All roads lead to the thyroid gland: Review of two popular "scarless" thyroidectomy approaches

Thyroidectomy is the most common procedure performed in endocrine surgery. The standard surgical approach is via the anterior neck using a Kocher incision. Over the past two decades, minimally invasive and remote endoscopic approaches to thyroid surgery have emerged as surgeons attempt to improve the cosmesis of the surgery and move towards "scarless" approaches. Remote access techniques utilize strategically hidden incisions removed from the highly visible anterior neck. Rapidly emerging data shows these have comparable outcomes to the conventional open approach and result in high patient satisfaction and improved quality of life in thyroidectomy patients. The transoral endoscopic vestibular approach (TOETVA) and the robotic bilateral axillo-breast approach (BABA) are the two most common remote access approaches to date. In TOETVA, three incisions within the vestibular mucosa are used to access the thyroid. The use of standard laparoscopic instruments and a slightly less steep learning curve compared to other techniques have led to a successful adoption in North America. The robotic BABA technique uses 4 small, widely spaced incisions to provide ideal triangulation of instruments with a familiar midline view of the thyroid. Due to the robotic platform, it has a steeper learning curve but has seen great success in Asia. This article will review these two techniques, offering a comparison and highlighting the clinical trend and future implications.