The number of TOETVA surgeries has increased worldwide but the anatomical passage of trocars is not clearly defined. We aimed to define detailed surgical anatomical passage of the trocars in cadavers. The incisions in oral vestibule, anatomical pathways of trocars, affected mimetic muscles, neurovascular relations of trocars and histological correlation of surgical anatomy were investigated.
Four cadavers and 6 six patient oral vestibules were used. The locations of optimised vestibular incisions were measured photogrammetrically. Initial steps of TOETVA surgery were performed on cadavers according to those optimal incisions. TOETVA preformed cadavers dissected to determine anatomical passages of the trocars. Afterwards, flap of lower lip and chin were zoned by software appropriate to the trocars routes. Histological analyses of the zones were made in correlation with dissections.
Mimetic muscles associated with median (MT) and lateral trocars (LT) are orbicularis oris, mentalis, depressor anguli oris, depressor labii inferioris and platysma muscles. Trocars affect mimetic muscles in the perioral, chin and submental regions in different ways. The risk of mental nerve injury by MT is low. LT pass through the DLI muscle. The transmission of LT to the subplatysmal plane in the submental regions can be in two different ways. The arterial injury risk is higher with LT than the MT.
The surgical anatomy of the perioral, chin and submental regions for the initial TOETVA steps has been defined. Detailed surgical anatomical passages of the MT and LT were determined. Anatomical pattern to reach subplatysmal plane are presented. Mimetic muscles effected by trocars were determined. Endocrine surgeons should know the anatomical passage of TOETVA trocars.
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Witzel K, von Rahden BH, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22:1871–1875
Benhidjeb T, Wilhelm T, Harlaar J, Kleinrensink GJ, Schneider TA, Stark M (2009) Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 23:1119–1120
Karakas E, Steinfeldt T, Gockel A, Schlosshauer T, Dietz C, Jager J, Westermann R, Sommer F, Richard HR, Exner C, Sesterhenn AM, Bartsch DK (2011) Transoral thyroid and parathyroid surgery—development of a new transoral technique. Surgery 150:108–115
Wilhelm T, Harlaar JJ, Kerver A, Kleinrensink GJ, Benhidjeb T (2010) Surgical anatomy of the floor of the oral cavity and the cervical spaces as a rationale for trans-oral, minimal-invasive endoscopic surgical procedures: results of anatomical studies. Eur Arch Otorhinolaryngol 267:1285–1290
Karakas E, Steinfeldt T, Gockel A, Westermann R, Kiefer A, Bartsch DK (2010) Transoral thyroid and parathyroid surgery. Surg Endosc 24:1261–1267
Wang C, Zhai H, Liu W, Li J, Yang J, Hu Y, Huang J, Yang W, Pan Y, Ding H (2014) Thyroidectomy: a novel endoscopic oral vestibular approach. Surgery 155:33–38
Makay O, Dionigi G, Celik S (2018) Scarless Thyroidectomy-Atlas of TOETVA (Transoral Endoscopic Thyroidectomy Vestibular Approach) (Turkish: İzsiz Tiroidektomi Vestibüler Yaklaşim ile Transoral Endoskopik Tiroidektomi TOETVA Atlası), 1st edn. İstanbul Tıp Kitabevleri, İstanbul
Wilhelm T, Metzig A (2010) Video. Endoscopic minimally invasive thyroidectomy: first clinical experience. Surg Endosc 24:1757–1758
Wilhelm T, Metzig A (2011) Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J Surg 35:543–551
Richmon JD, Holsinger FC, Kandil E, Moore MW, Garcia JA, Tufano RP (2011) Transoral robotic-assisted thyroidectomy with central neck dissection: preclinical cadaver feasibility study and proposed surgical technique. J Robot Surg 5:279–282
Lee HY, Hwang SB, Ahn KM, Lee JB, Bae JW, Kim HY (2014) The safety of transoral periosteal thyroidectomy: results of Swine models. J Laparoendosc Adv Surg Tech A 24:312–317
Anuwong A (2016) Transoral Endoscopic Thyroidectomy Vestibular Approach: a series of the first 60 human cases. World J Surg 40:491–497
Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY (2018) Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg 153:21–27
Jitpratoom P, Ketwong K, Sasanakietkul T, Anuwong A (2016) Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves’ disease: a comparison of surgical results with open thyroidectomy. Gland Surg 5:546–552
Yang J, Wang C, Li J, Yang W, Cao G, Wong HM, Zhai H, Liu W (2015) Complete endoscopic thyroidectomy via oral vestibular approach versus areola approach for treatment of thyroid diseases. J Laparoendosc Adv Surg Tech A 25:470–476
Dionigi G, Chai YJ, Tufano RP, Anuwong A, Kim HY (2018) Transoral endoscopic thyroidectomy via a vestibular approach: why and how? Endocrine 59:275–279
Dionigi G, Bacuzzi A, Lavazza M, Inversini D, Boni L, Rausei S, Kim HY, Anuwong A (2017) Transoral endoscopic thyroidectomy: preliminary experience in Italy. Updates Surg 69:225–234
Dionigi G, Lavazza M, Wu CW, Sun H, Liu X, Tufano RP, Kim HY, Richmon JD, Anuwong A (2017) Transoral thyroidectomy: why is it needed? Gland Surg 6:272–276
Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, Richmon JD (2018) Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc 32:456–465
Dionigi G, Lavazza M, Bacuzzi A, Inversini D, Pappalardo V, Tufano R, Kim HY, Anuwong A (2017) Transoral endoscopic thyroidectomy vestibular approach (TOETVA): from A to Z. Surg Technol Int 30:103–112
Bilge O, Celik S (2017) Cadaver embalming fluid for surgical training courses: modified Larssen solution. Surg Radiol Anat 39:1263–1272
Richmon JD, Pattani KM, Benhidjeb T, Tufano RP (2011) Transoral robotic-assisted thyroidectomy: a preclinical feasibility study in 2 cadavers. Head Neck 33:330–333
Anuwong A, Kim HY, Dionigi G (2017) Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences. Gland Surg 6:277–284
Inabnet WB 3rd, Fernandez-Ranvier G, Suh H (2018) Transoral endoscopic thyroidectomy—an emerging remote access technique for thyroid excision. JAMA Surg 153:376–377
Karakas E, Anuwong A, Ketwong K, Kounnamas A, Schopf S, Klein G (2018) Transoral thyroid and parathyroid surgery: implementation and evaluation of the transoral endoscopic technique via the vestibular approach (TOETVA). Chirurg 89:537–544
Clark JH, Kim HY, Richmon JD (2015) Transoral robotic thyroid surgery. Gland Surg 4:429–434
Lee HY, Richmon JD, Walvekar RR, Holsinger C, Kim HY (2015) Robotic transoral periosteal thyroidectomy (TOPOT): experience in two cadavers. J Laparoendosc Adv Surg Tech A 25:139–142
Bakkar S, Al Hyari M, Naghawi M, Corsini C, Miccoli P (2018) Transoral thyroidectomy: a viable surgical option with unprecedented complications—a case series. J Endocrinol Invest 41:809–813
Zhang M, Xie Q, Wang Y, Wang P (2017) Surgical anatomy for transoral endoscopic thyroid surgery through vestibular approach (TOETVA). Ann Thyr 2:1–7
Nakajo A, Arima H, Hirata M, Mizoguchi T, Kijima Y, Mori S, Ishigami S, Ueno S, Yoshinaka H, Natsugoe S (2013) Trans-oral video-assisted neck surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc 27:1105–1110
Park JO, Kim MR, Kim DH, Lee DK (2016) Transoral endoscopic thyroidectomy via the trivestibular route. Ann Surg Treat Res 91:269–272
Kim HJ, Hu KS, Kang MK, Hwang K, Chung IH (2001) Decussation patterns of the platysma in Koreans. Br J Plast Surg 54:400–402
Hwang K, Jin S, Hwang SH, Chung IH (2006) Innervation of upper orbicularis oris muscle. J Craniofac Surg 17:1116–1117
Mitsukawa N, Moriyama H, Shiozawa K, Satoh K (2014) Study on distribution of terminal branches of the facial nerve in mimetic muscles (orbicularis oculi muscle and orbicularis oris muscle). Ann Plast Surg 72:71–74
Saylam C, Ucerler H, Orhan M, Uckan A, Ozek C (2007) Localization of the marginal mandibular branch of the facial nerve. J Craniofac Surg 18:137–142
Batra AP, Mahajan A, Gupta K (2010) Marginal mandibular branch of the facial nerve: an anatomical study. Indian J Plast Surg 43:60–64
Cai C, Huang Y, Zhang T, Chai L, Wang G, Shi L, Wiegand S, Güldner C, Günzel T, Wilhelm T (2015) Anatomical study of surgical approaches for minimally invasive transoral thyroidectomy: eMIT and TOPP. Minim Invasive Ther Allied Technol 24:340–344
Alsaad K, Lee TC, McCartan B (2003) An anatomical study of the cutaneous branches of the mental nerve. Int J Oral Maxillofac Surg 32:325–333
Drs. Servet Celik, Ozer Makay, Mustafa Deniz Yoruk, Ilke Bayzit Kocer, Murat Ozdemir, Kubilay Dogan Kilic, Canberk Tomruk, Okan Bilge, Yigit Uyanikgil and Gianlorenzo Dionigi declare that they have no conflicts of interest or financial ties to disclose.
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Celik, S., Makay, O., Yoruk, M.D. et al. A surgical and anatomo-histological study on Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). Surg Endosc 34, 1088–1102 (2020). https://doi.org/10.1007/s00464-019-06856-1
- Surgical anatomy
- Histological preparation
- Oral vestibule
- Perioral and chin region
- Mimetic muscles