DOI: 10.

1590/0100-6991e-20181951 Original Article

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA):

initial experience in Brazil.

Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA): experiência

inicial no Brasil.

Marco Antonio Scirea Tesseroli1; Mauricio Spagnol2; Álvaro Sanabria3.

A B S T R A C T
Objective: to present the initial experience in Brazil with transoral endoscopic thyroidectomy by vestibular approach
(TOETVA). Methods: prospective study of patients undergoing TOETVA in the Department of Head and Neck Surgery
of Hospital Regional do Oeste, Chapecó, Santa Catarina. Patients between 18 and 65 years of age, ASA I and II, with
maximum glandular volume of 35cm3 and nodules up to 4cm were candidates for the study. Data of the patients,
nodules, surgical time, complications, and length of hospital stay were recorded. Results: nine patients were operated
between May 2017 and April 2018. All were women, aged 33-64 years. The size of the nodule ranged from 1cm to
4cm. Two patients had malignant neoplasia and total thyroidectomy was performed in eight cases. Seven patients were
hospitalized for only one day. One patient had a minor complication on skin, but there were no lesions of the laryngeal
recurrent nerves or definitive hypoparathyroidism. Conclusion: TOETVA is a safe technique for well-selected patients,
with favorable conditions and special concern for aesthetic results.

Keywords: Thyroidectomy. Mouth. Minimally Invasive Surgical Procedures. Thyroid Neoplasms. Endoscopy.

INTRODUCTION prominent than the scars left by traditional

procedures.

T
hyroidectomy is the most commonly With the advent of natural orifice transluminal
performed surgical procedure by head and endoscopic surgery (NOTES)6, several studies have been
neck surgeons. The currently widely used surgical published around world7,8. In 2016, Anuwong et al.9
technique is similar to that originally described described the transoral endoscopic thyroidectomy by
by Kocher, with some minor modifications. vestibular approach (TOETVA)10, which showed results
Since the advent of endoscopic thyroidectomy, comparable to the ones of the open thyroidectomy,
this approach has gained popularity and many but with the advantage of not leaving any visible scar.
variations have emerged, such as cervical TOETVA is a very new technique performed with
endoscopic 1, axillary2, axillo-mammary3,4, and conventional laparoscopic instruments. Although
retroauricular 5 accesses, which may or may widely adopted in Asia, the experience in Europe and
not have robotic assistance. The main reason America is still small, and there are no reports of this
for adopting the endoscopic technique is the technique in Brazil.
aesthetic result, which is achieved by reducing Here we present the initial experience in
the size of the scar, or by placing it in a less Brazil, discussing the particularities of this technical
visible area. However, all these techniques leave innovation and our specific approach, adapted to
visible scars that are sometimes larger or more our health system.

1 - Hospital Regional do Oeste, Department of Head and Neck Surgery, Chapeco, SC, Brazil. 2 - Universidade Comunitária da Região de Chapecó
(UNOCHAPECÓ), Surgery, Faculty of Medicine, Chapeco, SC, Brazil. 3 - Universidad de Antioquia, Fundación Colombiana de Cancerología, Clínica
Vida, Surgery Department, Medellin, Antioquia, Colombia.

Rev Col Bras Cir 45(5):e1951

 Tesseroli
2 Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil.

METHODS dilator - and then a 10mm trocar is inserted to

accommodate the lens. Two other small incisions
The candidates for the study were patients (5mm) are made laterally on the labial mucosa,
between 18 and 65 years of age, ASA I and II, with near the commissures, almost at the transition
maximum thyroid gland volume of 35cm3, and between the mucosa and the vermilion of the
nodules up to 4cm. Patients with previous cervical lip, and adrenaline-added saline solution is then
surgery, radiotherapy, and hyperthyroidism were injected through these incisions, and the 5mm
excluded. Data on the clinical characteristics of the trocars are introduced. CO2 is injected at a
patients, thyroid volume and nodule size, cytologic pressure from 6mmHg to 9mmHg in a flow rate
and histological diagnoses, surgical time, length of 15L/min. Dissection follows steps very similar
of hospital stay, drain use, and complications to open surgery, except for the fact that the view
were recorded. Patients’ satisfaction with the is craniocaudal and the infrahyoid muscles are
procedure was inquired in the second week and pulled laterally by stitches that are passed through
in the third month after the procedure, asking the skin and pulled externally. The caudal limit of
whether, hypothetically, they would repeat the dissection is the sternal furcula and the laterals are
same type of procedure or would choose the open the anterior borders of the sternocleidomastoid
technique. All patients received informed consent muscle. Another difference is the retrograde
and the study was approved by the hospital's dissection of the recurrent laryngeal nerve. For
ethics committee. nerve monitoring, the monopolar hook was used
disconnected from the electrical source and its
Surgical technique
posterior extremity was tapped with the needle
We followed the technique described by of the nerve monitor.
Anuwong et al.10 TOETVA is performed with the Depending on the size of the gland, it
same videolaparoscopic materials, using a 30º lens may be necessary to fragment it before its removal
and a vessel sealer or ultrasonic device. To optimize (through the central incision of the lip). We wore
the space in the oral cavity, we used nasotracheal a surgical glove as an endobag, within which the
intubation in anesthesia. thyroid can be fragmented, if necessary, and then
A transverse incision of approximately removed, thereby preventing dissemination of
1.5cm is made on the middle portion of the thyroid tissue at surgical site.
lower lip mucosa anterior to the labial frenulum,
RESULTS
deepening through the musculature with
monopolar cautery until reaching the lower edge Nine patients were operated between
of the mandible. Then, 30ml of adrenaline-added May 2017 and April 2018. All were female. The
saline solution (250ml/1ml) are injected into the clinical characteristics of the patients, gland size,
subplatysmal space through this incision using and surgical data are presented in table 1. There
a Veress needle. The next step is to perform a was no conversion to open surgery. In one patient,
blunt dissection employing a rigid cylindrical besides thyroidectomy, a lower parathyroid
material - we have used a Hegar cervical resection was performed due to an adenoma.

Rev Col Bras Cir 45(5):e1951

 Tesseroli

Table 1. Characteristics of patients who underwent TOETVA.

Patient Gender Age Gland Size of Preoperative Surgery Surgical Time of Hospital Histological Complications
volume nodule cytological time (min) drain use discharge diagnosis
(cm3) (mm) diagnosis (Bethesda (days)
classification)
1 F 64 19 40 II TT 240 3 Following Adenoma Chin skin bruise
day
2 F 35 13 28 IV TP 150 2 Following Adenoma None
day
3 F 52 6.1 17 II TT+ParT 180 2 Following Adenoma Dehiscence of suture of
day the labial mucosa
4 F 49 11.9 24 V TT 185 3 Following Papillary None
day carcinoma
5 F 33 8 17 V TT 240 3 Same day Papillary Nodule rupture; thermal
carcinoma lesion on the skin of the

Rev Col Bras Cir 45(5):e1951

chin
6 F 63 4.3 10 IV TT 210 3 Following Adenoma Chin skin bruise
Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil.

day
7 F 50 11 18 V TT 185 1 Following Adenoma None
day
8 F 41 8.9 25 II TT 195 1 Same day Adenoma None
9 F 40 13.3 25 III TT 180 1 Following Adenoma Chin skin bruise
day
TT= total thyroidectomy; TP= partial thyroidectomy; ParT= parathyroidectomy.
3
 Tesseroli
4 Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil.

One patient who had a nodule located in the issues and, when compared to other endoscopic
upper pole of the thyroid had rupture of the techniques, it has some advantages such as:
tumor while seizing the gland for dissection. This smaller dissection area; access to the two lobes of
patient received 50mCi of I-131 two months after the gland through the same incision; the surgical
surgery, with no anomalous uptake in scintigraphy, equipment is the same used in videolaparoscopic
and undetectable thyroglobulin levels with TSH surgery; and the costs are lower when compared
stimulation. In this same patient, there was a with robotic surgery12.
thermal lesion formation on the skin of the chin Regardless of the pros, there are some
due to the very superficial dissection during the limitations in TOETVA. Due to the size of the incision
creation of the tunnel for introducing the 10mm (approximately 1.5cm), sometimes it is necessary
trocar. As a consequence, a 4x2mm wound was to fragment the gland in order to extract it, which
formed and it took about three weeks to resolve it, can compromise an adequate anatomopathological
leaving a very discreet scar. evaluation, such as margins, capsular invasion, and
In the first evaluation, all the patients said tumor size.
they were satisfied with the procedure; however, in In patients who have the upper pedicle
the second interview, in the third month after the in a very high position, dissection may be more
surgery, one patient, the same who had a thermal challenging. Dissection can also be problematic
skin lesion, showed dissatisfaction, saying that if she if the tumor is located in the upper pole, since
had chosen the traditional pathway, her diet would manipulation of this area is essential to expose
have not been changed in the first postoperative the recurrent laryngeal nerve in TOETVA, and the
days (liquids and soft foods only). seizure of this pole can cause tumor rupture. In
men, the more prominent thyroid cartilage may
DISCUSSION
make dissection more difficult. Other issues that
NOTES technique was described many should be considered are the costs, which are
years ago, initially for cholecystectomy and greater when compared to the open technique,
appendectomy11. However, the expansion of and the surgical time, which is usually higher
this technique to the neck area occurred very if compared to the classical approach. As for
slowly due to anatomical issues, which made it indications and contraindications, there are
impossible to create a good working space, and different opinions.
the lack of instruments for adequate dissection Our surgical time was long in all cases,
and hemostasis. The emergence of the ultrasonic however, not higher than the surgical time
energy scalpel and optical instruments made published in many other previous publications 13;
possible the completely transoral endoscopic and it is expected to decrease with the learning
approach. curve, with an improvement after the first
Although the anterior region of the neck twenty cases 14. We did not observe major
favors the formation of discreet scars, some patients complications, such as recurrent laryngeal
may have unfavorable esthetic results. TOETVA nerve injury, definitive hypoparathyroidism,
completely eliminates any concern with aesthetic infection, and hematoma, nor the need to

Rev Col Bras Cir 45(5):e1951

Tesseroli
Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil. 5

convert to the cervical approach. Many authors and whether there are changes in the function or in
have demonstrated safety levels comparable to the aesthetics of the lip/chin (a case of lip weakness
those of the classical technique 9,10,14. The use of was described16). Problems related to skin lesions
drains is still under discussion, but, due to the were also reported17.
magnification of the image and the employment Finally, cost is an important point to
of modern vessel sealing instruments, they could consider. Compared to open surgery, this new
be avoided in most cases. Regarding outpatient approach requires special materials as exposed
thyroidectomy, these first cases were carefully before. However, the revolution of laparoscopic
observed, but we believe that the indications will and robotic surgeries brought to many institutions
be exactly the same as in patients undergoing the technology to make it possible to implement
open thyroidectomy. this technique, even in developing countries,
An important point is about the risk of overcoming the difficulties of acquiring materials
infection due to the contact of the saliva with a and specific instruments. In addition, nowadays
sterile field. Data from the already published series vessel sealers are commonly used in open
did not show an increase in the number of surgical thyroidectomies, and, so, they could not be
site infections. As a general recommendation, a considered as an extra cost. The time, which is
short period of antibiotic prophylaxis is prudent longer, will be decreased with the learning curve,
because of the surgery’s classification as "potentially as has been demonstrated by other endoscopic
contaminated." We have used clindamycin for 24 procedures.
hours. Our initial impression was extremely
One of the major concerns among the positive, without major complications and with
authors is related to the risk of mental nerve excellent aesthetic results. It seems to be a useful
injury. However, there seems to be no real risk of technique to be offered to well-selected patients
injury since the most recently described technique (not to all patients), with favorable conditions for
is followed15. Other questions that need to be the surgery and special concern for the aesthetic
answered are whether nerve monitoring provides result. This is a surgical innovation which will
better results or not, if there is more fibrosis in the certainly undergo further modifications. More
surgical bed or greater area of paraesthesia at the studies should be conducted to answer the topics
site of the patch detachment and trocar passages, raised here.

R E S U M O
Objetivo: apresentar a experiência inicial no Brasil com a tireoidectomia transoral endoscópica por abordagem vestibular
(TOETVA). Métodos: estudo prospectivo de pacientes submetidos à TOETVA no Serviço de Cirurgia de Cabeça e Pescoço
do Hospital Regional do Oeste, Chapecó, Santa Catarina. Foram candidatos para o estudo os pacientes entre 18 e 65 anos
de idade, ASA I e II, com volume glandular de até 35cm3e nódulos de até de 4cm. Dados dos pacientes, dos nódulos,
tempo cirúrgico, complicações, e tempo de internação foram registrados. Resultados: nove pacientes foram operados
entre maio de 2017 e abril de 2018. Todos eram mulheres, com idades entre 33 e 64 anos. O tamanho do nódulo variou
de 1cm a 4cm. Dois pacientes eram portadores de neoplasia maligna e a tireoidectomia total foi feita em oito casos. Sete
pacientes tiveram uma internação de apenas um dia. Um paciente sofreu uma complicação menor na pele, mas não
ocorreram lesões dos nervos laríngeos recorrentes ou hipoparatireoidismo definitivo. Conclusão: a TOETVA é uma técnica
segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos.

Descritores: Tireoidectomia. Boca. Procedimentos Cirúrgicos Minimamente Invasivos. Neoplasias da Glândula Tireoide.
Endoscopia.

Rev Col Bras Cir 45(5):e1951

 Tesseroli
6 Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil.

REFERENCES 11. Steinemann DC, Müller PC, Probst P, Schwarz AC,

Büchler MW, Muller-Stich BP, et al. Meta-analysis
1. Hüscher CS, Chiodini S, Napolitano C, Recher A. of hybrid natural-orifice transluminal endoscop-
Endoscopic right thyroid lobectomy. Surg Endosc. ic surgery versus laparoscopic surgery. Br J Surg.
1997;11(8):877. 2017;104(8):977-89.
2. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endo- 12. Pan JH, Zhou H, Zhao XX, Ding H, Wei L, Qin L,
scopic neck surgery by the axillary approach. J Am et al. Robotic thyroidectomy versus convention-
Coll Surg. 2000;191(3):336-40. al open thyroidectomy for thyroid cancer: a sys-
3. Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi tematic review and meta-analysis. Surg Endosc.
E, Ohashi S, et al. Endoscopic thyroid surgery through 2017;31(10):3985-4001.
the axillo-bilateral-breast approach. Surg Laparosc 13. Shan L, Liu J. A systemic review of transoral thy-
Endosc Percutan Tech. 2003;13(3):196-201. roidectomy. Surg Laparos Endosc Percutan Tech.
4. Choe JH, Kim SW, Chung KW, Park KS, Han W, 2018;28(3):135-8.
Noh DY, et al. Endoscopic thyroidectomy using a 14. Russell JO, Clark J, Noureldine SI, Anuwong A, Al
new bilateral axillo-breast approach. World J Surg. Khadem MG, Yub Kim H, et al. Transoral thyroid-
2007;31(3):601-6. ectomy and parathyroidectomy - A North American
5. Terris DJ, Singer MC, Seybt MW. Robotic facelift series of robotic and endoscopic transoral approach-
thyroidectomy: II. Clinical feasibility and safety. La- es to the central neck. Oral Oncol. 2017;71:75-80.
ryngoscope. 2011;121(8):1636-41. 15. Kim HY, Chai YJ, Dionigi G, Anuwong A, Richmon
6. ASGE; SAGES. ASGE/SAGES Working Group on JD. Transoral robotic thyroidectomy: lessons lear-
Natural Orifice Translumenal Endoscopic Surgery ned from an initial consecutive series of 24 patients.
White Paper October 2005. Gastrointest Endosc. Surg Endosc. 2018;32(2):688-94.
2006;63(2):199-203. 16. Richmon JD, Kim HY. Transoral robotic thyroidec-
7. Witzel K, von Rahden BH, Kaminski C, Stein HJ. tomy (TORT): procedures and outcomes. Gland
Transoral access for endoscopic thyroid resection. Surg. 2017;6(3):285-9.
Surg Endosc. 2008;22(8):1871-5. 17. Bakkar S, Al Hyari M, Naghawi M, Corsini C, Miccoli
8. Park JO, Kim CS, Song JN, Kim JE, Nam IC, Lee P. Transoral thyroidectomy: a viable surgical option
SY, et al. Transoral endoscopic thyroidectomy via with unprecedented complications-a case series. J
the tri-vestibular routes: results of a preclinical ca- Endocrinol Invest. 2018;41(7):809-13.
daver feasibility study. Eur Arch Otorhinolaryngol.
2014;271(12):3269-75. Received in: 07/08/2018
9. Anuwong A. Transoral Endoscopic Thyroidectomy Accepted for publication: 09/17/2018
Vestibular Approach: a series of the first 60 human Conflict of interest: none.
cases. World J Surg. 2016;40(3):491-7. Source of funding: none.
10. Anuwong A, Sasanakietkul T, Jitpratoom P, Ket-
wong K, Kim HY, Dionigi G, et al. Transoral endo- Mailing address:
scopic thyroidectomy vestibular approach (TOETVA): Marco Antonio Scirea Tesseroli
indications, techniques and results. Surg Endosc. E-mail: mastesseroli@yahoo.ca
2018;32(1):456-65. alvarosanabria@gmail.com

Rev Col Bras Cir 45(5):e1951