Journal of Surgical Case Reports, 2022;1, 1–5

https://doi.org/10.1093/jscr/rjab623
Case Series

CASE SERIES

Scarless total thyroidectomy via transoral endoscopic

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vestibular approach: initial case series in a developing
Asian country
Ralph Victor Yap1 ,* and Manuel Villamor Jr.1 ,2
1
Department of Surgery, Cebu Doctors’ University Hospital, Cebu City, 6000, Philippines and 2 Section of
Minimally Invasive Surgery, Department of Surgery, Cebu Doctors’ University Hospital, Cebu City, 6000,
Philippines
*Correspondence address. Department of Surgery, Cebu Doctors’ University Hospital, Osmeña Blvd, Cebu City, Cebu 6000, Philippines.
Tel: (63) 0917-130-1923; Fax: (032) 255-5555; E-mail: rvyapmd@gmail.com

Abstract
Conventional open thyroidectomy may leave a visible scar postoperatively and can lead to impaired quality of life. Since 2016,
the transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has gained popularity due to being a true ‘scarless’
procedure. However, minimally invasive thyroidectomy has not been widely adopted in the Philippines yet. From August 2019
to December 2019, nine patients (mean thyroid nodule size of 3.1 cm) underwent TOETVA with one open conversion due to
adherent papillary cancer. Majority had a blood loss of <100 ml, whereas mean operative time was 149.8 ± 20.5 minutes. Five
patients developed hypocalcemia (three transient), whereas two patients reported transient lower lip numbness. TOETVA is
a safe and feasible novel procedure for both benign and malignant thyroid diseases. Care must be taken in selecting patients
who opt for TOETVA, and that surgeons should reassess their limitations before implementing this technique in their surgical
practice.

INTRODUCTION variety of endoscopic techniques have been developed. Namely,

Thyroidectomy, which was pioneered and advanced by Theodor these include endoscopic anterior/breast, axillary, postauricular
Kocher has greatly evolved over the decades with further and transoral approaches. These can be done in combination
improved outcomes [1]. It remains a standard treatment for with the other techniques using conventional laparoscopic
a variety of benign and malignant thyroid diseases. The instruments or robotic systems.
conventional open thyroidectomy (COT) is performed via an The transoral approach has gained more popularity since
anterior cervical neck incision that may leave a visible scar the publication of the first 60 human cases that successfully
postoperatively. About 10% of patients who underwent COT are underwent transoral endoscopic thyroidectomy via vestibular
likely to pursue a revision of their scars at a later time. Regardless approach (TOETVA) by Anuwong in 2016 [3]. The procedure
of scar type, the quality of life in these patients after surgery is requires a 10-mm incision in the center of the oral vestibule and
impaired as well [2]. In an attempt to improve cosmesis/aesthetic two stab incisions laterally to accommodate 5-mm trocars. It
outcomes by avoiding incisions on the cervical neck area, a perfectly hides the mucosal wounds and heals without scarring.

Received: November 9, 2021. Accepted: December 20, 2021

Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2022.
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1
 2 R.V. Yap and M. Villamor Jr.

Figure 2: Follow-up at 6 months from surgery showing the patient’s (A) oral

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vestibule and (B) anterior neck totally free from a scar.

Figure 1: (A) Placement of a transcutaneous silk 2-0 holding suture on the midline
to aid in initial dissection. (B) Division of the strap muscles along the median
(POD) 1 and 2, respectively. Six patients received penicillin-based
raphe using an L-hook cautery. (C) Retraction of the strap muscle cephalad and antibiotics while cephalosporin was given in three patients.
laterally with a transcutaneous silk 2-0 suture to expose the right thyroid lobe. (D) Patients were discharged home after a mean of 3.1 days (range
Right PGs (black arrow) and RLN identified after completely removing the thyroid 1.8–8.9) (Table 1). After a mean follow-up of 10 months (range 8–
gland. 12), five patients developed hypocalcemia (three transient and
two permanent) and two patients reported transient lower lip
numbness that resolved within 1 month. There was no wound
Multiple studies that followed have shown this approach to be hematoma, surgical site infection, wound dehiscence (Fig. 2A)
safe, feasible, reproducible and can be an alternative to COT for or hoarseness (Table 2). One patient with a malignant biopsy
benign and select malignant thyroid nodule(s) [4–6]. underwent radioactive iodine therapy 2 months after surgery.
Minimally invasive and endoscopic thyroidectomies may The status of a patient’s cervical neck at 6 months postop is
have been performed in the Philippines, a developing country shown in Fig. 2B.
with a substantial incidence of benign and malignant thyroid
diseases. However, local data are lacking as these techniques are
currently not widely adopted among our local head and neck
DISCUSSION
and general/laparoscopic surgeons. Thus, this study aims to In the Philippines, minimally invasive and endoscopic thyroid
share our initial single-institution case series of TOETVA in the surgeries have already been performed but no local guidelines
Philippines in terms of safety and feasibility. have been set up yet since the 2013 update on (local) clinical
practice guidelines on thyroid nodules [7]. The American Thyroid
Association stated that remote access thyroid surgery has a
CASE SERIES role in patients who fit strict selection criteria and that this
We retrospectively reviewed the medical charts of all patients approach requires to be performed by surgeons with a high level
who underwent TOETVA from 1 August 2019 to 31 December of expertise. However, their position statement was based on the
2019, in our institution. The patients’ clinicopathologic data most commonly utilized techniques in 2015 namely, endoscopic
and postoperative outcomes were recorded. The institution’s and robotic breast, axillary, bilateral axillo-breast and facelift
research ethics committee approved this study (Protocol Code approach [8].
2-2020-005). Written informed consent was provided by all The popularity of TOETVA started in 2016 after Anuwong
patients. successfully performed the first largest series of 60 patients. His
Preoperatively, all patients underwent ultrasound of the cer- inclusion criteria include (i) thyroid gland diameter of <10 cm,
vical neck, serum thyroid hormone testing and fine-needle aspi- (ii) follicular neoplasm, (iii) Grave’s disease and (iv) papillary
ration biopsy of the most dominant or suspicious nodule. All pro- microcarcinoma without nodal metastasis [3]. Secondly, the
cedures were performed by a senior surgeon (M.V.) experienced ideal patient candidate is motivated to avoid a neck scar, has a
in open thyroid and laparoscopic surgeries and who already benign nodule with a diameter of <4 cm, tumor/nodule located
completed 20 TOETVA procedures elsewhere. We adopted most away from the recurrent laryngeal nerve (RLN) and pathologic
of Anuwong’s indications and operative steps in performing thyroid lobe that is ipsilateral to the surgeon’s dominant hand.
TOETVA (Fig. 1) [4]. To safely implement such a technique in clinical practice,
A total of nine patients underwent TOETVA (eight females Razavi et al. [9] has recommended that the surgeon is well
and one male) with a median age of 54 ± 12 years. The mean versed in procedures of the central neck, performs high-volume
nodule size was 3.1 cm with almost 80% of the patients having a open thyroidectomies, familiar with laparoscopic/endoscopic
multinodular disease. All patients had total thyroidectomy via instrumentation and is competent in neck/thyroid ultrasound.
TOETVA with a mean operative time of 149.8 ± 20.5 minutes. We completed TOETVA in two out of three patients with
The final biopsy showed benign colloid goiter in six patients PTC having a nodule size of 1 and 3.7 cm, respectively. A large
and papillary thyroid cancer (PTC) in three patients. The sixth single-center study has shown that TOETVA can be performed
case was converted to open thyroidectomy due to adherence of safely with central neck dissection in patients with PTC. There
tumor (PTC on final biopsy) to surrounding strap muscle. No were no open conversions; however, the mean tumor size in
other intraoperative complications/events were recorded. The their study was 0.7 ± 0.4 cm (largest 1.9 cm) [10]. Performance of
majority of the patients had a blood loss of <100 ml and no a selective neck dissection to levels III and IV during TOETVA
patient required blood transfusion postoperatively. The mean in patients with PTC has shown to be safe and feasible in a
visual analog scales (VAS) were 2.6 and 1.5 on postoperative days pilot study [11]. We believe that TOETVA may be safely done
 Scarless total thyroidectomy via transoral endoscopic vestibular approach 3

Table 1. Patients’ clinicopathologic characteristics

Case # Age Sex ASA BMI Nodularity Largest nodule IV Antibiotic Operative EBL (ml) Final LOHS
size (cm) used time (mins) Biopsy (days)

1 40 F 1 22.8 Multinodular 3.2 Meropenem 145 100 Colloid 2.8

Goiter
2 69 F 2 28.7 Uninodular 3.6 Ampicillin + 135 <100 Colloid 1.9
Sulbactam Goiter
3 54 F 1 24.3 Multinodular 2.5 Cefoxitin 170 <100 Colloid 3.9
Goiter
4 45 F 2 26.9 Multinodular 4.2 Cefuroxime 157 <100 Colloid 1.8
Goiter
5 41 F 1 22 Multinodular 3.7 Ampicillin + 151 <100 Papillary 1.8
Sulbactam Thyroid

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Carcinoma
6 58 M 2 24.9 Uninodular 4.8 Ampicillin + Converted to Open Papillary 3
Sulbactam Thyroid
Carcinoma
7 28 F 2 21.5 Multinodular 1 Ampicillin + 130 < 100 Papillary 2
Sulbactam Thyroid
Carcinoma
8 57 F 2 26.9 Multinodular 2.6 Ampicillin + 185 150 Colloid 8.9
Sulbactam Goiter
9 56 F 2 24.1 Multinodular 2.6 Amoxicillin 125 < 100 Colloid 1.9
+ Clavulanic Goiter

ASA, American Society of Anesthesiologists physical status classification; BMI, body mass index; EBL, estimated blood loss; IV, intravenous; LOHS, length of hospital
stay (postoperative).

Table 2. Postoperative outcomes The majority of our patients (75%) had a blood loss of <100 ml.
In a comparative analysis, blood loss was lower in TOETVA com-
VAS, mean + SD
pared with COT (38.25 ± 38.9 vs. 101.8 ± 126.6 ml) [14]. However,
POD 1 2.6 ± 1.8
no significant difference in blood loss was found in a larger
POD 2 1.5 ± 1
cohort of 216 patients [12]. It requires appropriate surgical skills,
POD 3 (n = 2) 2±1
Complications n =8 a meticulous technique and a careful selection of patients to
Tracheal perforation 0 achieve minimal blood loss.
Hematoma 0 There were no occurrences of postoperative hematoma and
Surgical site infection 0 seroma formation in our series. The rate of hematoma formation
Wound dehiscence 0 after TOETVA is low (0.1%) [12]. In a recent meta-analysis, no sig-
Hypocalcemia nificant difference was observed between TOETVA and COT for
Transient 3 such complications [15]. Likewise, the incidence of seroma for-
Permanent 2 mation after TOETVA in 425 patients is 4.7%. This phenomenon
Hoarseness/RLN injury 0 may be noted within POD 2–5 and can be managed with simple
Lower lip numbness aspiration [3, 16]. In contrast to COT, the risk factors for seroma
Transient 2 formation may be attributed to extensive flap creation, patient’s
Permanent 0 age, use of drain, operative duration, tumor size and surgeons’
SD, standard deviation.
operative volume. The use of no-drain in our series relied on the
surgeon’s experience and comfort without its use in his experi-
ence with COT. Drain site on the skin can still yield scars in the
postoperative setting. Albeit very small, this opposes the goal of
in patients with PTC of ≤4 cm in size but should be carefully having a totally ‘scarless’ procedure. Although still controversial,
screened and selected preoperatively. Additionally, the surgeon it is possible and safe to not put a drain in TOETVA but should be
should have a low threshold for open conversion in case of tumor used with caution especially at the initial learning phase of the
adherence. In a recent review article by Russel et al. [12], the surgeon [17].
rate of conversion to open surgery during TOETVA was 0.9% Compared with COT, TOETVA was found to have a signifi-
and the common reasons for such conversion were uncontrolled cantly lower postoperative VAS, specifically on the neck, cervical
bleeding and unexpected tumor size. back and swallowing, ranging from 0.8 to 2.3 in the first 48 hours
All patients in our study received total thyroidectomy via [5, 18]. This benefit reflects the ‘minimally invasive’ nature of the
TOETVA with a mean operative time of 149.8 ± 20.5 minutes. technique. Interestingly, an oral vestibule incision is considered
The largest series comparing TOETVA and COT has shown that less painful compared with a Kocher incision. When compared
operative time was longer in the former group. Their mean with other techniques of thyroidectomy using the endoscopic or
operative time of bilateral thyroidectomy using TOETVA was robotic approach, TOETVA requires less flap dissection leading
135.1 ± 37.6 minutes [3]. As the surgeon gains more experience to lower postoperative pain scores [5].
with TOETVA, operative time is also expected to decrease given TOETVA is considered a ‘clean-contaminated’ case, thus
the short learning curve, ranging from 7 to 15 cases [12, 13]. requiring prophylactic antibiotics. The rate of wound infection
 4 R.V. Yap and M. Villamor Jr.

in a review article is 0.1% and no significant difference was CONFLICT OF INTEREST STATEMENT
observed in a meta-analysis comparing TOETVA and COT [12,
None declared.
15]. Varying antibiotic prophylaxis was used during the initial
cases in our series but we have shifted to amoxicillin with
clavulanic acid during the ninth and in the succeeding cases
FUNDING
following the protocol of Anuwong et al. [3] where they reported
no occurrence of surgical site infection out of 422 cases. Also, An educational grant through the Department of Surgery, Cebu
the use of preoperative oral mucosa antiseptic solution has to Doctors’ University Hospital was provided by Johnson and John-
be emphasized as well. son (Parañaque City, Philippines), Inc.
The most common complications following TOETVA are
injuries to the parathyroid glands (PG) manifesting as hypoparathy-
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