Preliminary experience with the transoral endoscopic thyroidectomy vestibular approach in selected complex cases: a case series and literature review.

Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) offers a scarless alternative to conventional thyroidectomy. Although established selection criteria exist, clinical scenarios exceeding these parameters are increasingly encountered in practice, yet evidence regarding their safety and feasibility remains limited. This study aimed to systematically review published indications for TOETVA and to preliminarily explore its feasibility in patients with conditions beyond conventional criteria through a case series analysis. Methods: A comprehensive literature review was conducted across PubMed, Web of Science, and the Cochrane Library for studies published up to July 2026, yielding 800 records, of which 131 studies met the inclusion criteria and were analyzed. Articles reporting specific inclusion criteria for TOETVA were analyzed, including thyroid size, gland volume, and maximum resected benign or malignant nodule sizes. In addition, a retrospective case series was performed involving seven patients who underwent TOETVA at a tertiary center between January 2021 and February 2024. Indications included bulky thyroid glands, large benign nodules, intrathyroidal T3a papillary thyroid carcinoma (PTC), and PTC with concomitant neck masses. Surgical feasibility, perioperative outcomes, complications, and recurrence were evaluated. Results: A total of 131 studies met the inclusion criteria. Most reports limited thyroid diameter to ≤10 cm and gland volume to ≤45-50 mL. For benign nodules, the most frequent upper limit was ≤6 cm, while for malignant tumors, ≤2 cm was the most common criterion. The case series included one bulky thyroid gland, one large benign nodule, two intrathyroidal T3a PTCs, and three PTCs with concomitant neck masses. All operations were successfully completed via TOETVA without conversion to open surgery. The mean operative time was 196 ± 25.3 min, mean drainage volume was 104 ± 67 mL, and mean postoperative hospital stay was 3.14 ± 1.68 days. One patient experienced transient hypoparathyroidism, and no recurrences or major complications were observed during a median follow-up of 34 months (range, 25-58 months). Conclusions: TOETVA is feasible for carefully selected patients beyond standard indications strictly within highly experienced centers, following thorough preoperative imaging and multidisciplinary team (MDT) evaluation. However, we strongly caution against a generalized expansion of indications. In these complex cases, oncologic safety must always be prioritized over cosmetic benefits, and further multicenter evidence is required to confirm long-term outcomes.