Commonly asked questions regarding the Transoral Thyroid and Transoral Parathyroid procedure. (last updated 10/7/2019)

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What Is Scarless Thyroid Surgery and Scarless Parathyroid Surgery?

Scarless thyroid and parathyroid surgery allows for the safe and total removal of either the thyroid or parathyroid glands with absolutely no external scarring on the neck. The term "scarless thyroid surgery" can be confusing because there are several types of thyroid and parathyroid surgical techniques that have been called “scarless” in the past. Some of these approaches include the trans-axillary thyroidectomy, bilateral axillo-breast approach, the facelift approach, and transoral thyroidectomy.  Of all these options, only the transoral thyroidectomy and parathyroidectomy leaves no visible scar anywhere on the body. All the other approaches are not truly scarless in that they leave a visible scar somewhere on the body, just not on the neck. With the transoral approach the scars are hidden on the inside of the lower lip, and thus in practical terms is “truly scarless”. The technical or medical term for transoral thyroidectomy is TOETVA (transoral endoscopic thyroidectomy vestibular approach), and for parathyroidectomy is TOEPVA (transoral endoscopic parathyroidectomy vestibular approach). When searching online or in medical journals these acronyms are what refer to the transoral procedure being done today.

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Why do Some Patients Choose Transoral Thyroidectomy or Transoral Parathyroidectomy Over the Traditional Approach?

Despite advances in the traditional thyroid and parathyroid procedures that have resulted in smaller scars, traditional thyroid and parathyroid removal will always result in a visible scar on the neck. In many cases this scar will heal well over time, however each patient is different, and often it is unknown prior to surgery just how well the traditional scar will heal. Unlike surgery on other parts of the body, the scar on the neck is always visible and very difficult to hide on a daily basis.  One of the main reasons people choose the transoral approach is because it offers a cosmetically superior outcome to the traditional approach. When surveyed 82% of people would prefer a scarless approach as long as outcomes were equivalent (1). However, cosmetic superiority is not the only reason that some patients choose the transoral approach. Traditional thyroidectomy and parathyroidectomy incisions reduce a person’s control over their own medical privacy. Because thyroidectomy and parathyroidectomy incisions are nearly impossible to hide, other people will always be able to see the scar, and so there is no way of concealing the fact that a person has had a surgery in the past on the neck. For example, a person with high blood pressure does not have to announce to every person they encounter that they are taking blood pressure medications, but the traditional neck incision is just such a silent announcement. Recent studies have shown that when a person with a scar on the neck meets someone new, rather than having direct eye contact, a person’s eyes first divert to the neck scar rather than to making eye contact. Some patients prefer to have more control over who does and does not know about their medical and surgical history, and the transoral approach allows them this increased medical and personal autonomy. Third, just as these incisions are visible to others, the neck incision is also constantly visible to the patient themselves. This can serve as a daily reminder of the underlying problem and the surgery itself, and some people prefer not to have that reminder (2). Here are some interviews with patients discussing these issues in their own words. 

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Is Transoral Thyroidectomy and Transoral Parathyroidectomy Safe and Effective?

Based on current medical literature the transoral thyroidectomy and parathyroidectomy procedures are as safe as the traditional approach when the transoral approach is done by an experienced surgeon. This can be confusing because an internet search may present articles that were written prior to new medical data that were published in January of 2018. The transoral thyroidectomy and parathyroidectomy procedures in the form currently being used in the United States were first reported in the medical literature in March of 2016 (3). The transoral approach remained relatively obscure in the United States until late 2016 to early 2017 when the first cases done in the United States were reported in the medical literature (4,5). Shortly after this several articles appeared in both the medical literature and in the press which expressed appropriate concern and reservations regarding these new operations (6,7). However, the majority of these concerns were later addressed in follow-up studies of the procedure. In January of 2018 a landmark study of 425 transoral cases was published (8). The study found that when compared with traditional surgery the transoral approach did not have higher rates of infection, recurrent laryngeal nerve injury, or hypoparathyroidism.  The main caveat to these data is that in order to achieve these outcomes a surgeon must have experience with the procedure. Based on these data the transoral approach is as safe as the traditional approach when done in the properly selected patient and by a surgeon with experience in the transoral approach. 

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How is Transoral Thyroid and Transoral Parathyroid Surgery Done?

The formal medical name of the transoral operation is Transoral Thyroidectomy Vestibular Approach (TOETVA) or Transoral Parathyroidectomy Vestibular Approach (TOEPVA). The oral vestibule is the space between the bottom front teeth and the lower lip, thus in this operation the neck is approached or accessed through the space between the bottom lip and the teeth. First, three small incisions between 3-10 mm are made on the inside of the lower lip. Through these incisions small laparoscopic instruments that are about the diameter of a pen are passed under the skin and down to the thyroid or parathyroid. Here is an animated video describing the technique. From this point standard laparoscopic techniques are used to remove the thyroid or parathyroid. These laparoscopic techniques are the same techniques that surgeons have been using for the last 30 years to remove organs such as the gallbladder, appendix, and colon. Once the organ is resected, it is placed inside a bag and removed through the middle incision in the lower lip. The incisions are then closed with stitches that will dissolve on their own. Below is a short animation that describes the procedure.

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Who is a Candidate for Scarless Thyroid or Parathyroid Removal?

Many individuals who need their thyroid or parathyroid glands removed are potential candidates for scarless thyroid surgery. However, there are some restricting factors pertaining to gland size and overall medical condition. 

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Based on recent medical literature candidates for the scarless thyroid surgery may have the following diagnoses (9):

• Thyroid cancer nodule less than 2 cm

• Thyroid removal for benign conditions such as goiter or Graves’ disease

• Benign thyroid nodule less than 6 cm

• Primary hyperparathyroidism with well localized imaging studies

 

For more detailed information on the eligibility for the procedure you can read this medical journal article (10).

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Is Transoral Thyroidectomy and Parathyroidectomy Painful?

How much pain to expect after surgery is one of the most commonly asked question when preparing for any operation. The amount of pain and length of discomfort experienced after transoral thyroidectomy and parathyroidectomy is similar to that of the traditional approach. Most patients do not require prescription strength pain medication for more than 2-3 days, after which over the counter pain relievers like ibuprofen are sufficient. While every person reacts differently to pain and surgery, many patients have been surprised to find that there is often minimal pain after transoral thyroidectomy or parathyroidectomy. What is more commonly described is a sense of fullness, tightness, and pressure around the chin, lower lip, and upper neck. This is due to temporary swelling and bruising that occurs immediately after the surgery which subsides within 1 to 2 weeks in the majority of cases. The lip incisions themselves are relatively pain free and most patients are more aware of feeling the sutures that hold the incisions together than they are of pain at the incision sites. Of course, it is important to keep in mind that everyone's experience is different with regards to pain after surgery, and thus what is typical for most people may not be typical for any particular individual person.

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What to Expect After Transoral Thyroid or Parathyroid Surgery

After surgery you will wake up in the recovery room. Most patients will be able to go home the same day of the procedure. Occasionally some patients will need to be kept in the hospital overnight for observation. If that is the case, then usually that person will go home the morning after the procedure after breakfast. After any thyroid or parathyroid surgery, regardless of whether it is the traditional or transoral approach, you can expect to have a sore throat when you swallow, a scratchy voice, and a stiff neck. The majority of these symptoms will go away in the first 2-3 days. In addition to this you will experience swelling and bruising of the incisions, regardless of the approach. With the traditional approach this will be centered on the visible incision.

 

With the transoral approach in the immediate postoperative period you can expect to have swelling of the lower lip, chin, and upper neck. There may also be some bruising in these areas as well. The majority of this swelling and bruising will go away within the first 7-10 days. By two weeks in the majority of cases a casual observer would not be able to tell you had any surgery at all. After the second week there might be the sensation of some firmness and tightness of the area, but there will be no visible change in the lip, chin, or neck. This tightness is a normal reaction to any surgical incision site and will go away over time.

 

You will have three small incisions on the inside of the lower lip which will have dissolvable sutures keeping them closed. These incisions typically do not hurt very much, but the sutures can feel irritating after the first few days. To protect these sutures it is recommend that you slowly resume a regular diet. This means liquids on the first day, soft food on the second (Banana, Apple Sauce, Rice, Toast, etc.), and then a regular diet on the third day. You should also maintain good oral hygiene and brush your teeth daily, just being careful not to disturb the sutures. You may also be prescribed a prescription strength mouth wash which you would use for the first week after each meal. 

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Future Outlook of Transoral Thyroid and Transoral Parathyroid Surgery

Previous types of “scarless” thyroid and parthyroid surgeries have had limited success in the United States. This is partly because most of these other operations either have significant limitations, increased pain relative to the traditional approach, or require the assistance of a surgical robot. The transoral approach addresses all these concerns and offers a truly scarless alternative to the traditional approach with a similar risk profile, similar amounts of postoperative discomfort and similar recovery times. This has allowed the procedure to expand quite rapidly outside the United States. It is estimated that there have been approximately 2,500 of these cases performed worldwide (As of 2019) in just 3 years time. Within the United States adoption has not been as fast, however its adoption has been much faster than any of the previous alternative approaches. One of the biggest challenges facing more widespread adoption of the transoral approach is the ability to adequately train surgeons in the technique as well as continued data collection on surgical populations in the United States. This medical journal article addresses the adoption and expansion of transoral endocrine surgery in more detail (10).

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References

1. Coorough NE, Schneider DF, Rosen MW, et al. A Survey of Preferences Regarding Surgical Approach to Thyroid Surgery. World J Surg. 2014;38(3):696-703. doi:10.1007/s00268-013-2405-y

2. Choi Y, Lee JH, Kim YH, et al. Impact of Postthyroidectomy Scar on the Quality of Life of Thyroid Cancer Patients. Ann Dermatol. 2014;26(6):693. doi:10.5021/ad.2014.26.6.693

3. Anuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. World J Surg. 2016;40(3):491-497. doi:10.1007/s00268-015-3320-1

4. Udelsman R, Anuwong A, Oprea AD, et al. Trans-oral Vestibular Endocrine Surgery. Ann Surg. 2016;264(6):e13-e16. doi:10.1097/SLA.0000000000002001

5. Inabnet WB, Suh H, Fernandez-Ranvier G. Transoral endoscopic thyroidectomy vestibular approach with intraoperative nerve monitoring. Surg Endosc. 2017;31(7):3030-3030. doi:10.1007/s00464-016-5322-y

6. Bagely D. New Thyroid Surgery Technique Leaves No Visible Scar, but Experts Warn Caution - Endocrine News. Endocrine News. https://endocrinenews.endocrine.org/new-thyroid-surgery-technique-leaves-no-visible-scar-experts-warn-caution/. Published 2017. Accessed April 3, 2019.

7. Hodin RA. Comment on Udelsman et al. Ann Surg. 2016;264(6):e17. doi:10.1097/SLA.0000000000002010

8. Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh Q-Y. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg. 2018;153(1):21-27. doi:10.1001/jamasurg.2017.3366

9. Razavi CR, Russell JO. Indications and contraindications to transoral thyroidectomy. Ann Thyroid. 2017;2(5):12-12. doi:10.21037/aot.2017.10.01

10. Grogan RH, Suh I, Chomsky-Higgins K, et al. Patient Eligibility for Transoral Endocrine Surgery Procedures in the United States. JAMA Netw Open. Published online May 31, 20192(5):e194829. doi:10.1001/jamanetworkopen.2019.4829