Recently, the first thyroid removal through the mouth has been performed at national level. It is an intervention performed at the Hospital de Bellvitge by Dr. Pablo Moreno, head of the Endocrine Surgery Unit of this hospital.
What does the minimally invasive surgery of thyroid removal through the mouth consist of?
It is a minimally invasive surgical procedure called Transoral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA). It has been developed over the last three years and is proving to be as effective and safe as standard surgery, as well as adding an aesthetic superiority, as it leaves no visible scar on the patient’s neck. Although corroborating studies are still lacking, it seems that in the immediate postoperative period the patient has less pain sensation.
It is an operation performed with conventional endoscopic instruments. Three small incisions are made in the back of the lower lip to place the optics and instruments to perform the surgery. The thyroid gland, located in the lower part of the neck, is accessed from the anterior part of the chin. In this way, the scar is hidden because it is located inside the labial and buccal mucosa, inside the mouth.
This technique is currently applied to small thyroid tumors. Dr. Moreno explains that it has obvious advantages in terms of esthetic impact and postoperative quality of life.
Origins of the TOETVA technique and international applications
It is a technique that began to be used in Asia due to the fact that there it is still a problem or a cultural taboo to have a scar on the neck, whether in men or women. It is a stigma that causes women, for example, to have problems getting married and, in the case of men, to be associated with the fact that they are ex-convicts. This is why the technique has developed so much in Southeast Asia. Dr. Moreno trained there, specifically in Bangkok (Thailand), with Dr. Ang Koon Anuwong, a pioneer in this technique and with an experience of more than 900 cases.
The procedure is already performed in other countries such as the USA, Switzerland, Italy and Germany.
The first case operated by Dr. Moreno was performed last November on a patient with a benign 3cm lesion in the thyroid and a family history of thyroid nodules. She was discharged 24 hours after surgery.
Currently, Dr. Moreno has performed 14 cases with excellent results so far, although, as he says, we must be cautious. The key to success is proper patient selection, since not all patients are candidates for this approach.
Pathologies of the thyroid gland and special incidence in women
Thyroid diseases are very frequent, especially in women. In fact, it is estimated that one out of every two women over 50 years of age will have a thyroid nodule that we can see or palpate, as in the case of the patient operated on by Dr. Moreno, who states that the percentage between the sexes is 3 to 1 (3 women operated on for every man).
Gender determines, but there are also other factors that influence, such as heredity (family transmission), which can be accelerated or not depending on other environmental factors, diet, etc.
It is true that in recent years there has been an increase in thyroid pathologies, such as thyroid cancer. However, this is closely related to the fact that nowadays early diagnosis (and non-invasive imaging studies) make it possible to distinguish both small lesions and more aggressive cases. Thus, whereas years ago it was necessary to wait until the pathology was visible (goiter, for example) or clinical alterations were evident, such as hyperthyroidism or hypothyroidism, nowadays millimetric lesions can be discovered by chance when performing imaging studies.
Importance of the function of the thyroid and parathyroid glands
The thyroid and parathyroid glands are located in the lower part of the neck, in a very small but delicate anatomical area.
Anatomically it is a space enclosed between large vessels: the carotid arteries and jugular veins that are responsible for the vascularization of the head and neck, while containing the laryngeal nerves, whose injury can negatively alter the patient’s quality of life.
On the other hand, there are the parathyroid glands (usually numbering 4) which regulate calcium metabolism and are very susceptible to transient or permanent injury in the context of thyroid surgery. This is because they are 4-5 mm in size and weigh no more than 50 milligrams. Their permanent injury leads to a lack of calcium in the blood and generates a chronic disease that also causes serious problems in the quality of life of our patients.
Evolution of thyroid surgery
The evolution of thyroid surgery has been remarkable in recent years. Thus, we have gone from large incisions in the neck 7-10 cm to minimally invasive surgery. Dr. Moreno was a pioneer in our country in minimally invasive surgery, performing thyroidectomies and parathyroidectomies with incisions between 1.5 and 3 cm since 2002.
In 2005, Dr. Moreno also initiated a program of outpatient thyroid surgery, also a pioneer in Spain; currently, more than 400 outpatient thyroidectomies have been performed in which not only have there been no complications, but the patients have a high degree of satisfaction.
Dr. Moreno affirms that endocrine surgery is constantly evolving and that it is the obligation of Endocrine surgeons to seek and offer treatments that, while maintaining the safety and efficacy already achieved with conventional surgery, improve the quality of life of our patients and, why not, with a more favorable cosmetic effect. We are on the right track, but we must keep our common sense and not forget that the benefit must be for the patients.