Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Open Thyroidectomy for Graves' Disease: A Systematic Review and Meta-Analysis.

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a scarless, minimally invasive alternative to conventional open thyroidectomy (OT). Although TOETVA has shown acceptable safety outcomes in thyroid surgery, its role in Graves' disease remains uncertain because of the technical complexity associated with hypervascular thyroid glands.

METHODS

A systematic search was conducted across PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials through May 2026. Comparative studies evaluating TOETVA versus OT in adults with Graves' disease were included. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using the I2 statistic. Risk of bias and certainty of evidence were evaluated using ROBINS-I and GRADE.

RESULTS

Three retrospective comparative studies including 357 patients with Graves' disease were analyzed; 141 underwent TOETVA, and 216 underwent open thyroidectomy (OT). TOETVA was associated with significantly longer operative time (MD +44.4 minutes; 95% CI: 22.7-66.2; P < .01; I2 = 70.4%). No significant differences were observed regarding recurrent laryngeal nerve dysfunction, parathyroid dysfunction, hematoma, or surgical site infection. Mental nerve injury (2.13%) and conversion to open surgery (0.71%) were uncommon after TOETVA. Sensitivity analyses confirmed the robustness of operative time findings.

CONCLUSION

TOETVA appears to be a safe and feasible alternative to OT for Graves' disease, with comparable postoperative complication rates but longer operative times. Further prospective multicenter studies are needed to confirm these findings.