Skip to main content
Log in

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

  • Viewpoint
  • Published:
Endocrine Aims and scope Submit manuscript


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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Q.Y. Duh, Presidential address: minimally invasive endocrine surgery—standard of treatment or hype? Surgery 134, 849–857 (2003)

    Article  PubMed  Google Scholar 

  2. J.F. Henry, Minimally invasive thyroid and parathyroid surgery is not a question of length of the incision. Langenbecks Arch. Surg. 393(5), 621–626 (2008).

    Article  PubMed  Google Scholar 

  3. G. Dionigi, L. Boni, M. Duran-Poveda, Evolution of endoscopic thyroidectomy. Surg. Endosc. (2011).

  4. G. Dionigi, Evidence-based review series on endoscopic thyroidectomy: real progress and future trends. World J. Surg. 33(2), 365–366 (2009).

    Article  PubMed  Google Scholar 

  5. K. Witzel, B.H. von Rahden, C. Kaminski, H.J. Stein, Transoral access for endoscopic thyroid resection. Surg. Endosc. 22, 1871–1875 (2008)

    Article  CAS  PubMed  Google Scholar 

  6. P. Miccoli, G. Materazzi, P. Berti, 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, 957–958 (2010)

    Article  PubMed  Google Scholar 

  7. T. Benhidjeb, T. Wilhelm, J. Harlaar, G.J. Kleinrensink, T.A. Schneider, M. Stark, 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, 1119–1120 (2009)

    Article  CAS  PubMed  Google Scholar 

  8. T. Wilhelm, A. Metzig, Endoscopic minimally invasive thyroidectomy: first clinical experience. Surg. Endosc. 24, 1757–1758 (2010)

    Article  PubMed  Google Scholar 

  9. T. Wilhelm, A. Metzig, Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J. Surg. 35, 543–551 (2011)

    Article  PubMed  Google Scholar 

  10. E. Liu, A. Qadir Khan, J. Niu, Z. Xu, C. Peng, Natural orifice total transtracheal endoscopic thyroidectomy surgery: first reported experiment. J. Laparoendosc. Adv. Surg. Tech. A 25, 586–591 (2015)

    Article  PubMed  Google Scholar 

  11. G. Dionigi, F. Rovera, L. Boni, Commentary on transoral access for endoscopic thyroid resection ‘Witzel, K., von Rahden, B.H., Kaminski, C., Stein, H.J.: Transoral access for endoscopic thyroid resection. Surg. Endosc. 22, 1871–1875 (2008). Surg. Endosc. (2009)

    Article  Google Scholar 

  12. A. Anuwong, Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. World J. Surg. 40, 491–497 (2016)

    Article  PubMed  Google Scholar 

  13. R. Udelsman, A. Anuwong, A.D. Oprea, A. Rhodes, M. Prasad, M. Sansone, C. Brooks, P.I. Donovan, C. Jannitto, T. Carling, Trans-oral vestibular endocrine surgery: a new technique in the United States. Ann. Surg. 264, e13–e16 (2016)

    Article  PubMed  Google Scholar 

  14. H.Y. Kim, Y.J. Chai, G. Dionigi, A. Anuwong, J. Richmon, Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients. Surg. Endosc. (2017).

  15. A. Anuwong, T. Sasanakietkul, P. Jitpratoom, K. Ketwong, H.Y. Kim, G. Dionigi, J.D. Richmon, Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg. Endosc. (2017)

  16. A. Anuwong, H.Y. Kim, G. Dionigi, Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences. Gland Surg. 6(3), 277–284 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  17. G. Dionigi, M. Lavazza, C.W. Wu, H. Sun, X. Liu, R.P. Tufano, H.Y. Kim, J.D. Richmon, A. Anuwong, Transoral thyroidectomy: why is it needed? Gland Surg 6(3), 272–276 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  18. J.O. Russell, J. Clark, S.I. Noureldine, A. Anuwong, M.G. Al Khadem, H. Yub Kim, V.K. Dhillon, G. Dionigi, R.P. Tufano, J.D. Richmon, Transoral thyroidectomy and parathyroidectomy—a North American series of robotic and endoscopic transoral approaches to the central neck. Oral Oncol. 71, 75–80 (2017).

    Article  PubMed  Google Scholar 

  19. G. Dionigi, R.P. Tufano, J. Russell, H.Y. Kim, E. Piantanida, A. Anuwong, Transoral thyroidectomy: advantages and limitations. J. Endocrinol. Invest. (2017)

  20. G. Dionigi, A. Bacuzzi, M. Lavazza, D. Inversini, L. Boni, S. Rausei, H.Y. Kim, A. Anuwong, Transoral endoscopic thyroidectomy: preliminary experience in Italy. Updates Surg. 69(2), 225–234 (2017).

    Article  PubMed  Google Scholar 

  21. G. Dionigi, M. Lavazza, A. Bacuzzi, D. Inversini, V. Pappalardo, R.P. Tufano, H.Y. Kim, A. Anuwong, Transoral endoscopic thyroidectomy vestibular approach (TOETVA): from A to Z. Surg. Technol. Int. 30, 103–112 (2017)

    PubMed  Google Scholar 

  22. G. Dionigi, A. Bacuzzi, M. Lavazza, D. Inversini, V. Pappalardo, L. Boni, S. Rausei, M. Barczynski, R.P. Tufano, H.Y. Kim, A. Anuwong, Transoral endoscopic thyroidectomy via vestibular approach: operative steps and video. Gland Surg. 5(6), 625–627 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

Download references

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.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Hoon Yub Kim.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Informed consent

For this type of study formal informed consent is not required as the study does not involve participants.

Additional information

Research involving human participants and/or animals

This article does not contain any studies with human participants and/or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: