Transoral Endoscopic Thyroidectomy Vestibular Approach: Lessons from a Five Years’ Experience

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has demonstrated excellent cosmetic and clinical outcomes with low complication rates. In addition to a relatively steep learning curve, TOETVA offers a real alternative to open and minimally invasive techniques. TOETVA is indicated for hemithyroidectomies in patients without prior neck surgery. Technically, it involves a 10-mm incision on the inside of the lower lip, followed by subplatysmal hydrodissection to create a space between the platysma and infrahyoid musculature. Three trocars are inserted prementally through the lower lip approaches. In our clinical experience with TOETVA, several critical steps and appropriate solutions were defined: 1. team positioning and technical improvement using a 4 K laparoscopic tower; 2. lateral and cranial positioning of lateral trocars to avoid mental nerve injury; 3. initial hydrodissection of subplatysmal space; 4. use of a dissector that gradually creates the surgical field in the anterior neck; 5. infrahyoid musculature retraction with externally fixed sutures; 6. intraoperative neuromonitoring routinely performed through the trocars or percutaneously through a 1-mm incision; 7. specimen removal using a recovery bag. Our results confirm the feasibility and safety of TOETVA combined with a steep learning curve. Further studies are needed to determine potential indications in standard care.