Trans-oral Vestibular Endocrine Surgery

To the Editor: The standard approach to thyroid and parathyroid surgery is by a transverse cervical Kocher incision. Although safe and the standard of care in Western countries, in Asia it is considered cosmetically disfiguring. In response, surgeons in Korea, China, Japan, and Thailand developed trans-axillary,1 trans-areolar (breast),2 and retro-auricular approaches to resect thyroid and parathyroid lesions.3 Each is associated with unique morbidities that have limited widespread adoption. Natural orifice transluminal endoscopic surgery was described employing a trans-oral approach for thyroid surgery in porcine models4 and cadaver dissections.5 Recently, Anuwong6 demonstrated outstanding results in 60 patients undergoing trans-oral vestibular thyroidectomy in Thailand. We traveled to Bangkok to learn the technique, obtained procedural credentialing, developed FDA-compliant instruments and Dr Anuwong joined us in the United States. We report the first seven consecutive cases performed outside of Asia. This study was performed after credentialing committee review and approval of a limited series. All cases were performed at Yale-New Haven Hospital between March 29, 2016 and April 1, 2016 by 2 experienced endocrine surgeons. Written consent and IRB approval were obtained to perform a retrospective chart review of a prospective data base. Adult patients who required thyroid or parathyroid surgery were candidates, 7 were selected, 5 had thyroid, and 2 had parathyroid surgery. The patient characteristics, cases, and results are listed in Table 1.TABLE 1: Patient CharacteristicsAll cases were performed by a dedicated nursing, anesthesia, and surgical team. The patient's mouth was cleansed with chlorhexidine and intravenous antibiotics were administered. General anesthesia was induced with midazolam, fentanyl, propofol and rocuronium. Intubation was achieved with the aid of McGill forceps, using a small Ring–Adair–Elwin nasal endotracheal tube. Anesthesia was maintained with propofol, rocuronium, hydromorphone, and sevoflurane in an air–oxygen mixture. Postoperative nausea and vomiting were minimized utilizing ondansentron, dexamethasone, metoclopramide, and dimenhydrinate. After induction, the neck was hyperextended. Three incisions were made in the lower lip vestibule and the mental nerves were protected. Three ports: a central 10 to 12 mm, and 2 lateral 5 mm ports were employed (Fig. 1A). A 30-degree 10 mm camera in the central port displayed the procedure. Hydro-dissection was employed with a Veress needle through which 40 cc of NaCL containing epinephrine (1 mg in 500 cc NaCL) was injected to create a subplatysmal space, which was dilated with an Anuwong dissector and maintained with insufflation of CO2 at 6 mm Hg. The operative setup is shown in Figure 1B. The medium raphe was mobilized exposing the thyroid and a hanging trap door suture was brought through the skin to distract the strap muscles. For thyroidectomy the isthmus was transected, the thyroid lobe was mobilized, the blood vessels were isolated, coagulated, and transected. The recurrent laryngeal nerves and parathyroid glands were seen and protected. For parathyroid surgery, the thyroid lobe was mobilized and the enlarged parathyroid gland localized by preoperative imaging was resected. An intraoperative rapid parathyroid hormone (PTH) assay confirmed the adequacy of resection.7FIGURE 1: Operative setup. A, Incision sites in lower lip vestibule; B, Operative setup with ports inserted in lower lip vestibular. Light is trans-illuminated on the patient's neck. The operative image is viewed under magnification on a video monitor.A retrieval pouch was used to extract the specimen. This technique accommodates a normal or moderately enlarged thyroid lobe or parathyroid adenoma. The strap muscles were reapproximated and the vestibular incisions were closed. Drains were not employed. A compression dressing was applied to the anterior neck and the patients were admitted. Five patients underwent successful thyroidectomy (Table 1). The indications included a toxic thyroid adenoma, multinodular goiters, an indeterminate thyroid nodule, and a papillary thyroid microcarcinoma. The operative procedures were thyroid lobectomies (n = 3), a total thyroidectomy for multinodular goiter, and a total thyroidectomy with a limited central neck dissection for a micropapillary carcinoma. The two patients who underwent parathyroidectomy had curative results as evidenced by normalization of both intraoperative plasma PTH and postoperative serum PTH and calcium levels. The incision to closure times ranged from 144 to 296 minutes (mean 222 min). Parathyroidectomies and thyroid lobectomies were of shorter duration compared with total thyroidectomy with or without central neck dissection. Blood loss was minimal and all patients were extubated in the operating room. All underwent pre- and postoperative laryngoscopy. There were no cases of recurrent laryngeal nerve injury, mental nerve injury, hypoparathyroidism, bleeding, infection, hematoma, seroma, tracheal injury, subcutaneous emphysema, mediastinal emphysema, epistaxis or conversion to open surgery. The mean length stay was 1.1 days. For patients with benign disease including primary hyperparathyroidism, toxic thyroid adenoma, or multinodular goiter the pathological analyses were straightforward. In the case of potential malignancy with a Hürthle cell neoplasm there was no difficulty evaluating the entire tumor capsule and the histologic diagnosis was a Hürthle cell adenoma. The patient with a micropapillary carcinoma also had a clear pathologic evaluation demonstrating an intact thyroid lobe and associated central lymph nodes (Fig. 2A). Histology of the 7 mm micropapillary carcinoma is shown in Figure 2B. She also had a left thyroid lobe 2 mm micropapillary carcinoma and 4 lymph nodes with microscopic metastatic papillary cancer. In summary, we did not encounter any pathologic compromise due to the trans-vestibular technique.FIGURE 2: Pathologic findings. A, Operative photograph of the right thyroid lobe and limited central neck dissection specimen retrieved via the vestibular approach in patient 3; B, Low magnification (2×) Hematoxylin and Eosin stain demonstrating a 7 mm micro-papillary carcinoma in the right thyroid lobe.Postoperative images at 4 and 30 days of a representative patient are shown in Figure 3. The lip incisions healed with minimal scarring and open cervical incisions were avoided. All patients indicated that they preferred visible scar avoidance. A video, https://links.lww.com/SLA/B110 recording of patient 6 obtained at 30 days postoperatively is available online.FIGURE 3: Postoperative images of patient number 6 on postoperative days 4 and 30.We have demonstrated the applicability and safety of trans-oral vestibular natural orifice transluminal endoscopic surgery in 7 consecutive patients in the United States for thyroid and parathyroid surgery. We have not utilized this technique for larger thyroid cancers because of the potential of compromising either the operative procedure or pathologic analysis. Because mobilization and resection are performed under magnification excellent image quality enhances protection of critical structures. Trans-oral vestibular endocrine surgery should ideally have a morbidity profile equivalent or superior to the conventional approach. We were concerned about unique complications including infection, mental nerve injury, and subcutaneous or mediastinal emphysema. These were avoided due to meticulous technique, nerve protection, and utilization of a low CO2 insufflation pressure. In addition, we did not encounter complications associated with conventional trans-cervical endocrine surgery as there were no cases of recurrent laryngeal nerve injury or hypoparathyroidism. We did not employ drains and did not encounter postoperative seromas or hematomas. Although operative times were longer we anticipate that these will rapidly decrease. No operative procedure will be free of complications. Recurrent and mental neve injuries as well as postoperative hematomas and seromas have been noted by other investigators. Mental nerve injuries can be transient or permanent, result in decreased sensation of the lower lip and an inability to sense hot liquids. Although this complication was observed during the early phase of operative development, it appears to have been eliminated by moving the lateral 5 mm vestibular incision sites anteriorly as demonstrated in Figure 1A. There is a theoretic concern about removing relatively large specimens via the 1.2 cm central port. Although a normal sized thyroid lobe can easily be extracted, larger tumors pose challenges. The specimen is inserted into a nylon rib-stock pouch and when necessary the lateral surface of the thyroid lobe can be cut in the pouch to increase pliability for extraction. We do not, however, violate the capsule of indeterminate thyroid nodules or employ this technique for large thyroid cancers. There are substantive differences between our patients compared with their Asian counterparts and our perioperative management also differs. Thai patients are generally petite females with diminutive chins. Our patients are larger. Our mean length of stay is 1 day, whereas in Asia it is 3 to 4 days. Finally, we do not routinely employ drains even for total thyroidectomy. The trans-oral vestibular approach requires specialized training, but has the potential for widespread applicability. We estimate that this technique will be appropriate for 10% to 20% of thyroid and parathyroid cases. Approximately 130 thousand cases were performed in the United States for thyroid nodular disease in 2011.8 This underestimates the cases because it excludes surgery for Graves’ disease or hyperparathyroidism. Nonetheless, a conservative estimate suggests that the trans-oral vestibular approach could be employed in thousands of cervical endocrine surgery patients per year in the United States. The trans-oral vestibular approach has the potential to transform thyroid and parathyroid surgery in a pattern reminiscent of laparoscopic cholecystectomy. There are many similarities compared with the early days of laparoscopic cholecystectomy when significant challenges were encountered, embraced, and reconciled. Several institutions have or will soon adopt this approach. There will be a demand to train a cadre of surgeons and we anticipate professional society support for this initiative. Avoidance of a cervical incision is important to many individuals, not limited to professional actors and models and this technique will offer a safe option.

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