Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

Summary

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

Abstract

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO₂ insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Introduction

Conventional open thyroidectomy has been safely performed using a cervical incision for more than 100 years¹. Although most patients have efficient scar healing and the cosmetic effect is generally acceptable, a permanent scar on the neck always draws immediate attention from common observers². Nearly 20% of post-thyroidectomy patients experience self-awareness, and more than 10% consider further treatments to remove the scar³. Moreover, a negative impact of the cervical incision on health-related quality of life (HRQOL) has also been reported⁴. Varied remote-access approac....

Protocol

The study was approved by the medical ethics committee of West China Hospital, Sichuan University (2018[457]), and written informed consent was obtained from all subjects.

1. Preoperative preparation

1. Patient eligibility
   1. Select patients who have stringent cosmetic requirements and meet the following criteria: (1) a benign nodule <4 cm in diameter; (2) a differentiated thyroid carcinoma (DTC) <2 cm in diameter without clinical lateral lymph node metastasis or distance metastasis; and (3) no imaging indication of central lymph node metastasis or a metastatic lymph node <2 cm in diameter without fusion a....

Results

We set up a routine clinical pathway for patients with TOETVA at the center. Laryngoscopy and a thyroid ultrasound are carried out on each patient before the operation. Parathyroid hormone (PTH), thyroid function, 25-dihydroxy vitamin D (25-OH-VD), and serum calcium are routinely measured before the operation, and all of them except for thyroid function are remeasured 1 day after the surgery. In our hospital, Foley catheters are routinely used for patients who will have a TOETVA surgery of more than 3 h. The Foley cathet.......

Discussion

TOETVA is characterized by the full exposure and dissection of the central lymph nodes, which is significantly advantageous in the treatment of differentiated thyroid carcinoma with cN1a^10,13,14,15. However, it should be noted that due to the limited operating space, it is relatively difficult to deal with the big tumors located in the upper pole of the thyroid gland. The surgical indications a.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Allis Grasping Forceps,310 mm x 5 mm	AESCULAP	PO111R
Button Electrode Tip	AESCULAP	GK385R
Ceramic Electrode	AESCULAP	GK384R
Complete Trocar	AESCULAP	EJ751R
Endoscope	Olympus	WA53005A
IONM	Medtronic	NIM-3.0
Light Transmitting Bundle	Olympus	WA03310A
Maryland Dissecting Forceps, 310 mm x 5 mm	AESCULAP	PO102R
Monopolar Handle (5 mm diameter, 33 cm working length)	AESCULAP	GK372R
Pneumoperitoneum tube,4 m	STRYKE	620-240-223
Pyramidal Tip Obturator	AESCULAP	EJ755R
Reusable Monopolar Cable	AESCULAP	GK245
Scissors	AESCULAP	P0004R
Suction irrigation tube	AESCULAP	PG027R
Super Righting Needle Holder, 5 mm	AESCULAP	PL414R
Veress	TianSong	E2014.6