In this episode of PodMD we speak to endocrine and general surgeon, Dr Suren Jayaweera tells us of an alternative surgery for thyroid nodules, scarless thyroid surgery or otherwise known as a Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). He discusses the benefits and disadvantages, as well as which patients will be applicable for this surgery
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*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Today I’d like to welcome to the PodMd studio Dr Suren Jayaweera is an Australian trained endocrine and general surgeon, with a special interest in benign and malignant disease of the thyroid and parathyroid glands, endoscopic trans-axillary thyroid surgery and workup and management of adrenal disease. He also performs elective and emergency surgery for gallbladder disease and hernias.
The topic of today’s discussion is scar less thyroid surgery.
Suren, can you describe for our listeners what remote access thyroid surgery is?
Traditional thyroidectomy places the scar in a prominent position on the lower part of the neck. And this scar can result in significant anxiety, particularly for younger patients or those who are prone to keloid scar formation. Remote access thyroid surgery refers to new techniques which place scars away from the neck and this is now gaining recognition as safe as a feasible alternative to traditional open surgery in appropriately selected patients
So, what are some of the techniques that will be used?
Probably the most commonly utilised currently is a transaxially approach which can be performed robotically um this is a technique that has been popularised in South Korea, there’s also endoscopic approaches- so that’s using the same equipment we use for- say a laparoscopic cholecystectomy or a appendectomy using, small incisions, ah and air insufflation. Sometimes these approaches use a periareolar incision as well, around the nipple complex around the breast. And we’ve now seen these techniques around for over a decade and therefore they’ve now been large-volume studies. For example, I think now in South Korea they’ve published over 10,000 transaxially robotic thyroidectomies, so the expertise is certainly there. I’ve seen and trained in Vietnam with a transaxially endoscopic thyroidectomy where at the time, when I was there in 2013- they had performed over 2,500 so, these techniques have been around for a while and they’re now gaining popularity overseas as well. the other approach which I’m really excited about is a technique which has been developed in Thailand, or popularised and that’s a transoral approach.
Right, so this is a very new approach- why would you use transoral?
The main reason for the transoral approach is that it leaves no visible external scars so, there’s no incision on the neck, there’s no incisions in the axillar, no periareolar incisions. Um so it’s a truly scarless surgery. I first became aware um of this technique when I attended the International Association of Endocrine Surgeon’s conference in Thailand in 2015 and there was a young surgeon there that presented his first 60 cases of this technique that I thought showed some promise, however, the reading the room it was almost palpable apprehension. Now, fast forward 2 years and the same young, Thai surgeon at the same conference, this time in Switzerland presented, this time with 700 cases and at this conference he was supported by the then president of the International Association of Endocrine Surgeon’s ah from the united sates who stood up and said “I’ve adopted this technique and I believe it’s the real deal.” And since then it’s become more widely accepted internationally and ah many strong endorsements from many leading endocrine surgeon’s ah in the united states and around the world.
So, what’s transoral thyroidectomies actually about? Where are incisions placed?
So, the incisions for a transoral thyroidectomy are placed behind the lower lip. There’s three incisions, ah one central incision, if you place your tongue between your bottom lip and your teeth- that’s where that incision will be. And there’s also two lateral incisions- so there’s a 10-millimetre central port and 5-millimetre ports. It then involves tunnelling around the chin to reach the neck space.
Wow, and are there any risks to the transoral thyroidectomy?
Yeah, look- the risks of transoral thyroidectomy have um have been a concern addressed by the ah report in the Journal of American Medical Association in 2018. And, they’ve found that the risks for transoral thyroidectomy are actually similar to that as those for open surgery. Finding no significant difference in recurrent laryngectomy, no significant difference in hypocalcaemia in the case of total thyroidectomies and ahh no significant difference in bleeding rates. One risk that is unique to transoral thyroidectomy that is not encountered in the open approach is the potential for mental nerve injury which may result in paraesthesia of the lower lip. The rates which have been reported so far are in the region of 1% and the technique has been subsequently modified to try and minimise the risk of that as well. Most patients experience a transient period of paraesthesia of the chin um but that usually resolves after a few weeks.
Ok, and obviously with any new technique GP need to know the indications for the transoral approach
Currently what we’re offering a transoral thyroidectomy for are symptomatic, benign thyroid nodules measuring up to four centimetres, so that’s a decent size smaller nodules with indeterminate cytology. So, Bethesda system of fine needle aspirate between categories three and four and also cytologically confirmed papillary microcarcinomas. So, PTC’s which are one centimetre or less where also performing the transoral approach. So, basically when you look at the Bethesda system more likely a nodule is malignant than a smaller nodule, we’re prepared to take out via the transoral approach currently.
And where do you think this could go in the future? What’s the direction transoral approach is heading?
I think there’s quite a bright future for the transoral approach. AS we improve our technique and get our experience up. We’ll be prepared to take on larger nodules, larger multinodular goitres and more advance malignant disease. we’ll also be looking at expanding our indications to include graves disease and as the head of paediatric endocrine surgery at Monash it’s exciting for me because I’ve got a regular ahh a number of teenagers with Graves disease for whom a scar across their neck whilst a teenager is a concern. I think the technique is also readily adaptable to robotic surgery when the cost of the robot’s fall for the hospital and the patient. So, I think there’s every chance that this technique will survive well into the future.
Fantastic, well I’ve really enjoyed learning something new today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on scar less thyroid surgery.
1. Transoral endoscopic thyroid surgery is a safe, feasible, cost effective alternative to open thyroidectomy appropriately selected patients who are motivated by the scar on your neck. There is ah no um … talking here.. cut all…
2. It can be encouraging for hospitals to know that ahh there is effective theatre utilisation and no increase for hospital stay for patients
3. Ah and thirdly there’s the obvious benefit to the patient that they can have thyroid surgery with no visible scar or neck
Great, well thanks again for your time and the insight’s you’ve provided.
Thank you very much for having me.