endoscopic thyroidectomy.

1. Endoscopic Thyroidectomy Through
Oro-vestibular Route (ETOVR)
Published in Indian Journal of Surgery
3 January 2020
-Dr. Rachitha Radhakrishnan
Post Graduate
Unit chief – Dr. C. Rajasekaran
S IV unit
Dept. Of General Surgery
VMKVMCH

2. Introduction
• Minimally invasive techniques -integral part of
many surgical sub-specialities.
• Nodular thyroid goitre (NTG) -commonest
endocrine surgical disorders
• Various endoscopic techniques and novel
routes

3. Endoscopic thyroidectomy
techniques
– Endoscopic anterior breast
approach
– Endoscopic axillary approach
– Endoscopic axillo breast
approach
– Endoscopic post auricular and
axillary approach
– Endoscopic transoral
approach
Robotic thyroidectomy
procedures
– Robotic transaxillary
– Robotic retroauricular
– Robotic transoral

4. Materials and Methods
• Prospective study
• Over a period of 28 months from May 2016 to
November 2018.
• Written informed consent was obtained

5. Indications for surgery
• Nodules ≤ 4 cm
• Pressure symptoms
• Benign nodules
• Cosmetic reasons
• Patient’s choice

6. Inclusion criteria
• Patient’s informed consent
• Cytology proven benign nodules
• Age 18 - 50 years

7. Exclusion criteria
• Graves’ disease
• Malignancy
• Previous thyroid surgery
• Neck irradiation
• Non- consenting patients.

8. Pre op preparation
• Pre-operative chest physiotherapy and
incentive spirometry.
• Optimisation of comorbidities
• Maintaining a good oral hygiene for 2 days
before surgery.

9. Surgical technique
• Supine with 30° reverse Trendelenburg
position and extension of the neck with arms
placed by the side of the chest.
• Nasotracheal intubation
• After draping, the neck and oral cavity are
prepared.

10. • 10-mm frenulotomy incision
• Two 5-mm lateral incisions, 2 cm away on
either side of frenulotomy site.
• Adrenaline/normal saline solution used for
hydrodissection
• Veress needle was used to hydrodissect the
chin, submental region and neck in
subplatysmal plane.

11. • Hydrodissection
– Vertically : between chin and jugular notch
– Horizontally : between medial borders of both the
sternomastoid muscles.
• Long hemostat was used to bluntly dissect.

12. • Ports
– 11-mm trocar: through frenulotomy -30° camera
– two 5-mm trocars : through lateral port sites -
working ports
PORT ACCESS THOUGH
LOWER GINGIVAL SULCUS
THREE TROCAR PLACEMENT

13. • Cervical linea alba opened up.
INTRA OP VIEW AFTER CUTTING
LINEA ALBA

14. • Plane developed between the sternothyroid
and sternohyoid muscles.
• 3–0 vicryl stitch was applied through the
sternohyoid muscle and skin.
• Sternothyroid muscle is cut.

15. • Thyroid gland was retracted medially.
• Ipsilateral superior pole is skeletonised.
• Clip is applied to superior vascular pedicle.

16. • Sectioned with HS close to the thyroid gland.
• Further rotated medially to identify
– superior parathyroid gland (SPG)
– recurrent laryngeal nerve (RLN).

17. • Inferior thyroid artery, branches and ligament
of Berry (LB) are sectioned close to the thyroid
gland.

18. • For hemithyroidectomy
– Isthmus sectioned at junction of isthmus and
opposite lobe
• For total thyroidectomy
– same procedure repeated on the contralateral
side.

19. • Endobag inserted and the specimen extracted.
• Under vision through one of the ports.
EXTRACTION OF SPECIMEN THROUGH
CENTRAL PORT

20. • No drain placed.
• Cervical linea alba approximated with
intracorporeal suturing using 3–0 vicryl.
CLOSURE OF PORT SITE

21. SCARLESS COSMESIS OF NECK

22. Results
• 104/123 (87.7%) underwent hemithyroidectomy.
• 19/123 (12.3%) underwent total thyroidectomy.
• The mean age of the cohort was 23 ± 4.2 years
• Average duration of the disease was 10.4 ± 5.2
months

23. • Operative time of ETOVR was 116 ± 16 min
• Encouraged for early ambulation and returned
to normal activity and diet within 2 days.
• Only oral liquids for first 2 days.
• Discharged on the 3rd post- operative day.

24. • No episodes of
– symptomatic or permanent hypocalcemia
– neck hematoma
– significant pain
– oral cavity bleeding
– recurrent laryngeal nerve palsy
– surgical site infections.
• Incidence of temporary biochemical
hypocalcemia was 22/123 (18%).

25. Endoscopic thyroidectomy
techniques
– Endoscopic anterior breast
approach
– Endoscopic axillary approach
– Endoscopic axillo breast
approach
– Endoscopic post auricular and
axillary approach
– Endoscopic transoral
approach
Robotic thyroidectomy
procedures
– Robotic transaxillary
– Robotic retroauricular
– Robotic transoral
Discussion

26. • The objectives of any ET technique are best
cosmesis with cure and low morbidity.
• Indications for surgical thyroidectomy
– pressure symptoms
– cosmetic concern
– suspected or fear of malignancy.

27. Complications
• Potential complications
– Mental Nerve Palsy
– Spread of Oral Infection
– Morbidity due to high insufflation pressures

28. • complication of gas-dependent ET
– hypercarbia.
– subcutaneous emphysema
– mediastinal emphysema
– cardiac arrhythmias
• Morbidity -high insufflation pressures
• Avoided: standard low insufflation pressures
(5–6 mmHg)

29. Conclusion
• This novel ETOVR technique appears to be a
safe and optimal approach of thyroidectomy
for benign thyroid nodules.
• Proper case selection, expertise in minimal
access surgery and extensive experience in
thyroid surgery are key to the success of this
technique.

30. THANK YOU