Ed’s choice explores a systematic review examining one of the recent innovations in head and neck surgery. It may come as a surprise to some that within a few years of the first published cases of transoral vestibule thyroidectomy, an ‘attractive’ first systematic review has been published. This paper includes robotic and endoscopic data and is worth scrutiny in journal club as the complication rates appear equivalent to open surgery, although with some new additions. Importantly the two RCTs recruited 12 and 41 patients, and six of the seven case series had less than 20 patients, the rest being retrospective with a lack of blinding or randomisation throughout. Absence of detail allows little analysis for procedural length (mean range from 60 to 265 minutes) and hospital stay (mean range from 1.1 to 8.2 days). The single biggest contributor to these pooled data, weighing in with 422 patients in a retrospective cohort study, was Anuwong 2018 (JAMA Surg 2018;153(1):21-7) and is probably the only paper worth further reading. Royal Colleges are calling for regulation of innovative surgical technologies and certainly more robust data would be welcome here.

Charles Giddings FRCS(ORL-HNS), FRACS
Consultant ENT, head and neck surgeon, Monash Health, Melbourne, Australia.


In recent years, surgeons have been working towards the holy grail of scarless thyroid surgery. Techniques have included approaches from the axilla and breast-chest. The main drawback is the amount of dissection required to get to the thyroid and the increased complications including brachial plexus injury. More recently, the transoral vestibule approach has been popularised with large numbers being performed by Anuwong (a Thai surgeon). Proponents of this technique claim there is significantly less dissection than the others, with reduced complications. This systematic review assessed feasibility, safety and possible indications of this procedure. Eleven articles, with 864 patients that underwent the procedure, met the inclusion criteria and were included for analysis. Recurrent laryngeal nerve injury rate was 3.1% and hypoparathyroidism rate was 5.6%. It is unclear whether these rates were temporary or permanent. However, these rates seem comparable to traditional thyroid surgery. There was a lack of uniformity regarding indications and contraindications between papers, but the authors concluded the technique could be considered for any thyroid surgery. However, tumour size and patient anatomical factors may prohibit the procedure to be completed. Conversion to an open procedure remains an option if the transoral approach proved not to be technically possible. Overall, this preliminary review supports the use of this novel approach but calls for larger well-designed studies to further evaluate its safety and efficacy. 

Transoral vestibule approach for thyroid disease: a systematic review.
Chen S, Zhao M, Qiu J.
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Sidhartha Nagala

Royal Hallamshire Hospital, Sheffield, UK.

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