Clinical Application Research Of Transoral Endoscopic Thyroidectomy Vestibular Approach

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The technique and advantage of TOETVA Objective:To discuss the surgical method,process and characteristics of transoral endoscopic thyroidectomy vestibular approach and to explain the surgical effect and cosmetic effect.Methods:A retrospective study was conducted on 198 patients who underwent endoscopic thyroid surgery in the thyroid surgery department of the first affiliated hospital of nanchang university from January 2015 to January 2020.The operative parameters and postoperative complications of 157 patients undergoing TOETVA were analyzed.The blood loss,infection rate,lymphatic dissection,cosmetic score and postoperative immune indexes(interleukin-6,c-reactive protein and cortisol)of 47 patients undergoing endoscopic radical thyroidectomy via oral vestibular approach and 41 patients undergoing radical thyroidectomy via breast and breast approach were compared.Results:1.General information: 157 patients received TOETVA.Nine were male and148 were female.The age range was 13-48 years(mean 30.11±7.83 years).There were 89 patients with grade 3,53 patients with grade 4 and 15 patients with grade 5.Eighty-three patients underwent unilateral TOETVA surgery,27 patients underwent bilateral TOETVA surgery,and 47 patients underwent radical TOETVA surgery.There were no significant differences in age,gender,and b-ultrasound score between the two groups(P > 0.05).2.There were 83(52.9%)patients who underwent unilateral TOETVA thyroid surgery,27(17.2%)patients who underwent bilateral TOETVA thyroid surgery,and47(29.9%)patients who underwent radical thyroidectomy via oral vestibular approach.3.Related complications after TOETVA: temporary hypothyroidism occurred in11 cases(7.0%),temporary recurrent laryngeal nerve(RLN)injury in 10 cases(6.4%),subcutaneous hematoma in 3 cases(1.9%),postoperative infection in 6 cases(3.8%),and subcutaneous scar traction in 1 case(0.6%).There was no permanent parathyroidism and no permanent RLN damage.No mental nerve injury,subcutaneous emphysema,trachea injury,esophageal injury,pneumothorax and other complications occurred.4.In the oral vestibular approach group vs the thoracic and breast approach group,there was less blood loss(P=0.02<0.05),more thorough lymph node dissection(P < 0.01),and higher postoperative beauty scores(P < 0.01).There was no significant difference in the incidence of surgical complications(temporary RLN injury,temporary parathyroid injury,subcutaneous hematoma and postoperative infection)(P > 0.05).5.The detection values of interleukin-6 in the oral vestibular approach group and the thoracic and breast approach group at 8h after the operation were different(P=0.02<0.05),the difference was statistically significant,and there was no significant difference in the detection values of interleukin-6,c-reactive protein and cortisol during the rest of the perioperative period(P > 0.05).Conclusion:TOETVA can achieve thyroid resection under the endoscope through natural channels,and there is no postoperative scar on the body surface,which can achieve a good cosmetic effect.Moreover,compared with other approaches of endoscopic thyroidectomy,the lymph nodes were more thoroughly dissected.It is the best minimally invasive endoscopic thyroid surgery with guaranteed safety and efficacy.Part? Safety of TOETVA Objective:To discusses the safety basis of TOETVA and the study of improving safety with intraoperative nerve monitoring.Methods:Statistical analysis was performed to compare the surgical parameters and complications of 35 cases of TOETVA + monitoring of recurrent laryngeal nerve and54 cases of TOETVA.The influence of patients with hashimoto's thyroiditis on the parameters of endoscopic thyroidectomy via vestibular approach was analyzed.Results:1.There was no difference in age,gender,surgical methods,number of recurrent laryngeal nerve exploration,and incidence of hashimoto's thyroiditis between the TOETVA+IONM group and the TOETVA group(P > 0.05).2.TOETVA+IONM group vs TOETVA group: shorter operation time(P < 0.01),less intraoperative blood loss(P=0.03 < 0.05),less postoperative drainage(P=0.001 <0.05),lower rate of recurrent laryngeal nerve injury,and no significant difference in the incidence of parathyroid gland injury(P=0.70 > 0.05).3.TOETVA with hashimoto vs TOETVA without hashimoto: the operation time was longer(P < 0.01),the rate of temporary recurrent laryngeal nerve injury was higher(P < 0.01),and there was no significant difference in the incidence of intraoperative blood loss,postoperative drainage volume and temporary parathyroid gland injury(P > 0.05).4.TOETVA+IONM with hashimoto vs TOETVA with hashimoto: shorter operative time(P=0.001 < 0.01),lower postoperative drainage rate(P=0.03 < 0.05),lower rate of recurrent laryngeal nerve injury(P=0.001 < 0.01),and no difference between intraoperative blood loss and the incidence of temporary parathyroid gland injury(P > 0.05).Conclusion:Endoscopic thyroidectomy through the vestibular approach is difficult for thyroid surgeons due to its narrow operation space and top-down vision.Especially for patients with hashimoto's thyroiditis,the application of intraoperative nerve monitoring technology can effectively prevent the injury of recurrent laryngeal nerve during the operation and effectively improve the safety of the operation.It also guarantees the experience of minimally invasive endoscopic surgery and rapid recovery of patients.Part ? Research on ERAS model of TOETVA Objective:To explore the feasibility,safety and application advantages of TOETVA with ERAS perioperative mode.Methods:By comparing TOETVA in the perioperative mode of 89 cases with TOETVA in the perioperative mode of 68 cases with conventional perioperative mode,the differences in perioperative complications,surgery appointment time,hospital stay,hospital expenses and patient satisfaction were analyzed and compared.Results:1.ERAS group vs conventional group: there was no significant difference in patients' age,gender,b-ultrasound score and surgical method(P > 0.05).2.There were no complications such as permanent hypothyroidism,permanent RLN injury,chin nerve injury,subcutaneous emphysema,tracheal injury,esophageal injury,pneumothorax in the ERAS group and the conventional group.There was no significant difference in the incidence of complications such as temporary thyroid function injury,temporary RLN injury,subcutaneous hematoma,postoperative infection,and subcutaneous scar traction(P > 0.05).3.ERAS group vs conventional group: shorter surgical appointment time,shorter hospitalization time,lower hospitalization cost and higher patient satisfaction(P < 0.01).Conclusion:Under ERAS perioperative mode,endoscopic thyroidectomy via oral vestibular approach has shorter appointment time,shorter hospitalization time,lower hospitalization cost and is more acceptable to younger patients.In such a short postoperative hospitalization observation,the complications did not increase,the safety can be guaranteed.With the rapid development of ERAS,more patients can get high-quality,safe,effective and timely treatment..