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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Anaesthetic management of transoral endoscopic thyroidectomy via vestibular approach


 Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

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Date of Submission04-Aug-2022
Date of Acceptance26-Aug-2022
Date of Web Publication07-Oct-2022
 


How to cite this URL:
Rajan S, Roy RA, Sasikumar NK, Paul J. Anaesthetic management of transoral endoscopic thyroidectomy via vestibular approach. Airway [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=358061




The recently described procedure of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) permits thyroid surgery without a cutaneous scar. This technique is fast gaining popularity amongst patients and surgeons. During TOETVA, the surgery is done via small incisions on the inside of lower lip and is considered a safe technique.[1],[2],[3]

A 23-year-old female with a solitary thyroid nodule was posted for TOETVA. She had no comorbidities. She was kept nil per oral and premedicated with alprazolam 0.25 mg, pantoprazole 40 mg and metoclopramide 10 mg on the night before and on the day of surgery. In the operation theatre, electrocardiogram, noninvasive blood pressure and pulse oximetry monitoring were established, and the patient was preoxygenated. She was given midazolam 0.05 mg/kg, fentanyl 2 μg/kg and propofol 2 mg/kg slowly by intravenous (IV) route. After induction, atracurium 0.5 mg/kg was given IV and after 3 min, the patient was intubated nasally with a 7 mm ID ivory-cuffed endotracheal tube (ETT). The throat was packed with a moist roller gauze and the eyes were lubricated, taped and padded to avoid inadvertent trauma to the eyes. The patient was positioned supine with neck extended over a bolster placed below shoulders. Both arms were tucked in on either side. Anaesthesia was maintained with oxygen:air mixture (1:1) at 2 LPM flow and 1%–1.5% isoflurane, maintaining a minimum alveolar concentration at 1. Volume controlled ventilation with respiratory rate of 14/min, tidal volume 400 mL and peak end expiratory pressure of 5 cm H2O was used. Initially, the end tidal carbon dioxide (ETCO2) ranged between 35 and 40 mm Hg.

Carbon dioxide (CO2) was insufflated intraoperatively through ports inserted via small incisions on the inside of lower lip to the surgical site [Figure 1]a at a pressure of 7 mm Hg and a flow rate of 10 LPM for the endoscopic procedure [Figure 1]b. About 30 min after CO2 insufflation, ETCO2 started to show a gradual increase to 45–50 mm Hg which was managed by increasing the respiratory rate to 18/min while maintaining the same tidal volume. The surgery lasted 3 h, and the intraoperative period was uneventful. Injection paracetamol 1 g was given 30 min before completion of surgery. At the end of surgery, the throat pack was removed, oral and ETT suctioning were done, residual neuromuscular blockade was antagonised with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg and the patient was extubated when awake. The postoperative period was uneventful.
Figure 1: Ports being inserted via small incisions on the inside of lower lip (a) and endoscopic procedure being performed (b)

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The major anaesthetic requirements during TOETVA are nasal intubation and avoidance of patient movements intraoperatively. Although the surgery could be performed with oral intubation with ETT fixed near the angle of mouth, nasal intubation reduces chances of intraoperative tube compression and accidental extubation. The chances of hypercarbia during CO2 insufflation should be anticipated which can be easily managed by increasing the respiratory rate. Airway pressure required during ventilation for TOETVA is significantly lower than that required for laparoscopic surgeries.[4] Although risks of vessel and nerve injuries are present, these are considered lesser than routine surgeries as the use of magnified stereoscopic visualisation allows more meticulous dissection and control of bleeding.[5] Care should be taken to avoid hyperextension of the neck and pressure injury to the eyes. It is advisable to keep CO2 insufflation pressures to 6 mm Hg or less to avoid problems related to reduced venous drainage, CO2 embolism and subcutaneous emphysema.

During TOETVA, providing general anaesthesia through a nasal ETT with constant monitoring of patient's position, respiratory and haemodynamic changes ensures optimal patient outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Russell JO, Razavi CR, Shaear M, Chen LW, Lee AH, Ranganath R, et al. Transoral vestibular tyhyroidectomy: Current state of affairs and considerations for the future. J Clin Endocrinol Metab 2019;104:3779-84.  Back to cited text no. 1
    
2.
Fernandez-Ranvier G, Meknat A, Guevara D, Taye A, Suh H, Inabnet WB. Transoral endoscopic thyroidectomy vestibular approach: A single-institution experience of the first 50 cases. Surg Innov 2020;27:439-44.  Back to cited text no. 2
    
3.
Zheng G, Ma C, Sun H, Wu G, Guo Y, Wu G,et al. Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study. Eur J Surg Oncol 2021;47:1346-51.  Back to cited text no. 3
    
4.
Patel RD, Gowani N, Nadkarni M, Rege S, Devalkar P. Anaesthetic management in transoral endoscopic thyroidectomy. J Clin Diagn Res 2017;11:UD07-8.  Back to cited text no. 4
    
5.
Anuwong A. Transoral endoscopic thyroidectomy vestibular approach: A series of the first 60 human cases. World J Surg 2016;40:491-7.  Back to cited text no. 5
    

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Correspondence Address:
Sunil Rajan,
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
India
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Source of Support: None, Conflict of Interest: None



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