A presentation on the latest technique to remove the thyroid gland; via the transoral route. This novel technique is a form natural orifice trans-endoscopic surgery (NOTES) and is truly scarless. Comparisons with the traditional open and other remote endoscopic techniques are explored.

1. Scarless Thyroid
Surgery
Chea Chan Hooi
MD, MS, FMAS, DMAS, CMIA, AMM
Borneo Medical Centre (Miri)

2. Content
• Anatomy
• Function
• Clinical features
• Investigations
• Treatment options
• Medicine
• Surgery
• Radioiodine
• Q&A

3. Anatomy
• Butterfly shaped
• 30 - 50% of population have
pyramidal lobe
• Goitre = enlarged thyroid gland

4. Function
• Cardiac
• Increase heart rate
• Increase cardiac output
• Respiratory
• Increase respiration rate
• Biochemical
• Increase basal metabolic rate
• Increase protein and carbohydrate metabolism
• Nervous system
• Potentiates brain development
• Increase sympathetic activity
• Reproductive
• Increase endometrial thickness

5. Classification of thyroid disorders
• Anatomical
• Solitary nodule
• Dominant nodule of MNG
• Multinodular goitre (MNG)
• Diffuse goitre
• Functional
• Hyperthyroidism (↑)
• Hypothyroidism (↓)

6. History
• Compressive symptoms
• Malignancy component
• Risk factors
• Red flags
• Cancer spread symptoms
• Thyroid status
• Hyper or hypothyroidism
symptoms
• Past thyroid or neck surgery

11. Graves eye signs
NO SPECS
Class 0 None
Class 1 Only signs (lid retraction ± lag)
Class 2 Soft tissue (conjunctival & lids edema, injection)
Class 3 Proptosis
Class 4 Extraocular muscles involvement
Class 5 Corneal involvement
Class 6 Sight loss (usually CNII)

12. Tests
• TFT
• TSH
• T4
• T3
• Antibodies
• Anti-TPO
• Anti-Tg
• Thyroglobulin
• ECG
• CXR
• CT scan

13. Treatment options
• Cancer
• Surgery
• Radioiodine
• Hyperthyroidism
• Medical
• Radioiodine
• Surgery
• Thyroiditis
• Medical
• Less is more

14. Thyroidectomy - removal of thyroid
• By extent
Hemithyroidectomy

15. • Open
• Via collarneck incision
• Endoscopic
•Facelift incision
approach
•Breast-axillary
approach
•Transoral

28. Facelift approach

31. Breast approach

34. Transoral thyroidectomy

43. Possible complications
General
• Bleeding
• Infection
• Hoarseness of voice
• Surrounding organ injury
Specific
• Chin numbness
• Lip asymmetry

48. Advantages
• No visible scar
• Minimal skin area dissected, less
bleeding, less infection, less
thickening
Disadvantages
• New technique
• Not for huge goitres
• Potential contamination by oral
cavity bacteria
• Numbness at chin

49. Patients who are not suitable
• Previous radiotherapy to neck
• Previous neck surgery
• Goitre extends into chest
• Goitre stuck to other organs
• Needs extensive lymph node dissection
• Nodule > 6cm

50. ?

51. Conclusion
• Goitres are common
• Beware of red flag symptoms that suggest malignancy
• Surgery had always been a main treatment option for goitres
• Transoral thyroidectomy avoids a visible neck scar
• Transoral thyroidectomy is the next frontier in thyroid surgery

52. TQ!
Q&A?