I. Suh1, C. Viscardi1, Y. Chen1, I. Nwaogu1, R. Sukpanich1, J. E. Gosnell1, W. T. Shen1, C. D. Seib1, Q. Duh1 1University Of California – San Francisco,Department Of Surgery, Endocrine Surgery Section,San Francisco, CA, USA
Introduction: The transoral endoscopic approach for thyroid and parathyroid surgery is the latest remote-access endocrine surgical technique aiming to eliminate a visible anterior neck incision in selected patients. The early experience in North America has demonstrated promising safety and efficacy results, but as expected has uncovered unique challenges and drawbacks. We present a case series of our institutional experience and evolution in the technique in response to our perceived challenges.
Methods: We reviewed all patients who successfully underwent transoral endoscopic thyroid and parathyroid surgery at our institution from 4/2017-6/2018. A technical innovation to the technique was introduced midway in the experience. Demographics, surgical indications, technical details, and perioperative outcomes were recorded in a prospective database and analyzed retrospectively.
Results: 13 patients underwent transoral endoscopic thyroid and parathyroid surgery, with mean follow-up of 23 weeks. Mean age was 39 years, and all but one were female. Eleven patients underwent thyroidectomy and 2 patients underwent focused parathyroidectomy. Of the ten patients who underwent thyroidectomy for nodular disease or papillary thyroid carcinoma, the FNA cytology and mean nodule size were as follows: 1) Bethesda II nodules: 3.1 cm (n=6); 2) indeterminate nodules: 3.3cm (n=1), and 3) papillary thyroid carcinoma: 1.2cm (n=3). There were no injuries to the recurrent laryngeal or mental nerves. One patient undergoing total thyroidectomy had transient hypocalcemia which resolved within 1 month.
The first 5 cases were performed with the traditional transoral endoscopic technique with 3 incisions in the oral vestibule. Amongst these cases, 3 patients complained of pain at the midline of the chin that lasted for 3 months. The capsules of two specimens for benign or indeterminate nodules were disrupted in the specimen retrieval bag during extraction through the mouth. In response, we developed a hybrid transoral and submental technique (TOaST) in which the 1cm middle incision is placed in a hidden submental location (Figure). The subsequent 8 cases were performed with this hybrid approach. There were no differences in technique-specific complications between the traditional and TOaST approaches. The TOaST approach had no instances of significant chin pain or specimen disruption, and cosmetic outcomes remained excellent.
Conclusion: We present a pilot series of our institution’s evolution in the transoral endoscopic approach to thyroid and parathyroid surgery, incorporating a technical innovation that addresses unique challenges that we identified in this procedure and population.
