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Explore This IssueMarch 2021
Over the years, many alternative surgical approaches, so-called “remote-access” techniques, have been described for thyroid surgery, driven by cosmetic concerns. Such techniques have used both endoscopic and robotic approaches from different body sites, including the axilla, breast, and retro-auricular regions. These are considered by many to be overly cumbersome, costly, and unnecessary, however, particularly given the generally good cosmetic results and complication rates achieved with open thyroidectomy (OT). Certain complications, such as the possibility of brachial plexus injury in the transaxillary approach, have made surgeons wary of such remote-access techniques.
In the past several years, a novel transoral approach has been developed. Initial studies attempted to utilize a sublingual incision in the floor of the mouth for endoscopic access to the thyroid. This specific approach never gained much traction; however, a relatively new approach, solely using the oral vestibule (transoral endoscopic thyroidectomy by vestibular approach), has become increasingly popular around the world, including in Western countries where remote-access thyroid surgery has largely been shunned in the past.
Transoral thyroidectomy can be safely performed in a select group of patients. The transoral vestibular approach has unique advantages over previously described remote-access approaches for thyroidectomy. This approach compares favorably to traditional open approaches in very carefully selected patients. Transoral thyroidectomy is reasonable to offer patients who meet specific criteria (see Table 1). Caution is advised in certain patients until further studies are available, as the current evidence is low quality. Regardless, this emerging technique warrants further study. All patients should be informed of the complications specific to transoral thyroidectomy, including the possibility of conversion to OT.
Suggested Surgical Candidacy Criteria
|Indications||Contraindications||Further study needed|
Patient wants to avoid cervical scar
Benign nodule or low suspicion of malignancy: <6 cm nodule diamete
Micropapillary carcinoma or high suspicion of malignancy: <1 cm
Total thyroid diameter <10 cm
|Previous neck/chin surgery or radiation|
Overt or suspicion of extrathyroidal extension
Lymph node metastasis
Grave’s disease, thyroiditis, hyperthyroidism
Central neck dissection
Differentiated thyroid cancer 1–2 cm