Byline: S. Rege, M. Janesh, S. Surpam, V. Shivane, A. Arora, A. Singh
Background: Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique. Materials and Methods: We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel. Results: From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline. Conclusion: Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.
Thyroidectomy remains a very common procedure in everyday surgical practice to date. However, in recent times, there has been an increasing demand for better safety and better cosmesis. The use of endoscopes and endoscopic instruments for thyroid surgery has allowed surgeons to make small incisions and be minimally invasive.
Endoscopic thyroidectomy can be broadly classified into direct or cervical and indirect or extra-cervical approaches depending on the site of the incision. In the direct approach, a smaller incision is taken on the neck, and endoscopic instruments are used resulting in less surgical dissection and the technique is truly minimally invasive. Extra-cervical approaches such as those approaching from the breast or axilla result in the absence of a visible scar in the neck but require a large amount of surgical dissection. The transoral approach in which the access is through the vestibule of the mouth not only minimizes the surgical dissection but also results in a scar-less neck.