Open thyroidectomy is currently the standard surgery option for thyroid diseases. However, this approach unavoidably leaves a visible neck scar. Many modified techniques have been developed to reduce the size of the neck scar, including minimally-invasive open thyroid surgery and video-assisted thyroidectomy (MIVAT). Recently, Natural Orifice Transluminal Endoscopic Surgery (NOTES) for thyroidectomy was developed. This surgical technique completely avoids visible cutaneous scarring by means of an approach through the oral cavity. Two techniques have been described:
1) a sublingual approach, which causes severe tissue damage with a high complication rate and 2) an oral vestibular approach.
The indications for TOETVA are:
- – Thyroid gland of a diameter not exceeding 10 cm
- – Benign thyroid nodule(s)
- – Papillary microcarcinoma with no evidence of metastasis
- – Follicular neoplasm
- – Well-controlled Graves’s disease.
- – Grade 1 substernal goiters
Early experience demonstrated that TOETVA can be performed safely on patients who had previously undergone surgery or radiation at the chin and neck area. Moreover, it was no longer contraindicated for patients with dental braces.
All patients underwent routine investigation including thyroid function tests, neck ultrasonography, and/or fine needle aspiration. Patient preparation is identical to that for standard open surgery. Dental evaluation by a dentist is only necessary for patients with severe oral hygiene issues. No routine dental examination is required.
The patient is placed in the supine position. The shoulders are lifted with sandbags and the neck is slightly extended. All patients receive general anesthesia with nasotracheal intubation. The oral cavity is cleaned with 0.05% Hibitane in water. The surgeon is at a point above the patient’s head, while the assistant and the camera operator stand on either side of the patient’s neck. A 10-mm incision is made in the center of the oral room just above the lower part of the labial frenum. Next, 30 ml of 1: 500,000 saline adrenaline (1 mg of adrenaline in 500 ml of NSS) is injected through a Veress needle through the incision site for hydrodissection in the anterior area of the muscles of the neck and the workspace is opened using a medium-size Kelly clamp. CO2 insufflation is maintained at 6 mmHg with a flow rate of 15 L / min through the 10 mm central trocar. Two 5 mm trocars are inserted through the lateral incisions into the working space parallel to the 10 mm trocar.
The boundaries of the subplatysmal work space are defined as follows:
- 1) lower border in the sternal notch,
- 2) lateral borders at the edges of the sternocleidomastoid muscles, and
- 3) upper border in the thyroid cartilage.
Thyroid dissection is performed by preserving the superior thyroid nerve and the parathyroid glands. The recurrent laryngeal nerve is identified and the specimen is extracted by endobag. If total thyroidectomy is necessary, the procedure is repeated on the contralateral side. For papillary microcarcinoma patients, level VI dissection of the central lymph node of the neck is routinely performed. The strap muscles are re-approximated using Polyglactin 3/0 sutures. The oral cavity incisions are closed using Polyglactin 4/0 sutures.
A gauze pressure dressing is placed around the chin for 24 h. Sipping water is allowed immediately after surgery. Patients receive a liquid diet on the day of surgery (day 0) and a soft diet for 1 day postoperatively. Patients are allowed to rinse their mouths with mouthwash and brush their teeth 1 week after the operation. Intravenous antibiotics are given for 48 h and switched to oral antibiotics for 7 days postoperatively. If a surgical drain is deemed necessary, it is removed on day 2 after the procedure. Patients are admitted for 2–3 days, with follow-up visits at 1 week, 1 month, 3 months, 6 months and 1 year after surgery. Patients are assessed for vocal cord function using a flexible or rigid laryngoscope.
The TOETVA technique is feasible and safe in selected patients. The advantages of this technique over other remote access approaches include its ability to afford equal access to both sides of the neck, the decreased tissue dissection required, and the excellent view of the anatomy provided, similar to an open approach. Further, it is the only approach that avoids any cutaneous scarring. However, further prospective studies are necessary to evaluate the value of the procedure, its risks and long-term results.