First scarless thyroid surgery to treat thyroid cancer (L-r) Mr Oikonomou with patient, Patrik, four weeks after his surgery Interview with Mr Georgios Oikonomou, consultant ENT, Head and Neck, Robotic, Thyroid Surgeon Surgeons from St George’s, Croydon, and Kingston University Hospitals NHS Foundation Trust have performed the first-ever scarless thyroid surgery on patients with low-risk papillary thyroid cancer. We asked consultant ENT, Head and Neck, Robotic, Thyroid Surgeon Mr Georgios Oikonomou, about this exciting procedure and its potential to treat patients with benign nodules, Graves’ disease, hyperparathyroidism and low-risk thyroid cancers. The surgeon’s perspective What is scarless thyroid surgery? Transoral Thyroid and Parathyroidectomy Surgery Vestibular Approach (TOETVA and TOEPVA) is the only truly scarless thyroid procedure. It involves making incisions in the inner lower lip (oral vestibule) so it does not involve the skin at all. Procedures carried out transorally, either robotically or endoscopically, include total- and hemi-thyroidectomy, level VI neck dissection and parathyroidectomy. We perform this under general anaesthetic. What are the advantages of this procedure over conventional surgery? The main advantage is it leaves no visible scarring. It can offer significant benefits to patients who have a history of poor scarring (keloid or hypertrophic* scars). For example, we know that 10% of patients seek revision surgery for scarring often many years after their surgery. Recovery is also much quicker with this approach because we are not cutting through layers of muscles like we do in open surgery. Patients undergoing transoral surgery do have numbness around the cheek but this settles within four weeks. Currently, the patient stays in for one night after surgery, but we hope to be able to offer day surgery in the near future, as is the case in the USA. What about safety? Extended studies over the past 10 years have shown that the transoral thyroidectomy approach is just as safe as conventional surgery. Patients also report lower post- operative pain compared with open thyroid surgery. Which patients is it suitable for? Transoral surgery may be suitable for: • Benign thyroid nodules of approximately less than 4 cm • Low risk-thyroid cancers – papillary and follicular thyroid carcinoma • Well controlled Graves’ disease • Hyperparathyroidism • Parathyroid carcinoma It is not suitable for people who have had previous open neck surgery. Are you the only NHS Trust offering the transoral procedure for patients with low-risk thyroid cancers? Yes, we are currently the only Trust that offers scarless thyroid surgery to diagnosed thyroid cancer patients who meet the eligibility criteria. All of our patients are discussed through the joint St George’s and Royal Marsden Hospital Head & Neck and Thyroid Cancer Multidisciplinary Team (MDT) meeting. If they are suitable we offer TOETVA to them. We have successfully treated six papillary thyroid cancer patients with clear margins to date. The largest stage tumour treated is T2. This means the cancer was completely inside the thyroid, and that it was more than 2cm but no greater than 4cm across. Will it be made more widely available in the UK? Although scarless surgery has gained popularity, particularly in Asia and North America, it is very much in its infancy in the UK. We believe that scarless thyroid and parathyroid surgery provide multiple benefits to selected patients and should be offered as part of the NHS’ thyroid service. Along with our colleagues from the Royal Berkshire NHS Foundation Trust, we have been leading the effort to establish this procedure in the UK. I have undergone extensive training in this procedure in Brazil under Prof Leandro Rangel, who is a high volume TOETVA and TEOPVA surgeon. My counterpart at St George’s and Kingston Hospitals (London), Mr Enyi Ofo, Consultant ENT Head & Neck, Thyroid, Parathyroid and Robotic Surgeon, has also undergone the same training. We have also contributed to establishing the United Kingdom Remote Access Thyroid Surgery (UKRATS) group to spread awareness among the UK surgical community about this novel procedure and training requirements. The UKRATS group is now working with Bristol University to develop a multi-centre study to apply for NICE approval in 2025. We have been accepted to present our Enhanced comprehensive framework for secure implementation of the TOETVA service’ at major thyroid surgery meetings. Do you accept referrals? Yes. Patients interested in the procedure can be directly referred by their GP and/or by contacting us on [email protected] Tel: 0208 725 8052, PA, Ms Anne Galt. They would require an initial consultation in our clinic and subsequent appropriate imaging (thyroid ultrasound thyroid and possibly FNA biopsy) to confirm whether they meet the criteria for TOETVA. If they do we can add them to our waiting list for the procedure to take place at St George’s Hospital, London. The patient's perspective Patrik underwent scarless surgery earlier this year for a 2cm+-sized nodule on the right side of his thyroid. This was ‘indeterminate’ but was confirmed as thyroid cancer through post-operative cytology. How was your nodule first picked up? By good fortune essentially. When having investigations for an abdominal sports injury, the MRI inadvertently spotted a lump on my thyroid. I had no real symptoms to indicate a problem with my thyroid except an intermittently hoarse voice. I had no visible lump or difficulty swallowing. What investigations did you undergo and when was thyroid cancer diagnosed? Following the MRI I was referred to an endocrinologist at the same hospital. The nodule was deemed to be ‘benign’ from the results of the initial ultrasound and biopsy. When I had the same tests six to nine months later the results were the same. To be prudent, I was advised to take these tests one final time in another six months. This time I had the tests on the NHS at St. George’s Hospital under the care of Mr Georgios Oikonomou as my private cover had run out. The nodule was no longer considered ‘benign’ but ‘inconclusive’. The cancerous tissue had not yet been detected. Nevertheless, I was advised to have the nodule removed through surgery.** The procedure took place in February 2024. Were you given an option for either conventional or transoral surgery? Yes. Mr Oikonomou offered me both, carefully explaining the risks involved and the respective implications of each procedure. Why did you choose the transoral procedure? I was keen to avoid any external scarring and the transoral option seemed appealing on that basis. I also understood that recovery time could be shorter. However, Mr Oikonomou did make clear that the transoral option is a ‘novel’ procedure. Since it has a much shorter track record, supporting data etc. than conventional surgery, I had some concerns about taking this option. However, I was greatly reassured that one of the world’s leading transoral thyroidectomy surgeons would supervise Mr Oikonomou during the procedure. Whilst there was also a small risk of damage to my vocal cords to consider, I was happy to undergo the transoral option. How was the procedure and immediate recovery? I had never had surgery of any kind so I didn’t really know what to expect. After the surgery, I woke up on the ward pain-free and on an IV drip. I just felt very tired and groggy. I didn’t like being on the busy ward but was discharged after one night’s stay. The first eek or two at home immediately after were challenging. I was quite fatigued, my face was very swollen and the sutures in my mouth made eating quite cumbersome. Thankfully I was in no pain and did not need to take the painkillers prescribed, only antibiotics and the mouthwash. My throat felt ok as well. Within two to three weeks or so, the sutures in both the corners of my mouth and at the bottom of my lower jaw had all fallen out and the swelling had totally gone. At this point, I began working again from home and life slowly returned to normal (exercise etc.). During my appointment in this two-week period, Mr Oikonomou informed me that cancerous tissue had been detected in the part of the thyroid that they removed. However, my blood tests, ultrasound and surrounding lymph nodes were all clear. Based on this Mr Oikonomou, and the MDT team, were all very confident that all traces of the cancer had been removed. How are you now? I’m feeling well overall! Life returned to completely normal about a month after the procedure. From that point my only real concern was the uncomfortable scar tissue in my mouth. This is unfortunately to be expected after such a procedure. However as time has passed it has very slowly receded, and the discomfort caused has largely disappeared. Now I don’t even really think about it anymore. I’m told that it should recede further as well. What would you say to anyone who has been offered this procedure? It’s difficult to answer this because I only have experience of the transoral approach so cannot compare it against conventional thyroid surgery. However, my experience has been very positive indeed. This was for the large part due to Mr Oikonomou’s meticulous and considerate approach throughout. Overall I would encourage anyone in a similar position to me to undertake the transoral approach. *Keloid scar = a scar that grows beyond the original wound site, Hypertrophic scar = a thick, raised scar. **Fine Needle Aspiration Cytology results determine how thyroid nodules should be managed. Thyroid nodules classified as Thy3f, and Thy4 will usually involve a diagnostic hemithyroidectomy to investigate whether there is cancer. A classification of Thy3a suggests some atypical features and will normally be referred for further ultrasound and/or FNA. They may be discussed at a multi-disciplinary team (MDT) meeting if the result is Thy3a on a repeat sample. A classification of Thy5 is diagnostic of malignancy and will involve therapy. Read our interview with Mr Ram Moorthy, consultant ENT surgeon, about scarless thyroid surgery Manage Cookie Preferences Please ensure Javascript is enabled for purposes of website accessibility