Journal of Endocrinological Investigation

, Volume 40, Issue 11, pp 1259–1263 | Cite as

Transoral thyroidectomy: advantages and limitations

  • G. Dionigi
  • R. P. Tufano
  • J. Russell
  • H. Y. KimEmail author
  • E. Piantanida
  • A. Anuwong


In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, “transoral thyroidectomy” (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10 cm; (b) US-estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conventional endoscopic instruments and is probably the best scarless approach to the thyroid because of the short distance between the thyroid and the incisions placed intra-orally that do not result in any cutaneous scar and upon following the surgical planes. Experts in TOT organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologist to develop the standards for practicing this emerging technique.


Thyroid Thyroidectomy Mini-invasive thyroidectomy Transoral thyroidectomy 


Author contributions

(I) Conception and design: Gianlorenzo Dionigi, Hoon Yub Kim, Angkoon Anuwong; (II) Administrative support: Gianlorenzo Dionigi, Ralph P. Tufano, Angkoon Anuwong; (IV) Collection and assembly of data: Gianlorenzo Dionigi, Hoon Yub Kim, Ralph P. Tufano; (V) Data analysis and interpretation: Gianlorenzo Dionigi, Hoon Yub Kim, Ralph P. Tufano, Angkoon Anuwong; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Compliance with ethical standards

Conflict of interest

The authors have no conflict of interest to disclosure, and no other funding or financial relationship with the surgical industry.

Ethical approval

The study was approved by the institutional ethics committee of Department of Medicine and Surgery, University of Insubria.

Informed consent

All patients were provided the particular details for their surgeries and informed consent obtained from each patient.


  1. 1.
    Dralle H (2006) Impact of modern technologies on quality of thyroid surgery. Langenbecks Arch Surg 391:1–3CrossRefPubMedGoogle Scholar
  2. 2.
    Dionigi G, Barczynski M, Chiang FY, Dralle H, Duran-Poveda M, Iacobone M, Lombardi CP, Materazzi G, Mihai R, Randolph GW, Sitges-Serra A (2010) Why monitor the recurrent laryngeal nerve in thyroid surgery? J Endocrinol Invest 33(11):819–822CrossRefPubMedGoogle Scholar
  3. 3.
    Souberbielle JC, Brazier F, Piketty ML, Cormier C, Minisola S, Cavalier E (2017) How the reference values for serum parathyroid hormone concentration are (or should be) established? J Endocrinol Invest. 40(3):241–256. doi: 10.1007/s40618-016-0553-2 [Epub 2016 Oct 1. Review. PubMed PMID: 27696297] CrossRefPubMedGoogle Scholar
  4. 4.
    Pacella CM, Papini E (2013) Image-guided percutaneous ablation therapies for local recurrences of thyroid tumors. J Endocrinol Invest 36(1):61–70CrossRefPubMedGoogle Scholar
  5. 5.
    Miccoli P, Materazzi G, Baggiani A, Miccoli M (2011) Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 34(6):473–480. doi: 10.3275/7617 CrossRefPubMedGoogle Scholar
  6. 6.
    Cassio A, Corbetta C, Antonozzi I, Calaciura F, Caruso U, Cesaretti G, Gastaldi R, Medda E, Mosca F, Pasquini E, Salerno MC, Stoppioni V, Tonacchera M, Weber G, Olivieri A, Italian Society for Pediatric Endocrinology and Diabetology, Italian Society for the Study of Metabolic Diseases and Neonatal Screening, Italian National Institute of Health, Italian National Coordinating Group for Congenital Hypothyroidism, Italian Thyroid Association, Italian Society of Pediatrics, Italian Society of Neonatology, Italian Society of Endocrinology, Associazione Medici Endocrinologi (2013) The Italian screening program for primary congenital hypothyroidism: actions to improve screening, diagnosis, follow-up, and surveillance. J Endocrinol Invest 36(3):195–203. doi: 10.3275/8849 PubMedGoogle Scholar
  7. 7.
    Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L (2004) Minimally invasive video-assisted thyroidectomy: five years of experience. J Am Coll Surg 199(2):243–248CrossRefPubMedGoogle Scholar
  8. 8.
    Tan CT, Cheah WK, Delbridge L (2008) “Scarless” (in the Neck) endoscopic thyroidectomy (SET): an evidence-based review of published techniques. World J Surg 32(7):1349–1357CrossRefPubMedGoogle Scholar
  9. 9.
    Yeung GH (2002) Endoscopic thyroid surgery today: a diversity of surgical strategies. Thyroid 12(8):703–706CrossRefPubMedGoogle Scholar
  10. 10.
    Duh QY (2003) Presidential address: minimally invasive endocrine surgery–standard of treatment or hype? Surgery 134(6):849–857CrossRefPubMedGoogle Scholar
  11. 11.
    Henry JF (2008) Minimally invasive thyroid and parathyroid surgery is not a question of length of the incision. Langenbecks Arch Surg 393(5):621–626. doi: 10.1007/s00423-008-0406-3 CrossRefPubMedGoogle Scholar
  12. 12.
    Ng JW (2004) Minimally invasive surgery or minimal-incision thyroidectomy? Arch Surg 139(7):802CrossRefPubMedGoogle Scholar
  13. 13.
    Dionigi G, Boni L, Duran-Poveda M (2011) Evolution of endoscopic thyroidectomy. Surg Endosc 25(12):3951–3952. doi: 10.1007/s00464-011-1763-5 (author reply 3953) CrossRefPubMedGoogle Scholar
  14. 14.
    Dionigi G (2009) Evidence-based review series on endoscopic thyroidectomy: real progress and future trends. World J Surg 33(2):365–366. doi: 10.1007/s00268-008-9834-z CrossRefPubMedGoogle Scholar
  15. 15.
  16. 16.
    Cunningham SC (2006) Minimally accurate nomenclature. Surg Endosc 20(6):998CrossRefPubMedGoogle Scholar
  17. 17.
    Cuschieri A (1992) “A rose by any other name…” Minimal access or minimally invasive surgery? Surg Endosc 6(5):214CrossRefPubMedGoogle Scholar
  18. 18.
    Miccoli P, Materazzi G, Berti P (2010) Natural orifice surgery on the thyroid gland using totally transoral video-assisted thyroidectomy: report of the first experimental results for a new surgical method: are we going in the right direction? Surg Endosc 24(4):957–958CrossRefPubMedGoogle Scholar
  19. 19.
    Witzel K, von Rahden BH, Kaminski C et al (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22:1871–1875CrossRefPubMedGoogle Scholar
  20. 20.
    Benhidjeb T, Wilhelm T, Harlaar J et al (2009) Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 23:1119–1120CrossRefPubMedGoogle Scholar
  21. 21.
    Wilhelm T, Metzig A (2010) Endoscopic minimally invasive thyroidectomy: first clinical experience. Surg Endosc 24:1757–1758CrossRefPubMedGoogle Scholar
  22. 22.
    Wilhelm T, Metzig A (2011) Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg 35:543–551CrossRefPubMedGoogle Scholar
  23. 23.
    Liu E, Qadir Khan A, Niu J, Xu Z, Peng C (2015) Natural orifice total transtracheal endoscopic thyroidectomy surgery: first reported experiment. J Laparoendosc Adv Surg Tech A 25(7):586–591CrossRefPubMedGoogle Scholar
  24. 24.
    Woo SH (2014) Endoscope-assisted transoral thyroidectomy using a frenotomy incision. J Laparoendosc Adv Surg Tech A 24(5):345–349CrossRefPubMedGoogle Scholar
  25. 25.
    Benhidjeb T, Stark M (2011) Endoscopic minimally invasive thyroidectomy (eMIT): safety first! World J Surg 35:1936–1937CrossRefPubMedGoogle Scholar
  26. 26.
    Anuwong A (2016) Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. World J Surg 40(3):491–497CrossRefPubMedGoogle Scholar
  27. 27.
    Clark JH, Kim HY, Richmon JD (2015) Transoral robotic thyroid surgery. Gland Surg 4(5):429–434PubMedPubMedCentralGoogle Scholar
  28. 28.
    Lee HY, Richmon JD, Walvekar RR, Holsinger C, Kim HY (2015) Robotic transoral periosteal thyroidectomy (TOPOT): experience in two cadavers. J Laparoendosc Adv Surg Tech A 25(2):139–142CrossRefPubMedGoogle Scholar
  29. 29.
    Lee HY, You JY, Woo SU, Son GS, Lee JB, Bae JW, Kim HY (2015) Transoral periosteal thyroidectomy: cadaver to human. Surg Endosc 29(4):898–904CrossRefPubMedGoogle Scholar
  30. 30.
    Lee HY, Hwang SB, Ahn KM, Lee JB, Bae JW, Kim HY (2014) The safety of transoral periosteal thyroidectomy: results of Swine models. J Laparoendosc Adv Surg Tech A 24(5):312–317CrossRefPubMedGoogle Scholar
  31. 31.
    Inabnet WB 3rd, Suh H, Fernandez-Ranvier G (2016) Transoral endoscopic thyroidectomy vestibular approach with intraoperative nerve monitoring. Surg Endosc [Epub ahead of print] Google Scholar
  32. 32.
    Park JO, Kim MR, Kim DH, Lee DK (2016) Transoral endoscopic thyroidectomy via the trivestibular route. Ann Surg Treat Res 91(5):269–272CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Witzel K, Hellinger A, Kaminski C, Benhidjeb T (2016) Endoscopic thyroidectomy: the transoral approach. Gland Surg 5(3):336–341. doi: 10.21037/gs.2015.08.04 CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Udelsman R, Anuwong A, Oprea AD, Rhodes A, Prasad M, Sansone M, Brooks C, Donovan PI, Jannitto C, Carling T (2016) Trans-oral vestibular endocrine surgery: a new technique in the United States. Ann Surg 264(6):e13–e16CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Endocrinology (SIE) 2017

Authors and Affiliations

  • G. Dionigi
    • 1
  • R. P. Tufano
    • 2
  • J. Russell
    • 2
  • H. Y. Kim
    • 3
    Email author
  • E. Piantanida
    • 4
  • A. Anuwong
    • 5
  1. 1.1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine SurgeryUniversity of Insubria (Varese-Como)VareseItaly
  2. 2.Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery CenterKUMC Thyroid Center Korea University, Anam HospitalSeoulKorea
  4. 4.Endocrine Unit, Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
  5. 5.Minimally Invasive and Endocrine Division, Department of SurgeryPolice General HospitalBangkokThailand

Personalised recommendations