Transoral Endoscopic Vestibular Approach Research Articles

Comparative Analysis of Transoral Endoscopic Parathyroidectomy Vestibular Approach and Focused Open Surgery for Primary Hyperparathyroidism Treatment: A Single Center Experience.

BACKGROUND Primary hyperparathyroidism is one of the most common endocrine disorders, for which the definitive treatment is surgical parathyroidectomy. Generally, surgical exploration is performed as open focused neck surgery. The vestibular route is a new approach to minimally invasive endoscopic parathyroidectomy. This retrospective study from a single center in Turkey aimed to compare surgical outcomes from the transoral endoscopic vestibular approach (TOEPVA) vs direct open parathyroidectomy in 57 patients. MATERIAL AND METHODS Our study included data from 57 patients. TOEPVA was performed in 20 of these patients who did not want a cervical scar, and focused surgery was performed in the remaining 37 patients. The variables we analyzed were size, volume, and localization of the adenoma, operative time, presence of bleeding, presence of the recurrent laryngeal nerve damage, preoperative, short-term, and long-term postoperative PTH levels, use of drain, presence of postoperative hypocalcemia, and short-term and long-term calcium levels. RESULTS No laryngeal nerve and mental nerve damage was observed in either group. The mean operative time in focused open surgery was 80.54±33.1 min, while the mean operative time in TOEPVA was 128.21±30.88 (p: 0.794) min. The mean hospitalization period of patients who underwent open surgery was 3.29±1.9 days, while the mean discharge days of patients who underwent endoscopic surgery was 2.40±1.2. (p>0.05). CONCLUSIONS TOEPVA is a safe method in patients who underwent parthyroid surgery to avoid cervical scarring.

Transoral endoscopic vestibular approach Sistrunk procedure (TEVAS)-case report and scoping review.

Thyroglossal duct cyst (TGDC) is the most common congenital neck mass among the pediatric population. Less than 10% of the cases occur in adults. The standard of care for TGDC is surgical treatment with the Sistrunk procedure via a traditional transverse cervicotomy. This technique involves the resection of the cyst with its tract and the central portion of the hyoid bone body to avoid recurrence. The transoral vestibular approach has gained popularity as an alternative approach to open neck surgery in order to eliminate the transcervical scar associated with these procedures. We describe a case of an endoscopic Sistrunk procedure performed by the transoral vestibular approach. A scoping review of the transoral endoscopic vestibular approach Sistrunk procedure (TEVAS) was performed. The PubMed, Medline, Cochrane, Lilacs, Scielo, Mary Ann Libert and Scopus databases were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting inclusion and exclusion criteria. The case was successful and without complications. Five studies were included in the final analysis for this review. This novel approach to the Sistrunk procedure is an effective alternative way to treat TGDC in selected patients who are motivated to avoid a visible neck scar.

Gasless submental-transoral combined approach endoscopic thyroidectomy: a new surgical technique.

The development of transoral endoscopic vestibular approach thyroidectomy (TOETVA) has been limited by inherent defects, such as mental nerve injury and carbon dioxide (CO2)-related complications. Herein, we proposed a new technique without CO2 called gasless submental-transoral combined approach endoscopic thyroidectomy (STET) to solve the problems in TOETVA. We reviewed 75 patients who successfully underwent gasless STET using novel instruments at our institution from November 2020 to November 2021. A main incision of approximately 2 cm was made in the natural submental crease line and then combined with two vestibule incisions to complete the procedure. Demographic data, surgical technique and perioperative outcomes were retrospectively recorded. Thirteen male and sixty-two female patients with a mean age of 34.0 ± 8.1 years were enrolled in this study. Sixty-eight patients had papillary thyroid carcinomas and seven had benign nodules. We successfully performed all gasless STET without conversion to open surgery. The average postoperative hospital stay was 4.2 ± 1.8 days. One transient recurrent laryngeal nerve injury and two transient hypoparathyroidisms were observed. Three patients complained of slight lower lip numbness on the first postoperative day. One case of lymphatic fistula, subcutaneous effusion, and incision swelling occurred each, all of which were conservatively cured. One patient developed a recurrence six months after surgery. Gasless STET using our own designed suspension system is technically safe and feasible with reasonable operative and oncologic results.

Scarless Neck Feminization by Transoral Endoscopic Vestibular Approach Chondrolaryngoplasty: A Prospective Cohort.

Chondrolaryngoplasty (laryngeal-prominence reduction) is a gender affirmation surgery for transgender women, or for cisgender people desiring an esthetic correction. Up until recently, chondrolaryngoplasty required a visible neck scar. The transoral endoscopic vestibular approach (TOEVA) is gaining widespread use as a scarless alternative for thyroid/parathyroid surgeries. This study aims to describe the feasibility, safety, and outcomes of TOEVA-chondrolaryngoplasty, based on the first-ever performed cases. A prospective cohort. An academic referral center. Adult patients interested in chondrolaryngoplasty underwent scarless TOEVA-chondrolaryngoplasty between 2019 and 2022, according to the described protocol. Video stroboscopy was recorded pre-and postoperatively. Surgical data, adverse events, and complications were recorded. Patients' satisfaction was measured using an outcome instrument for esthetic chondrolaryngoplasty. Twelve patients (10 transgender women, a cisgender man, and a woman) were included. The mean age was 26.7 ± 6.5 years, ranging from 19 to 37. The average operative time was 3:01 ± 0:51hours. The thyroid cartilage and laryngeal prominence were easily and safely approached and reduced, with no adverse events or major complications. All patients were discharged on postoperative day 1. A single patient had a temporary mental nerve hypoesthesia that resolved spontaneously. Otherwise, no other complications were encountered. Vocal folds' function remained unchanged in all patients. Patients were very much to completely satisfied with the surgical results as measured by the outcome instrument; median (interquartile range), 25 (21-27.75). In this first reported cohort of scarless TOEVA-chondrolaryngoplasty, this approach was proven to be safe and feasible, with no adverse events or major complications, and with high patient satisfaction.

Transoral Endoscopic Vestibular Approach Sistrunk Procedure: Surgery Video

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

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries – A case series

BackgroundWe present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach. MethodsRetrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed. OutcomesAll 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma. ConclusionTransoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.

Impact of Transoral Endoscopic Vestibular Approach Thyroidectomy on Pathologic Assessment.

Since 2016, transoral endoscopic thyroid resection with vestibular approach (TOETVA) has been increasingly performed in the United States. Although guidelines for the procedure are evolving, indeterminate and malignant preoperative cytopathologic diagnoses are not a contraindication. There are limited data related to the pathologic examination of these specimens. To examine the clinicopathologic features of TOETVA specimens with particular attention to limitations of interpretation of pathologic parameters and final diagnosis. We reviewed age, sex, preoperative imaging and cytologic diagnoses, surgical pathology, and clinical follow-up data in TOETVA resections from our institution for procedures performed between March 2016 and December 2019. Fifty cases of TOETVA were identified, comprising 48 women and 2 men with a mean age of 47 years. Preoperative cytologic diagnoses were available in 47 cases and included 19 nondiagnostic/benign (Bethesda I/II), 24 follicular lesion of undetermined significance/suspicious for follicular neoplasm (Bethesda III/IV), and 4 suspicious/malignant diagnoses (Bethesda V/VI). Thirty-four cases (68%) among the surgical resection specimens showed disruption and/or fragmentation. Thirty-nine cases were negative for carcinoma, including hyperplasias and benign/indolent neoplasms. Eleven cases exhibited papillary thyroid carcinoma. Final diagnoses were reached in all disrupted/fragmented cases. In 2 cases of papillary thyroid carcinoma, tumor size, microscopic extrathyroidal extension, and margin status could not be determined. A significant proportion of TOETVA specimens are disrupted/fragmented, which can compromise information about tumors, including size, number, margin status, and microscopic extrathyroidal extension. Given that these parameters inform treatment and follow-up, this should be considered when selecting patients for TOETVA.

Transoral sistrunk procedure

Thyroglossal duct cysts are a common congenital, midline neck mass. Surgical excision of the mass and its embryonic tract including the middle portion of the hyoid bone and suprahyoid musculature, is known as the Sistrunk procedure and is a key to preventing recurrence. One of the few drawbacks of this surgical approach is that can leave aesthetically noticeable scars. A novel way to avoid such a scar is to use a transoral endoscopic vestibular approach similar to what is used in the transoral endoscopic thyroidectomy vestibular approach. This approach is both safe and effective in the appropriately selected patient. It allows for adequate resection of the thyroglossal duct cyst and its tract while avoiding a cervical incision.

OUTCOME OF TRANSORAL ENDOSCOPIC THYROIDECTOMY VESTIBULAR APPROACH (TOETVA) IN COMPARISON WITH OPEN THYROIDECTOMY FOR BENIGN THYROID NODULES

Open thyroidectomy; is the gold standard surgical procedure for thyroid diseases, but the incision scar in the anterior aspect of the neck due to this approach cannot be avoided and may results in a permanent cosmetic defect. Therefore, there is a need to improve postoperative quality of life, including cosmetics. Recently, transoral endoscopic thyroidectomy has been developed; it is a natural orifice thyroid surgery, minimally invasive and completely scar free. This study aimed to describe the outcome, patient’s satisfaction, and complications after hemithyroidectomy for benign thyroid nodules by transoral endoscopic vestibular approach in comparison with open approach. This study was conducted in Al-Shiffa General hospital, Basrah, Iraq from August 2017 to June 2019 and was approved by a local ethical committee.Fifty patients with benign thyroid nodules who are candidate for hemithyroidectomy were included in the study; they were divided into two groups according to the method for thyroidectomy which was either conventional open or transoral endoscopic thyroidectomy vestibular approach based on the patients’ preferences. All operations were performed by the same surgical team. The results of this study showed that 24 (48%) of them operated upon by transoral endoscopic thyroidectomy vestibular approach, while the remaining 26 (52%) patients have been operated upon by open thyroidectomy approach. Transoral endoscopic thyroidectomy vestibular approach reported significant longer operative time, has comparable rate of complications with an excellent cosmetic outcome and better postoperative patients’ satisfaction in comparison to open thyroidectomy.In conclusion, transoral endoscopic thyroidectomy vestibular approach is a safe and feasible procedure with an excellent cosmetic outcome and better patients’ satisfaction. At present, it is a relatively time-consuming procedure and, therefore, candidate patients with a strong motivation for scar free surgery are recommended.Key words: Thyroidectomy; Endoscopic thyroidectomy; Transoral thyroidectomy; Benign, Nodule

The variable direct cost and cost drivers of transoral endoscopic thyroidectomy vestibular approach.

As transoral endoscopic thyroidectomy vestibular approach grows in popularity, there is a need for data on cost in order to better characterize its value to patients. To this end, we compared the variable direct cost of transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy and determined which factors drive the increased cost for the transoral approach. Patients undergoing thyroid lobectomy and total thyroidectomy that met inclusion criteria for transoral endoscopic thyroidectomy vestibular approach, including those patients that opted for management via the transcervical approach, between 8/2016 and 4/2019 were reviewed. The variable direct cost for the surgical encounter was collected and means were compared between the transoral and transcervical cohorts for lobectomy and total thyroidectomy respectively. The operative time independent variable direct cost was similarly compared between cohorts. Out of 238 patients, 118 (50%) were managed via transoral endoscopic thyroidectomy vestibular approach and 120 (50%) were managed via transcervical approach thyroidectomy. Mean variable direct cost, our primary outcome, was $4,455 (SD 1,129, 95% CI: 4,204-4,706) for transoral lobectomy and $3,179 (SD 687, 95% CI: 2,990-3,369) for transcervical lobectomy [t(132.05)=8.09, P<0.001] representing a difference in cost of $1,276 (SD 158, 95% CI: 964-1,587). Mean variable direct cost was $4,681 (SD 829, 95% CI: 4,405-4,957) for transoral total thyroidectomy and $3,645 (SD 876, 95% CI: 3,431-3,858) for transcervical total thyroidectomy [t(79.92)=5.98, P<0.001], representing a difference in cost of $1,036 (SD 173, 95% CI: 691-1,381). Differences in energy devices alone account for $487.53 and $447.96 of the cost differences, respectively. The differences in mean variable direct cost between transoral endoscopic vestibular approach and transcervical approach for lobectomy and total thyroidectomy were $1276 and $1036 respectively, amounts far less than some believe them to be. This data will be invaluable as we ultimately aim to define the value of transoral endoscopic thyroidectomy vestibular approach.

Balloon Dilators for Fast and Safe Flap Dissection in Transoral Endoscopic Vestibular Approach Thyroidectomy Vestibular Approach (TOETVA)

Balloon Dilators for Fast and Safe Flap Dissection in Transoral Endoscopic Vestibular Approach Thyroidectomy Vestibular Approach (TOETVA)

Adoption of the transoral endoscopic vestibular approach by head and neck surgeons without prior laparoscopic/robotic experience

Transoral endoscopic vestibular approach (TOEVA) for thyroidectomy (TOETVA) and parathyroidectomy (TOEPVA) is gaining popularity, yet knowledge is based on a limited number of studies, mostly performed by surgeons experienced in laparoscopic\robotic surgery. All patients who underwent TOEVA at our institution between February 2018 and October 2019 were followed prospectively. Main outcomes were ability to accomplish surgery endoscopically (failure defined as conversion to open approach) and complications. Seventy-one patients (52 TOETVA and 19 TOEPVA) were included. 98% (51/52) and 100% (19/19) of TOETVA and TOEPVA surgeries were accomplished endoscopically, respectively. Transient vocal cord and mental nerve injuries rates were 8.4% (6/71) and 2.8% (2/71), respectively. Thyroid carcinoma was diagnosed in 27 patients (51.9%), all completely excised with clean margins. Adoption of the TOEVA suggested framework by head and neck surgeons without prior experience in laparoscopic/robotic techniques is feasible resulting in nearly 100% of surgeries accomplished endoscopically.

Endoscopic thyroidectomy: Which one is the better technique for the beginners?

Introduction:Endoscopic thyroidectomy is an advanced procedure and has a long learning curve. Most commonly employed approach is combined axillary-breast approach (ABA). Recently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) is being popularised as a scarless procedure. However, it is not established whether TOETVA or ABA approach is better to begin with.Purpose:The purpose of the study was to compare the initial experience of TOETVA and ABA with respect to difficulties and outcomes.Methodology:A prospective non-randomised interventional study was conducted including the initial ten patients in each group who underwent hemithyroidectomy for benign solitary thyroid nodule. Sigma plot version 12.3 was used for the statistical analysis.Results:All the patients were female and comparable with respect to age (33.2 vs. 28.2 years) and size of nodule (2.7 vs. 3 cm) (TOETVA vs. ABA). The operative time (121 vs. 138.5 min, P = 0.34) and blood loss (50 vs. 60 ml, P = 0.9) were similar in both the groups. Even though the flap raising time was significantly less with TOETVA group (29.3 vs. 47.2 min, P < 0.001), it was associated with more difficulty in approaching upper pole (P = 0.02) and lower pole (P < 0.001), more intra-operative events (30% vs. 10%, P = 0.58) and conversions to open (20% vs. 10%, P = 1). Similarly, post-operative pain scoring was more with TOETVA (3 vs. 2, P = 0.04). Hospital stay was similar in both the groups (2.5 vs. 3 days, P = 1). Patients in both the groups had both overall and cosmetic satisfaction.Conclusions:Axillary-breast approach should be preferred to start learning the endoscopic thyroidectomy, as it is easier and safer than transoral endoscopic vestibular approach.

Transoral Robotic Thyroidectomy with Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve and External Branch of the Superior Laryngeal Nerve

Introduction: Transoral thyroidectomy has recently gained popularity owing to its superior cosmetic outcomes and low morbidity.1–3 The transoral endoscopic vestibular approach is more commonly adop...

Transoral endoscopic excision of cystic hygroma vestibular approach in adult (novel approach): a case report

Lymphangioma, soft tissue tumor was originally reported by R. Backer in 1828 and “cystic hygroma” name was first given by Wernker in 1834. It can occur in the head, neck, axilla, cervico-facial regions and below tongue. Although it is well recognized in children, it may present in adulthood. Cystic hygroma neck is traditionally removed via an overlying incision near or over the swelling. The resultant scar can be displeasing to an adult. Various endoscopic approach present in literature for excision are via neck, anterior chest, combined or robotic assisted. We here, are reporting transoral endoscope excision of cystic hygroma via vestibular approach. A 51 year old female with swelling over anterior aspect of neck, trans-illumination positive, diagnosis confirmed on CT neck, of size ~4×4 cm was our case. We decided for transoral endoscopic vestibular approach for excision, first of its kind with no assisted approach. Patient discharged after 3 post-operative days (PODs). There was mild seroma which resolved within a week. Transoral endoscopic excision of cystic hygroma via vestibular approach without any assisted approach can be applied in adult. Various approach present in literature for excision of cystic hygroma are via neck, anterior chest or combined or robotic assisted. Hence this approach can be an excellent choice for adult cystic hygroma patients who desire to avoid a neck incision. Transoral endoscopic excision of cystic hygroma via vestibular approach was successfully performed. Patient was satisfied with good cosmosis. It results in good cosmesis and better dissection. Hence can be a new method of excision of cystic hygroma in adult.

Scarless Neck Feminization: Transoral Transvestibular Approach Chondrolaryngoplasty.

Importance: Chondrolaryngoplasty or reduction of laryngeal prominence is a gender affirmation surgery for transgender women, or for male patients desiring an aesthetic surgery. Several variations of the procedure were suggested, yet to date, all described chondrolaryngoplasty procedures involved a visible neck scar. Objective: To describe a novel technique for scarless chondrolaryngoplasty, transoral endoscopic vestibular approach (TOEVA)-chondrolaryngoplasty, and to report the results of first ever performed cases. Design, Setting, and Participants: This was a prospective cohort at an academic referral center. Adult transgender women, interested in chondrolaryngoplasty who never had previous surgery of their neck or vocal folds, were offered both transcervical chondrolaryngoplasty and scarless TOEVA-chondrolaryngoplasty. Four patients aged 21 to 33 years, who preferred TOEVA-chondrolaryngoplasty, were consented and recruited. Interventions: The surgical technique was successfully examined on two cadavers. Subsequently, all surgical procedures were conducted according to the described study protocol and technique, between April and June 2019. Main Outcomes: Vocal assessment was recorded preoperatively and repeated 4 to 6 weeks after surgery for comparison. Surgical documentations as well as adverse surgical events and complications were recorded. To measure outcome, 1-2 months postoperatively, all patients filled an outcome instrument for aesthetic chondrolaryngoplasty (seven questions on a 5-point Likert scale) based on previously designed questionnaires for chondrolaryngoplasty and facial plastic surgery. Results: Duration of operative time ranged from 90 to 150 min. No adverse events or complications were recorded during surgery. All patients were discharged 1 day postoperatively. A single patient had a mild temporary mental hypoesthesia that resolved 2 months after surgery, no other complications were encountered. Vocal folds' function remained unchanged in all four patients. All operated patients were highly satisfied with the surgical results as measured by the outcome instrument; three out of the four patients responded with perfect scores, and the fourth patient responded with 90% of the perfect score. Conclusions: This report is the first description of scarless chondrolaryngoplasty through TOEVA. On a series of four patients, TOEVA-chondrolaryngoplasty appeared to be safe, with no adverse events or major complication, and with extremely high patient satisfaction. Further clinical evidence is required to establish a widespread use of this surgical technique.

Preoperative Imaging Localization and Intraoperative Indocyanine Green-Enhanced Fluorescence Guidance for Focused Transoral Endoscopic Parathyroidectomy Vestibular Approach

Abstract Background: Focused parathyroidectomy evolves the preferable surgical policy for primary hyperparathyroidism (PHPT).1–3 Transoral endoscopic vestibular approach furnishes a scarless choice...