The Learning Curve for Transoral Endoscopic Thyroidectomy Without Neuromonitoring: Analysis of First 103 Cases From India.

Abstract

Objective: Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) offers a scarless alternative to conventional thyroidectomy. Most studies incorporate intraoperative neuromonitoring (IONM), which may be unavailable in resource-limited settings. We evaluated the learning curve, feasibility, and safety of TOETVA without IONM.

Study design: Retrospective.

Setting: A retrospective analysis of 103 patients undergoing hemithyroidectomy by TOETVA between February 2020 and January 2025 was conducted at a tertiary care center in central India.

Method: Learning curve assessment was performed using Cumulative Sum (CUSUM) analysis, and outcomes were compared between phase 1 (cases 1-50) and phase 2 (Cases 51-103). Statistical analyses included independent t tests for continuous variables and chi-square tests for categorical variables (P < .05).

Results: Mean operative time significantly decreased from 185 ± 24 minutes in phase 1 to 105 ± 12.95 minutes in phase 2 (P < .001), with proficiency achieved after 50 cases. Nodule size was larger in phase 2 (4.5 ± 2.3 cm vs 3.0 ± 1.0 cm, P = .003). The conversion rate was 4.9%, with no permanent recurrent laryngeal nerve palsy. Hoarseness of voice and seroma rates remained unchanged (P = 1.00), whereas hospital stay significantly decreased (P < .001).

Conclusion: TOETVA without IONM is feasible and safe, demonstrating a well-defined learning curve with low complication rates. These findings support its adoption in low-resource settings.