Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

Tsung-Jung Liang, I-Shu Chen, Shiuh-Inn Liu, Tsung-Jung Liang, I-Shu Chen, Shiuh-Inn Liu

Abstract

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Keywords: oral vestibule; parathyroidectomy; platysma muscle; robotic; transoral endoscopic thyroidectomy; working space.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Patient was placed in slight neck extension. The loose skin can be lifted (dotted line) after CO2 insufflation and provide sufficient working space for instrumentation.
Figure 2
Figure 2
Vestibular incision design in transoral thyroidectomy.
Figure 3
Figure 3
Chin perforation (arrow) by inadvertent use of Kelly clamp during central tract dissection.
Figure 4
Figure 4
Dissection is performed deeper at the periosteal level (asterisk) of the mandible.
Figure 5
Figure 5
Trocar insertion in transoral thyroidectomy. Trocars with small head are preferred and the left lateral trocar should be inserted a bit deeper to avoid inter-trocar interference (arrow). The venting side port should be turned away from center and faced outside (arrowhead) to eliminate collision.

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