Transoral Vestibular Approach Research Articles

The intuitive da Vinci single port surgical system and feasibility of transoral thyroidectomy vestibular approach

: Remote-access thyroid surgery is increasingly implemented to reduce the morbidity of an anterior cervical incision resulting from traditional thyroid surgery. While most remote-access approaches leave a cutaneous scar, the recent development of the transoral vestibular approach (TOVA) enables the achievement of a truly scarless surgery, as all incisions are made in the oral vestibule. Unfortunately, the adoption of the robotic system in transoral thyroid surgery has been limited by the need for an additional axillary incision, prohibitive cost, and steep learning curve of robotic surgery. The Intuitive da Vinci single port (SP) robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA), introduced in 2018, may enable transoral robotic thyroid surgery without an axillary port. Additionally, the new SP system is equipped with two “joggle joints” in the robotic arms and endoscope, allowing for additional flexibility in a narrow workspace. Compared to previous generations, the SP robot offers a greater range of motion and more precise surgical control, a derivative of fully articulating instruments on a similar console like the Xi system. This review provides an overview of literature on the application of the intuitive da Vinci SP robotic surgical system via the TOVA in thyroid surgery.

Natural Orifice Endoscopic Thyroidectomy via Transoral Vestibular Approach (TOVA): Single Surgeon Experience from North India

The transoral vestibular approach (TOVA) is the shortest route for endoscopic thyroidectomy (ET) to approach the thyroid and is a totally scar free procedure, hence it has a clear cosmetic advantage not only over conventional open thyroid surgery but also over other remote access approaches for ET like axilla, breast and chest wall approaches. The aim of this study was to evaluate the feasibility, safety and our initial outcomes of TOVA and highlight the advantages of 3D endoscopic equipment in remote access thyroid surgery. We reviewed our prospectively maintained database who underwent ET. 42 patients who fulfilled the stringent inclusion criteria were offered TOVA. We have used novel Trans-vestibular approach with 3D technology for endoscopic thyroid surgery in all cases. Clinico-demographic profile, investigations, operative details, histopathology and postoperative complications and follow-up data were analyzed by using statistical analysis with SPSS19.00 version. Out of 203 ET operated during study period, 42 (20.69%) patients were operated through TOVA. Hemithyroidectomy were performed in all the patients. There were 3 men and 39 women (M:F = 1:13). Mean tumor size was 3.54 ± 1.17 cm. All patients were euthyroid. All patient had cytological diagnosis of Bethesda category II-IV and all underwent hemithyroidectomy. Mean operation time was 107.71 ± 17.60 min and post-operative length of hospital stay was 2.90 ± 1.28 days. Besides magnification, 3D endoscopy provided excellent depth perception which helped in precise dissection in the restricted space and aided in identification and preservation of the two most vital structures i.e. recurrent laryngeal nerve and parathyroid glands. As most of our patients present with larger goitres, not many patients desirous of ET can be offered TOVA. This novel TOVA has fairly stringent inclusion criteria, however it is the only approach which offers completely scarless endoscopic thyroidectomy and should be offered to eligible patients desirous of ET.

What is the Role of Transoral Thyroidectomy?

What is the Role of Transoral Thyroidectomy?

Extracervical endoscopic thyroid surgery via Bilateral Axillo-Breast approach (BABA).

Extracervical, scarless in-the-neck endoscopic thyroidectomy (SET) is a relatively new offshoot of minimal access neck surgery which is gaining popularity rapidly. Among all the approaches described, hybrid approaches such as axillary-breast and bilateral axillo-breast (BABA) are most practiced world over. We have performed more than 130 cases of SET using various approaches (ABA, BABA and transoral vestibular approach). We find BABA most suitable for patients who present with larger goitres (≥6cm), toxic glands or low-grade thyroid cancers and are desirous of SET. Here, we describe the surgical technique of BABA, its pros and pitfalls based on our experience.

Transoral endoscopic selective lateral neck dissection for papillary thyroid carcinoma: a pilot study.

Transoral endoscopic thyroid surgery via the vestibular approach (TOETVA) has been gradually accepted worldwide due to its scar-free effect on the neck. Even central cervical lymphadenectomy has been performed in some cases of papillary thyroid carcinoma (PTC). However, there are few reports involving lateral neck dissection with TOETVA. In this study, we attempted to perform selective lateral neck dissection (SLND) for PTC via a transoral vestibular approach. This prospective study was conducted from January 2016 to December 2018 in twenty PTC patients with unilateral T1 tumors without capsular invasion and patients with abnormal level III and IV lymph nodes who underwent SLND via a transoral vestibular approach. Endoscopic surgery was successfully accomplished in all 20 PTC patients. The mean age was 29.2 ± 5.5 (20-41) years. The mean operation time was 146.0 ± 18.7 (114-193) min. The average postoperative hospital stay was 6.8 ± 1.3 (5-10) days. The mean number of removed nodes was 7.4 ± 2.5 (4-12) in the central neck and 10.9 ± 2.8 (6-16) in the lateral neck, and the positive yield amounts were 2.0 ± 1.2 (0-4) and 2.7 ± 1.9 (0-6), respectively. No major complications occurred except for 1 case of transient unilateral recurrent laryngeal nerve palsy andtwo cases of effusionin theoperativearea. No evidence of persistent or recurrent disease was observed in these patients during a mean follow-up of 24.3 ± 9.1 (6-36) months. The cosmetic results and protection of personal privacy of this procedure were excellent. Endoscopic SLND via the transoral vestibular approach is feasible, safe, and effective for selected PTCs. A multicenter large comparative study is necessary.

Dr. Victoria Banuchi: my thoughts on starting a program of endoscopic transoral thyroidectomy vestibular approach

Dr. Victoria Banuchi: my thoughts on starting a program of endoscopic transoral thyroidectomy vestibular approach

Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy.

Objectives:The objectives of the study were to investigate the improvement in operation time for thyroid surgery gained using a modified endobag and suture and to accelerate the learning process for novice endoscopic surgeons.Materials and Methods:A retrospective study was conducted between 2 June 2015 and 1 November 2018. Medical records of patients who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) were retrieved and analysed. Comparisons of operative time with or without the use of modified equipment were calculated by the unequal variance t-test in lobectomy and isthmectomy groups.Results:Medical records of 102 patients (mean age: 39.1 years) were analysed. The size of thyroid nodule averaged 4.0 cm (range: 1.0–13.0 cm). TOETVA was applied for right lobectomy (57.8%), left lobectomy (34.3%), isthmectomy (3.9%) and total thyroidectomy (3.9%). Early in our experience, TOETVA required 168 min, whereas following the introduction of the modified endobag and extracorporeal suture, operative time was reduced to 30 min (P > 0.05).Conclusions:The use of modified equipment permitted shorter operation times. The time difference was not statistically significant but does represent a significant time-saving. The use of the modified equipment will simplify and speed up the learning process for novice endoscopic surgeons.

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO2 insufflation: Preclinical feasibility study.

Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision. In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers. A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands. In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.

Relevant Anatomy for the Transoral Vestibular Approach to the Thyroid and Parathyroid Glands

This paper highlights the key anatomical considerations for the surgeon to appreciate in order to carry out a safe and effective transoral vestibular approach to the central neck for thyroid and parathyroid dissection. The transoral, vestibular approach for thyroidectomy and parathyroidectomy avoids external, visible scarring altogether. This approach requires additional understanding of intraoral and cervical anatomy from an altered viewpoint compared with open central neck surgery as the surgeon creates a working space from the mouth to the neck and views the thyroid and parathyroid glands from a superior to-inferior position.

Endoscopic transoral parathyroidectomy: Initial experience.

We evaluate our initial experience of transoral vestibular approach parathyroidectomy (TOEPVA) for the treatment of primary hyperparathyroidism. We conducted a prospective study of patients with single parathyroid adenoma, using TOEPVA to perform the parathyroidectomy. The variables we analyzed were size, volume, and location of the adenoma, bleeding, identification, and preservation of the recurrent laryngeal nerve, injury to the mental nerve, and the effective cure rate, using measures of central tendency. Our study included 21 women, with an average age of 43 years. The recurrent laryngeal nerve and mental nerve suffered no permanent damage, the average size of the adenoma was 26.6 mm, and a volume of 3.95 mL. We were able to identify the adenoma and cure the hyperparathyroidism in 20 of the patients (95.2%). TOEPVA is viable and safe in who wish to avoid the cervical scar resulting for the patient with primary hyperparathyroidism.

A comparison of transoral vestibular and bilateral areolar endoscopic thyroidectomy approaches for unilateral papillary thyroid microcarcinomas.

IntroductionA transoral (TO) vestibular approach is a new remote access approach to avoid cutaneous scars in an endoscopic thyroidectomy (ET). And transoral endoscopic thyroidectomy (TOET) has been widely used in papillary thyroid microcarcinomas (PTMCs).AimTo evaluate and compare endoscopic thyroidectomies with central neck dissection using a bilateral areolar (BA) approach and TO approach in patients with unilateral PTMCs.Material and methodsIn total, 92 papillary thyroid cancer (PTC) patients undergoing an endoscopic unilateral thyroidectomy with central neck dissection via a TO (n = 48) or BA (n = 44) approach were retrospectively enrolled from August 2017 to December 2018. Differences in various factors, such as clinical characteristics, surgery-related parameters, including operative complications, and hospital durations and costs, were compared.ResultsNo significant between-group differences in the age and sex of the patients or the side, body mass index, total operative time, operative bleeding, superior parathyroid preservation in situ, operative complications, and postoperative day of discharge were found (all p > 0.05). The mean central neck dissection time, amount of postoperative drainage, extubation time, and inferior parathyroid preservation in situ were lower in the TO group as compared with these parameters in the BA group (all p < 0.05). The number of central lymph nodes resected and hospitalization costs were higher in the TO group as compared with those in the BA group (all p < 0.05).ConclusionsAn ET via the TO approach may be a good choice for unilateral PTMCs because of the shorter central neck dissection time, reduced postoperative drainage, better cosmetic satisfaction, and higher number of lymph nodes removed.

Transoral Thyroidectomy Using A Flexible Robotic System: A Preclinical Cadaver Feasibility Study.

Traditionally, most thyroid surgery utilizes a curvilinear cervical incision with a resulting permanent scar. Minimally invasive and remote access thyroid surgery techniques continue to evolve. Transoral approaches through a vestibular incision have been developed at several centers throughout the world, obviating the need for a cutaneous incision and optimizing aesthetics. To date this technique has been performed using rigid endoscopes or a linear robotic platform. The goal of this study was to test the feasibility of a novel flexible robotic system to perform a transvestibular thyroidectomy in a preclinical cadaver model. Preclinical feasibility study. Right and left thyroid lobectomies were successfully performed via a transvestibular approach in four cadavers. A single vestibular incision between bilateral mental nerves allowed entrance of the flexible robot in a subplatysmal plane in both male and female cadavers. The recurrent laryngeal nerves and parathyroids were identified and preserved. The flexible three-dimensional camera allowed excellent visualization and could be easily repositioned for optimal visualization of right and left structures. The flexible and wristed instruments enabled an atraumatic approach and allowed for precise surgical technique. The transoral vestibular approach to the central neck is a promising technique for thyroidectomy with optimal cosmesis and can be successfully accomplished using this novel flexible robotic system. Improvements in visualization and access offered by this system may improve application of this technique. NA Laryngoscope, 129:1482-1487, 2019.

Scarless Transoral Vestibular Approach for Thyroidectomy and Parathyroidectomy at a US Teaching Hospital

Scarless Transoral Vestibular Approach for Thyroidectomy and Parathyroidectomy at a US Teaching Hospital

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.

Transoral Endoscopic Thyroidectomy Vestibular Approach: Technical Tips and Tricks

Abstract Introduction: The transoral thyroidectomy vestibular approach has emerged as a new remote access surgical technique for the treatment of thyroid disease.1 With the benefit of being “scarle...

Endoscopic Thyroid Surgery Through Trans-oral Vestibular Approach (TOVA): A Case Series and Review of Literature

Endoscopic surgery is now standard of care for different Endocrine Disorders; the endoscopic thyroid surgery is becoming more popular and different approaches has been practice by many thyroid surgeon worldwide. Trans-orovestibular approach, based on the principle of natural orifice transluminal surgery is truly scar free thyroid surgery and has minimal dissection. We are presenting here three cases of benign solitary thyroid nodule operated endoscopically through trans-oro-vestibular approach in one male and two female patients. Describedabout the approach, challenges during surgery and outcome. These surgeries documented very few in literatures in live human patients. Transoral endoscopic thyroid surgery through vestibular approach is shortest and direct remote access approach. The need of limited dissection in this approach provides less complication and excellent cosmetic outcome in strictly selected patients.

Transoral thyroidectomy and parathyroidectomy – A North American series of robotic and endoscopic transoral approaches to the central neck

ObjectiveMost thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma. Materials and methodsData was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017. ResultsFifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life. ConclusionThe transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Transoral Endoscopic Parathyroid Cyst Removal

Introduction: Remote access approaches to the central neck have become increasingly popular in some parts of the world.1 Recently, the transoral vestibular approach has been employed effectively in North America with the assistance of international colleagues.2 The transoral approach offers direct access to the central neck, and can be used effectively and safely in a Western population. Materials and Methods: The aim of this video is to demonstrate the utility of the transoral vestibular approach for central neck lesions. A 30-year-old female with left-sided otalgia was noted to have an ipsilateral central neck mass. Ultrasonography showed a cystic 2.7 × 4.0 × 2.5 cm level VI mass extending into the mediastinum. Aspiration noted a parathyroid hormone level of 140 pg/mL, consistent with a parathyroid cyst. Three vestibular incisions were made in the oral vestibule, and insufflation was used to maintain a working space. Results: The left parathyroid cyst was removed endoscopically while preserving the adjacent normal parathyroid gland. There were no injuries noted to the mental or recurrent laryngeal nerves. Operative time was 110 minutes, and the patient was discharged within 23 hours. Final pathology analysis was consistent with a parathyroid cyst. The patient had an excellent outcome without a cervical incision or complications. Conclusions: Transoral endoscopic approaches can be safely used for central neck lesions. This approach provides optimal observation and avoids a cervical incision. No competing financial interests exist. Runtime of video: 8 mins 1 sec

Transoral thyroidectomy, vestibular approach using two ports: A novel technique

Cosmesis is a prime concern for many patients undergoing thyroid surgery. Postthyroidectomy scar-related apprehension among patients has forced the surgeons to develop techniques to reduce the scar or even without scar. We report a case of a young female with thyroid nodule who underwent transoral endoscopic thyroidectomy done through a novel technique (transoral vestibular approach using two ports) at our center as potentially scarless thyroid surgery.

Treatment of Carcinoma of the Thyroid

Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma.Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017.Fifteen patients underwent the procedure for removal of the thyroid (n = 12), parathyroid (n = 2) or both thyroid and parathyroid glands (n = 1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life.The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.