International Journal of Otorhinolaryngology and Head and Neck Surgery

Mehta R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):746-749

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Original Research Article

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20191742

Transoral transvsetibular thyroidectomy: an initial approach and experience

Raghav Mehta1*, Sanchit Jain2, Ravindra Soni1

1Department of ENT, 2Department of Surgery, RUHS College of Medical, Sciences, Jaipur, Rajasthan, India

Received: 23 January 2019

Accepted: 07 March 2019

*Correspondence:

Dr. Raghav Mehta,

E-mail: drraghavmehta@rediffmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The objective of the study was to record our intial experience of transoral transvestibular thyroidectomy and to ascertain the problems faced, their possible solutions and further suggestions.

Methods: Inclusion criteria were unilateral thyroid swelling, patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 8 cm; (b), USG estimated gland volume ≤40 ml, nodule size ≤50 mm, A benign tumor, such as a thyroid cyst, single-nodular goitre, or multinodular goitre. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and Harmonic.

Results: All transoral transvestibular thyroidectomy procedures were performed successfully with no conversions. The mean operative time was 112.5 (90-180) min. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients.

Conclusions: Transoral transvestibular thyroidectomy may provide a method for ideal cosmetic results. It also provides a wide and enhanced endoscopic view. Though more study and further instrumental development is required to fully embrace this procedure a preliminary experience show encouraging results.

Keywords: Transoral, Transvestibular, Endoscopic, Thyroidectomy

INTRODUCTION

Minimally invasive thyroid surgery entailing endoscopic thyroidectomy has in recent years become the new method of giving a cosmetically pleasing result with least trauma acceptable.

Since the time of Billroth when the mortality associated with thyroidectomy was nearly 40% more and more studies are designed to reduce the mortality and morbidity associated with thyroidectomy. Though Kocher by 1895 had reduced the morbidity to 0.2%, morbidity associated with the scar is still a concern for the patients.1-3

Transoral transvestibular thyroidectomy is a newer approach still in phase of its development. Though a newer approach it is one of the most promising approaches for surgical management of thyroid diseases with no scar and also with further advent an enhanced microscopic view with lesser hospital stay and better patient compliance.

METHODS

This study is a preliminary experience constituting of 6 cases done entirely with transvestibular route at RUHS College of Medical Sciences, Jaipur from January 2017 to December 2017.

Inclusion criteria

Inclusion criteria were unilateral thyroid swelling; patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 8 cm; (b); USG estimated gland volume ≤40 ml; nodule size ≤50 mm; a benign tumor, such as a thyroid cyst, single-nodular goitre, or multinodular goitre.

Figure 1: The initial setup, the operating surgeon and the assistant surgeons stand on the head end whereas the camera setup lies on the caudal side.
Figure 1: The initial setup, the operating surgeon and the assistant surgeons stand on the head end whereas the camera setup lies on the caudal side.
Figure 2: The 3 incisions marked, the lateral incisions of 5 mm carry the dissecting and coagulating instruments whereas the midline 10 mm incision caries the endoscope.
Figure 2: The 3 incisions marked, the lateral incisions of 5 mm carry the dissecting and coagulating instruments whereas the midline 10 mm incision caries the endoscope.
Figure 3: The placement of endoscope and instruments into the ports inserted, the operating surgeon handles the instruments in the lateral ports whereas the assistant helps in handling he endoscope.
Figure 3: The placement of endoscope and instruments into the ports inserted, the operating surgeon handles the instruments in the lateral ports whereas the assistant helps in handling he endoscope.
Figure 4: The creation of subplatysmal plane after insufflations of C02 gas between a pressure of 4-6 mm.
Figure 4: The creation of subplatysmal plane after insufflations of C02 gas between a pressure of 4-6 mm.
Figure 5: Plane dissected up to lateral border.
Figure 5: Plane dissected up to lateral border.
Figure 6: Dissection reaching up to suprasternal notch.
Figure 6: Dissection reaching up to suprasternal notch.
Figure 7: Shows separating the strap muscles.
Figure 7: Shows separating the strap muscles.
Figure 8: Strap muscles fully separated and whole of thyroid lobe exposed.
Figure 8: Strap muscles fully separated and whole of thyroid lobe exposed.
Figure 9: Dissecting the thyroid lobe from medial to lateral and using both clips and harmonic to address the incoming blood vessels.
Figure 9: Dissecting the thyroid lobe from medial to lateral and using both clips and harmonic to address the incoming blood vessels.
Figure 10: Thyroid lobe being separated from trachea and arrow showing Right side RLN.
Figure 10: Thyroid lobe being separated from trachea and arrow showing Right side RLN.

The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and harmonic.

Figure 11: Immediate post operative picture.
Figure 11: Immediate post operative picture.

RESULTS

Out of 6 cases we operated all the cases were in age group of 25 to 55 and all the cases were females. The largest swelling we removed was of 5 cm and the smallest of 3cm.In no cases we had to revert to open procedure and all cases were successfully done via endoscopic procedure. In 4 cases we were able to remove the whole lesion enbloc but in 2 cases we had to remove the lesion piece meal. No case suffered from any known complication like recurrent nerve palsy, haematoma or any infection. In one case there was parasthesia of the lower lips which recovered within 4 weeks.

Table 1: The type of thyroid swelling, its size and site.
Table reproduced from source PDF page 3

DISCUSSION

In recent years the paradigm of any surgical procedure not only entails the pathological outcome but also cosmetic consequences. Head and Neck Surgery is one of the most debilitating surgeries cosmetically and one of the most common reasons for patients non compliance for the procedure.

Transvestibular transoral thyroidectomy though a new and evolving procedure is a total scarless surgery in compared to other endoscopic surgeries like transaxillary or via lateral neck incision. But as of any new procedure this also has its limitations.

By the help of this article we aim to not only explain the procedure but also what were the problems faced and what can be done more in future to popularize the procedure.

Table 2: Problems faced and possible solutions.
Table reproduced from source PDF page 4

Further suggestions

Even with all the above changes still the procedure requires further changes and advancement and with our first hand experience following are the suggestions:

  • • A rotatable 2.7 mm scope would not only decrease the size of the ports but also lead to better circumferential view.
  • • Thinner and smaller instruments can be specifically designed for transoral endoscopic procedures.
  • • Though we have not used it in any procedure but we believe that in initial training stages nerve monitoring will definitely ease the procedure.

CONCLUSION

Transoral transvestibulr thyroidectmy in itself still requires a lot of advancement but transoral transvestibular procedure can also find implication in other neck surgeries in future like:

  • • Neck dissection,
  • • Submandibular gland excision,
  • • Laryngectomies,
  • • Neck Trauma surgeries.

A cosmetically better and enhanced endoscopic view with better patient compliance should necessarily make this procedure more popular both for the operating surgeon and the treated patient.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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