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Trans-Oral Thyroid Surgery: How It's Done

Transoral thyroid surgery is one of two scarless thyroid operations that allows a thyroid mass, thyroid cancer, or thyroid nodule to be removed without leaving any scar on the neck. The technique of transoral thyroid surgery is discussed in depth, showing the instruments used and where the incisions are made inside of the mouth.

How is Scarless Transoral Thyroid Surgery Performed?

Transoral thyroid surgery is done under the general anesthesia which means that you are completely asleep comfortably during the entire procedure. Positioning is similar to traditional open surgery with the patient lying on their back on the operating room table. However, instead of making a large incision in the front of the neck like is done in traditional thyroid surgery, transoral thyroid surgery uses three minimally invasive incisions inside and under the lower lip. Incisions for transoral thyroid surgery A 1/2 inch (12 mm) incision is placed in the middle and two ~5mm incisions are made towards the side of the lower lip. Through these three incisions, an endoscopic camera and two endoscopic instruments are tunneled and inserted over the chin down to the lower neck where the thyroid gland is located.

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During this process, care is taken not to injure a sensory nerve known as the mental nerve which comes out over the chin on both sides. This nerve controls the sensation over the chin and lower lip. The location of the incision, size of the incision, and the placement of instruments can all contribute to injury to this sensory nerve which may result in temporary or even permanent numbness or tingling around the mouth or the lips. Only a few percent of the patient experience mild transient numbness and tingling which completely resolves in a few weeks. Permanent injuries are extremely rare. Care must be taken during the initial process of instrument placement. Certain modifications have been made in the transoral technique to minimize the risk of mental nerve injury. It is very important for you to chose a surgeon who performs transoral thyroid surgery frequently because the risk of complications decreases dramatically with more experience.

Once the camera and two endoscopic instruments are inserted, under direct visualization, adequate working space is developed under the skin over the lower neck area where the thyroid gland is located. Then, the thyroid gland is carefully dissected from the surrounding structures. As in all thyroid surgeries, identifying and preserving the recurrent laryngeal nerve which controls the vocal cord and the voice box is of paramount importance.

During the scarless transoral thyroid surgery, the recurrent laryngeal nerve is continually monitored using a nerve monitoring device throughout the surgery. Preservation of the recurrent laryngeal nerve function is key in maintaining a good voice quality after the surgery. Similar to the mental nerve injury, a few percentages of the patients may experience a temporary voice weakness or hoarseness which recovers spontaneously over a short period of time. Very rarely, you may experience a permanent nerve injury. Such injuries will be detected during the surgery using the nerve monitoring device and treated accordingly. Again, this occurs very rarely.

During thyroid surgeries, saving parathyroid glands and its function is also very important to prevent potentially mild to even life-threatening complications due to low parathyroid hormone and low calcium levels. Therefore, parathyroid glands are always identified early and carefully dissected off the thyroid gland. With a magnification of the endoscopic camera, parathyroid glands can be readily identified along with its blood supply which is equally important in preserving the function of the parathyroid glands.

With the recurrent laryngeal nerve and parathyroid glands in mind, the thyroid gland is fully mobilized off the surrounding structures such as the trachea (the airway, windpipe) and the esophagus (food pipe). Blood vessels are carefully sealed off using advanced endoscopic energy devices. Once the dissection is completed, the specimen is placed in a retrieval bag and removed through the middle incision. If needed, the middle incision is extended and/or dilated to facilitate the removal. Large specimens may be difficult to be removed through the small mucosal incision over the chin. Therefore, a large specimen may be removed through a separate incision such as an armpit or under the chin that is cosmetically appropriate. Three incisions are closed with natural gut sutures which dissolve quickly for comfort and healing. Other than the standard antibiotic before the surgery, no further antibiotics are needed after surgery. Oral rinse is performed before and after surgery. Typically, the patients go home the same day. You may be placed on a liquid diet for one day.

Transoral thyroid surgery incisions heal exceptionally well. Mucosa lining heals very quickly, and scars become invisible. Sutures placed along the mucosal incisions will dissolve over several days. You may experience some swelling and/or mild bruising over the chin and lower lip area. A compressive dressing such as an elastic tape or a chin strap may be applied to help with the healing. There is very minimal restriction after the surgery.