Objective: As transoral endoscopic thyroidectomy vestibular approach (TOETVA) gains more prevalence in North America, it is imperative to continuously re-evaluate its safety and outcomes. We previously published the outcomes of our first 200 consecutive TOETVA cases, which showed that TOETVA had longer operative times than traditional transcervical approach thyroidectomy (TCA), but there was no significant difference in major complications between techniques. Herein, we re-evaluate the outcomes and safety of TOETVA with an additional cohort of 100 cases.
Methods: Retrospective review of TOETVA and TCA cases from August 2017 to June 2021 at an academic institution was performed. Patient demographics, BMI, and specimen pathology and size were compared between groups. Outcomes included operative time, major complications of conversion from TOETVA to TCA, hematoma, permanent hypoparathyroidism and permanent recurrent laryngeal nerve (RLN) injury, and minor complications of temporary hypoparathyroidism, temporary RLN injury, seroma, infection and permanent mental nerve injury. Outcomes were compared between groups and between cohorts of the first 200 versus most recent 100 TOETVA cases.
Results: A total of 830 cases were included: 300 TOETVA and 530 TCA cases. The TOETVA group had a higher proportion of females (86.7% vs 80.8%, p=0.03), younger median age (40(16-71)yr vs 49(10-84)yr, p<0.01) and lower median BMI (26.7(17.2-54.2) vs 28.8(17.1-74.3), p<0.01). The proportion of patients with Graves’ disease (TOETVA:15% vs TCA:13%) and mean maximum lobe size (TOETVA:5.3cm vs TCA:5.4cm) were comparable between groups, but the TCA group had a significantly larger proportion of pre-operative Bethesda category V/VI lesions (23% vs 14%, p<0.001). Overall, the median operative time was significantly longer for the TOETVA group for both lobectomy (125min vs 80min, p<0.001) and total thyroidectomy (180min vs 120min, p<0.001) and did not significantly change for the TOETVA group between the initial cohort of 200 cases and the most recent 100 cases. The overall rate of major complications was 1.7% in both groups. Only 2 TOETVA cases required conversion to open procedure (0.7%). A single case of permanent RLN injury occurred in the TCA group and a single case of permanent hypoparathyroidism occurred in the TOETVA group. A total of 7 cases of hematoma occurred following TCA (1.3%), with no incidences in the TOETVA group. The TOETVA group had a higher incidence of minor complications (14.3% vs 8.7%, p=0.02). The rates of temporary RLN injury (TOETVA:3.4% vs TCA:2.3%), temporary hypoparathyroidism (TOETVA:14.9% vs TCA:9.7%), seroma (TOETVA:1.4% vs TCA:1.3%) and infection (TOETVA:0.7% vs TCA:0.4%) were comparable between groups. The TOETVA group had 6 cases of permanent mental nerve injury, with only 1 of these occurring in the most recent 100 cases and 1 case of skin injury due to light-cord burn. No significant differences were found between the incidence of major and minor complications between the initial 200 and most recent 100 TOETVA cases.
Conclusions: TOETVA continues to have increased operative times, but similar rates of major complications compared to TCA, further supporting this approach as a safe option for thyroid surgery. Evaluation of outcomes and safety of TOETVA will continue as this cohort grows.