localized by preoperative imaging studies.The minimal access approaches to the thyroid gland may be broadly classified into three groups: the mini-open lateral approach via a small incision, minimally invasive video-assisted thyroidectomy via the midline and various endoscopic techniques. Endoscopic extracervical approaches have the main advantage of leaving no scar in the neck but cannot reasonably be described as minimally invasive as they require more dissection than conventional open surgery.Initially the indications for MIT were a solitary thyroid nodule of less than 3 cm in diameter in an otherwise normal gland. Today, MIT are also proposed in patients with small nodular goiters, Graves's diseases and low risk papillary thyroid cancers. Some concern remains about the radicality of MIT in this latter group but preliminary results are comparable to those of conventional surgery both in terms of I-131 uptake and serum thyroglobuline levels.Demonstrating the advantages of MIT and MIP over conventional surgery is not easy. Main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in conventional surgery. Several studies comparing conventional surgery with minimally invasive techniques using a cervical access have shown a diminution of postoperative pain, and better cosmetic results with minimally invasive techniques. MIP and MIT seem overall to be an advance but only randomized studies will demonstrate the real benefit.

Endoscopic minimally invasive thyroidectomy: first clinical experience

Background Since Theodor Kocher reduced the mortality rate of thyroidectomy from the 40% reported by Billroth to 0.2% in 1895, a collar incision with open removal of the thyroid gland is the standard procedure [1, 2]. In the past decade, efforts were made to reduce incision size and surgical access trauma by the use of endoscopic techniques. A first attempt was replacement of the central “Kocher incision” with lateral neck incisions and endoscopic removal of a thyroid lobe by Huscher on 8 July 1996 [3]. This lateral access was limited to removing only one lobe of the gland. The most common technique to date is the one developed by Miccoli et al. [4]. These authors reduced the incision to a size of 20 to 25 mm and operated on the thyroid by the use of video-endoscopic assistance (MIVAT). Several groups have described an access outside the frontal neck region via a chest [5–8], axillary [9], or combined axillary bilateral breast approach [10]. These accesses only moved the entry point from the frontal neck region to other regions, where they are still visible. The aforementioned minimally invasive approach and the conventional open approach do not respect anatomically given surgical planes and may therefore result in patient complaints, especially swallowing disorders after the scaring of the subcutaneous tissues. These extracervical approaches are associated with an extensive dissection in the access area and thus are maximally invasive. Therefore, we developed an exclusively endoscopic approach for thyroid resection [11] with standard instruments used for minimally invasive surgery (diameter, 3.5 mm). This endoscopic minimally invasive thyroidectomy (eMIT) technique was evaluated carefully by anatomic and cadaver dissections as well as ultrasound studies for technical realization and needs for instrument design [12]. To verify the safety and feasibility of the method, an animal trial was conducted in August 2008. Surgery was performed securely on five pigs, with very low blood loss. The postoperative behavior with special regard for feeding and pain reaction was normal until dissection. Especially, no local infection in the oral cavity or cervical spaces was noted.