Usually, a thyroidectomy is performed by making a horizontal incision in the anterior neck. In some cases, all of the thyroid gland and lymph nodes are removed this way. This surgical method will leave a visible horizontal scar on the patient's neck. 

TOETVA Surgical Procedure: Advantages and Disadvantages
Illustration: a patient undergoing TOETVA surgery


There is now a new thyroidectomy approach known as Transoral Endoscopic Thyroidectomy via the Vestibular Approach (TOETVA). This minimally invasive method of surgery has the advantage of having better results cosmetically. But it also has the disadvantages of a longer operating time, a higher level of technical difficulty, and unusable for large thyroid cancers.

Minimally invasive thyroidectomy is similar to conventional thyroidectomy in its surgical approach. The procedure for removing the thyroid gland in this operation is also the same as for conventional thyroidectomy. The difference is only in the length of the skin incision, which is less than 6 cm. These smaller incisions will improve cosmetics.

The incision scar on the neck is a cosmetic concern. As technology develops, the axilla or inside lips become access to reach the thyroid gland in a minimally invasive manner; this is to hide the surgical scars.

In 2008, Dr. Witzel published a new technique of minimally invasive thyroidectomy without skin incisions. This surgical technique is called Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA). TOETVA is an excellent choice for patients requiring thyroid surgery who wish to avoid neck incisions. 



What are the indications for TOETVA?

This surgical procedure is indicated for patients with benign thyroid nodules, Graves' disease less than 10 cm in size, and thyroid cancer measuring 1-2 cm who still have not had an extrathyroid extension.



Steps How to do TOETVA Surgical Procedure

  1. TOETVA is performed under general anesthesia through a nasotracheal tube.
  2. Clean the oral cavity with normal saline and povidone-iodine before making the incision.
  3. Tunnel under the neck's skin using a particular instrument through an incision hidden from under the patient's lip. Then, insert the camera and apply carbon dioxide gas to allow the neck's skin to expand, creating a working space.
  4. In the working space, dissect the strap muscle and the platysma muscle using a monopolar hook and an ultrasonic energy device (harmonic scalpel).
  5. Create a thyroid exposure by opening the deep fascia between the strap muscles at the centerline.
  6. Then perform thyroidectomy as indicated by the preservation of the recurrent laryngeal nerves and parathyroid glands.
  7. Remove the excised thyroid specimen through the endobag and remove it through a 10 mm incision in the oral cavity.
  8. The incision wound of the vestibule is sutured with absorbable thread.



Advantages of TOETVA

Cosmetically, TOETVA surgical procedure has advantages over conventional thyroidectomy. It is due to the TOETVA operation does not get the slightest incision in the neck skin.

Based on several studies conducted by Inabnet et al., Dionigi et al., and Wang et al., it can be concluded that by using TOETVA, it is easier to identify recurrent laryngeal nerves so that it can reduce the risk of recurrent laryngeal nerve injury.

Tartaglia et al. recorded other complications in a systematic study, with 736 cases who underwent TOETVA surgical procedure; transient recurrent laryngeal nerve palsy occurred in 34 cases, permanent recurrent laryngeal nerve palsy in 2 cases. Transient hypoparathyroidism occurred in 62 cases.

Also, Tartaglia et al. also noted that other complications were also rare, such as one case of bleeding from a surgery, 22 cases with seroma due to surgery, 20 cases with mental nerve injury.

After surgery, the pain incidence was smaller in TOETVA than conventional thyroidectomy, measured by a visual analog scale; the mean value was 3.

The length of stay of patients who underwent TOETVA surgical procedure was also relatively shorter; even a study in Brazil recorded only one treatment day.



Disadvantages of TOETVA

TOETVA surgical procedure requires a relatively long operating time (mean 110 minutes) than conventional thyroidectomy (mean 79 minutes) and requires special skills (a long learning curve). [4,10] Even the longest time to total thyroidectomy with the TOETVA technique is 345 minutes.

An important thing to consider is the risk of infection due to saliva contact with a sterile operating area. Some published serial data do not show an increase in the number of surgical site infections. However, as a general recommendation, short-term prophylactic antibiotics are prudent to administer because this classification of surgery is considered a "potentially contaminated" operation. The recommendation is to use clindamycin for 24 hours.

Although TOETVA surgical procedure rarely causes complications, subcutis emphysema may occur due to carbon dioxide buildup during surgery. This subcutis emphysema can last for 12 to 48 hours and causes discomfort in the patient.

Although TOETVA is cosmetically better, lip access can also cause problems after surgery. Richmon and Kim's study showed that there were 3 out of 17 cases of hypoesthesia and lower lip weakness after the TOETVA surgical procedure.

TOETVA is not suitable for malignant thyroid lesions larger than 2 cm and with extrathyroid extension. Consider performing other technical alternatives in such cases.



Summary
TOETVA is an innovation of thyroidectomy surgery performed without skin incisions. This operation is performed with access through an incision in the lip and using a special instrument (endoscope). There are many advantages with this operation: it is cosmetically better, the incidence of recurrent laryngeal nerve injury is suppressed, the pain after surgery is minimal, and the length of patient care is short. However, it should be noted that this operation also has several drawbacks, namely: a longer average length of operation, discomfort after surgery due to subcutis emphysema, risk of hypoesthesia and lower lip weakness, and narrow surgical indications so that performing this procedure on lesions—thyroid by certain criteria.


References
1. Dhingra JK. July 31,2015. Minimally Invasive Surgery of the Thyroid Treatment & Management. Available from: https://emedicine.medscape.com/article/1298816-treatment#d9
2. Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg. 2018 Jan 1;153(1):21-27. DOI: 10.1001/jamasurg.2017.3366. Available from: https://jamanetwork.com/journals/jamasurgery/fullarticle/2653288
3. Anuwong A, Kim HY, Dionigi G. Transoral endoscopic thyroidectomy using the vestibular approach: updates and evidence. Gland Surg. 2017 Jun; 6(3): 277–284.
4. Bakkar S, Al Hyari M, Naghawi M, Corsini C, Miccoli P. Transoral thyroidectomy: a viable surgical option with unprecedented complications-a case series. J Endocrinol Invest. 2018 Jul;41(7):809-813. DOI: 10.1007/s40618-017-0808-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29243180
5. Dionigi G et al. Transoral endoscopic thyroidectomy via vestibular approach: operative steps and video. Gland Surg. 2016 Dec; 5(6):625-627. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5233844/
6. Inabnet WB 3rd, Suh H, Fernandez-Ranvier G. Transoral endoscopic thyroidectomy vestibular approach with intraoperative nerve monitoring. Surg Endosc. 2017 Jul; 31(7):3030. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27834022
7. Le QV, Ngo DQ, Ngo QX. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): A case report as a new thyroid surgery technique in Vietnam. Int J Surg Case Rep. 2018; 50: 60–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083382/
8. Richmon JD dan Kim HY. Transoral robotic thyroidectomy (TORT): procedures and outcomes. Gland Surg. 2017 Jun; 6(3): 285–289. DOI: 10.21037/gs.2017.05.05. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503926/
9. Romanowski A. December 16, 2016. Novel Thyroidectomy Removes Organ Through the Lip. Available from: https://www.medscape.com/viewarticle/873309#vp_1
10. Tartaglia F et al. Transoral video-assisted thyroidectomy: a systematic review. G Chir. 2018 Sep-Oct;39(5):276-283. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30368265
11. Tesseroli MAS, Spagnol M, Sanabria Á. Transoral endoscopic thyroidectomy by vestibular approach (TOETVA): initial experience in Brazil. Rev Col Bras Cir. 2018 Nov 14;45(5):e1951. DOI: 10.1590/0100-6991e-20181951. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-69912018000500158&lng=en&nrm=iso&tlng=en
12. Wang et al. Implementation of Intraoperative Neuromonitoring for Transoral Endoscopic Thyroid Surgery: A Preliminary Report. J Laparoendosc Adv Surg Tech A. 2016 Dec; 26(12):965-971. Available from: https://www.liebertpub.com/doi/abs/10.1089/lap.2016.0291?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=lap