Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)
Table of Contents
Numerous minimally-invasive approaches to thyroidectomy have been developed over the years to minimize the neck surgical scar, many of which are performed using endoscopic or robotic assistance. However, a more diminutive anterior cervical scar still remains a problem for some patients, as well as more extensive dissections for remote access operations. Therefore, natural orifice surgery was adopted at select institutions, in an effort to perform a truly scarless thyroidectomy. Transoral endoscopic thyroidectomy has been the latest approach developed, known as the natural orifice transluminal endoscopic thyroidectomy which is categorized as a natural orifice transluminal endoscopic surgery (NOTES) procedure. There are several ways to perform the natural orifice transluminal endoscopic thyroidectomy. We present the transoral endoscopic thyroidectomy vestibular approach under general anesthesia.
Witzel et al. first reported the successful experimental performance of the endoscopic sublingual transoral thyroidectomy, through a single port using a modified axilloscope in ten porcine models and two human cadavers in 2008.1 In 2009, Benhidjeb et al. introduced a 3-port access vestibular approach; however, significant postoperative complications were noted, including temporary and permanent recurrent laryngeal nerve (RLN) injury, as well as transient mental nerve injury.2 More recently, successful transoral endoscopic thyroidectomy has been performed in many patients, without conversion to the standard open approach.3
The patient is a 45-year-old female who presents with a 2-cm left thyroid nodule. She had some throat complaints in 2014 at which time ultrasound (US) showed small subcentimeter thyroid nodules, and she was reassured. Subsequently, a few months ago she had an MRI of her neck for evaluation for her cervical pain and was noted to have an increase in the size of the left thyroid nodule. Now, a more recent US shows an increase in the thyroid nodule. There are no complaints of hoarseness or difficulty breathing. Occasionally, she has a globus sensation while supine. She has no history of radiation to the neck or face and no previous cervical operations. She is biochemically euthyroid and otherwise healthy, with a weight of 82 kg and a BMI of 29.2 kg/m.2 The physical exam revealed a palpable lesion in the left thyroid gland consistent with the sonographic findings, and flexible laryngoscopy demonstrated normal vocal cord movement.
Ultrasound shows a 6.0 x 1.9 x 1.6-cm right thyroid lobe and a 5.9 x 1.3 x 1.6-cm left thyroid lobe. In the left side there is a 2.0 x 1.0 x 1.2-cm thyroid nodule (previously 1.3 x 0.8 x 0.8 cm). In the right thyroid lobe there are several colloid cysts, 0.4 cm in maximal dimension. Fine-needle aspiration (FNA) reveals a Hurthle cell neoplasm.
Various options including continued surveillance were discussed with the patient, but since the lesion had demonstrated interval growth, and FNA revealed a Hurthle cell neoplasm, she wished to have a left thyroid lobectomy with transoral endoscopic thyroidectomy vestibular approach (TOETVA).
There are innumerable surgical options for the removal of the thyroid or parathyroid glands. The standard of care remains the open surgical approach; however, various minimally invasive techniques have been developed, largely for cosmetic purposes (i.e. the avoidance of a neck scar). In addition to cosmetic benefits, minimally invasive thyroidectomy has been shown to be feasible and effective with similar complication rates to the standard approach.
Anuwong initially reported on 60 patients undergoing TOETVA for various thyroid diseases, including thyroid cyst, nodular goiter, follicular neoplasm, Graves’ disease, and papillary microcarcinoma.3 No conversions were reported, and 3 patients (5%) reported transient hypoparathyroidism. Two (3.3%) reported RLN palsy and no permanent hypoparathyroidism, permanent RLN, or mental nerve injury. The postoperative infection rate was 0% with only one (1.67%) found to have a delayed hematoma. In 2016, Drs. Udelsman and Carling performed and reported the initial experience in the United States; two cases of transoral parathyroidectomy and five cases of TOETVA. The operations were successful, from both a technical and cosmetic perspective.4 The TOETVA can be performed with or without intraoperative neuromonitoring as reported by Wang et al. and Dionigi et al.5, 6 No transient or permanent RLN palsy were reported.
Recently, indications for TOETVA have been amended to now include the following criteria7:
- Thyroid diameter < 10 cm
- Benign tumor
- Follicular neoplasm
- Papillary microcarcinoma
- Graves’ disease
- Substernal goiter (grade 1)
Exclusion criteria include patients unfit for surgery or unable to tolerate anesthesia, and its role in thyroid cancer is still controversial.7 Moreover, transoral endoscopic parathyroidectomy (TOEPVA) for primary hyperparathyroidism and renal hyperparathyroidism has also been reported by Sasanakietkul and Carling et al.8, 9 Despite overall positive outcomes, there are several disadvantages of transoral thyroidectomy. The open approach provides a better anatomical understanding and surgical view than the view obtained with TOETVA (craniocaudal). Additionally, potential injury to mental nerves with this approach requires extensive surgeon experience to avoid this injury.10 Furthermore, because the incisions are made through the oral mucosa, there may be greater chance of infection; therefore, antibiotics are recommended preoperatively, whereas this is usually avoided with the open cervical approach. Lastly, some patients may experience temporary postoperative chin swelling with numbness, as well as a limitation of cervical extension, which usually resolve in 3–6 months. Overall, TOETVA has been shown to be a promising procedure with feasibility and safety in select patients.
In TOETVA, the following instruments are used: 30°, 10-mm endoscope, dilator, L-hook with monopolar coagulator, Maryland dissector, and laparoscopic vessel-sealing device. Preoperative prophylactic antibiotics and preparation with chlorhexidine are recommended. The patient’s airway is secured by a nasotracheal tube. The patient is positioned supine on the operating table, with the neck extended. A 10-mm incision (for placement of camera trocar) is made at the mid-vestibule. Two 5-mm incisions (working ports) are made superolaterally, away from mental nerves bilaterally. Hydrodissection is performed using a Veress needle by injecting a solution of diluted epinephrine (1 mg of epinephrine: 500 ml of normal saline). A tract is created with the dilator, and then the port is advanced, and an endoscope passed through the 10-mm incision. CO2 insufflation is limited to a maximum pressure of 6 mmHg to minimize the occurrence of subcutaneous emphysema. Dissection is carried down in a subplatysmal fashion to create the working space. The strap muscles are identified and divided at midline using an L-hook or vessel-sealing device. A hanging suture is created by passing a suture transcervically through the strap muscles and then back through the skin to elevate the strap muscles. After the thyroid gland is exposed, dissection is carefully undertaken over the isthmus, and then the thyroid is divided at the midline with the vessel-sealing device. The superior thyroid artery and vein are identified and transected close to the thyroid gland to avoid superior laryngeal nerve injury, as well as devascularization of the superior parathyroid glands. Next, the middle thyroid vein is identified and transected to retract the thyroid medially. At this point, the RLN can be identified in the tracheoesophageal groove. In a similar fashion, the inferior thyroid artery and vein are identified and transected, with preservation of the inferior parathyroid glands. The specimen is retrieved through the 10-mm incision using an endobag. After hemostasis is achieved, the strap muscles are reapproximated and the incisions are closed using absorbable sutures. A chin support is recommended for 24 hours to avoid contamination of the incisions with the patient’s saliva, as well as to minimize postoperative swelling. Oral intake can be restarted postoperatively.
The pathology revealed a 2-cm benign Hurthle cell adenoma in the left thyroid lobe, completely excised. The patient did very well postoperatively and was discharged on postoperative day one. She was then seen 10 days after, and the oral incisions were difficult to even identify. She had normal voice function and examination with flexible laryngoscopy.
- 30°, 10-mm endoscope
- L-hook with monopolar coagulator
- Maryland dissector
- Laparoscopic vessel-sealing device
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Witzel K, von Rahden BH, Kaminski C, et al. Transoral access for endoscopic thyroid resection. Surg Endosc. 2008;22(8): 1871-5. 10.1007/s00464-007-9734-6.
- Wilhelm T, Metzig A. Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg. 2011;35(3): 543-51. doi:10.1007/s00268-010-0846-0.
- Anuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: a series of the first 60 human cases. World J Surg. 2016;40(3): 491-7. doi:10.1007/s00268-015-3320-1.
- Udelsman R, Anuwong A, Oprea AD, eta l. Trans-oral vestibular endocrine surgery: a new technique in the United States. Ann Surg. 2016:264 (6): e6-13. doi:10.1097/SLA.0000000000002001.
- Wang Y, Yu X, Wang P, et al. Implementation of intraoperative neuromonitoring for transoral endoscopic thyroid surgery: a preliminary report. J Laparoendosc Adv Surg Tech. 2016;26(12): 965-71. doi:10.1089/lap.2016.0291.
- Russell JO, Clark J, Noureldine SI, et al. Transoral thyroidectomy and parathyroidectomy- a North American series of robotic and endoscopic transoral approaches to the central neck. Oral Oncol. 2017;71: 75-80. doi:10.1016/j.oraloncology.2017.06.001.
- Anuwong A, Sasanakietkul T, Jitpratoom P, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc. 2017;32(1): 456-65. doi:10.1007/s00464-017-5705-8.
- Sasanakietkul T, Carling T. Primary hyperparathyroidism treated by transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). Surg Endosc. 2017;31(11): 4832-3. doi:10.1007/s00464-017-5533-x.
- Sasanakietkul T, Jitpratoom P, Anuwong A. Transoral endoscopic parathyroidectomy vestibular approach: a novel scarless parathyroid surgery. Surg Endosc. 2016; 31(9): 3755-63. doi:10.1007/s00464-016-5397-5.
- Jitpratoom P, Ketwong K, Sasanakietkul T, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves’ disease: a comparison of surgical results with open thyroidectomy. Gland Surgery. 2016;5(6): 546-52. doi:10.21037/gs.2016.11.04.
Cite this article
Gibson C, Carling T. Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA). J Med Insight. 2021;2021(243). doi:10.24296/jomi/243.
Table of Contents
- Patient positioning
- Surgical approach and marking
- Secure airway with nasotracheal tube
- Make a 10-mm incision at the mid-vestibule (for camera), as well as two 5-mm incisions (working ports) superolaterally, away from mental nerves bilaterally
- Perform Veress needle hydrodissection
- Pass endoscope through the 10 mm port and insufflate to maximum of 6 mmHg CO2
- Develop subplatysmal working space
- Identify and divide strap muscles at the median raphe
- Elevate and secure the ipsilateral strap muscles with a hanging stitch
- Divide thyroid at the midline with a vessel sealing device
- Identify and transect the superior thyroid vessels close to the thyroid capsule
- Identify and transect the middle thyroid vein for medial mobilization of the thyroid lobe
- Identify and preserve the recurrent laryngeal nerve within the tracheoesophageal groove
- Identify and transect the inferior thyroid vessels close to the thyroid capsule
- Retrieve the specimen through the 10-mm incision using an endobag
- Close strap muscles
- Close dermis with 5-0 Prolene
- Place a chin support (for 24 hours post-op)
So, I'm Tobias Carling, and you're about to see a case of trans-oral endoscopic thyroidectomy vestibular approach, performing a left thyroid lobectomy.
This is a patient who is 45 years old, who initially was diagnosed with a thyroid nodule back in 2014. At that point it was relatively small and was never biopsied, but she had an MRI for other reasons, and at that point it was noted that the nodule had grown, and now measures 2.0 x 1.3 cm. Her overall dimension of the left thyroid lobe is 5.3 x 1.3 x 1.6 cm. And fine needle biopsy showed a Hurthle cell neoplasm. So, given that the nodule has shown interval growth, as well as has- features consistent with Hurthle cell neoplasia, uh, the patient is scheduled for a diagnostic left thyroid lobectomy.
For, uh, cosmetic purposes, the patient opted to have a trans-oral approach, endoscopically, as opposed to have an open cervical incision.
So, the steps of the operation, which you will see is, first, the positioning of the patient, and then the nasotracheal intubation. We then do a cleansing of her mouth, with chlorhexidine prep, and then we create the 3 port incisions. A 10-mm port site in the, in the middle of the vestibule, and 5-mm ports laterally. Then you dissect and create the subplatysmal flaps. This is done with a combination of hydrodissection, as well as a blunt dissector. After that the ports are placed, and the 10-mm camera, 30-degree angle, is inserted through the 10-mm port.
Subplatysmal flaps are then created. We identify the strap muscle, divide the strap muscle in the midline, and then mobilize the left thyroid lobe. Identify the trachea and divide the isthmus. Then we place a retractor suture in the- to the strap muscle. Identify and individually dissect out all the superior pole vessels, as will as the middle thyroid vein.
As you will see, I will identify the 2 parathyroid glands, the recurrent laryngeal nerve. And very important to do the nerve dissection, as always, very carefully, uh, to avoid any thermal injury or traction to the recurrent laryngeal nerve. Then, the thyroid lobe is resected through the Endo Catch device, and the strap muscle is closed.
Uh, this patient was a good candidate for a trans-oral approach, since the nodule was not significantly large, and her body habitus was favorable. Her BMI is 29, her weight is 86 kilos, and she's 165 cm tall.
In terms of the ports that we use, we use a Karl Storz, uh, 10-11 port. I particularly like this port because it's relatively narrow, so the ports don't bump into each other. And then we'll use two 5 ports, again, where the hub is relatively narrow, so, again, the ports don't bump into each other. That's what we're using for ports.
Then, in terms of the camera, we made a slight modification. So, we use a standard 10-mm camera with a 30-degree angle. On top of the camera, we'll place what's called a FloShield. And the advantage with the FloShield is that it emits a little bit of air in front of the camera, so it significantly reduces the time you need to clean the camera. So that's called the FloShield device.
In terms of the dissector, we will use a similar dissector as Dr. Anuwong in Bangkok. And this is just a regular dissector. The key when you make those is to make them not too sharp, but sharp enough that you can create the subplatysmal space.
In terms of energy devices, I essentially tried all of them, um, but I use for the most part, 2 of them. I use the LigaSure Maryland for larger vessels, as well as dividing the isthmus, as you will see. And then for finer dissection right around the recurrent laryngeal nerve, I use the bipolar Maryland. I find that that one works quite well right around the recurrent laryngeal nerve. Otherwise, the set up is relatively standard. We do use some hydrodissection, so that's saline with 1:1000 of epinephrine.
So we're putting this Ioban on, this is to protect her, as well as make sure there's no leakage. Okay. And- which is different from a total thyroidectomy. We actually do use antibiotics for this procedure. We used preoperative Ancef and, and Flagyl that she just got. Before she went into the operating room, she did a swish and swallow with chlorhexidine, which, we'll then rinse out the mouth with chlorhexidine as well, so…
When we prep and drape, we do that in such a manner, if we ever were to have to convert to an open procedure, we can do that without having to reprep and drape, obviously.
All right so the first part of the procedure, we start with doing another chlorhexidine rinse, making sure we get all areas. It's very important in the preoperative workup of the patient that you ask about previous dental hygiene, and obviously previous multiple dental abscesses would be a contraindication to the operation.
So, in terms of the anatomy, here's the lower chin, this is the lower lip. The sternal notch right here, clavicle on each side, and then the thyroid cartilage right here. So, the oral vestibule has a little frenulum right here. So, these are the lower teeth, so we're going to make the 10-mm incision right here. And then the mental nerve comes out right here on each side. So we always take care to make the 5-mm ports relatively high, right on the inside of the lip, as well as relatively lateral, to avoid injury to the mental nerve- down here.
All right, so everybody ready? So we're going to get started. So again, the 10-mm port is going to go right here, and then I'm going to make the 5-mm ports very lateral. So, we're starting.
And you have to be careful to make sure you don't go either too deep or too super, superficial because you can… get a, a burn. So I'm feeling for the tip of the Bovie. At the very tip there. Then I'll take a Kelly next.
Okay, so then, just using careful dissection, I make sure I get on top of the chin. Again, this is all done by feel. And the tissue's really tough here, so I need to make sure I'm right, right on top of the chin here. And then, to make it big enough.
Okay. And I'll take some hydrodissection now. So now, we're going to use some hydrodissection. So, I use a regular Veress needle, and then, again, saline with a little bit of epinephrine. And again, the angles really matter. So, I have a relatively acute angle and then, just as I go in the subplatysmal flap, I try to just go a few millimeters at a time. Make sure I'm in - stay in the correct plane. And then- going laterally.
And then, towards the left side. I'll take a little bit more. Okay. And then I'm going to use the dissector. Again, it's a little tight here, but then, holding my fingers against the chin so I have full control as I'm placing the dissector. And I'm aiming towards the sternal notch, making sure I lift up the skin as I dissect, to make sure I don't go too deep. And at all times, I can feel for the tip of the dissector. And I want to get all the way down to the sternal notch, as you can see here. And then, going laterally, same thing: feel for the tip. Okay, so that's nice and open. Just open that up a little bit more, okay.
And now I'm going to place the incisions for the 5 port, so - So, here's the canine, so, this is the central 10-mm port. So I'm going to place the 5-mm lateral and high up. So, right here. And then right here. Okay.
So I'll take the 10 port now. So, this is already hooked up to the insufflation. So we're going to use insufflation to 6-mmHg.
So again, we’re about down to the level of the thyroid cartilage. Just fix that light there, so it's perfect. Fix that light. Okay.
So, using a little bit more hydrodissection for the 5 ports. And here, the level here is between the port and the skin is very, very thin, so it's very important to just go a few millimeters and inject to make sure you don't penetrate the skin with the Veress needle. Or the port, for that matter. So the key with the 5-mm ports are that they pretty much parallel to the 10-mm port.
And this port.
Okay, so I'll take the 5 port now.
Again, being very careful to stay right lateral. So you can suck out the mouth, a little bit, Neeta.
Again, feeling for the tip. Making sure we're in the right plane. Okay, there we go, so that's perfect setup. And then, I can just use the dissector again, making sure we're sort of in the correct plane, here, which we are. I’m just opening that up a little bit.
So we're going to put a 2-0 silk stay suture just in front of the very tip of the 10. So we just put that into the skin. Cut that. All right, so, needle back. And then- and then the assistant will, at all times, pull the skin straight up in the air, like so, just to elevate it, to make sure we have a good working space.
All right, we'll take the camera, so get the camera now. Okay, so now let's see what we've got. Okay, that's good. You're going to crank that up. All right, so, is the insufflation on? Okay. Gas on, please.
So, you just start by opening up this space here. Just getting those bands in front of the camera. I'll take a Maryland coming in. Just breaking those bands down. Okay.
Oh, don't move around too much.
So now we’re starting to create the subplatysmal flap here. All right, let me come out and clean, here, Randal. Do you want to clean your port? Uh, the instrument.
So, we've got the strap muscle down here, platysma is up here, so, just starting to create the space here. Again, key here is to stay in the right plane on top of the anterior jugular veins, which is going to be down here. Come in a little bit, now. And again, I'm feeling, just to make sure I orient myself, so I can feel the tip on that hook cautery. So, come back here now. And I'm sort of pushing up the, the natural- or the error most people doing this dissection is that they stay, they go too deep, where they start getting into the strap muscle, which causes a little bit of bleeding, so, you actually want to stay up here in the ceiling, as opposed to go down in this area, at this- at this stage of the operation. So, I use my other Maryland to just push down on the strap muscle.
So here is the strap muscles, and then the midline is eventually going to be down here. As you can see, we just need to do a little bit more dissection here, laterally. To make sure we have enough space. So try not to get the camera dirty again. It should be good. Yep, you're good, don't move around too much, just stay where you are, you're fine. So again, here's the strap muscle, so I want to stay above that.
And the movement that you can see is due to the sort of continuous insufflation, where we keep the ports open, so we're continuously ventilating.
Okay. I don't want to see that fat in front of me. So, come back a little bit, you're a little bit too close, yeah.
Okay, so we go all the way out to the sternocleidomastoid muscle here. Stay up here, I want to see that. What's the Bovie at? 20. Yeah, it's- so, bring it up to 30. Yeah. For now.
All right, we're pretty much where we should be deep down there, we just need to do here, a little bit more laterally. Uh, too close, too close. Okay. All right, keep that straight there. All, right, so, that's good, so… Midline is right there, so we're going to start opening up the midline- there’s some dirt there, I don't want to see that. Right up here.
All right, so here is the midline. So, I'm going to switch to LigaSure now. Help me in and out here, will you? So, you grab the tip, and then- you pass that in. There you go, beautiful. A little bit, little bit off here, okay.
So, her trachea is slightly deviated. I'll take a suction. Okay so, down, so, come in here. So, down here, we're going to have- the trachea. Okay, I'll take a LigaSure. Just come in a little bit.
Okay, and then come back here a little bit. And let me switch back even more. Let me switch to hook cautery. Yep, right there. Now, opening the midline, so just follow me as I go.
Okay, come in a little bit. Oh, this little muscle is stuck here, so I just need to get- so that's the midline there. Just need to get in there. I don't want to see that stuff in front of me. All right, let me have the LigaSure again.
And then come a little closer. So just come- come down here. Muscle is a little stuck on her... All right, I'll take the hook cautery. Okay. Just show me, here. Okay. It's glaring a little bit too much there. Okay. Come underneath, here. Come back.
All right, so now we start seeing the thyroid gland here, the isthmus right here. Her muscle is a bit more fused than typical. As long as we stay here in the midline, we're good. Okay.
All right, so, you come back here, now. All right, let me have the LigaSure, now. Okay, follow me in.
All right, so before we get there, let's just go find the trachea below. Come back, come back. So, I'll go below the thyroid here, to identify the trachea. Follow me. Making sure we're in the midline, here. Okay, so we've got the trachea- so, we're underneath the isthmus there. And now come back.
Okay, so the next- come back. The next step of the operation is to divide the isthmus. So, we have a little bit of pyramidal lobe sitting right here, so I'll have the hook cautery now. So, you're going to make sure we resect the isthmus and the pyramidal lobe with the specimen here. I’m just opening up the strap a little bit more here. And then following the pyramidal lobe up. And then…
And then get down underneath onto the trachea here. So here is the trachea. Just going to open up the pyramidal lobe a little bit more, make sure we get the whole thing. And then- so now you can bring the cautery down to 20. So now we have the trachea nicely exposed here. And I don't give up with my other, left hand, but rather just continue to hold the isthmus up in the air.
And now, we're going to switch to our LigaSure and divide the isthmus with the LigaSure. So the nodule is going to be right here, so I'm going to divide the isthmus, making sure I get the whole lesion. So, I stay a little bit towards the right side. And since I opened up the trachea, already below, I have a straight shot, just following the trachea.
This patient has some element of thyroiditis, so, the thyroid is a little bit more stuck than usual to the trachea. Follow me in there, so I can see now. Yeah, yeah. Okay, I’ll take electrocautery.
So gen- just gently peel- peel all the thyroid tissue off- off the trachea here. Just make sure we get the whole thing, here. Okay, now let me switch to… Just want to make sure I get the all of that isthmus. Again, staying right on the trachea. I want to see that white glistening trachea, beautifully like this. Okay, I'll take the hook cautery, now.
So, come and show me right here. All right. All right, so, here I'm dissecting now the aspect on the trachea. So, just come a little closer. So, again, this patient has some thyroiditis, it's a little bit stickier than usual. So, come right here. But I want to stay right on the trachea. As we say, trachea's your friend until you're in it.
So, I don't move around too much with my left hand, I just sort of gently hold it up, but you want to try to avoid jumping around too much. I have a good exposure here seeing the trachea. So, just carve the trachea. It’s a little stuck right here. Then come back here. Okay, come a little bit further south. All right, so I'm just going to advance that a little bit further south. All right, come here now. Yep, you've got to get past there. All right, take a LigaSure now, so that's some inferior pole vessels, I can take there with a LigaSure. Again, staying right on the trachea, here. All right, and then come around the corner up here.
Okay, I'll take a LigaSure, I mean hook cautery. All right, so, come and show me here. Okay, come back now. All right, so that's pretty good. So, come back now, I want to see that- pyramidal lobe is still a little bit adherent there, so we're going to- just open that up a little bit more. Okay, come in a little bit. That's very good. Alright, so…
I might just reflect that over. Have another- take the LigaSure, now. So now we're going to start peeling some of that strap muscle over a little bit, so still in muscle here. It's a little stuck again. Part of it is from the thyroiditis. So, I'm going to now reflect that medially. And now, we sort of see that nodule right there. So, we still have muscle stuck here. So just... Yep, come back a little- Oh, whoa whoa, no, don't move around too much. You're not going to get a good angle until I'm past that anyway, so... All right, so take a hook cautery now.
So, as you can see here, I still have muscle adherent here, so I'm just going to score, score this, making sure I don't get into the thyroid, but I can peel, peel that strap muscle off. I still have a little bit of muscle stuck here onto the cricothyroid, so, that friendly space of the cricothyroid, space between the thyroid and the cricothyroid muscle will be right there, so, again, I'm just going to follow that and then just gently peel that off. This muscle is a little stuck, here, onto the nodule but not, certainly not invaded. But this is more of a inflammatory response from the thyroiditis. Come back here.
Sometimes, to get good exposure to the upper pole, you need to just divide a little bit of strap muscle, right at this plane here. All right, so let me take a look there. And then come back here, I can do a little bit more work here. It'll give me a little bit more mobilization. Okay.
All right, just clean that for a second. and I'll take a LigaSure in the meantime. Yeah, I'll switch. All right, so… And I just very patiently go, step-by-step, in a very safe manner, here. I'm just going to grab that little bit deeper, and crank crank that thyroid over.
Again, pretty significant amount of thyroiditis. You see how stuck that- strap muscle is onto the thyroid, so you just have to be patient here. Fortunately, that's my middle name. I’m just gently reflecting that, like so. Okay. That's good, so… Again, we'll take the hook cautery back. Do a little bit more dissection here, under the trachea.
Starting to get closer to the superior pole vessel. Eventually the nerve is going to be down in here, but we still have some ways to go. Okay, I'll take the LigaSure. Okay. All right, I’ll take the hook. So come back down here. Again, we're just going to open this up a little bit more. Reflect that strap. There's a little bit of cricothyroid muscle still stuck up here. You need to give me some other angle there- yeah. All right, LigaSure.
Okay, so now, the thyroid is almost ready to deliver, so come here now. Follow me in here. All right, come back. Okay. That's good. All right, so, take a hook cautery. All right, so where- where's that oozing from- okay. Take a suction for a second. All right, so we're going to be ready for a quick switch, okay. All right.
Just a little bleeding from the capsule, here. All right, so, that's good. So we still, as you can see- a fair amount of stickiness right here, so we… And we're almost ready to put in that lateral... Yeah. Now we start seeing the upper parathyroid there. Okay, LigaSure.
So, come in now. Show me that para there. It's likely to be the upper parathyroid. Okay. So, let's see, we're going to just move this one down a little bit more. Okay, and then… Come back here, all right. So now, we have those- so come in now.
So, the nerve is going to be down here. We just saw the parathyroid. So, as long as I stay up here, and just, in an isolated fashion, take the superior pole vessels. And then just gently peel that down. Gently peel that down, I'm just going to…
I'm going to take that little vessel, before it bleeds. And just peel that gently down. Okay. So we can do a little bit more here. So just- just take those vessels as well, okay. That's nice. And then there's one little vessel right here. Okay, so now, come in. Okay, I think you're going to actually start seeing the nerve right down there. Okay, we're going to put in the stitch right now. You see what I'm talking about? Just before, actually- Just keep that, keep that view, come back. Okay. All right, give me the suction now. Can you show me, I want to see right- right down here. I think we still have a little bit of ways to go there. All right. All right, I'll take the Liggy.
All right, so let's get that lateral stitch, now. So now, we're going to put in the lateral retractor stitch. So, I want to see right up here. All right, I don't know if you guys can see here, so if you come in. So this suture's just going to- So, I'm looking on the inside there, so, I want it sort of midway on the- over the strap muscle, right there. Okay. Okay, you need- you to need to show me one way or another, so, you know, a little move- Yeah, there we go. All right, take a needle driver. All right, so we want to place this suture around midway here, and you want to get this relatively deep down here because it just gives you more leverage. Come back now, come back, I can't see anything. Can we have a step stool for her, or something? It seems like... Would that be easier?
Okay, and then we come out through the skin. Grab it in the skin, there. All right, can I have some light on, or something? All right, you don't have it? No, it's not out. Oh, Okay. Here's a step stool behind you. Thank you. You've got to push through that skin. Go ahead. Okay. It slides on the skin, so you sort of have to grab it real quick, and, yeah, there we go. All right, you got it? All right, so now, cut that. Clamp it.
All right, you come out and clean. And then you're going to- So this one- so this suture, you pull straight lateral, so those will go about 70 degrees against each other. This goes straight up in the ceiling.
All right. That's good, so let me have the hook cautery. All right, so come here now. I want to stay on the trachea, follow the trachea down, yeah. All right, so that's good. So, we're going to do a little bit more work on the trachea, here.
All right, so follow that south. I want to follow the trachea. Okay, that's good. Come back now, now take the- we’re going to take the- LigaSure next, so just come in now. Here's the middle thyroid vein. So we're going to ligate that next. All right. LigaSure. Yep, thank you. Come in here a little bit. Okay.
And here is the lower parathyroid. See that it sits in that fat- so these are inferior pole vessels. So, I know those are safe because they're medial to the nerve. Medial to the parathyroid, which is medial to the nerve. So, it's very safe, so I can take those already now. Okay, and then come back. We've got the two parathyroids peeled down, so now we can elevate this a little bit more.
And now, I'll take the hook cautery. Come back here.
There's another little vessel that we're going to ligate too- while we can peel down some of this muscle more. Uh, I don't- I want to see right here. Yep. And then, now we can take that vessel, so take a LigaSure, now. Okay, and then show me this vessel.
Okay, let's come back now. All right, I'll take the hook cautery back. Oh, come- come back. All right, I'm going to try to get that from above.
Come back. Okay, come in. Let's see that parathyroid there, okay. So, I'll have the LigaSure. Then I'm going to switch to the Karl Storz. Yeah, the bipolar, in a second. So, you can see the upper parathyroid. So, I'm just very gently going to start peeling that off. So now, I'm getting close to nerve country. So now, I'm going to switch to the bipolar instead of LigaSure. Let's have the bipolar pedal up, and all that stuff.
So, we gently, gently peel down the parathyroid. It's a little bit pulled up here, so- show it better to me. Okay. Just zoom in, show the para. It looks beautifully, right? Okay. Okay. Okay, we got the bipolar working, now? Yep, bipolar is ready.
Come in here, now. I want to see that para there. So, gently going to peel down the parathyroid. Is this even working? Just, just, just stay there where you are. I want to see right here.
Come in here. So, go in there- I think I see the nerve there, right, so- See it right there? Right. Okay, come back a little bit. Right here, follow me now, follow me now. So, you're going to change the angle, look from the side, because the nerve is going to be medial- Yeah, exactly, beautiful. So, stay in that, stay in that spot, now. Okay, come back a little bit, now.
So, let's just come in here. Hmm, I think that's too close. Well, that's the- This is the inferior thyroid artery that's pulsating. Go in and show that, then come back. Go in and show that. That's the inferior thyroid artery. And then come back now.
There's the upper para, so the nerve is going to be medial to that. It might actually be all the way up here. Right, so I need to see this. Okay. So, that's safe.
I’ll take a suction, suction. Okay. Let me have the- I'll do a quick switch to LigaSure.
Okay, I’ll take a suction. Come back a little bit. I need, I have like a millimeter to get underneath my other retractors, so you need- so then, come in, so you've got to sort of follow me there. All right, so you come back. Let me get in there. All right. Okay, squirt.
So, what happened there, I bipolared that vessel but then, it still- still continued to ooze. Okay, all right, so let's go back and work on our nerves. Stay there. So, I think the nerve is going to be right here, so… Let me just have a coiled fine Maryland, now.
Okay, so… Beautiful, right?
So, I want to see where it's heading. So it's clearly heading down there, and you see, it's right there. That's where we saw it before, and it's actually- come in now. It actually has a nice little bifurcation there, too, so it's got a lateral esophageal branch. So, that's nice, okay. I'll take the bipolar.
So again, because of the thyroiditis, everything is a little sticky in this case, including the nerve. But, as you can see, the nerve is starting to fall away nicely there. So, I'm just going to stay lateral here.
All right, let me have that LigaSure now. All right, suction, and then switch-a-roo. I don't love that, so- all right, let's do something else. We'll come back to that little bleeder. And now, I want to start taking some of this. Yeah. I don't- yeah, I don't love it. All right, suction. All right, I think we can go ahead and ligate this now.
All right, so just show me where the nerve is heading. So as long as we stay up there, see? It's just I'm back bleeding from the thyroid, so… Nerve looks good, but that's another middle thyroid vein.
All right, show me the nerve. Okay, take a suction. And then bipolar will be next. Just pushing the nerve gently down here. The nerve is heading down there, so let me have the Liggy now, coming up. Come back, show me- come back in- well, come back- yeah, so that- okay. All right, so that's safe, right, with those nerves heading down there. And we already peeled the paras down. So, the key for the camera operator here is to always keep the nerve in view.
All right, take a suction.
CHAPTER 11All right, so that's a little bleeder, so let's fix that now. That was what was bleeding before, so let's do switch-a-roo.
All right, take a suction irrigation. Now I'll take that. Okay, so now, let's see… Now we're going to start taking down the ligament of Berry here, so… Okay, so, let me have the bipolar now. All right, so I want to see the nerve here. Uh, yeah, I want to see, can we see the nerve better? No? No, okay.
Let me just have a pair of scissors, I'm just going to… Fine sciss- Yeah. Like, really good ones that work. In the meantime, I'll take the hook cautery. These are going to work, right?
Okay. All right, just clean that. Yes, so I'm going to use my left hand now, so whatever is easier. So key at this level of the operation is to, obviously, get all the tissue, but not put too much tension onto the nerve there, as we come across the ligament of Berry. Again, that's just a little back bleeding, so I want to see that corner right there. Okay. Okay, I’ll take the bipolar now.
Just show me where the nerve- nerve is all the way there, okay. What is this crud here? Oh, that's just a pyramidal, okay. Follow me in there. Okay, and now switch to LigaSure. Actually, I'll have the suction first.
All right, we are almost going to be done now, because now, once we have the nerve down here, life will be easier. Okay. I’ll take a suction.
Okay, and then, we'll take… Yep, I'll have a hook cautery. All right. Okay, Ligasure. Okay, so, I need to see this angle here, and where the nerve is going, right? That's beautiful, right?
All right, show me the nerve. This is the recurrent laryngeal nerve down there, that's a lower para. So, I make sure I stay up here, close to the thyroid capsule. And that's… And that's the left thyroid lobe out. Yeah.
Okey dokey. So, the key is the orientation here. So, we tried multiple different bags as well, and, to be honest, none of them are perfect, but this is the- the best we have, but it's still a little bit too, a little bit too stiff. It's very strong, so it's not going to break, but it's a little bit too stiff, we found this in the urological applications.
So, we're putting the whole… All right, let me have the shears, now. Okay, I'll have a Kelly- just let those hang. I'll take a Kelly.
As I said, this bag works okay, but it's still a little bit stiff, so we could- come up with some better bag that's a little bit less stiff. All right, we got the sponge stick coming up. I’ll take another Kelly. So, take this in your hand. Take that.
You can't sort of force this because then you risk breaking the bag, so you just have to be patient.
There we go. Okay, so that was the specimen. So, the specimen is going to be a left thyroid lobe- for permanent pathology. All right, so we're going to put the ports back.
Okay. All right, we'll take a port cleaner. All right, now the lights can go out, guys. I'll take the Maryland and a squirt.
Okay, so orient, this is the trachea. This is the lower parathyroid we peeled off previously. You can come in and show that. Fix that focus. So, this is the lower parathyroid gland. Come back. This is the recurrent laryngeal nerve clearly dissected out here. And all the way, as it enters, at the ligament of Berry. So, here's the ligament the Berry, and the upper parathyroid's already retracted underneath, here. But, as you could see earlier, we did peel that down and preserve that.
So now, next step, we're going to close the strap muscle. So, let's cut this out, so heavy scissors. So, this is the V-Loc, the 3-0 Vicryl V-Loc suture.
So this is a V-Loc suture, that we use to close- the- strap muscle. So again, the strap muscle is not a strength layer. This is just to re-approximate…
Care is taken to avoid injuring the interior jugular vein, obviously. Okay. Okay. All right, let me have a scissors. All right, give us a Valsalva then. Can you relax a little bit on your hand. Give us a Valsalva. Valsalva. Valsalva-ing to 30. All right, just look over here. Okay, and look over here. There's something… Is it up there? Yeah, okay, LigaSure. It probably would have just stopped with some- you know, yeah, with some pressure, but we might as well fix it. Okay, good- all lights on, gas off, camera off.
We'll close this now. I'm going to close this in 2 layers. So, the deeper, muscular layer for the 10 port. Yep, so we use a 4-0 Chromic- for the muscle layer, which is a running. Okay, so let's just re-approximate the- the muscle. Yeah, so now we're doing the mucosal layer again- running here.
And these suture's usually just absorb and fall out by themselves, but if they- if it still bothers the patient a week after, we can just cut them out in the- in the clinic. Okay, now.
All right, so that- so that looks beautiful, and it's sort of amazing how quickly they'll remove, so when you see them back about a- a week later, you can hardly see- see those incisions. All right, so we're all done, we're going to break down.
In the postoperative setting, the care of the patient is very similar as open surgery. The patient should be counseled that they might have some numbness around the chin, and that can stay there for quite some time. Uh, we give them instructions how to do a rinse, and cleaning of their teeth, which they can do in the immediate postoperative period. We let the patient have a soft diet already, the same day after the operation, and the patients will go home following the operation.
If you wish to perform this operation, I would recommend spending some time with surgeons that have significant experience. There's also training courses, and the American Association of Endocrine Surgeons can help you identify surgeons that have significant experience with this operation. And most surgeons are happy to proctor other surgeons in this technique. It's important to have significant experience with open surgery, before you consider doing the trans-oral approach.