Evolution of transoral endoscopic thyroidectomy vestibular approach according to the IDEAL framework

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery which aims to avoid a neck scar. The IDEAL Framework is a scheme for evaluating the life cycle of surgical innovation. Whether the development of TOETVA has followed the stages of the IDEAL Framework is unknown. This review article demonstrates that TOETVA has evolved closely in line with this scheme and is currently at the exploration stage (stage 2B). The basic steps and indications for this technique have been standardized and it is now being replicated in many centres around the world. The IDEAL Framework will be a useful roadmap for the adoption and safe implementation of TOETVA. Background The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework. Methods A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework. Results Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration). Conclusion There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.