Surgical Education Cadaver Model Video for Transoral Endoscopic Thyroidectomy Vestibular Approach

Abstract

Introduction:

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) may represent the next phase of minimally invasive endocrine surgery, and early clinical experience shows that TOETVA is indeed possible in selected patients. ^{1 –4} This surgical education video depicts the step-by-step technique of TOETVA with anatomic landmarks in a male cadaver model. This video is useful for surgeons starting a transoral program and those endocrine centers offering TOETVA courses.

Methods:

TOETVA is performed under general anesthesia with naso- or orotracheal intubation. ⁵ The patients are in a supine position with slight neck extension created by a pillow placed under the shoulders and in a 15° Trendelenburg bed position. Important anatomical references—midline of the neck, anterior border of the sternocleidomastoid muscle, and the clavicles—can be marked over the skin as guidelines for the flap dissection. The first 10 mm incision is made at the center of the oral vestibule, with a subsequent space created passing the mandibular area and submental space to the anterior neck and spread laterally using an electrical scalpel and Kelly clamp forceps. A blunt-tipped 10-mm trocar is inserted for a 10 or 5 mm 30° laparoscope. ^{4 –10} Two 5 mm trocars are inserted at the junction between the incisor and canine on both sides pointing down to the anterior neck under direct endoscopic vision. The working space is created beneath the platysma. The strap muscles are divided and retracted by cutting the midline linea alba cervicalis and deep fascia. For better exposure, strap muscles are retracted laterally with an external hanging suture. The median raphe of the strap muscle is divided to expose the operative field from the thyroid cartilage to the sternal notch. Then the Delphian lymph nodes and/or the pyramidal lobe are resected to clearly identify the cricothyroid muscles and the cartilage surface. The thyroid isthmus is divided to expose the trachea and the strap muscle is dissected from the thyroid lobes' surfaces. The middle thyroid vein, superior thyroid artery, and vein are ligated close to the thyroid. During upper pole dissection, the external branch of the superior laryngeal nerve is preserved. The upper pole of the gland is lifted and the recurrent laryngeal nerve (RLN) is identified parallel to the trachea in the tracheoesophageal groove. RLN exposure and dissection of the nerve is cranio-to-caudal. All parathyroid glands are identified and preserved. The specimen is removed using an endobag through the 10-mm incision and sent for pathology analysis. Contralateral thyroidectomy is accomplished only if the RLN electromiographic signal of the first side is preserved. If required, a surgical drain is placed through a 5-mm incision in the axilla. ^{11 –13} The strap muscles are reapproximated. The surgical wounds are closed using running 4.0 absorbable sutures.

Results:

The postoperative course of a TOETVA patient is customized. No dressing is required. Oral antibiotics and mouthwash three times per day are prescribed for 5–7 days. Patients start an oral diet on day 0 postoperatively. Patients can take a shower and men may shave that evening. Discharge from hospital is dictated by the common rules of the thyroid surgery.

Conclusion:

This video depicts a TOETVA in a cadaver model. The methodology and step-by-step dissection are included with anatomical landmarks. This procedure can be accomplished with the assistance of a team approach and standard laparoscopic instruments.

No competing financial interests exist.

Authors' Contributions: Conception and design were by G.D., K.Y.H., and Z.D.; administrative support was provided by all authors; collection and assembly of data were the responsibilities of Z.D.; data analysis and interpretation were taken care of by G.D. and K.Y.H.; all authors had contributed to article writing and have given final approval of the article

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Funding Information: No funding was received for this article

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Consent: Informed consent was obtained from all individual participants included in the study

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Runtime of video: 9 mins 53 secs