TOETVA has some drawbacks including a narrow operating area and a comparatively challenging external branch of the superior laryngeal nerve exposure. This protocol improves the application of TOETVA IN clinical practice and reduces the learning curve. TOETVA is characterized by the full exposure and dissection of the central lymph nodes which is significantly advantageous in the treatment of differentiated thyroid carcinoma with cN1A.
After anesthetizing the patient using an ultrasonic scalpel make the working space and widen it to both sternocleidomastoid muscles laterally and along the subplatysmal plane to the sternal notch inferiorly. Divide the linea alba colli with an ultrasonic scalpel and separate part of the strap muscle from the thyroid gland. Then, using a 20 milliliter needle, pierce the skin at the level of the inferior corner of the thyroid cartilage and place a pull hook through the hole to grab the separated part of the strap muscle.
Use the ultrasonic scalpel to separate the remaining part of the strap muscle and expose the common carotid artery. Find the vagus nerve and record the signal using intraoperative neuromonitoring. Next, hold the inferior margin of the isthmus using non-traumatic forceps.
Then use an ultrasonic scalpel to cut the isthmus from the inferior portion of the cricoid cartilage and expose the trachea. For the lobectomy of the Transoral Endoscopic Thyroidectomy Vestibular Approach, or TOETVA, locate the trachea first and use it as a reference. Using non-traumatic forceps, hold the upper pole of the thyroid and divide the cricothyroid space with the ultrasonic scalpel.
Transect part of the sternothyroid muscle to expose the upper pole of the thyroid. Sever the superior thyroid artery and vein to free the lateral glands from the top down. Lift the upper pole of the gland and find the recurrent laryngeal nerve or RLN under direct visualization.
Next, separate the thyroid capsule from the trachea. Then divide the inferior thigh vessels and cut Berry's ligament with the ultrasonic scalpel. Remove the unilateral lobe of the thyroid gland from the trachea.
After locating the inferior parathyroid gland, dissect the pretracheal and prelaryngeal lymph nodes using an ultrasonic scalpel. Cut the connective tissue in front of the carotid artery to determine the lateral boundary of the central lymph nodes. End the connective tissue in front of the trachea to determine the medial boundary of the central lymph nodes.
Sweep the anterior side of the left RLN, or the anterior and posterior sides of the right RLN to complete the central lymph node dissection. Remove the specimens using endoscopic pouches. Wash the surgical wound repeatedly with warm, sterile distilled water.
Place a surgical drain through a small skin puncture in the anterior neck. Reapproximate the strap muscles. Finally, close the oral wounds with 5-O absorbable sutures.
Baseline characteristics and representative results of the 32 cases of TOETVA and the 97 cases of open surgery are shown here. The mean age, and gender composition of the patients differed between the two groups. Younger female patients choose the TOETVA method.
The operation time of the TOETVA was longer than open surgery. No significant differences in the number of harvested lymph nodes were observed between the two groups. In terms of the metastatic lymph nodes, the ratio of extrathyroidal extension in tumor size differed between the two groups, meaning the characteristics of the tumors differed between the two groups.
No significant differences in postoperative parathyroid hormone and postoperative calcium were found between the two groups. When the RLN is in the vicinity of a hemorrhage, using an electrotherm or an ultrasonic scalpel for hemostasis without figuring out the anatomy of the RLN and the surrounding conditions should be avoided.
