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经口腔前庭入路腔镜甲状腺手术规范化操作与并发症预防
Standardized operation and complication prevention in transoral endoscopic thyroidectomy via vestibular approach
经口腔前庭入路腔镜甲状腺手术（TOETVA）是近年来甲状腺外科发展较快的无体表瘢痕术式，在保证治疗效果的同时，兼具较好的美容效果和隐私保护优势。随着该术式的推广，围手术期操作规范化及并发症防控的重要性日益凸显。安全开展该术式有赖于严格把握适应证与禁忌证，完善口腔准备、预防性应用抗菌药物及麻醉配合，合理完成切口设计、腔隙建立和套管置入。术中应重视颏神经显露与保护、皮瓣分离层次选择、CO2压力控制、带状肌悬吊、甲状腺上极处理、喉返神经识别与热损伤预防、甲状旁腺保护、中央区操作、标本规范取出及引流管理等关键环节。其中，经“彭氏三角”定位喉返神经、规范止血、避免肿瘤种植及减轻唇周组织损伤，对提高手术安全性具有重要意义。感染、高碳酸血症、喉返神经损伤、甲状旁腺功能减退、出血、皮肤灼伤、淋巴漏及唇周麻木等并发症，均需在术前评估、术中精细操作和术后处理中实施针对性预防。严格遵循标准化流程，有助于降低并发症发生率，提高手术安全性和有效性，并进一步促进该术式规范开展。
Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is a rapidly developing scarless technique in thyroid surgery, offering favorable cosmetic and privacy benefits while maintaining therapeutic efficacy. With its broader adoption, standardized perioperative management and complication prevention have become increasingly important. Safe implementation of this procedure depends on strict selection of indications and contraindications, adequate oral preparation, prophylactic antibiotic use, close anesthesia coordination, and proper completion of incision design, working-space creation, and trocar placement. Intraoperative management should focus on mental nerve exposure and protection, proper flap dissection planes, carbon dioxide pressure control, strap muscle suspension, superior pole dissection, identification of the recurrent laryngeal nerve and prevention of thermal injury, preservation of the parathyroid glands, central compartment manipulation, standardized specimen retrieval, and drainage management. In particular, localization of the recurrent laryngeal nerve with the aid of “Peng’s triangle”, meticulous hemostasis, prevention of tumor implantation, and reduction of perioral tissue injury are crucial for operative safety. Complications including infection, hypercapnia, recurrent laryngeal nerve injury, hypoparathyroidism, bleeding, skin burns, lymphatic leakage, and perioral numbness should be prevented through targeted measures across the preoperative assessment, meticulous intraoperative operation, and postoperative management. Strict adherence to standardized procedures may reduce complication rates, improve surgical safety and efficacy, and further promote the standardized application of this technique.
经口腔前庭入路腔镜甲状腺手术 / 甲状腺手术 / 规范化操作 / 并发症预防 / 喉返神经 / 甲状旁腺
transoral endoscopic thyroidectomy via vestibular approach / thyroid surgery / standardized operation / complication prevention / recurrent laryngeal nerve / parathyroid gland
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Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars.To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT).This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias.Operative time, blood loss, and complications related to thyroid surgery.Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group.The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.
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中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会, 海峡两岸医药卫生交流协会台海甲状腺微创美容外科专家委员会, 等. 经口腔前庭入路腔镜甲状腺手术专家共识(2018版)[J]. 中国实用外科杂志, 2018, 38(10):1104-1107. DOI: 10.19538/j.cjps.issn1005-2208.2018.10.02.
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中国医师协会外科医师分会甲状腺外科专家工作组, 中国研究型医院学会甲状腺疾病专业委员会, 中国医疗保健国际交流促进会普通外科分会, 等. 全腔镜甲状腺手术中国专家共识(2025版)[J]. 中国实用外科杂志, 2025, 45(9):961-968. DOI: 10.19538/j.cjps.issn1005-2208.2025.09.01.
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马军杰, 王平. 经口入路腔镜甲状腺手术的现状及展望[J]. 中国普通外科杂志, 2023, 32(5):640-647.DOI: 10.7659/j.issn.1005-6947.2023.05.002.
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易亮, 柳泽洋, 彭小伟, 等. 经口腔前庭入路腔镜甲状腺手术适应证及禁忌证[J]. 中华耳鼻咽喉头颈外科杂志, 2020, 55(10):975-979.DOI:10.3760/cma.j.cn115330-20200507-00384.
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Transoral endoscopic thyroidectomy vestibular approach is the natural orifice surgery to avoid surgical scars. However, mental nerve injury is a characteristic complication. Herein, we report the development of a novel method to dissect the mental nerve proactively during surgery to minimize the morbidity from mental nerve injury.In this study, a total of 105 patients from June 2016 to February 2018 were categorized as the mental nerve dissection group (MND) or not mental nerve dissection group (NMND). We analyzed the demographics, operative data, hospital stay, pathologic results, and postoperative complications between the two groups.There were no significant differences with respect to age, gender, tumor size, extent of surgery, the amount of bleeding, or postoperative hospitalization between groups. The specimen removal time was shorter in the MND group. The average operation time in both groups was similar, but the operation time for a hemithyroidectomy with CND in the MND group was shorter than in the NMND group. The VAS pain scores and complication rates that included transient hypocalcemia, seroma, subcutaneous emphysema, transient, and permanent recurrent laryngeal nerve palsy did not differ significantly between groups. In terms of mental nerve injury, the morbidity rate in the MND group was lower than in the NMND group.The modified endoscopic thyroidectomy involving dissection of the mental nerve via the oral vestibular approach is safe and feasible. It is beneficial to protect the mental nerve and for specimen removal which is worth clinical promotion.
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李慧, 彭小伟, 李赞, 等. 改良经口入路腔镜甲状腺手术的临床应用分析[J]. 中华外科杂志, 2019, 57(9):686-690.DOI: 10.3760/cma.j.issn.0529-5815.2019.09.006.
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The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC.This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%).The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up.TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.
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侯建忠, 郭伯敏, 康杰, 等. 经口腔前庭入路与全乳晕入路腔镜单侧甲状腺癌手术的临床疗效比较[J]. 腹腔镜外科杂志, 2019, 24(8):561-565. DOI:CNKI:SUN:FQJW.0.2019-08-001.
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李武, 伍鹏, 李赞, 等. 经口腔前庭入路腔镜甲状腺手术并发症预防及处理: 单中心1941例及文献报道152例多中心数据分析[J]. 中国普通外科杂志, 2022, 31(11):1422-1429.DOI: 10.7659/j.issn.1005-6947.2022.11.002.
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To investigate the clinical efficacy and safety of endoscopic thyroidectomy through the oral vestibular approach and the breast approach. Retrospective analysis was done on clinical data of 80 patients who received an endoscopic thyroidectomy from April 2018 to March 2019. The research group had endoscopic thyroidectomy through the oral vestibular approach, whereas the control group had endoscopic thyroidectomy through the areola breast approach. Comparison between the two groups including intraoperative bleeding, operation time, total postoperative drainage, drainage time, postoperative sustained pain time, recovery feeding time, postoperative hospitalization duration, satisfactory esthetic outcomes of incision, central lymph node clearance, skin injury, infection incidence, and complications such as facial hematoma, subcutaneous emphysema, abnormal feeling of the neck and chest, and pleural injury was recorded. There was no significant difference between the two groups in the amount of intraoperative bleeding, operation time, total postoperative drainage, drainage time, postoperative sustained pain time, recovery feeding time, and postoperative hospitalization time (> .05). The incidence of complications such as skin injury, infection, wound hematoma, subcutaneous emphysema, abnormal feeling of the neck and chest, and pleural injury was not statistically different between the two groups (> .05). There was no significant difference in the number of lymph nodes cleaned in the central area between the two groups (> .05). The overall satisfaction of the patients with the cosmetic effects of the incision (100.00%) was higher than that of the control group (90.00%). The clinical treatment effect and safety in the two groups were similar, but the transoral group had better cosmetic effects.
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To report the clinical implications of an initial experience with transoral endoscopic thyroidectomy vestibular approach (TOETVA).From March to November 2017, five cases of TOETVA were performed. Data reported include patient demographics, indication for surgery, extent of surgery, operative time, the need to convert to cervicotomy, the length of hospital stay and post-operative pain and morbidity. Unconventional complications regarded as specific for TOETVA were reported. The burden of surgery on the patient's quality of life was evaluated using the 36-item short form (SF-36) health survey 1 month after surgery.All patients were females with a mean age of 36 years. They all underwent a right-sided hemithyroidectomy for a solitary thyroid nodule measuring on average 3.5 cm in size. The nodule was reported as Bethesda category II (n = 3), III (n = 1), and IV (n = 1) on fine needle aspiration cytology. The mean operative time was 122 min. Conversion to a transverse cervicotomy was required in one case. None of the patients developed post-operative bleeding, and none experienced vocal fold or mental nerve palsy. Surgical site infection did not occur. All patients developed subcutaneous emphysema that resolved within 12-48 h. All patients reported a long-standing bothersome pulling sensation along the surgical track that resulted in a poor outcome in some scales of the SF-36 survey. Flap perforation occurred in one case. The median VAS score was 3.Patients strongly motivated to undergo a novel surgical procedure tailored to their needs and desires should be properly counselled particularly regarding unconventional procedure-related complications.
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Transoral thyroidectomy is a kind of "natural orifice transluminal endoscopic surgery (NOTES)" which is now being performed in increasing frequency. However, the safety and feasibility have not been concluded yet.A systemic literature search was performed in Pubmed, Cochrane, and Embase databases to identify all studies written in English and published up to April 2017. The keywords used were "transoral endoscopic," "transoral robotic," "oral vestibular endoscopic," and "oral vestibular robotic" combined with "thyroidectomy" or "thyroid surgery."Ten articles containing 211 cases matched the review criteria. The weighted average operative time was 119.9 minutes with an average intraoperative blood loss of 35.5 mL while the weighted average length of hospital stay was 4.0 days. The overall conversion rate to open surgery was 1.9%. An overall incidence rate of temporary hypoparathyroidism was 7.1%, temporary recurrent laryngeal nerve injury was 4.3%, whereas of mental nerve palsy was 4.3%.According to those reviewed literatures, we can conclude that transoral thyroidectomy is safe and feasible in well-selected patients and offers good perioperative and postoperative outcomes.
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廖声有, 欧阳振福, 唐棻. 解剖颏神经单切口经口腔前庭入路腔镜甲状腺手术的应用价值[J]. 医学信息, 2022, 35(17):70-72. DOI:10.3969/j.issn.1006-1959.2022.17.017.
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艾青, 黄志恒, 江将, 等. 经口腔前庭入路腔镜甲状腺切除术中不放置引流的临床回顾性分析[J]. 岭南现代临床外科, 2025, 25(3):168-173. DOI:10.3969/j.issn.1009-976X.2025.03.004.
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