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Transoral endoscopic thyroidectomy via a vestibular approach: why and how?

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Abstract

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel, scar-free surgical procedure that does not require visible incisions. Indications for TOETVA are as follows: predicted gland width on diagnostic imaging ≤10 cm; a thyroid volume outline of <45 mL or dominant nodule dimension of ≤50 mm; three or four Bethesda lesions; a primary papillary microcarcinoma without local or distant metastasis; and patient request for optimal esthetic results. Contraindications are as follows: patients unfit for general anesthesia; precedent radiation in the head, neck, upper mediastinum; antecedent neck surgery; recurrent goiter; a gland volume of >45 mL or main nodule diameter of >50 mm; and documentation of lymph node or distant metastases, tracheal/esophageal infiltration, preoperative laryngeal nerve palsy, hyperthyroidism, mediastinal goiter, or an oral abscess. Patients with poorly differentiated or un-differentiated cancer, dorsal extrathyroidal radius, and/or lateral neck metastasis are not suitable for TOETVA. Following the introduction of a robotic surgical system, enabling a three-dimensional surgical view and the use of articulating instruments, TOETVA became suitable for most differentiated thyroid cancers without evidence of extensive extrathyroidal invasion or lateral neck metastasis. The procedure is performed using a vestibular approach and three-port technique; a 10-mm port is used for the 30° endoscope, two 5-mm ports are used for the dissecting and coagulating instruments, and an 8-mm port is placed in the axillary fold during the robotic procedure to enhance fine countertraction of tissue for radical oncological dissection. TOETVA follows surgical planes and is probably the best scar-free approach to the thyroid, given the short distance between the gland and intraoral incisions.

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Author contributions

(I) Conception and design: G.D., H.Y.K., A.A.; (II) administrative support: G.D., R.P.T., A.A.; (III) collection and assembly of data: G.D., H.Y.K., R.P.T.; (IV) data analysis and interpretation: G.D., H.Y.K., Y.J.C., R.P.T., A.A.; (V) manuscript writing: all authors; (VI) final approval of manuscript: all authors.

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Authors and Affiliations

  1. Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy

    Gianlorenzo Dionigi

  2. Department of Surgery, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Dongjak-gu, Seoul, South Korea

    Young Jun Chai

  3. Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Ralph P. Tufano

  4. Minimally Invasive and Endocrine Division, Department of Surgery, Police General Hospital, Bangkok, Thailand

    Angkoon Anuwong

  5. Department of Surgery, Korea University College of Medicine, Seoul, Korea, Anam Hospital, Seoul, Korea

    Hoon Yub Kim

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  1. Gianlorenzo Dionigi
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  2. Young Jun Chai
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  3. Ralph P. Tufano
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  4. Angkoon Anuwong
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  5. Hoon Yub Kim
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Correspondence to Hoon Yub Kim.

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Dionigi, G., Chai, Y.J., Tufano, R.P. et al. Transoral endoscopic thyroidectomy via a vestibular approach: why and how?. Endocrine 59, 275–279 (2018). https://doi.org/10.1007/s12020-017-1451-x

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  • DOI: https://doi.org/10.1007/s12020-017-1451-x

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