Following the ATA guidelines, all patients included in this study were <= 18 yr old. Between June and December 2020, four patients were admitted to the Department of Head and Neck Surgery and selected for the transoral approach. All these patients had a preoperative assessment, including thyroid hormonal level tests, neck ultrasound examination, and fine-needle aspiration (in line with The Bethesda System for Reporting Thyroid Cytopathology:TBSRTC).
Inclusion criteria for TOETVA were as follows: (1) thyroid nodule (TBSRTC II-IV) <= 6 cm in size; (2) thyroid nodule (TBSRTC V-VI) <= 2 cm in size with no lymph node involvement; (3) total size of thyroid gland <= 10 cm in diameter per lobe.
Contraindications for TOETVA included (1) previous anterior neck surgery, (2) tracheal or esophageal invasion, (3) previous radiation to the head or neck, (4) recurrent laryngeal nerve palsy, (5) oral cavity infection, (6) uncontrolled hyperthyroidism, and (7) patients under 10 years of age or less than 30 kg of weight.
The surgical steps have been described in previous publications and are based on Anuwoong's technique. In brief, the patients were placed in a supine position. After intubation, three incisions were made in the oral vestibule for the insertion of endoscopic 5-10 mm trocars. To insert a 30-degree endoscope, a 5-mm central trocar is recommended, especially for pediatric patients. Working space was then created by using a hook cautery and/or an ultrasonic scalpel. Next, the strap muscles were retracted laterally with a transcutaneous suture. The pyramidal lobe was dissected and separated from the trachea. The isthmus was then divided, and the superior thyroid vessels were dissected and divided using an energy device. The upper parathyroid gland and then the recurrent laryngeal nerve (RLN) were identified. The thyroid lobe was dissected from the trachea and the RLN while preserving the lower parathyroid. The specimen was put into an Endo Catch bag and removed via a central incision (Figure 1).