Advanced Surgical Approaches in Graves’ Disease
As part of the main programme in Singapore, we are pleased to present a dedicated Endocrine Surgery Cadaveric Workshop, organised in collaboration with EUGOGO (European Group on Graves’ Orbitopathy).
Surgery remains an important component of the multidisciplinary management of Graves’ disease, particularly in patients with significant orbitopathy, large goitres, suspicious thyroid nodules, relapsed disease, medication intolerance or a preference for definitive treatment. Total thyroidectomy provides a rapid and definitive cure of hyperthyroidism, eliminating the possibility of recurrent hyperthyroidism following antithyroid drug therapy.
An additional consideration in patients with Graves’ orbitopathy is the autoimmune nature of the disease. Thyroidectomy removes the principal source of thyroid antigen and is associated with a substantial decline in circulating TSH-receptor antibodies (TRAb). High TRAb titres are an established risk factor and biomarker for Graves’ orbitopathy.
Current EUGOGO recommendations recognise thyroidectomy as a preferred treatment option in patients with mild active Graves’ orbitopathy, while patients with moderate-to-severe active disease generally require treatment of the orbitopathy before definitive treatment of the thyroid. Avoidance of radioactive iodine may also be particularly attractive in patients at risk of orbitopathy progression, given the recognised association between radioactive iodine and increased TRAb levels and orbitopathy activity in susceptible patients.
With advances in surgical technique and perioperative technology, thyroidectomy can now be performed with excellent safety outcomes in experienced, high-volume centres. Intraoperative nerve monitoring, meticulous capsular dissection and technologies such as near-infrared autofluorescence for parathyroid identification have further enhanced strategies for preserving the recurrent laryngeal nerves and parathyroid glands.
This workshop provides participants with an opportunity to explore contemporary surgical techniques for Graves’ disease through focused didactic teaching followed by hands-on cadaveric dissection. The programme has been designed to bridge the gap between theoretical knowledge and operative practice, with emphasis on surgical anatomy, technical considerations, patient selection and strategies for safe thyroid and neck surgery.
Workshop Highlights
The cadaveric programme will focus on three key surgical approaches:
1. Endoscopic BABA Thyroidectomy
Participants will be introduced to the bilateral axillo-breast approach (BABA), including relevant surgical anatomy, patient positioning, creation of the working space and key steps of endoscopic thyroidectomy.
The bilateral axillo-breast approach (BABA) provides a remote-access route to the thyroid while avoiding a visible cervical incision. By using bilateral axillary and periareolar access points, the approach provides a relatively symmetrical working trajectory to both thyroid lobes and the central neck.
A particular strength of BABA is its familiar anterior view of the thyroid and bilateral neck, allowing the surgeon to approach both lobes through a relatively similar operative field to conventional thyroidectomy. The approach also provides excellent magnified visualisation of important structures, including the recurrent laryngeal nerves and parathyroid glands. Robotic platforms further enhance the approach through three-dimensional magnified vision, wristed instruments and improved instrument articulation, facilitating precise dissection in the confined operative space.
The technique does requires understanding of the remote-access anatomy and creation of a large subcutaneous working space. Its learning curve, operative time and patient-selection considerations make cadaveric training particularly valuable, allowing participants to appreciate the surgical planes and spatial relationships before applying the technique in clinical practice.
2. Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)
The workshop will provide practical exposure to TOETVA, including the transoral approach, establishment of the working space, identification of critical anatomical structures and important technical considerations for safe endoscopic thyroid surgery.
TOETVA represents a truly scarless thyroidectomy approach with no external cervical or chest scars, and excellent cosmetic outcomes. It utilises the oral vestibule as the access route to the neck and provides a short and relatively direct pathway to the thyroid and the central compartment. TOETVA has been successfully applied to selected patients with Graves’ disease, with published series demonstrating its technical feasibility and comparable short-term surgical outcomes to open thyroidectomy in experienced hands.
The transoral route introduces unique technical considerations, including creation of the working space, maintenance of orientation, protection of the mental nerves and management of the oral access site. Hands-on cadaveric dissection provides an opportunity to understand the anatomy, develop three-dimensional spatial awareness and practise the steps of the approach in a controlled environment.
3. Open Modified Radical Neck Dissection
Participants will also perform cadaveric dissection of an open modified radical neck dissection, with emphasis on cervical surgical anatomy, identification and preservation of critical structures, lymph node compartmentalisation and principles of oncological neck dissection.
Didactic Teaching + Hands-On Dissection
The workshop will follow an interactive format designed to maximise practical learning.
Each of the three surgical components will begin with a 15-minute focused didactic lecture, covering the relevant anatomy, operative principles, technical steps and key surgical considerations. This will be followed immediately by hands-on cadaveric dissection, allowing participants to apply the concepts discussed during the lecture under faculty guidance.
The faculty will comprise predominantly experienced local endocrine surgeons, providing participants with the opportunity for close interaction and practical discussion throughout the cadaveric sessions.
Who Should Attend?
The workshop is intended for surgeons and surgical trainees with an interest in endocrine surgery, thyroid surgery and contemporary approaches to the surgical management of Graves’ disease.
Participants will have the opportunity to:
- Review and understand relevant surgical anatomy in a cadaveric setting
- Learn the operative steps of BABA and TOETVA thyroidectomy
- Practise the key steps of open modified radical neck dissection
- Discuss surgical decision-making, patient selection and technical challenges with experienced endocrine surgeons
- Translate didactic teaching into practical operative experience through supervised cadaveric dissection
Observer Participation
For participants who are unable to commit to hands-on dissection, paid observer-only positions will also be available.
Observers will be able to attend the didactic lectures and observe the cadaveric demonstrations and participant dissection sessions, providing an opportunity to gain exposure to these surgical approaches without participating directly in the hands-on component.
Certification & CME
All participants will receive a certificate of participation.
CME hours will also be provided, subject to the relevant accreditation requirements.
We look forward to welcoming surgeons and trainees to Singapore for an engaging programme combining the multidisciplinary principles of Graves’ disease and Graves’ orbitopathy with practical exposure to contemporary endocrine surgical techniques.
