Scarless thyroid surgery at Yanhee: transoral thyroidectomy (TOETVA)
What TOETVA is
A thyroidectomy removes all or part of the thyroid gland, which sits at the base of the front of the neck. The conventional operation reaches it through a horizontal incision across the lower neck, and that incision leaves a permanent line in a place nobody can cover.
TOETVA reaches the same gland from above. Three incisions are made in the oral vestibule, the gutter between the lower lip and the gums, and the surgeon works downward under the skin of the chin and neck to the thyroid. The gland comes out through the mouth. The incisions inside the lip heal in a moist environment and leave nothing visible from the outside, which is why the procedure is described as scarless rather than minimal-scar. The scars exist; they are inside your mouth.
Where the technique comes from
TOETVA is a Thai innovation. It was developed by Dr. Angkoon Anuwong and colleagues in the Minimally Invasive and Endocrine Surgery Division at Police General Hospital in Bangkok, and the first series of 60 human cases, operated between April 2014 and January 2015, was published in World Journal of Surgery in 2016. Bangkok has since hosted the International Thyroid NOTES Conference, the meeting where surgeons doing this work compare technique and outcomes.
That matters practically rather than patriotically. When a technique originates somewhere, the surgeons in that country have had the longest access to proper training in it, and the learning curve for transoral thyroidectomy is real. It is a reason to ask a specific question at consultation: where did the surgeon learn this operation, and how many have they done.
Origin study: Anuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. World J Surg, 2016.
How the operation works
- Under general anaesthesia, three incisions are made inside the lower lip: one central for a 10 mm endoscope, and two smaller ones, about 5 mm, placed to the sides.
- A working space is created between the skin and the muscles of the neck, held open with low-pressure carbon dioxide, typically around 6 mmHg.
- The endoscope and instruments pass through the ports and the surgeon works down to the thyroid, identifying and protecting the recurrent laryngeal nerves, which control the vocal cords, and the parathyroid glands, which control calcium.
- The thyroid lobe or the whole gland is separated and removed through the mouth in a retrieval bag.
- The oral incisions are closed with absorbable stitches. Nothing is closed on the neck because nothing was opened there.
The placement of the two lateral ports is not arbitrary. In the earliest version of the technique they sat where they risked the mental nerve, which supplies sensation to the chin and lower lip, and numbness lasting more than six months was reported. After cadaver work the ports were moved outward, level with the canine teeth and just inside the lip, specifically to keep away from that nerve. Any surgeon offering this operation should be using the modified port placement.
Who it suits
Eligibility for TOETVA is defined in numbers, not by preference. The criteria used in the published series and in practice since are:
- Thyroid gland no more than about 10 cm across on ultrasound
- Estimated gland volume no more than about 45 mL
- Nodule no larger than about 50 mm
- A benign diagnosis: a thyroid cyst, or a single or multinodular goitre
- Indeterminate cytology in the Bethesda 3 or 4 categories
- Papillary microcarcinoma with no evidence of spread
An ultrasound and a needle biopsy are what establish whether you fit. Those come first; the choice of approach comes second.
Who it does not suit
The conventional neck approach remains the right operation for a substantial number of people, and being told so is not a downgrade. TOETVA is generally not offered where there is:
- A large or substernal goitre, or a gland beyond the size limits above
- Thyroid cancer with signs of growth beyond the gland, or spread to lymph nodes
- Previous surgery or radiation to the head or neck
- Existing recurrent laryngeal nerve palsy
- An active infection in the mouth
- Poorly controlled hyperthyroidism
- Any reason you cannot safely have a general anaesthetic
A surgeon may also convert to an open operation during surgery if the anatomy or the bleeding requires it. That is a safety decision, it is discussed as part of consent, and it is not a complication.
What the approach does not change
The scar is the only thing TOETVA moves. Everything else about a thyroidectomy stays the same, and this is the part most worth understanding before choosing an approach:
- The same gland is removed. If you have a total thyroidectomy you will need thyroid hormone replacement, taken daily, for the rest of your life, and periodic blood tests to adjust the dose. That is a consequence of removing the thyroid, not of how it was reached.
- The recurrent laryngeal nerves are at the same risk. They run beside the gland and control the vocal cords. Injury causes hoarseness or a weak voice, usually temporary, occasionally permanent.
- The parathyroid glands are at the same risk. Four small glands sit on the back of the thyroid and control calcium. Disturbing them causes low calcium, which is usually temporary and treated with supplements, occasionally permanent.
- It is the same seriousness of operation. Endoscopic and cosmetically invisible are not the same as minor.
Where the approach genuinely helps is the neck: no external wound, less disruption of the strap muscles and skin, and for many patients less postoperative discomfort in the neck and a quicker return to normal appearance.
Risks to understand
The risks that belong to any thyroidectomy: bleeding, infection, injury to a recurrent laryngeal nerve causing hoarseness or voice change, low calcium from parathyroid disturbance, and the need for lifelong hormone replacement after total removal.
The risks that belong specifically to the transoral route: numbness or altered sensation of the chin and lower lip from irritation of the mental nerve, which is usually temporary and is the reason the port positions were revised; infection, since the mouth is not a sterile field, which is why antibiotics and mouth care are part of the protocol; bruising over the cheekbones; perforation of the thin skin flap under the chin; tearing at the corner of the mouth from instrument movement; thermal injury to skin from the energy devices used in a shallow working space; and, rarely, problems related to the carbon dioxide used to hold the space open.
Ask your surgeon for their own figures rather than the published averages. A surgeon who has done enough of these to quote you their own numbers is the answer you want.
Recovery
Expect a swollen, tight feeling under the chin and along the front of the neck for the first days, and bruising that can extend up toward the jaw. Chin and lower-lip numbness is common early on and usually resolves over weeks; tell your surgeon if it persists.
Because the wounds are inside your mouth, aftercare is oral. Expect a soft or liquid diet at first, an antiseptic mouthwash, a course of antibiotics, and instructions to keep the mouth clean without disturbing the stitches, which dissolve on their own. Speaking is usually comfortable within days; your voice should be monitored and any hoarseness reported rather than waited out.
Yanhee is a 400-bed JCI-accredited hospital with an ICU and full medical backup on site, which is the relevant safety point for an operation on the neck: a rare bleeding complication after thyroid surgery needs an operating theatre and a team quickly, not a transfer.
What it costs at Yanhee
Transoral thyroid surgery is quoted after consultation, because the price depends on whether you need a lobectomy or a total thyroidectomy, on the diagnosis, and on the length of stay your case requires. Bring your ultrasound report and any biopsy result to the consultation, since those determine both eligibility and cost.
Procedure | Hospital Stay | Price (THB) |
TOETVA - Unilateral Lobectomy | 2 Nights + 1 patho included | 290,000 |
TOETVA - Total Lobectomy | 3 Nights + 2 pathos included | 330,000 |
See pricing and packages for published price lists, and general surgery for the wider surgical service. Flights and accommodation beyond the hospital stay are not included in any Yanhee package.
Frequently asked questions
Is TOETVA really scarless?
There is no scar anywhere visible. Three incisions are made inside the lower lip, in the gutter between lip and gums, and they heal in a moist environment without leaving a visible mark. The scars exist, they are simply inside your mouth rather than across your neck. That is the whole point of the approach.
Am I eligible for scarless thyroid surgery?
Eligibility is set by measurements and diagnosis, not preference. The usual criteria are a thyroid gland no more than about 10 cm across and about 45 mL in volume, a nodule no larger than about 50 mm, and a benign diagnosis such as a cyst or a single or multinodular goitre, indeterminate cytology in Bethesda categories 3 or 4, or a papillary microcarcinoma with no evidence of spread. An ultrasound and a needle biopsy establish whether you fit. A large or substernal goitre, cancer growing beyond the gland, previous neck surgery or radiation, existing vocal cord nerve palsy, active mouth infection or poorly controlled hyperthyroidism all point to the conventional neck approach instead.
Is it a safer or smaller operation than open thyroid surgery?
It is not a smaller operation. The same gland is removed, the recurrent laryngeal nerves that control your voice and the parathyroid glands that control your calcium are at the same risk, and a total thyroidectomy means lifelong daily thyroid hormone replacement either way. What the transoral route changes is the neck: no external wound, less disruption to the skin and strap muscles, and for many patients less neck discomfort afterwards. Choosing an approach on the scar alone is how people end up disappointed by an operation that went well.
Will my chin or lip go numb?
Numbness or altered sensation of the chin and lower lip is the complication specific to this approach, caused by irritation of the mental nerve, and it is usually temporary and resolves over weeks. Early in the technique's development the port positions caused numbness that lasted beyond six months in some patients; after cadaver studies the two side ports were moved level with the canine teeth and just inside the lip to avoid the nerve. Ask your surgeon to confirm they use the modified port placement.
Who developed TOETVA?
Dr. Angkoon Anuwong and colleagues in the Minimally Invasive and Endocrine Surgery Division at Police General Hospital in Bangkok. The first series of 60 human cases, operated between April 2014 and January 2015, was published in the World Journal of Surgery in 2016. Bangkok has since hosted the International Thyroid NOTES Conference, where surgeons performing transoral thyroid surgery compare technique and outcomes.
What is recovery like?
Expect swelling and a tight feeling under the chin and front of the neck for the first days, with bruising that can extend toward the jaw. Aftercare is oral: a soft or liquid diet at first, antiseptic mouthwash, a course of antibiotics because the mouth is not a sterile field, and instructions to keep the mouth clean without disturbing the dissolving stitches. Speaking is usually comfortable within days. Report any hoarseness or persistent numbness rather than waiting it out.
How much does it cost at Yanhee?
Transoral thyroid surgery is quoted after consultation, because the price depends on whether you need a lobectomy or a total thyroidectomy, on the diagnosis, and on the length of stay your case requires. Bring your ultrasound report and any biopsy result, since those determine both eligibility and cost.
Reviewed this page for medical accuracy. Doctor of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University (2007); board-certified in general surgery, Thai Board of General Surgery, Faculty of Medicine, Vajira Hospital (2014). Clinical fellowship in minimally invasive surgery at the Minimally Invasive Surgery Division, Department of Surgery, Police General Hospital (2017–2018) — the Bangkok unit where the transoral thyroid technique described on this page was developed. Endocrine surgery training in thyroid, parathyroid and adrenal surgery with the Thai Endocrine Surgeons Society (2016). International training in laparoscopic and robotic upper GI surgery at Chang Gung Memorial Hospital, Taiwan, and in endoscopic and laparoscopic surgery at Fukuoka Red Cross Hospital, Japan (2018). Speaks Thai, English and Chinese Teochew. Full profile and schedule.
Available doctors
Your surgeon is confirmed at consultation. Whichever surgeon you see, ask where they trained in the transoral technique and how many they have performed — this is a specialised operation with a genuine learning curve, and the question is a reasonable one.
- Doctor of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University (2007)
- Thai Board of General Surgery, Faculty of Medicine, Vajira Hospital (2014)
- Clinical fellowship in minimally invasive surgery, Minimally Invasive Surgery Division, Department of Surgery, Police General Hospital (2017–2018) — the unit where transoral thyroid surgery was developed
- Endocrine surgery training in thyroid, parathyroid and adrenal surgery, Thai Endocrine Surgeons Society, Police General Hospital (2016)
- International training in laparoscopic and robotic upper GI surgery, Chang Gung Memorial Hospital, Keelung and Taipei, Taiwan (2018); endoscopic and laparoscopic surgery as visiting scholar, Fukuoka Red Cross Hospital, Japan (2018)
- Resident in surgery, Vajira Hospital, Navamindradhiraj University (2010–2014); consultant general surgeon and then surgeon, Minimal Invasive Surgery Unit, Veterans General Hospital, Bangkok (2014–present)
- Committee, 14th Asia-Pacific Congress of Endoscopic and Laparoscopic Surgeons of Asia (ELSA 2019); member, International Association of Surgeons, Gastroenterologists & Oncologists (IASGO)
- Speaks Thai, English and Chinese Teochew