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Surg Technol Int. 2017 Feb 7;30:103-112.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z.

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1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Varese-Como), Varese, Italy.
Division of Anesthesia, Ospedale di Circolo, Fondazione Macchi, Varese, Italy.
Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, Korea.
Minimally Invasive and Endocrine Surgery Division, Department of Surgery Police General Hospital, Bangkok, Thailand.


We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≥45mL, (3) nodule size ≥5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

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