Transoral Endoscopic Total Thyroidectomy via Vestibular Approach (TOETVA)

Abstract

Transoral thyroidectomy is the first true “scarless” minimally invasive approach unlike its predecessors such as the transaxillary, bilateral axillo-breast, and retroauricular approaches because it does not involve any incision on the skin. The concept was first proposed by Witzel in 2008, when he demonstrated the first proof-of concept hybrid transoral thyroidectomy with human cadavers and animals. In the early stages of its development, the approach was sublingual, meaning that the access was made through the oral cavity inside the mandible. The sublingual access was considered to be less feasible, however, after the initial clinical application of this approach resulted in recurrent laryngeal and mental nerve injuries. The alternative method was the vestibular approach, first demonstrated in 2011, in which the access point was re-positioned exterior to the mandible and beneath the platysma muscle layer. This approach gained increasing popularity among the endocrine surgeons and in 2016, Anuwong published the first large scale human transoral endoscopic thyroidectomy vestibular approach (TOETVA) study including 60 cases. In this landmark study, the postoperative complication rates of the novel approach were reported to be comparable to the conventional open and minimally invasive thyroidectomies. The same group subsequently published a comparison study of 432 TOETVA and open thyroidectomy cases that were matched by propensity scores. The postoperative results of this study were comparable as well. At the moment, TOETVA is being conducted in more than 80 institutions across over 30 countries. The advantages of TOETVA, apart from its scarless nature, include median symmetric view which allows total thyroidectomy to be done without additional incisions, minimal transoral specific complications such as mental nerve injury and/or oral infection, and easy access to the central lymph nodes due to its cephalo-caudal orientation. The indications/contraindications and step by step procedures are described in detail in this chapter. This chapter was supported by National Research Foundation grant (No. 2019R1C1C1008384). © Springer Nature Switzerland AG 2022.