European Archives of Oto-Rhino-Laryngology

, Volume 267, Issue 8, pp 1285–1290 | Cite as

Surgical anatomy of the floor of the oral cavity and the cervical spaces as a rationale for trans-oral, minimal-invasive endoscopic surgical procedures: results of anatomical studies

  • Thomas Wilhelm
  • Joris J. Harlaar
  • Anton Kerver
  • Gert-Jan Kleinrensink
  • Tahar Benhidjeb
Head and Neck


Over the past 10 years, several minimally invasive procedures for thyroid surgery have been developed. Because of extensive dissection in the thoracic and neck region, the name “minimal-invasive” is misleading. The aim of this study was to define a new trans-oral access to the cervical spaces especially to the thyroid on the basis of natural orifice surgery. Three embalmed human specimens were dissected for complete review of the anatomical situation in the cervical region. In additional five fresh frozen human specimens after an experimental trans-oral endoscopic minimally invasive thyroidectomy the anatomical structures of the floor of the oral cavity as well as the anterior neck region were evaluated. It was possible to create a working space under the platysma muscle with respect to the surgical planes of the neck and fascial layers. Within this area, the pretracheal region can be reached and the thyroid gland can be visualized and resected. To access the working space, a trocar for endoscopic view is placed medially in the floor of the oral cavity sublingually. The trocar passes the muscles of the floor of the oral cavity easily without relation to relevant anatomical structures. A first exclusively sublingual approach had to be abandoned because triangulation of the instruments could not be reached. Therefore, the approach was modified by positioning the working trocars in the oral vestibule bilaterally. By this way, a road map for accessing all anterior cervical regions directly under the platysma muscle could be established and anatomical landmarks and areas of possible collateral damage could have been defined. This combined sublingual and bi-vestibular trans-oral endoscopic approach enables an easy access to all structures and spaces of the anterior neck region with respect to anatomical preformed layers neck, even to the thyroid as one of the more distant structures.


Endoscopic Minimal invasive Thyroidectomy Cadaver study Anatomy Floor of the oral cavity 



The project was supported by Karl Storz GmbH, Tuttlingen, Germany and the New European Surgical Academy (NESA), Berlin, Germany.

Conflict of interest statement

There is no financial relationship with the organizations that sponsored the research. The authors declare that there is no conflict of interest.


  1. 1.
    Hüscher CS, Chiodini S, Napolitano G, Recher A (1997) Endoscopic right thyroid lobectomy. Surg Endosc 11:877–878CrossRefPubMedGoogle Scholar
  2. 2.
    Miccoli P, Berti P, Coute M, Bendinelli C, Marcocci C (1999) Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest 22:849–851PubMedGoogle Scholar
  3. 3.
    Miccoli P, Berti P, Frustaci GL, Ambrosiani CE, Materazzi G (2006) Video-assisted thyroidectomy: indications and results. Langenbecks Arch Surg 391(2):68–71CrossRefPubMedGoogle Scholar
  4. 4.
    Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G (2001) Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 130(6):1039–1043CrossRefPubMedGoogle Scholar
  5. 5.
    Ruggieri M, Straniero A, Genderini M, D’Armiento M, Fumarola A, Trimboli P, Gargiulo P (2007) The eligibility of MIVA approach in thyroid surgery. Langenbecks Arch Surg 392:413–416CrossRefPubMedGoogle Scholar
  6. 6.
    Gagner M (1996) Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 83:875CrossRefPubMedGoogle Scholar
  7. 7.
    Brunt LM, Jones DB, Wu JS, Quasebarth MA, Meininger T, Soper NJ (1997) Experimental development of an endoscopic approach to neck exploration and parathyroidectomy. Surgery 122:893–901CrossRefPubMedGoogle Scholar
  8. 8.
    Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT (1998) Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg Endosc 12:202–205CrossRefPubMedGoogle Scholar
  9. 9.
    Yeung GH (1998) Endoscopic surgery of the neck: a new frontier. Surg Laparosc Endosc 8:227–232CrossRefPubMedGoogle Scholar
  10. 10.
    Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M (2000) Endoscopic neck surgery by the axillary approach. J Am Coll Surg 191:336–340CrossRefPubMedGoogle Scholar
  11. 11.
    Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, Kitajima M (2000) Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 10:1–4PubMedGoogle Scholar
  12. 12.
    Witzel K, von Rahden BH, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22(8):1871–1875CrossRefPubMedGoogle Scholar
  13. 13.
    Downton D, Qvist G (1960) Intra-oral excision of the submandibular gland. Proc R Soc Med 53:543–544PubMedGoogle Scholar
  14. 14.
    Bernhardt J, Gerber B, Schober H-C, Kähler G, Ludwig K (2008) NOTES—case report of a unidirectional flexible appendectomy. Int J Colorectal Dis 23:547–550CrossRefPubMedGoogle Scholar
  15. 15.
    Hochberger J, Menke D, Matthes K, Lamadé W, Köhler P (2009) Transluminale Interventionen (“NOTES”)–aktueller Stand. Dtsch Med Wochenschr 134:467–472CrossRefPubMedGoogle Scholar
  16. 16.
    Hogan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23:1512–1518CrossRefGoogle Scholar
  17. 17.
    Sodergren MH, Clark J, Athanasou T, Teare J, Yang G-Z, Darzi A (2009) Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice. Surg Endosc 23:680–687CrossRefPubMedGoogle Scholar
  18. 18.
    Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES-world’s first report. Surg Endosc 22:1343–1347CrossRefPubMedGoogle Scholar
  19. 19.
    Kalloo AN, Kantsevoy SV, Singh VK et al (2000) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastroenterology 118:A1039CrossRefGoogle Scholar
  20. 20.
    Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117CrossRefPubMedGoogle Scholar
  21. 21.
    Werner JA, Sapundzhiev NR, Teymoortash A, Dunne AA, Behr T, Folz BJ (2004) Endoscopic sentinel lymphadenectomy as a new diagnostic approach in the N0 neck. Eur Arch Otorhinolaryngol Head Neck 261:463–468Google Scholar
  22. 22.
    Malloy KM, Cognetti DM, Wildemore BM, Cunnane MF, Keane WM, Pribitkin EA, Rosen D (2007) Feasibility of endoscopic sentinel node biopsy in the porcine neck. Otolaryngol Head Neck Surg 136:806–810CrossRefPubMedGoogle Scholar
  23. 23.
    Sesterhenn AM, Folz BJ, Werner JA (2008) Surgical technique of endoscopic sentinel lymphadenectomy in the N0 neck. Oper Techn Otolaryngol 19:26–32CrossRefGoogle Scholar
  24. 24.
    Terris DJ, Haus BM, Gourin CG (2004) Endoscopic neck surgery: resection of the submandibular gland in a cadaver model. Laryngoscope 114:407–410CrossRefPubMedGoogle Scholar
  25. 25.
    Guyot L, Duroure F, Richard O, Lebeau J, Passagia J-G, Raphael B (2005) Submandibular gland endoscopic resection: a cadaveric study. Int J Oral Maxillofac Surg 34:407–410CrossRefPubMedGoogle Scholar
  26. 26.
    Kessler P, Bloch-Birkholz A, Birkholz T, Neukam FW (2006) Feasibility of an endoscopic approach to the submandibular neck region: experimental and clinical results. Brit J Oral Maxillofac Surg 44:103–106CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Thomas Wilhelm
    • 1
  • Joris J. Harlaar
    • 2
  • Anton Kerver
    • 2
  • Gert-Jan Kleinrensink
    • 2
  • Tahar Benhidjeb
    • 3
  1. 1.Department Otolaryngology, Head, Neck and Facial Plastic SurgeryHELIOS Kliniken Leipziger LandBornaGermany
  2. 2.Department of Neuroscience-Anatomy, Erasmus MCUniversity Medical Centre RotterdamRotterdamThe Netherlands
  3. 3.Department of General, Visceral, Vascular and Thoracic SurgeryCharité-Universitätsmedizin BerlinBerlinGermany

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