Development of a scarless and gasless trans-oral video-assisted thyroidectomy

Abstract

Background: Endoscopic techniques have been developed over the years to mitigate the visible curvilinear scar resulting from open thyroid surgery. The trans-oral endoscopic thyroidectomy via a vestibular approach (TOETVA) is the latest technique which offers visibly scarless surgery. Aim and Objectives: The aim was to develop a novel gasless modification to TOETVA. The objectives were: to reproduce the TOETVA with CO2 insufflation using Thiel embalmed cadavers; to develop a retraction device with the aim of eliminating CO2 insufflation; to compare the original TOETVA using CO2 insufflation with the gasless technique in embalmed cadavers; and to explore relative contraindications for gas insufflation in the neck and assess whether a gasless adaptation would improve outcomes. Methods: A new retraction device has been built in collaboration with the Faculty of Engineering and the Department of Anatomy. Nine Thiel embalmed cadavers were used: to replicate the standard TOETVA technique (n=3); to test the new device in a gasless technique (n=3) and to compare the intrajugular venous pressure using the standard TOETVA with the new technique (n=3). Using a blinded questionnaire, 4 thyroid surgeons compared the images retrieved from the standard TOETVA and the gasless modification. Results: Thiel embalmed cadavers are an appropriate medium to reproduce TOETVA, for the purpose of training and further development of the technique. The retracting device was successfully developed to eliminate the need of insufflation during TOETVA whilst still maintaining equivalent visualisation of anatomical landmarks. There was significantly higher intrajugular venous pressures with insufflation. Conclusion: Gasless TOETVA with the developed device is a viable modification to the technique that offers an augmented safety profile to patients undergoing TOETVA.