We thank all the patients who participated in this study for their cooperation. This research was supported by the project fund of the Science and Technology Department of Sichuan Province. (Grant No. 2021YFS0103).

The study was approved by the medical ethics committee of West China Hospital, Sichuan University (2018[457]), and written informed consent was obtained from all subjects.
1. Preoperative preparation
<ol>
	<li>Patient eligibility
	<ol>
		<li>Select patients who have stringent cosmetic requirements and meet the following criteria: (1) a benign nodule &#60;4 cm in diameter; (2) a differentiated thyroid carcinoma (DTC) &#60;2 cm in diameter without clinical lateral lymph node metastasis or distance metastasis; and (3) no imaging indication of central lymph node metastasis or a metastatic lymph node &#60;2 cm in diameter without fusion and fixation.</li>
		<li>Exclude patients who meet the following criteria: (1) medullary carcinoma or undifferentiated thyroid carcinoma; (2) oral or neck infections; (3) severe thyroiditis that has an acute impact on thyroid function; (4) suspicious invasion of the primary tumor or metastatic lymph node to adjacent organs, such as the esophagus, trachea, or recurrent laryngeal nerve (RLN); (5) location of the primary tumor in the upper pole; (6) previous history of neck surgery, ablation, or neck radiation; (7) biochemical evidence of uncontrolled hyperthyroidism; (8) substernal goiter; and (9) intolerance to surgery.</li>
	</ol>
	</li>
	<li>Patient preparation
	<ol>
		<li>Evaluate the patients preoperatively with fine-needle aspiration cytologic testing, parathyroid gland tests, thyroid function tests, laryngoscopy, and thyroid ultrasonography16.</li>
		<li>Ask the patient to prepare the oral cavity by using mouthwash (such as tinidazole) before and after meals at least 2 days before the TOETVA and keeping the mouthwash in the mouth for at least 15 s every time.</li>
	</ol>
	</li>
	<li>Equipment
	<ol>
		<li>Ensure the availability of the absorbable sutures (5-0) for oral wounds.</li>
		<li>Ensure the availability of all the instruments and materials required for the protocol (see Table of Materials).</li>
	</ol>
	</li>
</ol>
2. Surgical preparation
<ol>
	<li>Pre-operative preparation
	<ol>
		<li>Assess the anesthesia risk of surgery according to the American Society of Anesthesiologists&#39; classification17.</li>
		<li>Induce general anesthesia with orotracheal intubation using intraoperative neuromonitoring (IONM).</li>
		<li>Tape the eyes and nose, and pad the head to avoid inadvertent trauma.</li>
		<li>Perform catheterization.</li>
	</ol>
	</li>
	<li>Operation field 
	NOTE: Figure 1 shows the schematic of the operating room layout.
	<ol>
		<li>Let the operator stand in front of the patient&#39;s head. Let the first assistant stand on the left side of the patient&#39;s head. 
		NOTE: The first assistant will be responsible for holding the endoscope.</li>
		<li>Let the second assistant stand beside the patient&#39;s body according to the location of the lesion to hold the hook. Let the scrub nurse stand beside the patient&#39;s leg.</li>
		<li>Place the endoscopic equipment and monitor beyond the patient&#39;s feet.</li>
		<li>Place the patient in the supine position with the neck extended. Fix the patient&#39;s head with the top cuff during the operation to avoid neck rotation.</li>
	</ol>
	</li>
	<li>Disinfection
	<ol>
		<li>Skin disinfection: Prepare the upper chest, neck, and lower face with iodine solution three times according to the principle of top-down and in-out.</li>
		<li>Oral disinfection: Put the diluted iodine gauze into the mouth, disinfect the oral cavity with it three times, and rinse it with normal saline.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64437/64437fig01.jpg" /> 
Figure 1: A schematic of the operating room layout. <a href="https://www.jove.com/files/ftp_upload/64437/64437fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Designing the incisions and establishing the working space (Figure 2)
<ol>
	<li>Make the camera port incision with an electrotome; this should be a 20 mm transverse incision 5 mm above the frenulum through the alveolar mucosa of the central lower lip vestibule.</li>
	<li>Advance the camera port incision to the chin with an electrotome. Take care to avoid the penetration of the mentum skin. Use hemostatic forceps and a subcutaneous stripping rod to make a tunnel in the midline of the neck, and further extend to the lower neck.</li>
	<li>Place a 10 mm camera through the central port. Insufflate the working space with carbon dioxide gas to establish a pressure of 4 mmHg. 
	NOTE: The pressure of the carbon dioxide gas should be &#60;8 mmHg to avoid complications caused by high pressure.</li>
	<li>Make two 5 mm vertical incisions laterally from the first premolars for instrument placement.</li>
	<li>Use an ultrasonic scalpel to make the working space, and widen it to both sternocleidomastoid muscles laterally and along the subplatysmal plane to the sternal notch inferiorly. Use the traction of the skin suspension device, which is made of unabsorbable sutures (3-0) and rubber bands, to help expand the working space (Figure 3).</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64437/64437fig02.jpg" /> 
Figure 2: Positioning of the patient and the laparoscopic ports. The center one is the camera port. Arm I and Arm II are for instrument placement. <a href="https://www.jove.com/files/ftp_upload/64437/64437fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64437/64437fig03.jpg" /> 
Figure 3: The traction suspension device. The arrow points at the traction suspension device. The suspension device is made of unabsorbable string (3-0) and rubber bands. <a href="https://www.jove.com/files/ftp_upload/64437/64437fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
4. Thyroid lobectomy
<ol>
	<li>Divide the linea alba coli with an ultrasonic scalpel. Separate part of strap muscle from the thyroid gland.</li>
	<li>Use a 20 mL needle to pierce the skin at the level of the inferior corner of the thyroid cartilage, and place a pull hook through the hole. Use the pull hook to grab the separated part of the strap muscle.</li>
	<li>Use the ultrasonic scalpel to separate the remaining part of the strap muscle and expose the common carotid artery. Find the vagus nerve, and use the IONM to record the signal. 
	NOTE: The IONM technology helps to quickly locate, identify, and protect the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN). The use of IONM is encouraged; it is an excellent auxiliary tool, but not a mandatory tool.</li>
	<li>Use nontraumatic forceps to hold the inferior margin of the isthmus. Use the ultrasonic scalpel to cut the isthmus from the inferior portion of the cricoid cartilage and expose the trachea. For the lobectomy of the TOETVA, first locate the trachea, and take it as a sign.</li>
	<li>Use the nontraumatic forceps to hold the upper pole of the thyroid, and divide the cricothyroid space with the ultrasonic scalpel. Transect part of the sternothyroid muscle. Expose the upper pole of the thyroid.</li>
	<li>Sever the superior thyroid artery and vein. Free the lateral glands from the top down. Lift up the upper pole of the gland, find the RLN under direct visualization, and use the IONM to record the signal.</li>
	<li>Use the ultrasonic scalpel to separate the thyroid capsule from the trachea. Divide the inferior thyroid vessels, and cut the Berry&#39;s ligament with the ultrasonic scalpel.</li>
	<li>Remove the unilateral lobe of the thyroid gland from the trachea. Use the IONM to record the signal of the vagus nerve and RLN again.</li>
</ol>
5. Central lymph node dissection
<ol>
	<li>Locate the inferior parathyroid gland first, and try to retain it in situ. 
	NOTE: The thymus should be carefully identified and protected to ensure the functionality of the inferior parathyroid gland from the source of the thymus blood supply and to prevent accidental resection of the parathyroid gland. Carbon nanoparticles can be chosen to help facilitate the identification of the parathyroid glands and the dissection of the lymph nodes. Autotransplantation is feasible for parathyroid glands that cannot be retained in situ.</li>
	<li>Stretch the strap muscles to the outside as much as possible to fully expose the operative field.</li>
	<li>Identify the central lymph node compartment by the hyoid bone (superior), suprasternal fossa (inferior), carotid artery (lateral), superficial layer of the deep cervical fascia (anterior), and esophagus (posterior).</li>
	<li>Use the ultrasonic scalpel to dissect the pretracheal and prelaryngeal lymph nodes. Cut the connective tissue in front of the carotid artery to determine the lateral boundary of the central lymph nodes and 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 side of the right RLN to complete the central lymph node dissection. 
	&#8203;NOTE: The lateral margin should not be swept too deep in order to prevent damage to the vagus nerve and sympathetic trunk. When cleaning the inferior margin, injury to the innominate vessels and pleura should be avoided.</li>
</ol>
6. Removal of the specimen and closure
<ol>
	<li>Use endoscopic pouches to remove the specimens. 
	NOTE: To avoid ectopic implantation, the specimens should be completely removed by the endoscopic pouches.</li>
	<li>Wash the surgical wound repeatedly with a large amount of warm sterile distilled water.</li>
	<li>Place a surgical drain (4#) through a small skin puncture in the anterior neck.</li>
	<li>Re-approximate the strap muscles. Close the oral wounds with 5-0 absorbable sutures.</li>
</ol>
7. Parathyroid gland autotransplantation
<ol>
	<li>Preserve the parathyroid glands with normal saline, and examine them by frozen section biopsy.</li>
	<li>Cut the isolated parathyroid gland into tiny fragments of 1 mm x 1 mm x 1 mm with ophthalmic scissors. Mix the fragments with normal saline. Inject the mixture into the brachioradialis muscle of the forearm.</li>
</ol>

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V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+transoral+thyroidectomy+vestibular+approach+and+unilateral+axillobreast+approach+for+endoscopic+thyroidectomy:+A+prospective+cohort+study.">Comparison of transoral thyroidectomy vestibular approach and unilateral axillobreast approach for endoscopic thyroidectomy: A prospective cohort study.</a> Journal of Laparoendoscopic and Advanced Surgical Techniques. 31 (1), 11-17 (2020).</li><li>Bhattacharyya, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+cervical+nodal+metastases+in+patients+with+papillary+thyroid+carcinoma.">Surgical treatment of cervical nodal metastases in patients with papillary thyroid carcinoma.</a> Archives of Otolaryngology - Head and Neck Surgery. 129 (10), 1101-1104 (2003).</li><li>Lundgren, C. I., Hall, P., Dickman, P. W., Zedenius, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinically+significant+prognostic+factors+for+differentiated+thyroid+carcinoma:+A+population-based,+nested+case-control+study.">Clinically significant prognostic factors for differentiated thyroid carcinoma: A population-based, nested case-control study.</a> Cancer. 106 (3), 524-531 (2006).</li></ol>

The authors declare no competing interests.

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 cN1a10,13,14,15. However, it should be noted that due to the limited operating space, it is relatively difficult to deal with the big tumors located in the upper pole of the thyroid gland. The surgical indications a...

Conventional open thyroidectomy has been safely performed using a cervical incision for more than 100 years1. Although most patients have efficient scar healing and the cosmetic effect is generally acceptable, a permanent scar on the neck always draws immediate attention from common observers2. Nearly 20% of post-thyroidectomy patients experience self-awareness, and more than 10% consider further treatments to remove the scar3. Moreover, a negative impact of the cervical incision on health-related quality of life (HRQOL) has also been reported4. Varied remote-access approaches for thyroid surgery, such as axillobreast, transaxillary, retroauricular, and subclavian approaches, have been developed to avoid a visible neck scar5,6,7,8 by moving the cutaneous incision to less conspicuous locations.9 However, these approaches require wide-flap dissection to access the thyroid gland and still leave cutaneous scars at the incision sites10.
Since 2008, techniques for natural orifice transluminal endoscopic surgery for transoral thyroid surgery have been developed. These can be performed via the oral vestibular approach or the sublingual approach. The former is more popular because it is associated with fewer complications. In 2016, Anuwong published the first case series of 60 patients undergoing the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and identified an excellent prognosis11. In comparison with the remote-access methods, TOETVA is considered truly minimally invasive because the area of the flap dissection is similar to conventional open thyroidectomy, and it does not leave any scars on the body10.
TOETVA, a revolutionary endoscopic method, meets women&#39;s cosmetic needs and allows easy access to the bilateral thyroid and central compartment12. It is distinguished by the complete exposure and dissection of the central lymph nodes, which is beneficial in treating differentiated thyroid cancer with cN1a10,13,14,15. However, because of the limited operating space, dealing with large tumors in the upper pole of the thyroid gland is relatively challenging. The current study describes the step-by-step procedures of TOETVA.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Allis Grasping Forceps,310 mm x 5 mm</td>
			<td>AESCULAP</td>
			<td>PO111R</td>
			<td></td>
		</tr>
		<tr>
			<td>Button Electrode Tip</td>
			<td>AESCULAP</td>
			<td>GK385R</td>
			<td></td>
		</tr>
		<tr>
			<td>Ceramic Electrode</td>
			<td>AESCULAP</td>
			<td>GK384R</td>
			<td></td>
		</tr>
		<tr>
			<td>Complete Trocar</td>
			<td>AESCULAP</td>
			<td>EJ751R</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscope</td>
			<td>Olympus</td>
			<td>WA53005A</td>
			<td></td>
		</tr>
		<tr>
			<td>IONM</td>
			<td>Medtronic</td>
			<td>NIM-3.0</td>
			<td></td>
		</tr>
		<tr>
			<td>Light Transmitting Bundle</td>
			<td>Olympus</td>
			<td>WA03310A</td>
			<td></td>
		</tr>
		<tr>
			<td>Maryland Dissecting Forceps, 310 mm x 5 mm</td>
			<td>AESCULAP</td>
			<td>PO102R</td>
			<td></td>
		</tr>
		<tr>
			<td>Monopolar Handle (5 mm diameter, 33 cm working length)</td>
			<td>AESCULAP</td>
			<td>GK372R</td>
			<td></td>
		</tr>
		<tr>
			<td>Pneumoperitoneum tube,4 m</td>
			<td>STRYKE</td>
			<td>620-240-223</td>
			<td></td>
		</tr>
		<tr>
			<td>Pyramidal Tip Obturator</td>
			<td>AESCULAP</td>
			<td>EJ755R</td>
			<td></td>
		</tr>
		<tr>
			<td>Reusable Monopolar Cable</td>
			<td>AESCULAP</td>
			<td>GK245</td>
			<td></td>
		</tr>
		<tr>
			<td>Scissors</td>
			<td>AESCULAP</td>
			<td>P0004R</td>
			<td></td>
		</tr>
		<tr>
			<td>Suction irrigation tube</td>
			<td>AESCULAP</td>
			<td>PG027R</td>
			<td></td>
		</tr>
		<tr>
			<td>Super Righting Needle Holder, 5 mm</td>
			<td>AESCULAP</td>
			<td>PL414R</td>
			<td></td>
		</tr>
		<tr>
			<td>Veress</td>
			<td>TianSong</td>
			<td>E2014.6</td>
			<td></td>
		</tr>
	</tbody>
</table>

transoral endoscopic thyroidectomy vestibular approach for thyroid lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

We set up a routine clinical pathway for patients with TOETVA at the center. Laryngoscopy and a thyroid ultrasound are carried out on each patient before the operation. Parathyroid hormone (PTH), thyroid function, 25-dihydroxy vitamin D (25-OH-VD), and serum calcium are routinely measured before the operation, and all of them except for thyroid function are remeasured 1 day after the surgery. In our hospital, Foley catheters are routinely used for patients who will have a TOETVA surgery of more than 3 h. The Foley cathet...

Watch this Scientific Journal Video about Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy at JoVE.com

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

transoral-endoscopic-thyroidectomy-vestibular-approach-for-thyroid

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JoVE Journal

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3.4K Views.  Sichuan University. Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail. 

Video: Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

Primary Culture of Human Vestibular Schwannomas

Vestibular schwannomas (VSs) represent Schwann cell (SC) tumors of the vestibular nerve, compromising 10% of all intracranial neoplasms. VSs occur in either sporadic or familial (neurofibromatosis type 2, NF2) forms, both associated with inactivating defects in the NF2 tumor suppressor gene. Treatment for VSs is generally surgical resection or radiosurgery, however the morbidity of such procedures has driven investigations into less invasive treatments. Historically, lack of access to fresh tissue specimens and the fact that schwannoma cells are not immortalized have significantly hampered the use of primary cultures for investigation of schwannoma tumorigenesis. To overcome the limited supply of primary cultures, the immortalized HEI193 VS cell line was generated by transduction with HPV E6 and E7 oncogenes. This oncogenic transduction introduced significant molecular and phenotypic alterations to the cells, which limit their use as a model for human schwannoma tumors. We therefore illustrate a simplified, reproducible protocol for culture of primary human VS cells. This easily mastered technique allows for molecular and cellular investigations that more accurately recapitulate the complexity of VS disease.

Vestibular Schwannomas (VSs) are non-malignant tumors of Schwann cell (SC) origin, associated with mutations in the NF2 tumor suppressor gene. We report a reproducible, efficient protocol for primary human VS cell culture that allows for molecular and cellular experimental manipulation and analysis and recapitulates the heterogeneous nature of human disease.

Vestibular schwannomas (VSs) represent Schwann cell (SC) tumors of the vestibular nerve, compromising 10% of all intracranial neoplasms. VSs occur in ...

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.
Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.
The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because it offers a wide endoscopic view of the middle ear and a minimally invasive approach. The two main limitations are the loss of one operative hand and a narrow external auditory canal in younger children. Here, we present the case of a 3-year-old patient with a Potsic stage III congenital cholesteatoma adherent to the incus and branches of the stapes. A robotic-assisted TEES procedure was performed, during which a robotic arm with 6 degrees of freedom held a 0&#176;, 2.9 mm wide endoscope, enabling the surgeon to work in a narrow environment with both hands. The procedure's duration was 2 h and 9 min, including 16 min for the installation and draping of the robotic arm. After a trans-canal approach, the cholesteatoma was dissected from the ossicles using both a needle (or sickle knife) and suction to stabilize the ossicles and limit the risk of hearing trauma. The cholesteatoma was debulked to reduce its size, allowing it to be pushed under the malleus anteriorly and then separated from other adherences before removal. A tragal cartilage graft was used to reinforce the tympanic membrane.

This protocol describes the removal of congenital cholesteatoma using minimally invasive transcanal endoscopic ear surgery with a two-handed approach and a robotic endoscope holder.

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because ...

A Comprehensive Step-By-Step Guide for Exclusive Endoscopic Ossiculoplasty

Techniques of Endoscopic Ossiculoplasty

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This technique offers a panoramic view of the middle ear and provides an optimal magnification of the oval window region, the stapes' suprastructure, and the footplate, allowing great precision in prosthesis positioning during ossiculoplasty (OPL). Various techniques for ossicular chain reconstruction have been described in the literature. Either autologous or synthetic materials can be used for reconstruction. The use of a patient's own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the tympanic membrane. On the other hand, synthetic materials like titanium are light and rigid and do not require time-consuming prosthesis remodeling. The main objective of this article is to present a comprehensive step-by-step guide that serves as a surgical manual for exclusive endoscopic OPL. This guide will explain various forms of OPL using synthetic and autologous materials. The goal is to provide a comprehensive understanding of the various surgical techniques and support the integration into clinical practice.

Author Spotlight: Advancing Endoscopic Ossiculoplasty &#8211; Techniques, Innovations, and Practical Guidance for Clinical Integration

Exclusive Endoscopic ossiculoplasty (EEO) is a promising and minimally invasive approach for the treatment of conductive hearing loss due to ossicular chain disruptions and associated middle ear pathologies. Herein, step-by-step instructions and a discussion of various endoscopic ossiculoplasty techniques are presented.

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This ...

Treating Lumbar Spinal Stenosis with a Minimally Invasive Spine Surgery

Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ligaments. LSS encompasses central canal stenosis (CCS), lateral recess stenosis (LRS), and intervertebral foramen stenosis (IFS). The utilization of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained popularity in the treatment of CCS and LRS. This popularity is attributed to the rapid development of endoscopic instruments and the progress of endoscopic philosophy.
In this technical report, a detailed introduction to the steps and key points of LE-ULBD is provided. Simultaneously, a retrospective review of 132 consecutive patients who underwent LE-ULBD for central canal and/or lateral recess stenosis was conducted. The outcomes after more than two years of follow-up were assessed using the visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the modified MacNab criteria to evaluate surgical efficacy. All 132 patients underwent LE-ULBD successfully. Among them, 119 patients were rated as "excellent," while 13 patients were rated as "good" based on the modified MacNab criteria during the last follow-up. Incidental dural tears occurred in four cases, but there were no post-operative epidural hematomas or infections. The experience demonstrates that LE-ULBD is a less invasive, effective, and safe approach. It can be considered as an alternative option for treating patients with lumbar central canal stenosis and/or lateral recess stenosis.

Author Spotlight: Scope of LE-ULBD as a Safe, Effective, and Minimally Invasive Approach to Treat Lumbar Spinal Stenosis

The present protocol describes the steps and key points of lumbar endoscopic unilateral laminotomy for bilateral decompression for the treatment of degenerative lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ...

Synchronous Visualization of Thyroid Structural and Functional Information

Synchronous Triplanar Reconstruction Integrated with Color Doppler Mapping for Precise and Rapid Localization of Thyroid Lesions

This paper proposes a novel thyroid examination technique based on five-dimensional (5D) synchronous reconstruction of ultrasound data. The raw temporal sequences are reconstructed into 3D volumetric data reflecting anatomical structure. Triplanar visualization from three orthogonal planes is realized to provide a systematic inspection of the entire gland. Color Doppler imaging is integrated into each triplanar slice to map vascularity changes. This multi-modal fusion enables synchronous display of structural, functional, and blood flow information in the reconstructed 5D space. Compared to conventional scanning, this technique offers the benefits of flexible offline diagnosis, reduced dependency on scanning, enhanced intuitive interpretation, and comprehensive multi-aspect evaluation. By minimizing oversight errors, it could improve diagnostic accuracy, especially for novice practitioners. The proposed 5D fusion method allows rapid and precise localization of lesions for early detection. Future work will explore integration with biochemical markers to further improve diagnostic precision. The technique has considerable clinical value for advancing thyroid examination.

Author Spotlight: Integrating Ultrasound Imaging with Biochemical Markers for Thyroid Disease Diagnosis

Here we present a 5D ultrasound technique combining multi-planar 3D reconstruction and color Doppler fusion, which enables synchronous visualization of thyroid structural and functional information. By minimizing blind spots, this method allows rapid, precise localization of lesions to improve diagnostic accuracy, especially benefiting novice practitioners.

This paper proposes a novel thyroid examination technique based on five-dimensional (5D) synchronous reconstruction of ultrasound data. The raw temporal ...

Endoscopy from Kocher&#39;s Point Enabling Third Ventriculostomy and Pineal Biopsy

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the &lt;1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Author Spotlight: A Single-Entry Point Endoscopic Intraventricular Approach for Third Ventriculostomy and Pineal Biopsy

Pineal neoplasms frequently cause obstructive hydrocephalus and require histopathological diagnosis to decide the treatment regimen. They might be treated by surgical resection or chemoradiotherapy according to the pathological diagnosis. As a minimally invasive initial treatment, an endoscopic approach from Kocher's point enables both third ventriculostomy and biopsy.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain ...