Reviewed by Dr. Reza Lankarani, General SurgeonFounder | Surgical Pioneering Newsletter and Podcast Series Editorial Board Member | Genesis Journal of Surgery and MedicineJAMA Surg, Published Online: September 3, 2025doi: 10.1001/jamasurg.2025.3248OverviewThis briefing document summarizes key findings from a study comparing two surgical approaches for thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and Minimally Invasive Nonendoscopic Thyroidectomy (MINET). The study, conducted at a tertiary referral center in Taipei, Taiwan, between January 2021 and January 2023, aimed to evaluate surgical outcomes, safety, cost, and pathological integrity. Propensity score matching was used to ensure comparable cohorts of 210 patients for each surgical method, with a 12-month follow-up period.Key Themes 1. Cosmetic Outcomes and Patient PreferenceTOETVA offers superior cosmetic outcomes due to its "scarless" nature. This is a primary driver for its increasing popularity, fulfilling "the demand for scarless outcomes." MINET, while also minimally invasive, uses a smaller anterior cervical incision, which still results in a visible scar, albeit reduced compared to conventional thyroidectomy. The study found a 2.86% incidence of hypertrophic scarring at 12 months in the MINET group, while TOETVA had zero reported hypertrophic scars. 2. Operative Demands and CostTOETVA is associated with significantly longer operative and preparation times.Mean operative time for TOETVA was 127.9 minutes compared to 68.1 minutes for MINET, a difference of nearly an hour.Preparation time was also significantly longer for TOETVA (36.5 minutes vs. 22.0 minutes), attributed to "additional steps, such as the transition from orotracheal to nasotracheal intubation with a nerve integrity monitoring tube, meticulous facial area protection, and the setup of extra equipment." TOETVA incurs significantly higher overall costs. The mean overall cost for TOETVA was $4680, compared to $2734 for MINET, a difference of $1946. (Table 2, Results) This increased cost is consistent with previous studies. 3. Nerve and Parathyroid PreservationTOETVA demonstrates potential benefits in nerve and parathyroid preservation compared to MINET.Fewer Intraoperative Neuromonitoring (IONM) alerts: TOETVA had a significantly lower incidence of IONM alerts (1.6% vs. 5.0% for MINET). Specifically, traction-related IONM alerts were significantly less frequent in TOETVA (0.4% vs. 3.4%). This is potentially due to "enhanced magnification and angled dissection trajectory offered by the 30° endoscope used in TOETVA."Lower incidence of inadvertently resected parathyroid glands: TOETVA had a significantly lower rate of inadvertently resected parathyroid glands (4.7% vs. 10.9% for MINET). The study suggests that "the enhanced visualization offered by endoscopic techniques enabled better identification and preservation of smaller parathyroid glands." Clinical implications for hypoparathyroidism and vocal cord palsy: Despite the differences in intraoperative alerts and resected parathyroid tissue, there were no significant differences in the rates of postoperative vocal cord palsy (1.4% TOETVA vs. 2.4% MINET) or hypoparathyroidism (1.9% TOETVA vs. 3.3% MINET). This suggests that IONM alerts often reflect transient stress from which the nerve recovers, and remaining parathyroid glands can compensate. 4. Pathological Evaluation ChallengesTOETVA is associated with a significantly higher rate of specimen disruption and tumor capsule damage.Specimen disruption occurred in 12.9% of TOETVA cases compared to 3.8% in MINET.Incomplete tumor capsule integrity was observed in 3.3% of TOETVA cases versus 0.5% of MINET cases. Impact on diagnosis: This disruption "may complicate pathological evaluation" and hinder accurate assessment of macroscopic extrathyroidal extension, which is "essential for determining appropriate treatment and follow-up strategies." (Discussion) It can also "create a false impression of microscopic extrathyroidal extension or raise suspicion of its presence, potentially altering clinical management." The study highlights that "accurate differentiation between benign and malignant follicular neoplasms depends on the identification of capsular or vascular invasion," and traction during TOETVA specimen retrieval "may compromise capsular integrity, potentially obscuring or destroying key diagnostic features." 5. Postoperative PainTOETVA patients experienced slightly higher postoperative pain scores. The mean Visual Analog Scale (VAS) pain score was 0.88 for TOETVA compared to 0.38 for MINET. (Table 2, Results) This contradicts some previous studies but is attributed to the "smaller skin incision and the limited extent of flap dissection" in MINET, ensuring a fair comparison due to identical pain management protocols. LimitationsRetrospective design: Limits comprehensive evaluation of overall resource utilization, equipment maintenance, and indirect costs.Specific patient population: The study population had a relatively lower BMI, potentially limiting generalizability to patients with higher BMIs.Lack of long-term data: The study emphasizes the need for "multicenter prospective studies with extended follow-up" to assess long-term safety and cost-effectiveness. ConclusionsTOETVA offers a cosmetically superior and generally safe alternative to MINET, with advantages in nerve and parathyroid preservation. However, these benefits come with trade-offs: longer operative times, higher costs, and a greater risk of specimen disruption, which can complicate pathological assessment. The findings underscore the critical need for careful patient selection for TOETVA, particularly considering the implications for accurate pathological diagnosis. Further large-scale prospective studies are recommended to validate these findings and explore long-term outcomes and cost-effectiveness.Reza Lankarani M.D To access additional details, please refer to the Surgical Pioneering Podcast Series application available at the following link:https://Surgicalpioneer.codeadx.me
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