Transoral Neck Surgery

Preface
Contents
Contributors
Chapter 1: History and Evolution of Transoral Thyroidectomy Approach
	A Brief History of Thyroid Surgery
		New Millennium
	Idea and Rationale Behind the Transoral Thyroidectomy
	Preclinical Investigations
		Transoral Surgery in the Literature
		Anatomical Studies on Cadavers
		TOVAT Application on Living Animals
	Drawbacks Following Premature Clinical Implementation
		Concerns Regarding Our TOVAT Technique
	Clinical Breakthrough of the Transoral Thyroidectomy
	Conclusions and Future Considerations
	References
Chapter 2: The Ethics of Novel Surgical Techniques
	Introduction
		Early Adoption of Novel Surgical Techniques
			Preparation of the Surgeon for Adoption of Novel Techniques
		Appropriate Hospital Privileges
		Assembling the Team
		Discussion with Patients
	Conclusions
	References
Chapter 3: Alternative Remote Access Approaches to Endocrine and Neck Surgery
	Introduction
	Patient Selection
	Surgical Approaches
		Robotic-Assisted Gasless Transaxillary Approach
			Patient Positioning
			Incision and Landmarks
			Flap Creation
			Robot Docking
			Console Time
		Robotic-Assisted Retroauricular (Facelift) Approach
			Patient Positioning
			Incision and Landmarks
			Flap Creation
			Robot Docking
			Console Time
	Conclusion
	References
Chapter 4: Patient Selection for Thyroidectomy and Parathyroidectomy Using the Transoral Endoscopic Vestibular Approach
	Introduction
	Challenges Associated with TOETVA and TOEPVA
	Learning from Patient Selection in Pioneering Centers
	Current Indications and Contraindications for Transoral Thyroid Surgery
	How Should Surgeons Select Patients?
	Future Directions
	References
Chapter 5: The Role of Ultrasound in Transoral Endocrine Surgery
	Introduction
	Ultrasound Findings Informing Transoral Approach Selection for Thyroidectomy and Parathyroidectomy
		Anatomic Considerations
		Size
		Disease Location
		Inflammation
		Malignancy
	Conclusions and Summary
	References
Chapter 6: Lobectomy Versus Total Thyroidectomy in Suspicious or Malignant Thyroid Nodules
	Surgical Options and Outcomes in Low-Risk Well-Differentiated Thyroid Cancer
	Initial Surgical Decision-Making
	Components of Preoperative Risk Prediction
	Completion Thyroidectomy:
	Conclusion
	References
Chapter 7: Surgical Equipment, Supplies, and Setup for Transoral Thyroid and Parathyroid Surgery via the Vestibular Approach
	Introduction
	Preoperative Peculiarities
		Inclusion and Exclusion Criteria
		Preoperative Imaging
		Pre- and Postoperative Laryngoscopy
		Surgeon Candidacy
		First Assistant
		Second Assistant
		Nurse
		Surgical Anatomy
	Patient Preparation
		Dental Care
		Prophylactic Antibiotic
		Operation Room Setup
		Anesthesia Perspectives
		Positioning
		Disinfection
		Intraoral Solutions for Irrigation
		Draping
	Surgical Equipment General
	Equipment and Notes
		Hydrodissection
		Surgical Scalpel
		Electrocautery
		Veress Needle
		Clamps
		Vascular Tunneler
		Camera and Trocars
		CO2 Setup
		Suture Materials
	Endoscopic Instruments
		Maryland Dissector
		Atraumatic Grasper
		Traumatic Grasper
		Right Angle Clamps
		Endo-Peanut
		Endo-Needle Holder
		Endo-Scissors
		Endosurgical Clip Appliers
		Suction-Irrigator
	Specimen Extraction and Closure
		Extraction Bag
		Hemostatic Materials
		Adhesion Barriers
		Drain
		Compressive Dressing
		Intraoral Solutions for Irrigation
	Postoperative Peculiarities
		Discharge
		Follow-Up
	Energy-Based Devices for Transoral Thyroidectomy
		HARMONIC ACE® + 7 Shears with Advanced Hemostasis or HARMONIC HDI 1000 (Johnson & Johnson) (Fig. 7.38)
		ENSEAL® Round Tip Tissue Sealer (Johnson & Johnson)
		THUNDERBEAT (Olympus)
		LigaSure™ Maryland Jaw (Medtronic) (Fig. 7.39)
		Smoke Effect
		Safety Around the RLN
	Neural Monitoring in Transoral Thyroidectomy
		Literature on IONM in TOETVA
		Setting and Standards
		Teamwork with Anesthesiologist
		Equipment and Setup
			Stimulating Electrodes
			Recording Electrodes
			Nerve Monitor Systems
		EBSLN Monitoring
	Fluorescence Imaging in Transoral Thyroidectomy?
	Future Directions and Conclusions
	References
Chapter 8: Transoral Endoscopic Vestibular Approach Technique: Steps, Tips, and Pearls
	Introduction
	Indications
		Absolute Contraindications
		Relative Contraindications
	Preoperative Preparation
	Equipment and Energy Device Used
		Position of the Patient
	Room Setting
	Surgical Technique of Transoral Thyroidectomy via Vestibular Approach
		Central Neck Lymph Node Dissection
		Type of Operation
			Thyroid Lobectomy
			Total Lobectomy
		Reoperation
		Choices of Completion Thyroidectomy
	Postoperative Care
		On Postoperative Day 0
		On Postoperative Day 1
		Follow-Up
	Complications
		Intraoperative Complications
		Postoperative Complications
		Broken Suture
	References
Chapter 9: Benign Nodules and Goiters
	Introduction
	Assessment of Patients with Thyroid Nodules or Goiter
	Transoral Endoscopic/Robotic Thyroidectomy Vestibular Approach (TOETVA and TORTVA) for Benign Thyroid Nodules and Goiter
		General Concepts
		Patient Selection and Eligibility for Transoral Thyroidectomy
		Tips and Tricks for the General Management of Thyroid Nodules via the Transoral Approach
		Adverse Events and Complications of the Transoral Thyroidectomy
	Summary
	Conclusions
	Bibliography
Chapter 10: Transoral Management of Indeterminate Thyroid Nodules
	Introduction
	Indeterminate Thyroid Nodules: Definitions and Classifications
	Role of Molecular Genetic Testing in the Workup of Bethesda III/IV Nodules
	Transoral Thyroidectomy
		Technique and Evolving Indications
		Issues and Implications for Bethesda III/IV Thyroid Nodules
			Overall Safety and Feasibility of Transoral Thyroidectomy
		Size of Nodule and Implications on Intact Specimen Extraction
		Surgeon Judgment
	Conclusions
	References
Chapter 11: Transoral Endoscopic Vestibular Approach for Management of Thyroid Malignancies
	Introduction
	Epidemiological Trends of Thyroid Cancer
		Overdiagnosis Hypothesis
		Increased Incidence Hypothesis
		Epidemiology Trend Summary
	Thyroid Cancer Pathology and Staging
		Thyroid Cancer Pathology
		Thyroid Cancer Staging
	Thyroid Cancer Prognosis and Stratification
		Thyroid Cancer Prognosis
		Thyroid Cancer Stratification
	Trends in Thyroid Cancer Management
		Role of Ultrasound and Advance Imaging: Recommendations 6, 7, 10, 32, and 33 [48]
		Role of FNA: Recommendations 8, 10, 12, and 32 [48]
		Role of Molecular Testing: Recommendations 13, 14, and 15
		Role of Surgery: Recommendations 10, 12, 15, 17, 35, 36, and 37 [48]
		Summary of Change in Thyroid Cancer Management
	Transoral Endoscopic Vestibular Approach for Management of Thyroid Malignancies Within the 2015 ATA Guidelines
		Cost
		Learning Curve
		Patient Selection
		Summary of the Role for Oncological Endoscopic Thyroid Surgery Within the 2015 ATA Guidelines
	References
Chapter 12: Graves’ Disease
	Introduction
	Epidemiology
	Pathogenesis
	Clinical Presentation
		Graves’ Ophthalmopathy
	Diagnostic Evaluation
	Treatment
		ATD
		RAI
		Surgery
		Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) for Surgical Management of Graves’ Disease
	References
Chapter 13: Transoral Vestibular Approach Parathyroidectomy: Patient Selection Considerations and Technique
	Background
	Indications for Surgery
	Localization Studies
	Intraoperative Parathyroid Hormone Assay and Minimally Invasive Parathyroidectomy
	History of Remote Access and Transoral Parathyroidectomy
	Preoperative Planning
		Preoperative Setup
		Operative Procedure
		Postoperative Care
		Pitfalls
	Pearls
	Conclusion
	References
Chapter 14: Special Considerations: Obesity, Reoperation to Transoral Endocrine, and Neck Surgery
	Introduction
	Transoral Endocrine and Neck Surgery in Obese Patients
		Obesity as a Risk Factor
		Surgical Considerations
			The Impact of Body Habitus on Transoral Endocrine and Neck Surgery
			Obesity and Carbon Dioxide Embolism
			Anesthetic Considerations
			Preoperative Evaluation
			Intraoperative Care
				Patient Positioning
				Airway Management
				Surgical Techniques
		Postoperative Concerns
		Obstructive Sleep Apnea
		Conclusions
	Reoperation in Transoral Endocrine and Neck Surgery
		Indications for Reoperative Thyroidectomy and Parathyroidectomy
		Roles of Remote Access Approaches for Reoperation
		Approach to Reoperation in Transoral Endoscopic Thyroidectomy Vestibular Approach
		Operative Techniques for Reoperation in Transoral Endoscopic Thyroidectomy Vestibular Approach
		Complications of Reoperation in Transoral Endocrine and Neck Surgery
			Recurrent Laryngeal Nerve
			Superior Laryngeal Nerve
			Parathyroid Glands
		Flap-Related Complications
		Our Experience of Reoperation in Transoral Endocrine and Neck Surgery
		Conclusion
	References
Chapter 15: Central Neck Dissection for Transoral Endoscopic Thyroidectomy Vestibular Approach
	Anatomy of the Central Neck Dissection
	Prophylactic Versus Therapeutic Central Neck Dissection
	Contraindications for Transoral Central Neck Dissection
	CND Technique for TOETVA
		Rationale
	Technique and Literature Appraisal
		Endoscopic CND
		Robotic CND
	Summary
	References
Chapter 16: Transoral Robotic Thyroidectomy
	Introduction
	Indications and Contraindications
	Preoperative Requirements
	Procedures
		Working Space Formation
		Docking Stage
		Console Stage
		Postoperative Management
	Results
	Advantages and Disadvantages
		Advantages
		Disadvantages
	Conclusion
	References
Chapter 17: Decision-Making Process in Converting to an Open Approach
	Clinical Vignette
	Introduction
		Preoperative Assessment
		Intraoperative Assessment
	Preparation Involved in Case of Conversion
		Expert Opinion
	Conclusion
	References
Chapter 18: Transoral Endoscopic Thyroidectomy Vestibular Approach Complications and Safety: Reporting Objectives and Future Study Design
	TOETVA
		Surgical Steps and Complications
		Creation of Central Port Tract
		Lateral Port Placement
		Creation of the Subplatysmal Flap
		Dissection of the Superior Pole of the Thyroid
		Identification of the Recurrent Laryngeal Nerve
		Identification of the Parathyroid Glands
		Dissecting the Thyroid Free from the Trachea
		Specimen Removal
		Infection
		Conversion to Open Procedure and Hematoma
		TOETVA Safety Outcomes Study Design
		Superiority Trials
		Equivalence Trials
		Non-Inferiority Trials
	Conclusion
	References
Index