Scarless Surgery

Clinical Indications for Transoral

Endocrine Surgery and Implications for
Pathologists
Jordan M. Broekhuis, MDa,b, Benjamin C. James, MD, MSa,b,
Raymon H. Grogan, MD, MSc,*

KEYWORDS
 Transoral endocrine surgery  Thyroid cancer  Remote access surgery  Endocrine surgery
 Transoral endoscopic thyroidectomy vestibular approach

Key points
 Transoral endocrine surgery (TES) refers to the endoscopic approach to thyroidectomy and parathy-
roidectomy via incisions in the oral vestibule.
 The oral vestibular incisions are small, which can limit the size of surgical specimen that can be
removed while avoiding fracture and fragmentation.
 Existing observational data suggest TES for parathyroidectomy and thyroidectomy has similar compli-
cation profiles compared with open approaches and may result in improved quality of life and satis-
faction outcomes for patients.

ABSTRACT and bilateral axillo-breast approaches, have been

T
ransoral endocrine surgery (TES) is a scar-
less approach to thyroidectomy and para-
thyroidectomy for well-selected patients.
Criteria for the TES approach to thyroidectomy
include thyroid diameter less than or equal to
10 cm, benign nodule less than or equal to 6 cm,
or confirmed or suspected malignant nodule less
than or equal to 2 cm. Although fragmentation of
surgical specimens has been reported in TES,
additional studies are needed to evaluate the im-
plications of TES on pathologic examination.
OVERVIEW
Transoral endocrine surgery (TES) represents one
of the several remote-access approaches to sur-
gery of the thyroid and parathyroid glands.1 These
approaches, which also include the transaxillary
proposed with the goal of eliminating the cervical
scar. Although the term “transoral endocrine sur-
gery” is used broadly to describe thyroid and para-
thyroid operations performed via incisions in the
oral vestibule, the technical terms for these opera-
tions include transoral endoscopic thyroidectomy
vestibular approach and transoral endoscopic
parathyroidectomy vestibular approach.
Of the remote-access approaches to thyroid
and parathyroid operations, transoral endocrine
surgery has emerged as the preferred approach
for some patients and surgeons, given the lack of
required cutaneous incision and relatively short
distance required for creation of a subcutaneous
flap compared with other approaches. Use of the
transoral approach has increased in Asia and
among select high-volume centers in the United
States, and data from these centers suggest
similar rates of surgical complications.2 In addi-
tion, the elimination of a cutaneous scar may be
surgpath.theclinics.com

a
Harvard Medical School, Boston, MA, USA; b Department of Surgery, Beth Israel Deaconess Medical Center,
330 Brookline Ave, Boston, MA 02215, USA; c Michael E. DeBakey Department of Surgery, Baylor College of
Medicine, 7200 Cambridge Street, 7th Floor, Room A07-103, Houston, TX 77030, USA
* Corresponding author.
E-mail address: rgrogan@bcm.edu

Surgical Pathology 16 (2023) 163–166

https://doi.org/10.1016/j.path.2022.10.002
1875-9181/23/Ó 2022 Elsevier Inc. All rights reserved.
164 Broekhuis et al
preferable to many patients compared with the
cervical approach and may be associated with
improved quality of life outcomes.3,4 Society
guidelines regarding remote-access endocrine
operations contain broad statements recommend-
ing that the operation should only be performed by
high-volume, experienced surgeons.5,6 An addi-
tional consideration in applying TES is how and
when it can be used in cases of known or sus-
pected malignancy. Although data are limited, rec-
ommendations have been proposed based on
observational data and expert opinion.
Although uptake of transoral endocrine surgery
is limited by a substantial learning curve and
increased operative time,7 this approach has
grown in popularity in Asia and select US centers,
and thus familiarity of this approach and its impli-
cations for clinical pathology have become impor-
tant for pathologists. In this article, the authors
review the general approach to TES, its applica-
tions in thyroid and parathyroid surgery, and exist-
ing data informing the implications of these
approaches for pathologists.
OPERATIVE APPROACH
The operative approach to transoral endocrine
surgery has been extensively described else-
where.8 Here the authors provide an abbreviated
summary with emphasis on implications for the
surgical and pathologic outcomes described in
this article.
Incisions are made on the inner lower lip: a sin-
gle 5-mm transverse midline incision and 2 stab in-
cisions lateral to the first premolars. Access to the
subplatysmal space is gained via the midline port,
and this space is dilated before placement of a to-
tal of three 5-mm ports. The midline strap muscles
are divided and the thyroid isthmus transected.
The superior, middle, and lower thyroid vessels
are ligated with careful attention to preservation
of the recurrent laryngeal nerve. The ligament of
Berry is then divided, which frees the thyroid
completely from the trachea and surrounding
structures. Once the thyroid is resected, the sur-
geon dilates the central port up to 2 cm in diam-
eter, a bag is placed into the dissection space
through this port, and the specimen is removed
intact inside the bag.
SOCIETAL GUIDELINES AND EXPERT
CONSENSUS ON APPLICATIONS OF
TRANSORAL ENDOCRINE SURGERY
Society guidelines addressing remote-access ap-
proaches to endocrine surgery contain broad
statements about their use and generally do not
address specific indications. At the time of a
recently published statement by the American
Thyroid Association in 2016 on remote-access
thyroid surgery, TES was not yet in use in the
United States.6 However, this statement broadly
addressed remote access approaches and noted
that questions remained regarding operative
times, learning curves, and cost. The American
Thyroid Association (ATA) recommended that
alternative approaches to thyroidectomy (such as
TES) could be performed as long as strict selection
criteria were met and a high-volume surgeon with
experience in the alternative approach was doing
the procedure.
In 2020, the American Association of Endocrine
Surgeons released guidelines for the surgical man-
agement of thyroid disease in adults. These guide-
lines similarly acknowledged the limited data on
improved patient satisfaction and cosmetic results
for remote-access endocrine operations and rec-
ommended that remote-access thyroidectomy
be applied in “carefully selected patients, by sur-
geons experienced in the approach.”5
In addition, recommendations for applications
of TES based on expert opinion have been sug-
gested in the literature. For applications in thyroid-
ectomy, it has been recommended that TES be
applied in patients highly motivated to avoid a
cutaneous scar who otherwise meet ATA guide-
lines for lobectomy or total thyroidectomy.9 Sug-
gested inclusion criteria include the following: (1)
history of hypertrophic scarring or desire to avoid
anterior neck scar; (2) maximum thyroid lobe
dimension less than or equal to 10 cm or volume
less than or equal to 45 mL; (3) benign or indeter-
minate nodule of size less than or equal to 6 cm; (4)
suspicious or malignant nodule of size less than or
equal to 2 cm; and (5) substernal goiter above the
aortic arch.10,11 TES has also been applied in
cases of symptomatic goiter and Grave disease
or Hashimoto thyroiditis within the aforementioned
size constraints.11 Suggested exclusion criteria
include the following: (1) poorly differentiated or
anaplastic carcinoma; (2) central neck, lateral
neck, or extrathyroidal involvement; (3) known
recurrent laryngeal nerve injury; (4) prior transcer-
vical neck surgery; (5) oral abscess; and (6) general
inability to tolerate surgery or undergo
anesthesia.11
Application of TES to central neck dissection is
limited to cases of small thyroid cancers as dis-
cussed earlier, in which evidence of clinical nodal
metastasis is identified at the time of surgery.
Furthermore, central neck dissection should only
be considered by surgeons with sufficient TES
experience. TES is not currently considered
appropriate for dissection of the lateral neck. In

the case of thyroid malignancies, the importance
of removing the surgical specimen intact repre-
sents a particular challenge in TES, given the small
oral vestibular incisions.
Application of TES for parathyroidectomy is less
well described, but TES is generally considered an
option in cases of primary hyperparathyroidism.
Currently secondary and tertiary hyperparathy-
roidism are considered relative contraindications
to the procedure. Although nonlocalized ade-
nomas and multigland hyperplasia have not been
suggested to be strict contraindications to TES,
a single adenoma that has been localized by pre-
operative imaging is thought to be the ideal appli-
cation of TES.12 In addition, parathyroidectomy of
the inferior glands is thought to be less technically
challenging compared with the superior glands, as
visualization of the lower aspect of the neck is
more accessible with the angle of the camera.
TES is not recommended in cases of suspected
or confirmed parathyroid carcinoma.
EVIDENCE FROM OBSERVATIONAL DATA
Surgical Complications
Since TES was originally described in 2015, it is
estimated that at the time of writing there have
been more than 5000 cases done worldwide
including more than 700 in the United States. A
recent review of 689 transoral thyroidectomies
found that 99% of cases did not require conver-
sion to an open cervical approach but did require
longer operative times compared with the open
approach.13 There were no identified cases of per-
manent recurrent laryngeal or mental nerve injury
and very low rates of hematoma (0.1%) and neck
infection (0.1%).
A recent prospective multiinstitutional observa-
tional study of 101 consecutive transoral parathy-
roidectomies found this approach to be safe and
efficacious.2 This study, which included patients
with primary hyperparathyroidism who had a sin-
gle, well-localized adenomas on at least 2 preop-
erative imaging studies reported a success rate
of 98% by immediate normalization of PTH.
Furthermore, there were no reported cases of per-
manent recurrent laryngeal nerve injury or hypo-
parathyroidism. This study emphasizes the safe
application of TES for parathyroidectomy, espe-
cially in cases of single, well-localized adenomas.
Implications for Pathologic Evaluation
The most prominent implication of TES for pathol-
ogists is the removal of pathologic specimens via
the small incisions in the oral vestibule. It is impor-
tant to note that removing the specimen intact de-
pends on 2 variables, namely the size of the
Scarless Thyroid Surgery 165
midline opening that is created and the size of
the specimen. The midline opening in the begin-
ning of the operation is usually between 5 and
10 mm; however, it is possible to dilate this open-
ing to 2 cm without negative effects on chin cosm-
esis. Because the thyroid is relatively soft and
pliable, a specimen larger than 2 cm can be
extracted intact through a 2 cm opening; however,
it is not clear how large that cutoff is or should be.
There are also alternative means of removing the
specimen. Very limited data exist examining path-
ologic outcomes in TES. However, one recent
study evaluated 50 cases of transoral thyroidec-
tomies for a mean nodule size of 2.6 cm.14 Of
these 50 cases, 34 (68%) reported disruption or
fragmentation of the pathologic specimen,
although a final diagnosis was achieved in all
cases. However, there were 2 cases of papillary
carcinomas in which tumor size, microscopic
extrathyroidal extension, and margin status could
not be determined. An additional small study of
27 cases applied receiver operating characteristic
analysis to estimate the safest nodular diameter of
2 cm in order to avoid piecemeal removal.15 Over-
all, guidelines suggest that a relative cutoff of 2.0
to 2.5 cm be used for removal of well-
differentiated thyroid cancers due to the concern
of specimen disruption during extraction. It is likely
that even larger cancer specimens can be
extracted without any negative impact on histolog-
ic diagnosis; however, data are sparse. As the use
of TES increases, additional larger studies of the
impact of these operations on pathologic speci-
mens are needed to determine to what extent
these cases of fragmentation may be eliminated
as surgeons gain more experience in this
approach.
UPTAKE OF TRANSORAL ENDOCRINE
SURGERY APPROACHES
The uptake of TES in the United States has been
limited by several factors, including its learning
curve and access to appropriate training in the
technique. In addition, recent restrictions of elec-
tive operations as a result of the COVID-19
pandemic have likely limited the use of TES as
well as the ability to train surgeons on its use. An
additional proposed reason for the limited uptake
of TES is the limited, select group of patients
who meet the criteria required for TES. However,
a recent cross-sectional study of 1000 consecu-
tive thyroid and parathyroid operations found
that 55.8% were eligible for TES based on eligi-
bility criteria as described earlier.16 As time allows
for more surgeons to be trained in this technique
166 Broekhuis et al
pathologists may begin to see more cases of path-
ologic specimens from TES operations.
SUMMARY
TES is an approach to thyroid and parathyroid sur-
gery that eliminates the cutaneous scar and may
provide superior patient satisfaction and quality
of life outcomes in well-selected patients. Careful
consideration of eligibility for this approach based
on the criteria described earlier is important for the
application of TES. The pathologic examination of
surgical specimens obtained during TES is an
additional important consideration, given the size
of the oral vestibular incisions and previously
described limitations in the setting of specimen
fracture or fragmentation. Larger studies evalu-
ating the extend of nodal harvest and successful
pathologic evaluation are needed.
CLINICS CARE POINTS
 TES refers to the endoscopic approach to thy-
roidectomy and parathyroidectomy via inci-
sions in the oral vestibule.
 The oral vestibular incisions are small, which
can limit the size of surgical specimen that
can be removed while avoiding fracture and
fragmentation.
 Existing observational data suggest TES for
parathyroidectomy and thyroidectomy has
similar complication profiles compared with
open approaches and may result in improved
quality of life and satisfaction outcomes for
patients.
DISCLOSURE
R.H. Grogan received consulting fees from Med-
tronic. The remaining authors have no personal
or financial potential conflicts of interest to
disclose.
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