Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) procedure

The thyroid gland is a small butterfly-shaped gland in the neck, just in front of the windpipe (trachea). Its main job is to control metabolism — how our bodies use energy, by making and releasing hormones (chemicals that control some of the actions of cells and organs) into the bloodstream.

Sometimes it is necessary to remove part or all of the thyroid gland to treat certain conditions. This is called thyroidectomy. The standard way of doing this is through an incision (cut) through the skin and muscles in the neck. The Transoral Endoscopic Thyroidectomy Vestibular Approach allows the surgeon to operate on the thyroid gland using a endoscope (a thin tube-like instrument with a camera on the end and a channel inside through which surgical tools can be inserted) which instead is passed through small cuts on the inner surface of the lower lip and slipped under the skin of the chin and neck down to the thyroid gland. This type of operation is known as a minimally invasive procedure.

The TOETVA procedure can be used to treat many but not all types of thyroid conditions. It has been developed over ten years into an established procedure but is new to us here at University College Hospital. Our surgeons have been fully trained and are now able to offer this procedure to suitable patients needing thyroid surgery.

The standard thyroidectomy procedure leaves a scar on the neck. In most people this fades with time and becomes quite feint but will still be visible. In a small number of people the scar does not fade as much, and it can also be thickened and raised (a ‘hypertrophic’ or ‘keloid’ scar). The TOETVA procedure leaves no scars, and the cuts on the inner surface of the lower lip completely heal leaving no sign of the surgery.

Above - Scar on neck after standard thyroidectomy (would be expected to fade further over time)

Above - Healed cuts in inner lip two weeks after TOETVA 

The TOETVA procedure is known to be as safe and as effective as standard thyroidectomy.

The TOETVA procedure is a thyroidectomy operation but through remote access instead of the cut through the skin across the lower part of the neck. Similar to a conventional thyroidectomy operation, there are  

All treatments and procedures have risks.  

A recent high quality research article has reported on 1085 patients who have TOETVA procedure comparing the risks to 1085 patients who have had a conventional thyroidectomy. The results have shown that the risks were comparable particularly with voice change, recurrent laryngeal nerve injury, hypocalcaemia and blood loss during surgery. The operative time was slightly longer in the TOETVA group as was the length of stay in hospital.  

There was a temporary risk of mental nerve injury which can cause some abnormal sensation over the skin of the lower lip, gum and teeth. The reports have shown that there have been no permanent damage.

Problems that may happen straight away

The main risk here is bleeding or development of a large swelling that could interfere with breathing. The studies have shown that this risk is quite small and not higher than in conventional thyroidectomy.

Problems that may happen later

The main risk here is voice change and/or low calcium levels. Again, these risks are not higher than in a conventional thyroidectomy.

Problems that are rare, but serious

Burns to the skin over the chin area are very rare but could happen with TOETVA.

If you choose not to have the TOETVA procedure we will rediscuss suitable alternative treatments with you (see below).

For most patients surgery is the treatment of choice. If you do not wish to have the TOETVA procedure it is most likely we will recommend the conventional  thyroidectomy procedure. As described above, this involves removal of the thyroid tissue through an incision (cut in the neck). We have a separate Patient Information Leaflet which gives more information about this. 

There are other alternative treatments available, but these are not suitable for all patients or all conditions. We will discuss any that are possible options with you. 

Patients who have Graves’ disease (an immune condition which makes the thyroid gland make too much thyroid hormone) can be treated with drugs, but these have side effects and are not advisable in the long-term. Sometimes Graves’ disease can be treated with radioactive iodine (a special type of radiotherapy). An Endocrinologist (a doctor who specialises in hormone conditions) would be able to further advise you on these treatments. 

Radiofrequency ablation (a treatment that uses heat made by radio waves to destroy tissue) can sometimes be used to shrink large benign (non-cancerous) nodules (tissue lumps) in the thyroid to relieve pressure symptoms and improve appearance. We will discuss this treatment with you if it is an option for you.

Before your operation we will arrange for you to attend a pre-assessment appointment. You will be asked for details of your medical and medication history, and we will carry out some tests to make sure you are fit for the anaesthetic (the drugs and procedure that are used to keep you asleep during the operation) and the operation itself. Staff in the Pre-Assessment Clinic will tell you how to prepare for the operation, when to stop eating and drinking beforehand, and about the admission process.

The day of surgery

You will be admitted to hospital on the day of your surgery. You will meet a member of the Anaesthetic team and a member of the Surgical team before the operation. They will again explain the risks of the anaesthetic and the risks and benefits of the TOETVA procedure, and then will ask for your consent.

It is important that you are fully involved in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign the consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak with a senior member of staff again.  

Sometimes we may also ask you for your consent to include you in research projects. If this is the case, we will discuss this with you in detail beforehand.

This is an operation under a general anaesthetic. The patient will be completely asleep during the operation. 

The patient's neck is extended to facilitate the approach to the thyroid gland, and the oral cavity is prepared with antiseptic solution to minimize the risk of infection. The TOETVA procedure begins with three incisions: two lateral and one central, all within the lower lip's inner aspect, hidden inside the oral vestibule. These incisions are typically less than 1 cm in length and are strategically placed to minimize trauma to oral structures and provide optimal access to the thyroid gland. These incisions are used for trocars placement: the 10 mm trocar is central and the two 5 mm trocars are lateral. Blunt dissection is used to create a subplatysmal working space, which is expanded using dilators or insufflation with carbon dioxide to improve visibility and provide room for instrument manipulation. This working space extends from the chin to the sternal notch, and laterally to the sternocleidomastoid muscles on either side. The midline approach helps to minimize the risk of injury to the lateral neurovascular structures.

The strap muscles are identified and separated along the midline raphe to expose the thyroid gland. Careful attention is paid to preserve the integrity and vascular supply of the strap muscles for re-approximation during closure. Using laparoscopic instruments through the vestibular incisions, the surgeon begins careful dissection of the thyroid gland. Haemostasis is meticulously maintained using energy devices or clips to control blood vessels. The recurrent laryngeal nerve and parathyroid glands are identified and preserved. The thyroid lobectomy or total thyroidectomy is performed based on the preoperative indications.

Once the thyroid gland or lobes are dissected, they are placed in an endoscopic bag to avoid seeding of the working space and removed through one of the vestibular incisions. After ensuring complete haemostasis, the strap muscles are reapproximated, and the subplatysmal space is deflated. The oral vestibule incisions are then closed with absorbable sutures. The oral cavity is maintained with antiseptic mouthwash to reduce the risk of infection. Postoperative analgesia is managed according to UCLH protocol.

After the operation you will wake up in the Recovery Room. You will have an elasticated pressure dressing covering your chin and neck to help reduce swelling and bruising and an intravenous drip (a soft, thin tube into a vein through which fluids and medications can be given) in your arm. You may also have an oxygen mask on your face or small oxygen tubes in your nostrils until the sleepiness wears off. A Recovery nurse will look after you until you are ready to go to the ward. 

Once you are fully awake we will give you some water to drink to check you can swallow normally (very rarely the operation can temporarily affect swallowing) after which you will be able to eat and drink as you wish. 

Pain is usually only mild. Tell the nurses if you have pain and they will be able to give you medicine for this. 

Straight after the operation you may have a mildly sore throat, a slightly hoarse (scratchy) voice and/or stiff neck. These are normal side-effects and should go away within a few days. 

You will start taking a course of antibiotics which you will need to take for five to seven days. This is to prevent bacteria in the mouth causing an infection in the cuts on the inside of your lower lip. We will also give you a mouthwash to cleanse your mouth three times per day for five to seven days after the operation.  

You will start doing some mouth exercises which should be continued three to four times a day for five to seven days after the operation.

You will be encouraged to get out of bed and move around from about four hours after the operation, and you may wash and shower as soon as you feel able.

The next day

If you are having your whole thyroid gland removed or a second operation to remove the remainder of your thyroid gland you will have a blood test early in the morning to check the level of calcium and a hormone called parathormone which can be affected by the surgery. If the calcium level is low you will be given calcium supplements (usually as a drink / tablets, but sometimes into the intravenous drip).

You can start brushing your teeth as normal, taking a little extra care when brushing the lower front teeth behind your lip.

A member of the surgical team will come to see you later in the morning to check on your progress and the pressure dressing will be removed. The intravenous drip will be removed when it is no longer needed.

Most patients are then able to go home on the first day after their operation. Sometimes however it will be necessary for a person needing calcium supplements to stay in hospital a little longer, until their calcium level is satisfactory.

At home

You should rest for two to three days after you get home. It is normal to feel a little tired for a few weeks after surgery.

We advise you to avoid lifting or heavy exercise for two weeks after the operation.

You can drive when you feel ready but may need to first check with your insurance company, depending on your policy.

We usually advise patients to take one or two weeks off work, but this can vary depending on the type of work you do.

Hospital follow-up

We will give you an appointment to see us in the Outpatient Department two to three weeks after your operation. You will need to come to the hospital two or three days before this appointment to have a blood test to check your thyroid function (and calcium / parathormone levels if necessary) so that we have the results when we see you.

The thyroid tissue removed at the operation will be examined by a pathologist (a doctor who specialises in examining changes in body cells and tissues). We will inform you of the results and will also tell you if you need any further treatment or follow-up.

• Video explanation of the TOETVA procedure: https://youtu.be/iT5jSgixOWY 
• The British Association of Endocrine & Thyroid Surgeons has a useful Patient Information section: https://www.baets.org.uk/patients
• The British Thyroid Foundation is a charity which supports people with thyroid conditions: https://www.btf-thyroid.org/thyroid-surgery

UCLH cannot accept responsibility for information provided by other organisations

Pathway Co-ordinator (Monday to Friday 9 am–5 pm) 
Direct Line: 020 3447 9460 
Email: uclh.giadmissionsteam@nhs.net or uclh.endocrinesurgery@nhs.net

Address: Endocrine Surgery Department, Ground Floor West, 250 Euston Road, London. NW1 2PG 

Website: www.uclh.nhs.uk