Minimally invasive thyroid surgery: a narrative review

Introduction

Background

The field of thyroid surgery has witnessed a remarkable evolution over the past few decades, mainly driven by the need to reduce surgical trauma and scarring while also enhancing cosmetic outcomes and ensuring technique efficacy (1). Traditional open thyroidectomy, characterized by a collar incision, has been the gold standard since Theodor Kocher’s pioneering work in the late 19th century. While effective, this approach often leaves a visible neck scar, which can be a significant concern, particularly for younger patients and those with aesthetic considerations (1,2). The advent of minimally invasive techniques has revolutionized thyroid surgery, offering patients the benefits of reduced scarring, shorter recovery times, and less postoperative pain. Among these innovations, minimally invasive video-assisted thyroidectomy (MIVAT) emerged as a groundbreaking technique, significantly reducing the incision size and improving cosmetic results. However, this technique still required a cervical incision, which led to the development of extracervical techniques, such as the transaxillary, bilateral axillo-breast approaches (BABAs), and some transoral approaches (TOAs), including the transoral endoscopic thyroidectomy vestibular approach (TOETVA), which aimed to eliminate visible neck scars altogether (3,4). Nevertheless, these techniques also present unique challenges, such as longer operative times and the need for specialized training, which limits their widespread utilization and adoption (5,6).

Rationale and knowledge gap

The primary rationale for novel minimally invasive thyroid surgery techniques is to minimize visible scarring and reduce postoperative recovery time while maintaining surgical efficacy and safety (7). Despite these advancements, there remains a knowledge gap regarding the long-term outcomes and optimal patient selection criteria for these techniques. The extensive dissection required in some extracervical approaches has raised concerns about their invasiveness and potential complications. Additionally, the feasibility and safety of newer techniques, such as TOETVA, need further validation through high-quality studies (8).

Several papers have already addressed aspects of minimally invasive thyroid surgery by providing systematic and comprehensive reviews of TOETVA specifically examining minimally invasive approaches more broadly, and focusing primarily on complications (3,9). While valuable, these prior works either concentrated on individual facets of TOETVA or lacked the most recent developments in the field.

Objective

The objective of this manuscript is to provide a comprehensive overview of minimally invasive thyroid surgery, focusing on its evolution, techniques, patient selection, surgical details, postoperative management, complications, and outcomes. This overview is presented with particular emphasis on the TOETVA. Our narrative review situates TOETVA within the broader evolution of minimally invasive and remote-access thyroid surgery, providing historical and technical context while integrating the most up-to-date evidence through 2025, including large prospective series and recent meta-analyses. It highlights clinical aspects such as patient selection, perioperative optimization, and postoperative management, offering practical insights for surgeons. This review also aims to address current knowledge gaps and provide clinical recommendations based on the latest evidence. This study was presented in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-25-21/rc).

Methods

This comprehensive review was performed following a three-stage process: defining key research questions and keywords, carrying out the literature review, and compiling research findings. All contributing authors collaborated in various tasks, including developing a literature review protocol, setting inclusion and exclusion criteria, selecting an appropriate search methodology, identifying search engines, ensuring quality standards, and extracting relevant data for manuscript preparation. Articles were sourced from databases such as PubMed, ScienceDirect, and Springer Link, covering publications from their inception to 2025. The article selection process required the use of specific keywords such as: ‘thyroid surgery’, ‘thyroidectomy’, ‘cervical incision’, ‘MIVAT’, ‘BABA’, ‘TOETVA’, ‘robotic-assisted surgery’, ‘surgical outcomes’, ‘extracervical approach’, ‘postoperative complications’, and ‘cosmetic thyroid surgery’ (Table 1). The final list of included articles was validated by the corresponding author, who provided expert insights to synthesize the information and refine the manuscript draft (Table 2).

Evolution of minimally invasive thyroid surgery

The early stages of video-assisted thyroid surgery, specifically MIVAT, began in the late 1990s as an alternative to conventional open thyroidectomy (1). Introduced by Miccoli and colleagues, MIVAT aimed to reduce the invasiveness of traditional cervical incisions while maintaining surgical efficacy (10). Initially, this technique utilized a small central incision (1.5–2 cm) combined with endoscopic visualization to enhance precision and minimize tissue trauma. Using this small midline incision, the subplatysmal flaps were developed to expose the thyroid gland (11). A 5-mm endoscope is introduced to provide magnified visualization, allowing meticulous dissection. The superior and inferior pedicles of the thyroid lobe are carefully controlled using advanced hemostatic devices. The recurrent laryngeal nerve and parathyroid glands are identified and preserved to minimize complications. Once the affected thyroid lobe is mobilized, it is extracted through the small incision, followed by hemostasis and closure (12). Despite its benefits, MIVAT had limitations, including a steep learning curve for surgeons, restricted applicability to smaller thyroid nodules or benign conditions, and the potential for longer operative times in early adoption phases (13). Nevertheless, MIVAT laid the foundation for more advanced remote-access and robotic-assisted thyroidectomy techniques, further pushing the boundaries of minimally invasive endocrine surgery.

Following the MIVAT, multiple novel surgical approaches were developed and evaluated, such as the chest-breast approach (CBA), BABA, transaxillary approach (TA), retroauricular approach (RA), and TOA. These approaches are considered remote-access thyroid surgery due to their major conferred advantage of leaving no neck surgical scar (3).

The CBA was first developed in 2000 and later on modified to the current approach via the total mammary areolas (14). This technique includes a 10 mm incision on the medial margin of the right areola and two smaller incisions on the upper edge of the areola on both sides. These ports allow remote access for subcutaneous and subplatysmal dissection to expose the thyroid. A major concern of this procedure is the small scars on the breast/chest, which can be bothersome for younger women (15). Central neck dissection can also be an issue with CBA, given the bottom-up view, which can be obstructed by the sternum and clavicle. Nevertheless, a specific study indicated that this approach achieves equivalent therapeutic results to open surgery and conforms to the principle of radical tumor treatment for selected cases by well-trained surgeons (16). Zhang et al. evaluated the effectiveness of CBA and found that there were no significant differences when compared to the traditional open cervical approach in terms of the total number of lymph nodes resected (15).

Another recently developed approach is the BABA (2007), which involves four ports placed around both areolae and axillae (17). Two 10-mm ports are placed over bilateral supra-areolar margins, serving as the camera and main working port. Another 10-mm port is placed at the axillary skin fold on the side of the operating surgeon. The specimen is retrieved through this port. Finally, a 5-mm port is placed at the opposite axillary skin fold. A subcutaneous tunnel is then created on both sides, directed towards the neck. With this tunnel, the surgeon must carefully avoid going too deep into the breast parenchyma or too superficial into the dermis and cause bruising (17,18). However, if developed correctly, the working planes in the BABA allow the surgeon to optimally visualize anatomical structures and perform meticulous dissection, which results in superior surgical outcomes. The BABA is considered the most common approach for robotic-assisted thyroid surgery. Alramadhan et al. compared the surgical outcomes of BABA to conventional open approach in patients who had thyroid nodules with benign or intermediate fine-needle aspiration cytology results and found that BABA is comparable to COA in terms of complications and is safe and feasible when performed by experienced surgeons and for carefully selected patients who are concerned about neck scarring (19).

Other remote access approaches have been described, such as the TA and RA. Both approaches have favorable cosmesis results, given that the incision is considered hidden under the axilla or behind the ear. They also provide similar surgical and oncologic outcomes in selected cases to the open approach, which makes them desirable approaches for patients (20,21). Regarding the TA, it also confers a specific advantage in identifying the recurrent laryngeal nerve and parathyroid glands by providing a surgical view from lateral to medial (20). The main concern remains the large area of dissected tissue needed to obtain a view of the thyroid, which is associated with postoperative pain. Nevertheless, multiple meta-analyses have demonstrated that pain was significantly lower on postoperative day 1 and even 1 week after surgery after TA/RA compared to open thyroidectomy (6,22,23).

Among these remote-access techniques, the TOETVA has emerged as the most widely adopted in recent years. Unlike transaxillary or retroauricular routes, TOETVA provides a direct midline view, avoids visible scarring, and reduces the extent of subcutaneous dissection. First described by Anuwong et al. in 2016, this case series described the first successful TOETVA procedure on 60 human patients in Thailand (24,25). TOETVA has since gained international recognition as the leading minimally invasive alternative to open thyroidectomy. In the following sections, we focus on key technical aspect and outcome features of TOETVA.

TOETVA: patient selection and preoperative optimization

Patient selection for TOETVA is critical to ensure optimal outcomes and minimize complications. Suitable candidates typically include patients with a predicted gland width on diagnostic imaging of ≤10 cm, a thyroid volume of 45 mL, or a dominant nodule dimension of ≤50 mm. Indications also include Bethesda class III or IV lesions and primary differentiated carcinoma without local invasion or distant metastasis, particularly in patients seeking optimal cosmetic results (26). Contraindications encompass patients unfit for general anesthesia, those with prior radiation in the head, neck, or upper mediastinum, previous neck surgery, recurrent goiter, gland volume >45 mL, main nodule diameter >50 mm, and documented lymph node or distant metastases, tracheal/esophageal infiltration, preoperative laryngeal nerve palsy, hyperthyroidism, mediastinal goiter, or oral abscess (27). However, the other study has described proper management of central lymph node disease, and no difference regarding the number of lymph nodes has been noticed in comparison to an open approach (28).

Preoperative optimization involves a comprehensive assessment of the patient’s overall health and specific thyroid pathology. This includes a thorough history and physical examination, laboratory tests (e.g., thyroid function tests, calcium levels), and imaging studies [e.g., ultrasound, computed tomography (CT) scan if needed]. Optimization of comorbid conditions, such as hypertension and diabetes, is essential to reduce perioperative risks. Additionally, patient education regarding the procedure, potential risks, and postoperative care is crucial for informed consent and to set realistic expectations. It is recommended that TOETVA be performed by experienced surgeons in high-volume centers to ensure safety and efficacy (8,29,30). It is important to note that patient selection criteria for TOETVA are not entirely uniform across regions and institutions. One study recommended relatively strict thresholds for gland volume and nodule size, while another reported broader indications in high-volume centers with specialized expertise (28,29). These differences highlight the absence of a universal consensus. In practice, patient selection should be individualized by considering the surgeon’s experience, institutional protocols, and the patient’s anatomical and oncologic profile, alongside their preference for cosmetic outcomes

TOETVA: surgical technique

From a technical standpoint, the patient is positioned supine with slight neck extension to aid in subcutaneous dissection. Three laparoscopic ports are introduced through the oral vestibular area under the lower lip (31). The initial transverse incision is made centrally at approximately two-thirds of the distance between the inferior labial frenulum and the lower lip edge. Depending on the thyroid gland’s size, this incision typically ranges from 1 to 2.5 cm in length. A 10-mm trocar is inserted through the first incision as a camera port. Two 5-mm trocars are then inserted at both lateral sides of the oral vestibule (32). To safely create the subplatysmal space, hydro-dissection with saline is performed prior to blunt dissection and energy use, which helps separate tissue planes and minimizes the risk of thermal injury to the overlying skin. The plane is then developed down to the sternal notch with the sternocleidomastoid muscle forming the lateral border. Gas insufflation is then started, and this should be limited to 5 to 6 mmHg. The strap muscles are separated in the midline and retracted laterally to expose the thyroid and trachea (33). Using a 30°–45° endoscope, the thyroid gland is mobilized. The dissection proceeds from medial to lateral, taking care to identify and preserve the recurrent laryngeal nerve and parathyroid glands (25,34). It is preferable that intraoperative neuromonitoring be available. The thyroid specimen is then extracted through the central 10 to 25 mm incision. If the parathyroid gland is inadvertently removed, it should be immediately searched for in the specimen and auto-transplanted to the left brachioradialis (35). Lastly, the mucosal incisions in the oral vestibule and the linea alba cervicalis are closed with absorbable sutures (36).

TOETVA: postoperative management

Unlike thyroidectomies via the cervical approach, TOA requires administration of prophylactic antibiotics as well as oral mucosal disinfection to prevent infection due to the oral entry point of the surgery (37). Despite recent studies suggesting that routine antibiotic use may not be necessary, as there is no significant increase in infection rates between TOA and conventional approaches, intravenous antibiotic prophylaxis might still be reasonable to prevent surgical site infections due to the clean-contaminated nature of the procedure (37,38). Nevertheless, patients should be advised to maintain good oral hygiene to reduce the risk of infection (38). Voice assessments are also recommended to detect any recurrent laryngeal nerve injury, with formal laryngeal examination if voice changes are noted (39,40). Other potential complications to monitor include hematoma, infection, and nerve injury, and patients should be instructed to seek immediate medical attention if these occur (34). Lastly, early mobilization and a gradual return to normal activities are encouraged to promote recovery. Follow-up visits are essential to monitor for any delayed complications and to assess the overall recovery and function of the thyroid gland (29).

TOETVA: complications and technical challenges

Some major advantages of this procedure include the totally scarless approach as well as a top-down view, which exposes the central lymph nodes while avoiding field of view obstruction of the sternum and clavicle (41). It also provides closer access to the anterior neck and thyroid compared to other remote-access approaches, which decreases the trauma caused by extensive subcutaneous dissection. Some reports even show decreased postoperative pain and swallowing difficulties, better voice quality, faster recovery, and decreased incidence of wound-related complications (3,42). With respect to oncological safety, current data remain limited, as most published studies consist of small case series with relatively short follow-up. Although early reports suggest comparable oncological adequacy in terms of lymph node retrieval and margin status, high-quality prospective studies with long-term outcomes are needed before TOETVA can be widely recommended for malignant disease.

However, this procedure is not without any drawbacks. Due to the restricted field of surgery in the area of the oral vestibule, the three trocars are in very close proximity to each other, which can limit endoscopic movement and maneuvering and require a specific surgical skillset to master (11). Another important concern is intraoperative bleeding. The confined working space of TOETVA makes even minor bleeding technically challenging to control, with potential risks of obscuring the surgical field and prolonging operative time. Careful patient selection, meticulous hemostasis, and the availability of conversion to open thyroidectomy when necessary are critical for minimizing this risk. Recent studies have demonstrated that once surgeons become proficient in both the laparoscopic and cervical approach for thyroidectomies, they require an additional 11–40 cases to achieve proficiency of transoral thyroidectomy (40,43,44). Endoscopic equipment in TOETVA is inserted down toward the neck, making dissection difficult in cases of high-riding thyroid tumors of the upper poles. The mental nerve is at risk of injury during the incision, which may result in lower lip paresthesia postoperatively (31). CO₂ insufflation, limited to 5 to 6 mmHg, as mentioned above, is typically required, and due to the restricted suction and irrigation capabilities within the narrow neck air pocket, smoke and blood can obscure the surgical field. Also, this can generate subcutaneous emphysema, which is usually reabsorbed easily during the first hours, but should be taken into account for postoperative cosmesis reasons (3). As a result, the assistant must frequently clean the endoscope to maintain visibility. Additionally, the operative time tends to be significantly longer compared to traditional open thyroidectomy (8,45). In some instances, the resected thyroid specimen might be too large to be removed as a whole and requires dissection into smaller pieces to avoid any nerve injury while extracting through the middle incision. However, in selected cases of larger nodules, alternative approaches such as the transaxillary, retroauricular, or submandibular routes can be considered for specimen retrieval, allowing intact removal without the need for fragmentation. Infection is another concern because transoral incision is categorized as a clean-contaminated wound. However, few cases of infection have been reported in a series of studies about TOETVA. Whether antibiotics should be used during the perioperative period to avoid infection needs further study (37).

Other TOAs

Recently, several modifications have been introduced to enhance the TOETVA procedure, including the use of gasless instruments to prevent complications related to CO₂ insufflation (46). Another variation, the submental TOA, is considered an adaptation of TOETVA. In this technique, the traditional middle incision in the oral vestibule is replaced with an incision in the natural skin depression just below the chin (47). This adjustment simplifies the placement of the 10-mm central trocar by eliminating the need to detach the chin tissue from the mandibular periosteum. Compared to TOETVA, the submental approach offers several advantages, such as reducing lower lip trauma, lowering the risk of mental nerve (medial branch) injury, and decreasing the incidence of postoperative dysesthesia. Additionally, improved instrument triangulation helps prevent trocar conflicts, making this method a potentially more accessible option for performing “scarless” thyroidectomy (31,48).

Robotic-assisted thyroidectomy: current status and challenges

Minimally invasive thyroid surgery, including robotic-assisted techniques, has gained popularity due to its potential benefits in cosmetic outcomes and reduced recovery times. However, its adoption has been limited by several factors, including perceived technical challenges and a lack of training. Robotic-assisted thyroidectomy, particularly the gasless TA, has shown promising results in terms of safety and efficacy. A study by Stang et al. demonstrated that this technique is safe and effective, with low complication rates such as temporary dysphonia (6.0%) and permanent recurrent laryngeal nerve deficit (1.3%) (49). Additionally, the American Thyroid Association (ATA) has endorsed remote-access thyroid surgery, highlighting its comparable safety profile and efficacy to traditional methods (50).

The learning curve for robotic thyroidectomy is significant and studies indicate that proficiency is typically achieved after 35–40 cases, with improvements in operative times and complication rates as experience increases (50). Despite these advancements, barriers such as the need for specialized training and limited third-party payor coverage continue to hinder widespread adoption (51).

In summary, while minimally invasive and robotic-assisted thyroid surgeries offer several advantages, their broader adoption is constrained by technical challenges, training requirements, and reimbursement issues. The ATA’s endorsement and ongoing improvements in surgical techniques and training programs may help overcome these barriers in the future.

Conclusions

Minimally invasive approaches in thyroid surgery, particularly TOETVA, have demonstrated safety, reproducibility, and technical feasibility in recent years. The primary advantage of these approaches lies in their superior cosmetic outcomes, with some studies suggesting improved postoperative quality of life. However, careful patient selection remains crucial, as intraoperative complications, such as bleeding, can be challenging to manage in the confined working space. Additionally, while small case series have reported oncological safety, the current evidence remains insufficient to draw definitive conclusions. Further high-quality, large-scale studies are warranted to validate the oncological outcomes and establish clear guidelines for the use of TOETVA in thyroid malignancies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-25-21/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-21/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-21/coif). The authors have no conflicts of interest to declare.

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