Background: Endoscopic thyroid surgery, and particularly natural orifice transluminal endoscopic surgery (NOTES) approaches, have been gaining in popularity in order to avoid a visible neck scar. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a true scarless technique with a large case series demonstrating outcomes and safety comparable to traditional open thyroidectomy. However, the midline incision has several drawbacks including longer dissection distance to the thyroid, separation of the soft tissue overlying the mandible with subsequent sensory disturbances to the anterior chin and difficulties with extracting large lesions while maintaining an intact capsule. Here we describe a hybrid transoral and submental technique (TOaST) for thyroidectomy to overcome some of these shortcomings.

Case presentation: Our case is a 37yo, otherwise healthy female who had an enlarging multinodular goiter which was beginning to cause a globus sensation. She had a dominant 5.4cm nodule in the left lobe which was biopsy benign. On the right lobe, there was a 1.8cm nodule with biopsy reporting atypia or follicular lesion of unknown significance (Bethesda III). The patient wished to proceed with a total thyroidectomy but wanted to avoid a visible scar. A TOaST total thyroidectomy was offered to the patient.

Conclusion: In our single institution experience of 14 TOaST thyroid resections, we demonstrated that this technique can be a safe and viable alternative for select patients who wish to avoid a visible scar. It maintains the advantages of TOETVA while addressing some of the shortcomings of the central intra-oral incision.