Controversies in Thyroid Surgery: Debating Transoral Endoscopic Thyroidectomy versus Small Incision Thyroidectomy
Authors: Zuhair Dahham Hammood  
Published: May 2024

In the ever-evolving landscape of thyroid surgery, one cannot ignore the ongoing debate surrounding the optimal approach for thyroidectomy. minimally invasive thyroidectomy techniques have been developed. However, there is currently no single accepted technique in minimally invasive thyroidectomy (MIT) [1]. Proponents of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) advocate for its minimally invasive nature and favorable cosmetic outcomes [2]. Experienced thyroid surgeons performing thyroidectomy with an anterior incision, shortening the classic Kocher incision by 2-3 cm without the need for additional complex instruments with simple preparation and minimal costs, have obtained better cosmetic results compared to open surgery [1]. Supporters of open thyroidectomy with or without endoscopic assistance through a 3 to 4-cm incision (small incision thyroidectomy; SIT) argue that their approach achieves similar minimally invasive results while maintaining the safety and efficacy of traditional open surgery [3,4].
TOETVA has garnered attention for its innovative approach, utilizing a natural orifice—the mouth—as the entry point for thyroidectomy. Advocates of TOETVA highlight its cosmetic advantages, as the incisions are hidden within the oral cavity, resulting in virtually scarless necks. Furthermore, TOETVA offers reduced postoperative pain and faster recovery times than traditional open surgery, enhancing patient satisfaction and quality of life. Proponents argue that the evolution of TOETVA represents a paradigm shift in thyroid surgery, offering patients a less invasive alternative with comparable oncological outcomes [5]. Conversely, proponents of SIT through a 3 to 4-cm incision contend that their approach achieves similar minimally invasive results while preserving the safety and efficacy of traditional open surgery. They argue that the smaller incision size of open thyroidectomy minimizes tissue trauma and postoperative pain, leading to faster recovery times and superior cosmetic outcomes compared to larger incisions (Figure 1,2).
Moreover, advocates of SIT emphasize the importance of tactile feedback and direct visualization in ensuring optimal surgical outcomes, which may be compromised in endoscopic approaches such as TOETVA [2,3,5].
Among these contrasting viewpoints, it is essential to recognize that TOETVA and SIT have their respective strengths and limitations. While TOETVA offers the attraction of scarless necks and enhanced cosmetic outcomes, concerns remain regarding its learning curve and technical challenges, particularly in cases of large or multifocal thyroid tumors. Conversely, SIT boasts a long-standing safety and efficacy track record, with established surgical technique and perioperative care principles. However, its neck incision may be perceived as a drawback by patients seeking minimally invasive alternatives. Addressing these controversies requires understanding patient preferences, tumor characteristics, and surgeon expertise. Individualized decision-making is paramount, carefully considering the risks and benefits of each approach. Moreover, ongoing research and innovation are essential to refining surgical techniques and optimizing outcomes in thyroid surgery.