We thank all the patients who participated in this study for their cooperation. This research was supported by the project fund of the Science and Technology Department of Sichuan Province. (Grant No. 2021YFS0103).

The study was approved by the medical ethics committee of West China Hospital, Sichuan University (2018[457]), and written informed consent was obtained from all subjects.
1. Preoperative preparation
<ol>
	<li>Patient eligibility
	<ol>
		<li>Select patients who have stringent cosmetic requirements and meet the following criteria: (1) a benign nodule &#60;4 cm in diameter; (2) a differentiated thyroid carcinoma (DTC) &#60;2 cm in diameter without clinical lateral lymph node metastasis or distance metastasis; and (3) no imaging indication of central lymph node metastasis or a metastatic lymph node &#60;2 cm in diameter without fusion and fixation.</li>
		<li>Exclude patients who meet the following criteria: (1) medullary carcinoma or undifferentiated thyroid carcinoma; (2) oral or neck infections; (3) severe thyroiditis that has an acute impact on thyroid function; (4) suspicious invasion of the primary tumor or metastatic lymph node to adjacent organs, such as the esophagus, trachea, or recurrent laryngeal nerve (RLN); (5) location of the primary tumor in the upper pole; (6) previous history of neck surgery, ablation, or neck radiation; (7) biochemical evidence of uncontrolled hyperthyroidism; (8) substernal goiter; and (9) intolerance to surgery.</li>
	</ol>
	</li>
	<li>Patient preparation
	<ol>
		<li>Evaluate the patients preoperatively with fine-needle aspiration cytologic testing, parathyroid gland tests, thyroid function tests, laryngoscopy, and thyroid ultrasonography16.</li>
		<li>Ask the patient to prepare the oral cavity by using mouthwash (such as tinidazole) before and after meals at least 2 days before the TOETVA and keeping the mouthwash in the mouth for at least 15 s every time.</li>
	</ol>
	</li>
	<li>Equipment
	<ol>
		<li>Ensure the availability of the absorbable sutures (5-0) for oral wounds.</li>
		<li>Ensure the availability of all the instruments and materials required for the protocol (see Table of Materials).</li>
	</ol>
	</li>
</ol>
2. Surgical preparation
<ol>
	<li>Pre-operative preparation
	<ol>
		<li>Assess the anesthesia risk of surgery according to the American Society of Anesthesiologists&#39; classification17.</li>
		<li>Induce general anesthesia with orotracheal intubation using intraoperative neuromonitoring (IONM).</li>
		<li>Tape the eyes and nose, and pad the head to avoid inadvertent trauma.</li>
		<li>Perform catheterization.</li>
	</ol>
	</li>
	<li>Operation field 
	NOTE: Figure 1 shows the schematic of the operating room layout.
	<ol>
		<li>Let the operator stand in front of the patient&#39;s head. Let the first assistant stand on the left side of the patient&#39;s head. 
		NOTE: The first assistant will be responsible for holding the endoscope.</li>
		<li>Let the second assistant stand beside the patient&#39;s body according to the location of the lesion to hold the hook. Let the scrub nurse stand beside the patient&#39;s leg.</li>
		<li>Place the endoscopic equipment and monitor beyond the patient&#39;s feet.</li>
		<li>Place the patient in the supine position with the neck extended. Fix the patient&#39;s head with the top cuff during the operation to avoid neck rotation.</li>
	</ol>
	</li>
	<li>Disinfection
	<ol>
		<li>Skin disinfection: Prepare the upper chest, neck, and lower face with iodine solution three times according to the principle of top-down and in-out.</li>
		<li>Oral disinfection: Put the diluted iodine gauze into the mouth, disinfect the oral cavity with it three times, and rinse it with normal saline.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64437/64437fig01.jpg" /> 
Figure 1: A schematic of the operating room layout. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64437/64437fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Designing the incisions and establishing the working space (Figure 2)
<ol>
	<li>Make the camera port incision with an electrotome; this should be a 20 mm transverse incision 5 mm above the frenulum through the alveolar mucosa of the central lower lip vestibule.</li>
	<li>Advance the camera port incision to the chin with an electrotome. Take care to avoid the penetration of the mentum skin. Use hemostatic forceps and a subcutaneous stripping rod to make a tunnel in the midline of the neck, and further extend to the lower neck.</li>
	<li>Place a 10 mm camera through the central port. Insufflate the working space with carbon dioxide gas to establish a pressure of 4 mmHg. 
	NOTE: The pressure of the carbon dioxide gas should be &#60;8 mmHg to avoid complications caused by high pressure.</li>
	<li>Make two 5 mm vertical incisions laterally from the first premolars for instrument placement.</li>
	<li>Use an ultrasonic scalpel to make the working space, and widen it to both sternocleidomastoid muscles laterally and along the subplatysmal plane to the sternal notch inferiorly. Use the traction of the skin suspension device, which is made of unabsorbable sutures (3-0) and rubber bands, to help expand the working space (Figure 3).</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64437/64437fig02.jpg" /> 
Figure 2: Positioning of the patient and the laparoscopic ports. The center one is the camera port. Arm I and Arm II are for instrument placement. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64437/64437fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64437/64437fig03.jpg" /> 
Figure 3: The traction suspension device. The arrow points at the traction suspension device. The suspension device is made of unabsorbable string (3-0) and rubber bands. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64437/64437fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
4. Thyroid lobectomy
<ol>
	<li>Divide the linea alba coli with an ultrasonic scalpel. Separate part of strap muscle from the thyroid gland.</li>
	<li>Use a 20 mL needle to pierce the skin at the level of the inferior corner of the thyroid cartilage, and place a pull hook through the hole. Use the pull hook to grab the separated part of the strap muscle.</li>
	<li>Use the ultrasonic scalpel to separate the remaining part of the strap muscle and expose the common carotid artery. Find the vagus nerve, and use the IONM to record the signal. 
	NOTE: The IONM technology helps to quickly locate, identify, and protect the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN). The use of IONM is encouraged; it is an excellent auxiliary tool, but not a mandatory tool.</li>
	<li>Use nontraumatic forceps to hold the inferior margin of the isthmus. Use the ultrasonic scalpel to cut the isthmus from the inferior portion of the cricoid cartilage and expose the trachea. For the lobectomy of the TOETVA, first locate the trachea, and take it as a sign.</li>
	<li>Use the nontraumatic forceps to hold the upper pole of the thyroid, and divide the cricothyroid space with the ultrasonic scalpel. Transect part of the sternothyroid muscle. Expose the upper pole of the thyroid.</li>
	<li>Sever the superior thyroid artery and vein. Free the lateral glands from the top down. Lift up the upper pole of the gland, find the RLN under direct visualization, and use the IONM to record the signal.</li>
	<li>Use the ultrasonic scalpel to separate the thyroid capsule from the trachea. Divide the inferior thyroid vessels, and cut the Berry&#39;s ligament with the ultrasonic scalpel.</li>
	<li>Remove the unilateral lobe of the thyroid gland from the trachea. Use the IONM to record the signal of the vagus nerve and RLN again.</li>
</ol>
5. Central lymph node dissection
<ol>
	<li>Locate the inferior parathyroid gland first, and try to retain it in situ. 
	NOTE: The thymus should be carefully identified and protected to ensure the functionality of the inferior parathyroid gland from the source of the thymus blood supply and to prevent accidental resection of the parathyroid gland. Carbon nanoparticles can be chosen to help facilitate the identification of the parathyroid glands and the dissection of the lymph nodes. Autotransplantation is feasible for parathyroid glands that cannot be retained in situ.</li>
	<li>Stretch the strap muscles to the outside as much as possible to fully expose the operative field.</li>
	<li>Identify the central lymph node compartment by the hyoid bone (superior), suprasternal fossa (inferior), carotid artery (lateral), superficial layer of the deep cervical fascia (anterior), and esophagus (posterior).</li>
	<li>Use the ultrasonic scalpel to dissect the pretracheal and prelaryngeal lymph nodes. Cut the connective tissue in front of the carotid artery to determine the lateral boundary of the central lymph nodes and the connective tissue in front of the trachea to determine the medial boundary of the central lymph nodes. Sweep the anterior side of the left RLN or the anterior and posterior side of the right RLN to complete the central lymph node dissection. 
	&#8203;NOTE: The lateral margin should not be swept too deep in order to prevent damage to the vagus nerve and sympathetic trunk. When cleaning the inferior margin, injury to the innominate vessels and pleura should be avoided.</li>
</ol>
6. Removal of the specimen and closure
<ol>
	<li>Use endoscopic pouches to remove the specimens. 
	NOTE: To avoid ectopic implantation, the specimens should be completely removed by the endoscopic pouches.</li>
	<li>Wash the surgical wound repeatedly with a large amount of warm sterile distilled water.</li>
	<li>Place a surgical drain (4#) through a small skin puncture in the anterior neck.</li>
	<li>Re-approximate the strap muscles. Close the oral wounds with 5-0 absorbable sutures.</li>
</ol>
7. Parathyroid gland autotransplantation
<ol>
	<li>Preserve the parathyroid glands with normal saline, and examine them by frozen section biopsy.</li>
	<li>Cut the isolated parathyroid gland into tiny fragments of 1 mm x 1 mm x 1 mm with ophthalmic scissors. Mix the fragments with normal saline. Inject the mixture into the brachioradialis muscle of the forearm.</li>
</ol>

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V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+transoral+thyroidectomy+vestibular+approach+and+unilateral+axillobreast+approach+for+endoscopic+thyroidectomy:+A+prospective+cohort+study.">Comparison of transoral thyroidectomy vestibular approach and unilateral axillobreast approach for endoscopic thyroidectomy: A prospective cohort study.</a> Journal of Laparoendoscopic and Advanced Surgical Techniques. 31 (1), 11-17 (2020).</li><li>Bhattacharyya, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+cervical+nodal+metastases+in+patients+with+papillary+thyroid+carcinoma.">Surgical treatment of cervical nodal metastases in patients with papillary thyroid carcinoma.</a> Archives of Otolaryngology - Head and Neck Surgery. 129 (10), 1101-1104 (2003).</li><li>Lundgren, C. I., Hall, P., Dickman, P. W., Zedenius, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinically+significant+prognostic+factors+for+differentiated+thyroid+carcinoma:+A+population-based,+nested+case-control+study.">Clinically significant prognostic factors for differentiated thyroid carcinoma: A population-based, nested case-control study.</a> Cancer. 106 (3), 524-531 (2006).</li></ol>

The authors declare no competing interests.

TOETVA is characterized by the full exposure and dissection of the central lymph nodes, which is significantly advantageous in the treatment of differentiated thyroid carcinoma with cN1a10,13,14,15. However, it should be noted that due to the limited operating space, it is relatively difficult to deal with the big tumors located in the upper pole of the thyroid gland. The surgical indications and contraindications should be strictly followed to ensure the safe development of the operation. After completely dislocating the upper pole of the thyroid, the RLN is identified and further separated under direct visualization and monitored by IONM during the operation. When the RLN is in the vicinity of a hemorrhage, using an electrotome or an ultrasonic scalpel for hemostasis without figuring out the anatomy of the RLN and the surrounding conditions should be avoided, as this may result in accidental damage to the RLN. Wiping the blood with gauze strips can help to identify the anatomical relationship between the bleeding point and the RLN and, thus, stop the bleeding.
Following the report in 201611, transoral thyroid surgery has started to be adopted around the world13,18,19,20. According to one meta-analysis21 and five published systematic reviews22,23,24,25,26, TOETVA is safe and feasible in treating thyroid diseases. TOETVA, as a new endoscopic approach, satisfies the esthetic requirement because of the absence of a skin incision. Furthermore, it provides easy access to the bilateral central area and thyroid12. Surprisingly, most patients who underwent TOETVA in the center were female. A higher incidence of PTC and higher esthetic requirements in women may have contributed to this result.
The most common complications of thyroidectomy are RLN injury and hypoparathyroidism27. A meta-analysis of 10 articles involving 1,677 patients showed no significant difference in transient RLN injury, transient hypoparathyroidism, and transient hypocalcemia between TOETVA and non-transoral endoscopic thyroidectomy (NTET)28. The IONM showed that the neural signal of all the patients did not fade or disappear during the operation. The better view of the RLN and parathyroid gland provided by the endoscopic magnification might explain the result29,30.
Additional complications associated with TOETVA are surgical site infection and mental nerve injury, which can result in lip and/or chin numbness10. TOETVA is considered a clean-contaminated surgery because diverse bacterial flora, including anaerobic bacteria and gram-positive aerobic, colonize the mucosa of the oral cavity31. However, one meta-analysis showed no significant difference in the occurrence of wound infection between TOETVA and NTET28. The prophylactic measures, including prophylactic antibiotics, sterilization, and drainage, may contribute to this result32,33,34,35. In our center, the patients are asked to take oral antibiotics for 7 days after surgery, while other centers use oral antibiotics for different durations after surgery2,20,22. Further studies are needed to determine the standard antibiotic duration and dosage after TOETVA.
Tumor prognosis is the most important problem in cancer surgery. It is generally believed that lymph node metastasis is associated with tumor prognosis and higher mortality36,37. One meta-analysis reported that the central lymph node dissection rates of the TOETVA group and NTET group were comparable28. However, the follow-up duration of other remote access endoscopic methods is longer than that of TOETVA27. Building up a prospectively large-scale cohort, with procedures such as the bilateral axillo-breast approach (BABA) and transaxillary methods23,24,25, will be necessary to check the tumor prognosis.
TOETVA is an innovation in the concept of thyroid surgery. With the aim of ensuring the quality of surgery and curing diseases, it achieves the characteristic of minimal invasiveness and embodies the treatment concept of natural orifice transluminal endoscopic surgery (NOTES). TOETVA has the advantage of a top-down perspective and can be used to thoroughly dissect the central lymph nodes, which may play an essential role in improving the radical effect and long-term prognosis of endoscopic thyroid cancer surgery.

Conventional open thyroidectomy has been safely performed using a cervical incision for more than 100 years1. Although most patients have efficient scar healing and the cosmetic effect is generally acceptable, a permanent scar on the neck always draws immediate attention from common observers2. Nearly 20% of post-thyroidectomy patients experience self-awareness, and more than 10% consider further treatments to remove the scar3. Moreover, a negative impact of the cervical incision on health-related quality of life (HRQOL) has also been reported4. Varied remote-access approaches for thyroid surgery, such as axillobreast, transaxillary, retroauricular, and subclavian approaches, have been developed to avoid a visible neck scar5,6,7,8 by moving the cutaneous incision to less conspicuous locations.9 However, these approaches require wide-flap dissection to access the thyroid gland and still leave cutaneous scars at the incision sites10.
Since 2008, techniques for natural orifice transluminal endoscopic surgery for transoral thyroid surgery have been developed. These can be performed via the oral vestibular approach or the sublingual approach. The former is more popular because it is associated with fewer complications. In 2016, Anuwong published the first case series of 60 patients undergoing the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and identified an excellent prognosis11. In comparison with the remote-access methods, TOETVA is considered truly minimally invasive because the area of the flap dissection is similar to conventional open thyroidectomy, and it does not leave any scars on the body10.
TOETVA, a revolutionary endoscopic method, meets women&#39;s cosmetic needs and allows easy access to the bilateral thyroid and central compartment12. It is distinguished by the complete exposure and dissection of the central lymph nodes, which is beneficial in treating differentiated thyroid cancer with cN1a10,13,14,15. However, because of the limited operating space, dealing with large tumors in the upper pole of the thyroid gland is relatively challenging. The current study describes the step-by-step procedures of TOETVA.

<table><tbody><tr><td>Allis Grasping Forceps,310 mm x 5 mm</td><td>AESCULAP</td><td>PO111R</td><td></td></tr><tr><td>Button Electrode Tip</td><td>AESCULAP</td><td>GK385R</td><td></td></tr><tr><td>Ceramic Electrode</td><td>AESCULAP</td><td>GK384R</td><td></td></tr><tr><td>Complete Trocar</td><td>AESCULAP</td><td>EJ751R</td><td></td></tr><tr><td>Endoscope</td><td>Olympus</td><td>WA53005A</td><td></td></tr><tr><td>IONM</td><td>Medtronic</td><td>NIM-3.0</td><td></td></tr><tr><td>Light Transmitting Bundle</td><td>Olympus</td><td>WA03310A</td><td></td></tr><tr><td>Maryland Dissecting Forceps, 310 mm x 5 mm</td><td>AESCULAP</td><td>PO102R</td><td></td></tr><tr><td>Monopolar Handle (5 mm diameter, 33 cm working length)</td><td>AESCULAP</td><td>GK372R</td><td></td></tr><tr><td>Pneumoperitoneum tube,4 m</td><td>STRYKE</td><td>620-240-223</td><td></td></tr><tr><td>Pyramidal Tip Obturator</td><td>AESCULAP</td><td>EJ755R</td><td></td></tr><tr><td>Reusable Monopolar Cable</td><td>AESCULAP</td><td>GK245</td><td></td></tr><tr><td>Scissors</td><td>AESCULAP</td><td>P0004R</td><td></td></tr><tr><td>Suction irrigation tube</td><td>AESCULAP</td><td>PG027R</td><td></td></tr><tr><td>Super Righting Needle Holder, 5 mm</td><td>AESCULAP</td><td>PL414R</td><td></td></tr><tr><td>Veress</td><td>TianSong</td><td>E2014.6</td><td></td></tr></tbody></table>

transoral endoscopic thyroidectomy vestibular approach for thyroid lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

We set up a routine clinical pathway for patients with TOETVA at the center. Laryngoscopy and a thyroid ultrasound are carried out on each patient before the operation. Parathyroid hormone (PTH), thyroid function, 25-dihydroxy vitamin D (25-OH-VD), and serum calcium are routinely measured before the operation, and all of them except for thyroid function are remeasured 1 day after the surgery. In our hospital, Foley catheters are routinely used for patients who will have a TOETVA surgery of more than 3 h. The Foley catheter is also removed at 1 day after the surgery. Every patient is given 4 g of calcium gluconate through an intravenous drip after the surgery, and another 2 g is provided on the first day postoperatively. Oral calcium is not for routine use unless the patient has symptoms like numbness or tetany. Patients who have vitamin D deficiency are asked to take vitamin D supplementation after the surgery. Patients are discharged on the second postoperative day after removing the closed-suction drain unless there is a major adverse event like bleeding, hypocalcemia, or hoarseness. Patients are asked to take oral antibiotics for 5-7 days after the surgery.
At the center, TOETVA was performed on 32 patients with papillary thyroid cancer (PTC), and another 97 patients had traditional open surgery from November 2021 to April 2022 (Table 1). In the TOETVA group, the IONM showed the neural signal of all the patients to be in good condition during the operation. There was no case of postoperative hoarseness. Regardless of hypocalcemic symptoms, any decrease in the serum PTH level below the normal limit (normal range = 1.6-6.9 pmol/L) was defined as postoperative hypoparathyroidism, and a lack of recovery of the serum PTH level to the normal range more than 6 months postoperatively was defined as permanent hypoparathyroidism. If the reduction lasted less than 6 months, it was designated as transient. In the entire group, 12.5% (4/32) of the patients had transient hypoparathyroidism, and 0% had permanent hypoparathyroidism.
The mean age and gender composition of the patients differed between the two groups (p &#60; 0.05). Younger female patients were more likely to choose TOETVA. The operation time of the TOETVA was longer than that of open surgery (p &#60; 0.05). As no significant differences in the number of harvested lymph nodes were found between the two groups (p &#62; 0.05), the dissection range of central lymph nodes of TOETVA could be consistent with that of open surgery. In terms of the metastatic lymph nodes, the ratio of extrathyroidal extension and tumor size differed between the two groups (p &#60; 0.05), meaning the characteristics of the tumors differed between the two groups. No significant differences in postoperative PTH and postoperative calcium were found between the two groups (p &#62; 0.05). The two surgical techniques had identical effects on parathyroid function (Table 1).
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="3">Parameters</td>
			<td>TOETVA (N=32)</td>
			<td>Open surgery (N=97)</td>
			<td>P*</td>
		</tr>
		<tr>
			<td colspan="3">Mean age, years (range)</td>
			<td>34.00 (32.00-39.00)</td>
			<td>44.00 (35.00-51.00)</td>
			<td>0.000</td>
		</tr>
		<tr>
			<td colspan="3">Sex</td>
			<td></td>
			<td></td>
			<td>0.007</td>
		</tr>
		<tr>
			<td colspan="3">Female</td>
			<td>31</td>
			<td>73</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Male</td>
			<td>1</td>
			<td>24</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Preoperative PTH (pmol/L)</td>
			<td>5.04 &#177; 0.24</td>
			<td>5.41 &#177; 0.20</td>
			<td>0.228</td>
		</tr>
		<tr>
			<td colspan="3">Preoperative Calcium (mmol/L)</td>
			<td>2.28 &#177; 0.01</td>
			<td>2.31 &#177; 0.01</td>
			<td>0.205</td>
		</tr>
		<tr>
			<td colspan="3">Surgical extent&#160;</td>
			<td></td>
			<td></td>
			<td>0.790</td>
		</tr>
		<tr>
			<td colspan="3">Left</td>
			<td>11</td>
			<td>37</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Right</td>
			<td>21</td>
			<td>60</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Extrathyroidal extension</td>
			<td>11</td>
			<td>12</td>
			<td>0.005</td>
		</tr>
		<tr>
			<td colspan="3">Tumor size (cm)</td>
			<td>0.80 (0.6-1.00)</td>
			<td>1.75 (1.20-2.32)</td>
			<td>0.000</td>
		</tr>
		<tr>
			<td colspan="3">Operation time (min)</td>
			<td>190.03 &#177; 5.39</td>
			<td>102.00 &#177; 13.25</td>
			<td>0.000</td>
		</tr>
		<tr>
			<td colspan="3">Postoperative PTH (pmol/L)</td>
			<td>2.78 &#177; 0.17</td>
			<td>2.78 &#177; 0.01</td>
			<td>0.962</td>
		</tr>
		<tr>
			<td colspan="3">Postoperative Calcium (mmol/L)</td>
			<td>2.21 &#177; 0.25</td>
			<td>2.24 &#177; 0.12</td>
			<td>0.282</td>
		</tr>
		<tr>
			<td colspan="3">No. of harvested lymph nodes</td>
			<td>8.75 (5.00-12.70)</td>
			<td>8.00 (6.00-11.25)</td>
			<td>0.110</td>
		</tr>
		<tr>
			<td colspan="3">No. of metastatic lymph nodes</td>
			<td>0.75 (0-2.40)</td>
			<td>1.75 (0-2.50)</td>
			<td>0.002</td>
		</tr>
	</tbody>
</table>
Table 1: Baseline characteristics and results of the 32 cases of TOETVA and the 97 cases of open surgery. The median is presented for continuous variables with non-normal distribution. The mean &#177; standard deviation is presented for continuous variables with normal distribution. Differences in continuous variables between the groups were examined using a nonparametric test or the Student&#39;s t-test. The Fisher&#39;s exact test or Pearson&#39;s chi-squared test were used to examine the differences in categorical variables between the groups. A P value of &#60; 0.05 was considered statistically significant. Abbreviations: PTH = parathyroid hormone.

Watch this Scientific Journal Video about Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy at JoVE.com

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

transoral-endoscopic-thyroidectomy-vestibular-approach-for-thyroid

Nanyang Technological University

Research

JoVE Journal

Medicine

3.6K Views.  Sichuan University. TOETVA heeft enkele nadelen, waaronder een smal operatiegebied en een relatief uitdagende externe tak van de superieure blootstelling aan larynxzenuwen. Dit protocol verbetert de toepassing van TOETVA IN de klinische praktijk en vermindert de leercurve. TOETVA wordt gekenmerkt door de volledige blootstelling en dissectie van de centrale lymfeklieren, wat aanzienlijk voordelig is bij de behandeling van gedifferentieerd schildkliercarcinoom met cN1A.Na het verdoven van de patiënt met be...

Video: Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

An Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannomas using a Computer-Based Three-Dimensional Imaging System

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth perception is the limitation of this approach. With the loss of depth perception, the surgeon will be not able to perform delicate and particularly complicated surgery. A binocular endoscope has been developed to provide stereoscopic vision with better depth perception for complicated anatomic structures and has been applied in some endoscopic surgeries. However, the diameter of the endoscope is a limitation in the performance of transcanal otologic surgeries. A small diameter endoscope facilitates easier surgery in a restricted space. A computer-based 3D imaging system can obtain 3D images in real-time using a small monocular endoscope. In this study, to evaluate the feasibility of a computer-based 3D imaging system for endoscopic lateral skull base surgery, we applied this 3D imaging system in a transcanal transpromontorial approach in two patients with vestibular schwannomas. The surgical procedure was completed without complication in these two cases. There was no mortality, perioperative complications, nor notable postoperative complications. Using this computer-based 3D imaging system, a better depth perception and stereoscopic vision was observed compared to a conventional 2D endoscope. The improvement in depth perception offers superior management of the complicated surgical anatomy.

Here, we present a transcanal transpromontorial approach for vestibular schwannomas using a computer-based three-dimensional (3D) imaging system combined with a two-dimensional (2D) endoscope. This system provided stereoscopic vision, better depth perception and reduced visual fatigue. This 3D imaging system enabled the application of 3D vision technology in endoscopic lateral skull base surgery.

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth ...

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is almost completely reserved to a few referral centers that deal with a large proportion of this pathology. Practice on human specimens is not always possible for ethical, economic, or availability reasons. The aim of this study is to provide a reproducible method for the organization of a laryngeal laboratory on ex vivo animal models where it is possible to approach, learn, and refine laryngeal techniques. Porcine and ovine larynges are ideal, affordable, models to simulate laryngeal surgery given their similarity to the human larynx in their anatomical layout and tissue composition. Herein, the surgical steps of transoral laser surgery, open partial horizontal laryngectomy, and total laryngectomy are reported. The merging of endoscopic and exoscopic views guarantees an inside-out perspective, which is vital for the comprehension of the complex laryngeal anatomy. The method was successfully adopted during three sessions of a dissection course &#34;Lary-Gym&#34;. Further perspectives on robotic surgical training are described.

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

Combined Endoscopic and Transoral Approach for Total Maxillectomy

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely practiced for resecting maxilla. Compared with the traditional approaches, the combined endoscopic and transoral approach has many advantages such as avoiding facial incisions and postoperative scars and better visualization of the surgical margin. However, this technique is complicated to master and possess several challenges. Here, we demonstrate this approach step-by-step to show how to perform a total maxillectomy. We also reported nine cases with malignant tumors originating from the maxilla, and for all of them total maxillectomy was performed with combined endoscopic and transoral approach. Our data showed that the combination of the endoscopic and transoral approach could be used to resect the total maxilla successfully, though the tumor extended to the infratemporal and pterygopalatine fossa should be treated very carefully to avoid its spread in the local area. Furthermore, besides denture, other reconstruction methods should be attempted to improve the postoperative quality of life after the total maxillectomy.

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely ...

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Improved Thoracoscopic-Assisted Surgery for the Treatment of Metastatic Thoracic Vertebral Tumors

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic spread of these tumors to the thoracic vertebrae remains a significant challenge, often resulting in bone-related adverse events, such as pathological fractures and severe complications. To address this issue, a refined multidisciplinary approach has been explored, which utilizes thoracoscopic techniques for tumor resection and spinal interventions. Thoracoscopic techniques offer a minimally invasive alternative to traditional open surgical methods, aiming to reduce the overall trauma experienced by patients. By leveraging the advantages of thoracoscopy, clinicians can effectively resect metastatic tumors within the thoracic vertebrae while minimizing the impact on surrounding tissues and structures. This approach, combined with targeted spinal interventions, has the potential to improve patient outcomes and quality of life by mitigating the debilitating effects of pathological fractures and other complications associated with metastatic bone disease. The implementation of this multidisciplinary strategy, incorporating thoracoscopic tumor resection and spinal interventions, represents a promising avenue for the management of metastatic tumors within the thoracic vertebrae. Further research and clinical evaluation are necessary to fully elucidate the long-term benefits and establish the optimal treatment protocols for this patient population, ultimately enhancing the care and outcomes for individuals afflicted by this challenging condition.

Here, we present a protocol to demonstrate an improved thoracoscopic-assisted surgery for the treatment of metastatic thoracic vertebral tumors.

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic ...

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure.
The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection.
To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day.
Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter&#39;s size and mediastinal positioning.

Here, we present a protocol for retrosternal thyroid goiter resection using a thoracoscopic-assisted transcervical approach.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic ...

Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, the thyroid&#39;s unique physiological functions and intricate surrounding anatomy may result in various surgical complications. Mixed reality (MR), a real-time holographic visualization technology, enables the creation of highly realistic 3D models in the real world and facilitates multiple human-computer interactions. MR can be utilized for both preoperative evaluation and intraoperative navigation. First, semi-automatic 3D reconstruction of the neck from enhanced computed tomography images is performed using 3Dslicer. Next, the 3D model is imported into Unity3D to create a virtual hologram that can be displayed on an MR helmet-mounted display (HMD). During surgery, surgeons can wear the MR HMD to locate lesions and surrounding anatomy through the virtual hologram. In this study, patients requiring radical ET were randomly assigned to either the experimental group or the control group. Surgeons performed MR-assisted radical ET in the experimental group. A comparative analysis of surgical outcomes and the results of scales was conducted.&#160;This study successfully developed the neck 3D model and the virtual hologram. According to the NASA Task Load Index Scale, the experimental group exhibited significantly higher scores in &#39;Own Performance&#39; and lower scores in &#39;Effort&#39; compared to the control group (p = 0.002). Additionally, on the Likert Subjective Evaluation Scale, the mean scores for all questions exceeded 3. Although the incidence of surgical complications was lower in the experimental group than in the control group, the differences in surgical outcomes were not statistically significant.MR is beneficial for enhancing performance and alleviating the burden of surgeons during the perioperative period. Furthermore, MR has demonstrated the potential to enhance the safety of ET. Therefore, it is essential to further investigate the surgical applications of MR.

Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

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