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Scarless Endoscopic Parathyroidectomy (TOEPVA)

Scarless Endoscopic Parathyroidectomy allows removal of the parathyroid via a natural body orifice, with no need for an incision. Traditional parathyroidectomies leave a visible scar in the middle of the neck. But, advancements in endocrine surgery provide a scarless alternative to this procedure. In a scarless Endoscopic parathyroidectomy or known as Transoral Endoscopic Thyroidectomy Vestibular Approach (TOEPVA), the surgeon accesses the gland(s) through the patient’s mouth (called a “transoral” approach). Scarless endoscopic parathyroidectomy promises the same successful outcomes as conventional gland removal without any of the scarring.

Parathyroid surgery was initially described in 1925 when Felix Mandl, a young surgeon in Vienna, was able to successfully remove a parathyroid tumor from a patient with osteitis fibrosa cystica.  In the decades that followed, few significant technical changes occurred in parathyroid surgery; however, the procedure is now most commonly performed to treat primary hyperparathyroidism.

Traditionally, the standard technique was four-gland exploration with removal of any abnormal or enlarged gland(s). For more than 100 years, parathyroid surgery has been safely performed via an anterior neck incision . This scar heals well in the majority of patients, with generally acceptable cosmetic outcomes.

Because excellent cosmesis cannot be guaranteed, remote-access parathyroid surgery has evolved to address the potential morbidity of an anterior cervical incision. As parathyroid imaging techniques advanced, minimally invasive parathyroidectomy became more commonplace and provided an equally high cure rate, a lower complication rate, a shorter hospital stay, and a large reduction in hospital costs.

Scarless Endoscopic Parathyroidectomy (TOEPVA)

In 2016, Anuwong published the first case series for scarless endoscopic parathyroidectomy via the lower vestibule of the mouth with excellent outcomes. This came as a result of worldwide efforts to explore an alternative remote-access parathyroidectomy approach, specifically by utilizing natural orifice transluminal endoscopic surgery (NOTES) concepts.

Currently, TOEPVA, perhaps more than other remote-access techniques, is attracting patients who are interested in avoiding a neck scar. In the West, the endoscopic approach far exceeds the robotic approach, as the latter requires extended operative time, a longer learning curve and, occasionally, an axillary incision for the fourth arm of the robot.

TOEPVA can be performed for select patients with localized primary hyperparathyroidism (HPT). Those without parathyroid adenoma localization, recurrent or persistent primary HPT, suspected multigland disease, secondary or tertiary HPT, family history of MEN, suspected parathyroid carcinoma, or previous central neck surgery or neck irradiation therapy should be excluded from consideration.

Primary References
  1. Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. Anuwong A. et al, World J Surg 2016;40:491-7
  2. Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update, Jonathon O Russell et. al. Gland Surg. 2020 Apr;9(2):409-416.

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