Abstract
It is with great interest that we read the important report entitled “Comparative Study Between Endoscopic Thyroid Surgery via the Oral Vestibular Approach and the Areola Approach” by Guo et al. 1 We would like to make a few remarks with regard to the clinical implementation of these minimal invasive and natural orifice transluminal endoscopic surgery (NOTES) techniques of thyroid surgery, respectively.
As the worldwide first group who introduced the transoral thyroidectomy in 2008, we feel that it is important to bring some aspects to light pertaining to patient's safety. 2 The rationale behind developing the transoral thyroidectomy was the reduction of collateral damage and complications and fastening recovery of the patient when compared with the 140-year-old traditional cervical approach that is one of the highly standardized surgeries ever with a very low morbidity. When a new suggested surgical method departs substantially from current standard of care, scientific evaluation is a conditio sine qua non with regard to safety that must be secured before starting clinical implementation that has tremendous implications regarding expectations, surgeon responsibility, and most importantly patient's safety. 3 One has always to keep in mind the severe complications that occurred during the first premature applications of the transoral approach for thyroidectomy and parathyroidectomy because safety principles have not been consciously taken into consideration, for example, injury to the mental nerve with paresthesia and transient or permanent nonpainful numbness of the lower lip and chin, palsy of the hypoglossal nerve with dysgeusia, and swallowing problems.4–8 Meanwhile, the transoral method has been applied worldwide on hundreds of patients unveiling new complications inherent to the vestibular access itself, for example, fibrosis-induced long-lasting pulling sensation below the lower jaw, flap perforation, and diathermy-induced skin burn, probably attributed to the more extensive subplatysmal dissection.9,10 These major adverse events are specific to all extracervical thyroidectomies, for example, the axillo-bilateral-breast approach (ABBA) that occurred in two of our patients who underwent the ABBA technique. 11
With all due respect to Guo et al. and their study, we feel that despite the presented good results, conclusions on efficacy and effectiveness of the transoral method cannot be derived from a trial with a retrospective character. Furthermore, the authors did not decidedly discuss and highlight some of the mentioned potential severe complications and how to avoid them. One should not convey the impression that the transoral thyroidectomy is an easy procedure. The surgeon should have extensive experience in both thyroid and laparoscopic/endoscopic surgeries.
We gave birth to a new technique but also to a new complications' spectrum that is inherent to this new approach. For sure, cosmetics is an important aspect for patients but it should not be the primary target when developing and implementing a new method. Moreover, cosmetics should never go at the expense of patient's safety. This emphasizes the importance of proper and detailed patient counseling.
Beyond any doubt, NOTES is the next step in the evolution of minimally invasive surgery, and transoral thyroidectomy is a part of it. It represents a breakthrough for the patient and a paradigm shift in the history of thyroid surgery toward a scarless and hopefully also pain-free surgery.