Approaching the Thyroid Gland: North vs South—Is There an Optimal Endoscopic Technique?

Abstract

There are many different forms of remote access or “scarless” thyroid approaches. Currently, transoral endoscopic thyroidectomy vestibular approach (TOETVA) and robotic bilateral axillobreast approach (BABA) thyroidectomy are most prevalent approaches in the United States. With an appropriate patient selection, both approaches are being actively utilized at specialized centers for both benign and malignant thyroid neoplasms.^1–5 This video publication provides simple comparison between the two approaches while demonstrating various BABA robotic techniques including thyroid, parathyroid, and modified radical neck dissection. Both approaches provide midline view and symmetrical access to the neck. TOETVA utilizes three vestibular mucosal incisions that heals fast and becomes nearly invisible. BABA utilizes four skin incisions including bilateral anterior axillary skin fold and periareolar incisions. TOETVA surgeries are typically performed endoscopically whereas BABA surgeries are mostly performed robotically. As illustrated in this video publication, TOETVA typically utilizes more limited flap space than BABA. Compared with TOETVA's relatively narrow but acute approach angle, BABA provides more wider and flat approach angle along the chest wall. Although BABA's wide flap space can be considered more invasive, four widely spaced incisions across the chest wall provide ideal triangulation and maneuverability with two opposing graspers. Both approaches provide an excellent view with magnification. TOETVA provides completely symmetrical top-down anterior view, whereas BABA provides more familiar bottom-up oblique view of the thyroid. Specimens are retrieved via an endoscopic bag. Overtime, indications for these approaches have broadened, and recent publications have shown safety and efficacy of BABA robotic modified radical neck dissection (MRND) as illustrated in this video.^6–8 Implementation of “scarless” MRND via BABA is one of the key distinctions between TOETVA and BABA. To conclude, the choice of surgical approach depends on surgeon's preference and availability of resources. In all, safety and oncologic principles are of paramount and the surgical outcome as well as value should be continually monitored in these innovative approaches.

No competing financial interests exist.

Runtime of video: 11 mins 20 secs

First presented at the International Association of Endocrine Surgery conference, August 13, 2019.