Thyroid surgery is one of the most common surgical procedures done today. In 2014, over 150,000 thyroidectomies were performed in the United States (1). Thyroidectomy traces its origins back to the Middle Ages. The first described case was the removal of a large thyroid goiter by Albucasis in present day Cordoba, Spain in 952 A.D. (2). Ancient manuscripts describe a patient sitting up in front of the surgeon with a bag around his neck to collect blood while the surgeon removed the thyroid gland through a large neck incision. As expected, this procedure had high morbidity and mortality, and because of this, fell out of favor during the Middle Ages. As noted in a review by Dr. William Halsted, the mortality rate of thyroid surgery before the 19th century was approximately 40% (2). In the late 19th century, Theodor Billroth and his pupil, Theodor Kocher drastically refined this procedure and decreased its mortality to 1% (2). Since the early 1900s, thyroid surgery has continued to evolve to be the safe procedure that it is today.
In the past four decades, the incidence of identification of thyroid nodules and the subsequent diagnosis of thyroid cancer has increased over 200% (3). Much of this is due to improved medical imaging technology and increased overall access to medical care. With approximately a 3.6% increased incidence of thyroid cancer yearly, there is now more demand for thyroid surgery (3). While thyroid cancer classically was treated with a total thyroidectomy (TT), recent guidelines suggest that treatment can be limited to thyroid lobectomy for select cases with tumors <4 cm and no evidence of metastasis or multifocality (4). In addition, active surveillance can be considered as an alternative to immediate surgery in patients with very low risk thyroid malignancies (4). These and other changes, such as encouraging patients to seek surgery at high-volume centers of excellence (5), were with the intent to decrease morbidity caused by thyroid surgery.
In efforts to further reduce morbidity, endoscopic assisted, endoscopic remote, and robotic approaches have been developed to decrease the appearance of, or even eliminate, the midline cervical scar. Minimally invasive video assisted thyroidectomy (MIVAT), described in 2005, was the first attempt at using endoscopes in order to reduce the size of the scar. This was followed by endoscopic remote-access approaches. These include, among others, the trans-axillary technique, the bilateral axillo-breast approach, and the retro-auricular (facelift) approach. While none of these approaches leave a patient with a cervical scar, each represents a surgical compromise between a remote hidden scar and extensive tissue dissection to access the thyroid (6).
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the latest of these approaches. TOETVA was first described in the literature in 2011 by Richmon et al. (7). The first large clinical series were published by Yang in 2015 and Anuwong in 2016 featuring 41 and 60 cases conducted safely in Guangzhou, China and Bangkok, Thailand respectively (8,9). This approach uses three small incisions in the vestibule of the oral cavity to access the neck with laparoscopic ports. The surgery is performed endoscopically with the aid of carbon dioxide insufflation. Since 2016, adoption of this technique by many groups has been trialed and reported outcomes are promising. Contrary to the initial belief that this approach was only applicable to a small minority of cases, recent literature suggests that transoral endoscopic approaches to the midline neck may be widely applicable. A study published by Grogan et al. in 2019 reported that 55.8% of patients presenting to three high-volume academic centers would be adequate candidates for transoral endoscopic approach surgery (10). TOETVA is currently being performed internationally, at multiple institutions in Asia, Europe, South American, and the United States (6,11). In the following paper, we present a summary of the evidence supporting the application of this approach in select patients interested in avoiding a transcervical cutaneous scar.
Benefits of TOETVA
To date, the only well-studied benefit of TOETVA is the absence of a cutaneous scar. Although a having a midline neck scar has been historically regarded as a minor concern, it can carry significant morbidity for some patients (12,13).
Conventional open thyroidectomy leaves an appreciable transverse low cervical scar that usually ranges in size from 4–8 cm (14). The typical thyroidectomy patient is young, female (15), and more often than not, lives in a society where cosmetic concern is impressed upon its members (16). Individuals with scars, regardless of location and type are often not satisfied with their scar’s appearance and therefore adopt coping behaviors to hide the scar from perceived stigma (17). It has been well studied that patients can develop self-consciousness and psychological social stress from perceptions of the scar’s visibility (12,14,18). Visual tracking studies of open thyroidectomy patients compared to controls have shown that casual observers attend more to the neck and less to the peripheral face in patients that have a visible neck scar after open thyroid surgery (19,20). All in all, it appears these transcervical scars have some impact on quality of life (21). In fact, Choi and colleagues found that the quality of life impact associated with transcervical scars, regardless of type or severity, is similar to that found in patients with skin disorders like psoriasis and atopic dermatitis (22).
Minimally invasive approaches to thyroid removal exist and can successfully decrease the length of the transcervical scar. Nevertheless, this decreased scar length does not correlate to improved patient satisfaction (12,13,23-25). In fact, some patients are willing to undergo additional plastic surgery to improve scar appearance and cosmesis (15). Simply put, many patients do not want the traditional transcervical scar and may be willing to pay more money, travel farther and accept more medical complications just to receive a hidden scar (26,27).
In contrast to this significant quality of life impact created by a transcervical scar, TOETVA cases leave the patient with three small incisions in the oral vestibule which is a natural orifice. These mucosal incisions have been found to have a small quality of life impact (28). Many studies conducted globally with various number of TOETVA cases (4 to 81) report that all their patients have had complete postoperative satisfaction with the aesthetic appearance of their neck (8,9,29-40). Directly compared to remote access approaches like the transareolar-breast approach, TOETVA has been found to have a significantly better cosmetic effect (8,30,34,38). Furthermore, visual tracking studies have found no significant difference between TOETVA and control patients in the attention paid to their faces and necks by casual observers (19,20). This ultimately reveals that patients are getting a cosmetic result that does not distract the attention of the people around them, and thus patients are relieved of the burden of scar-induced body image distress and self-doubt. The issue is not merely a cosmetic one but one that touches on the desire for patient privacy with regards to their medical history.
In addition to significant benefits posed to the patient, to providers, TOETVA may add improved visualization of the cervical anatomy during surgery. Firstly, this approach allows excellent visualization of both recurrent laryngeal nerves (RLNs) as they insert into the larynx. Secondly, the in-plane view that is created by approaching via the oral vestibule creates a favorable angle of dissection along the plane of the recurrent laryngeal nerve. Also, the limited soft tissue dissection needed for this particular remote access technique could prove useful in patients with obesity who may have not been a candidate for other remote access approaches (6). Finally, as noted above, the broad operative indications are such that a large portion of patients presenting for thyroid surgery are candidates for this approach (10).
Rate of adoption compared to other remote access approaches
In this following section, we describe the results of our recently performed review of the global literature to compare the adoption trends of TOETVA and other remote access approaches.
Identification of the first published case series of TOETVA, trans-axillary approach thyroidectomy, bilateral axillo-breast approach thyroidectomy, and retro-auricular approach thyroidectomy was conducted. Four separate searches of the MEDLINE database were performed using the following queries: (I) “transoral endoscopic thyroidectomy vestibular approach”; (II) (“transaxillary”[tiab] OR “axillary”[tiab] OR “trans-axillary”[tiab]) AND “thyroidectomy”[tiab]; (III) (“retro-auricular”[tiab] OR “retroauricular”[tiab] OR “facelift”[tiab]) AND “thyroidectomy”[tiab]; (IV) (“Bilateral Axillo Breast approach”[tiab] OR “bilateral axillo-breast approach”[tiab] OR “BABA”[tiab]) AND “thyroidectomy”[tiab]. From the results of each query, a literature review of results was completed. Records that were not in English or published five or more years after the initial technique publication was excluded. Papers that documented cases of the technique in question were included. Cases were counted and summed cumulatively over a 5-year time period.
These searches of PubMed yielded 105, 283, 62, and 76 results for TOETVA, trans-axillary approach, retro-auricular approach, and BABA respectively (Figure 1). The initial case series for these four types of thyroidectomy first appeared in the literature in March 2016 (TOETVA) (9), November 2001 (trans-axillary) (41), March 2007 (BABA) (42), and August 2011 (retro-auricular) (43,44). A total of 1,813 TOETVA (6,11,29,30,34-37,40), 225 retro-auricular approach (43,45-51), 1,119 bilateral axillo-breast approach (42,53-58), and 205 trans-axillary approach (41,59-64), thyroidectomy cases were reported in the literature within the first 5 years of the technique’s existence (Table 1) (65-87). Figure 2 compares the cumulative number of cases published in the first 5 years of each approach. TOETVA had the most global range of publications in its first 5 years (16 countries) as compared to the trans-axillary (four countries), bilateral axillo-breast (one country), and retro-auricular (three countries) techniques.
Risks of TOETVA
In this following section, we describe the results of our recently performed review of TOETVA outcomes reported in the global literature.
A search of the MEDLINE database was conducted using the keywords “transoral endoscopic thyroidectomy vestibular approach”. Duplicate results were removed. A review of the literature describing cases performed was done. Publications that described only robotic transoral thyroidectomy cases or those that were in languages other than English were excluded. Those papers that documented at minimum the incidence of recurrent laryngeal nerve injury, hypoparathyroidism (HP), mental nerve injury (MNI), infection, conversion to open approach and operative time were included. Papers with overlapping authorship were scrutinized for cases that were reported at least once and the most inclusive publication was kept. If any questions arose about these reported cases, authors were contacted via email and clarifications were received.
A search of PubMed yielded 105 results that were published between 2010 and May 2020. No duplicates were found. Ten titles were excluded for being in a language other than English. Two titles were excluded for describing only robotic cases. Review of the literature yielded 52 publications that met inclusion criteria. Inspection of duplicated cases narrowed this to 36 publications reporting unpublished cases. Six of these papers were retrospective cohort studies, two were prospective cohort studies, two were randomized controlled trials and 26 were case series or case reports (Figure 3).
As of May 2020, 1,880 unique TOETVA cases have been described in the literature (Table 2) (6,8,11,29,30,34-40). This represents exponential growth in the number of new cases (65-89). Of these, 571 cases (30.4%) were total thyroidectomies, 1,274 (67.8%) were lobectomies and 35 (1.9%) were isthmusectomies (Table 3). Across these 1,880 cases, the average total operation time was 124.7 minutes. In the reviewed final 36 publications, 28 TOETVA cases (approximately 1.9%) were aborted intraoperatively and converted to an open approach.
An assessment of reported complications from these cases was conducted (Table 4). Carbon dioxide embolism occurred in 5 cases (0.3%). Hematoma occurred in 8 cases (0.4%), and surgical site infection in 20 cases (1.1%) (Table 5). With regards to injury of the recurrent laryngeal nerve, transient RLN palsy was observed in 74 cases (3.9%) and permanent RLN palsy noted in 11 (0.6%). HP was mentioned as a complication in some cases, occurring transiently in 96 (16.8%) and permanently in 5 cases (0.9%). MNI, defined by lower lip or chin paresthesia (90), was noted transiently in 113 cases (6%) and permanently in 2 cases (0.1%).
This review of TOETVA in the global literature establishes that TOETVA is increasingly common, has a safety profile similar to that of standard open thyroidectomy techniques (91-93), and reduces significant patient morbidity related to the transcervical scar.
TOETVA is feasible for both benign and malignant indications and this approach can be used for isthmusectomy, thyroid lobectomy and TT with or without central neck dissection. Although total operation time largely depends on the logistics of the operating environment and the experience of the surgeon, the average total operating time approximates 2 hours. This further supports the belief that the duration is similar to that of an open thyroidectomy (94). Additionally, intraoperative conversion to an open approach is rare (1.9%). Postoperative complications such as hematoma, infection, HP, and recurrent laryngeal nerve dysfunction are observed in patients undergoing all types of thyroidectomy. The outcomes after TOETVA are similar to those seen after open thyroidectomy (91-93). At a minimum, the safety of TOETVA does not appear to be inferior to the classic open thyroidectomy approach.
TOETVA introduces new complications that are not typically observed in the conventional approach such as risk of carbon dioxide embolism and MNI. Our review suggests that carbon dioxide embolism rarely occurs. MNI, defined as paresthesia of the lower lip or chin region, was the most common complication in the cases reported. Almost all of these complications were self-limited, with only permanent MNI seen in two cases. Similar hypoesthesia is often created anywhere flap elevation is completed, and generally recovers over time.
This review is not without limitations. Most significantly, we acknowledge that there are complications that have been underreported or not reported at all. Complications such as carbon dioxide embolus were reported more frequently in the past but have not been described in the literature for several years. While this could represent an evolution in the safety of the approach, it could also represent a publication bias. Despite these concerns, however, it is apparent that TOETVA is being widely adopted globally (Table 6), and these studies represent the combined results of those institutions with the largest volumes to date.
While it remains to be seen whether TOETVA becomes a standard alternative to open thyroidectomy, interest in the technique is growing. Our review of the first 5 years of published remote access approach cases in the literature establishes that, at least in the academic thyroid surgery community, TOETVA has been embraced more rapidly than the trans-axillary, bilateral axillo-breast and retro-auricular approaches in their initial years (Figure 2).
Lastly, the COVID-19 pandemic caused by widespread SARS-CoV-2 virus infection around the globe has led us to reevaluate our management of surgical candidates. It is important to proceed with caution while minimizing risk to patients and healthcare workers. At this point we would recommend SARS-CoV-2 testing of all TOETVA candidates and use of adequate personal protective equipment during this and other thyroidectomy approaches. We should consider the possibility of increased aerosolization during this approach when compared to conventional approaches.
TOETVA has been widely adopted across the globe and should be considered a novel but safe approach to thyroid surgery. It provides excellent cosmesis while demonstrating non-inferiority in terms of risk to the patient (RLN palsy, bleeding, infection, HP). Larger prospective studies should be done in the future to compare TOETVA to traditional thyroidectomy in terms of quality of life, voice outcomes and oncologic equivalency.
Provenance and Peer Review: This article was commissioned by the Guest Editors (Marcin Barczyński and Maurizio Iacobone) for the series “Recent Challenges in the Management of Thyroid Tumors” published in Annals of Thyroid. The article has undergone external peer review.
Peer Review File: Available at http://dx.doi.org/10.21037/aot-20-52
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aot-20-52). The series “Recent Challenges in the Management of Thyroid Tumors” was commissioned by the editorial office without any funding or sponsorship. Dr. JOR reports personal fees from Baxter, outside the submitted work. Dr. RPT reports personal fees from Medtronic, personal fees from Hemostatix, personal fees from RGS Healthcare, outside the submitted work. The other authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Banuchi VE, Ballakur SS, Russell JO, Tufano RP. Benefits and risks of scarless thyroid surgery. Ann Thyroid 2020;5:24.