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7 Technique of Thyroidectomy

Daniel Oertli

Contents the anatomic situation is complicated by prior sur-


gery [5]. However, neuromonitoring does not reliably
7.1 Introduction . . . 81 predict postoperative outcome [6,7]. A recent study
7.2 Extent of Surgery and Definitions . . . 82
based on 288 patients undergoing thyroid surgery
7.3 Preoperative Measures . . . 82
with intraoperative identification and intraoperative
7.4 Positioning and Draping . . . 82
neuromonitoring showed that the incidence of recur-
7.5 Surgical Steps . . . 82
rent nerve lesions in benign, malignant, and recur-
7.5.1 Skin Incision and Creation of Skin Flaps . . . 82
rent thyroid disease was not lowered by the use of in-
7.5.2 Strap Muscles . . . 83
7.5.3 Upper Pole . . . 83
traoperative neuromonitoring [8]. Although an intact
7.5.4 Isthmus and Pyramidal Lobe . . . 84 nerve function can be verified by this method, we do
7.5.5 Hilum of the Gland . . . 84 not recommend the routine use of RLN neuromoni-
7.5.6 Handling of the Parathyroid Glands . . . 85 toring.
7.5.7 Lower Thyroid Pole . . . 86 The endocrine surgeons success depends com-
7.5.8 Removal of the Lobe . . . 86 pletely on his or her devotion to a stepwise meticu-
7.5.9 Wound Closure . . . 86 lous and fine dissection technique. Several dissection
7.6 Reoperative Thyroid Surgery . . . 86 devices have recently been propagated for thyroid sur-
7.7 Minimally Invasive Thyroidectomy . . . 87 gery. The harmonic scalpel using ultrasonic frictional
References . . . 87 heating to seal vessels is widely used in laparoscopic
and open abdominal surgery. It is documented to be
safe and fast for cutting and coagulating tissue. Its use
for dissection during thyroidectomy has been evalu-
7.1 Introduction ated in several studies and has been compared to the
conventional clamp-and-tie technique. Two random-
Thyroidectomy is the most frequent intervention in ized studies [9,10] and two case-controlled studies
endocrine surgery. When performed in specialized [11,12] have shown that the harmonic scalpel signifi-
centers, the operation is safe with low morbidity and cantly shortens the operative time compared to the
a virtually 0% mortality [1]. Complications of thyroid conventional technique. This reduction of up to 20%
surgery are directly correlated to the extent of resec- in operative time has proved to be cost-effective [13].
tion and inversely proportional to the experience of Thyroidectomy using the electrothermal seal-
the operating surgeon [14]. Thus, the cornerstones ing technique has also been introduced and tested
of safe and effective thyroid surgery are an adequate [14,15]. However, this technique did not significantly
training, the understanding of the anatomy and pa- reduce operative time, blood loss, or the complica-
thology, as well as a meticulous dissection technique. tion rate compared to conventional knot-tying but it
The dissection must be based on a sound knowledge increased operative costs in one study [15]. All men-
of three-dimensional topographic anatomy, typical tioned studies compared new ultrasonic or diathermy
landmarks, and possible anatomic variations. The me- dissection devices with the conventional clamp-and-
ticulous dissection technique is achieved by a proper tie technique. However, no comparison with the uti-
exposure of all fine anatomic structures in a blood- lization of hemoclips to secure smaller vessels was
less dry surgical field. The use of magnifying glasses done. Personally, I make liberal use of hemoclips for
(magnification 2.53.5 ), bipolar coagulation, and thyroid and parathyroid surgery and I am convinced
fine titan clips or ligatures is highly recommended. that this speeds up the operation similarly to the use
Neuromonitoring has proved useful for identifying of the quite costly new devices.
the recurrent laryngeal nerve (RLN), in particular if
82 Daniel Oertli

7.2 Extent of Surgery between the medial borders of the sternocleidomas-


and Definitions toid muscles. The appropriate position of the neck
incision is approximately two finger breadths above
Until 2000 there was no uniformly applied definition the sternal notch or in the middle between the sternal
in the literature regarding the extent of thyroidec- notch and the thyroid cartilage. If the incision is too
tomy that should be performed for benign and malig- low, the tendency to keloid formation and resulting
nant pathologies. To fill this gap, Kebebew and Clark unsatisfactory cosmesis is increased.
formulated such a classification (Table 7.1) [16].
Lumpectomy or nodulectomy refer to removal of a
thyroid nodule alone with minimal surrounding thy- 7.4 Positioning and Draping
roid tissue. Partial thyroidectomy involves removal of
a nodule with a larger margin of normal thyroid tis- The patient is positioned with the neck extended.
sue. The definition of subtotal thyroidectomy belongs Rolled towels are placed under the shoulders which
to the bilateral removal of more than 50% of each lobe allow sufficient neck extension. A sponge doughnut is
including the isthmus. Lobectomy or hemithyroidec- placed under the occiput for adequate head support.
tomy refers to the complete removal of one lobe with In order to prevent venous congestion in the neck, the
the isthmus. Near total thyroidectomy is defined as head of the table is elevated to a 30 position during
the total extracapsular removal of one lobe including surgery. Disinfection is performed using an alcoholic
the isthmus with less than 10% of the contralateral agent without iodine which might interfere with post-
lobe left behind. During total thyroidectomy both operative radionuclear scanning and ablative therapy.
lobes and the isthmus are completely removed leaving The surgical field is draped from below the sternal
behind only viable parathyroid glands. notch up to the chin and on the posterior margin of
the sternocleidomastoid muscles.

7.3 Preoperative Measures


7.5 Surgical Steps
All patients should be rendered euthyroid before sur-
gery. Preoperative preparation of patients with thyro- Every surgeon should adopt a stepwise, standardized
toxicosis is particularly critical to avoid operative or strategy for thyroidectomy. One possible way (the
postoperative thyroid storm. The planned procedure authors recommendation) for a successful thyroidec-
should be discussed with the patient and informed tomy is presented below. Modifications may be neces-
consent must be obtained. Routine preoperative la- sary in the case of perithyroidal inflammation, large
ryngoscopy is not necessary if the patient does not re- goiters, or unexpected intraoperative findings.
port voice changes [17]. However, if patients have pre-
viously undergone any type of neck surgery or if the
voice appears to be altered, laryngoscopy is indicated. 7.5.1 Skin Incision and Creation
The tentative skin incision is marked preoperatively of Skin Flaps
using a permanent marker pen on the awake patient
with reclined neck. This is done in a symmetric fash- A curvilinear collar-type incision is placed trans-
ion along the Langers skin lines or in a skin crease in versally along the Langers line of the skin, i.e., the

Table 7.1 Definition of extent of resection


Thyroidectomy procedure Removal of: Indications
Partial (nodulectomy, lumpectomy) Nodule + margin of normal tissue Benign lesion
Subtotal More than one half of the thyroid gland Benign lesion
and isthmus
Lobectomy (= hemithyroidectomy) One entire lobe and isthmus Standard initial treatment for all indeter-
minate nodules
Near-total Lobectomy on one side, isthmectomy and Papillary carcinoma in a low-risk patient,
subtotal resection of contralateral lobe not requiring radioiodine ablation
Total Both lobes and isthmus Any other type of thyroid carcinoma
7 Technique of Thyroidectomy 83

standard Kochers incision. The use of a natural skin when the operating surgeon is positioned on the right
crease if present seems attractive. In order to optimize side of the patient. By predominantly blunt dissection,
cosmesis, the skin incision should be as long as nec- the anterior aspect of the respective thyroid gland is
essary but as short as possible. Personally, the author exposed. Caution should be applied while retracting
believes that a 4- to 5-cm incision allows safe thyroid- the strap muscles to avoid disrupting the medial thy-
ectomy in most cases and results in excellent cosme- roid veins. These veins are isolated and either ligated
sis. However, patients with larger tumors or goiters or clipped and divided. Proper exposure to the lateral
or those with short necks will require a larger inci- aspects of the thyroid gland is achieved using right-
sion for optimal exposure. The incision is carried out angled (de Quervain) retractors. Division of the strap
through the skin and the subcutaneous layer through muscles may be necessary in the case of a very large
the platysma muscle to the lateral extent of the skin goiter, when a central neck dissection is indicated, or
incision. The two skin flaps are created by dissect- in reoperative cases. The two muscles (sternohyoid
ing them away from the strap muscles upward to the and sternothyroid) are separated using diathermia.
thyroid cartilage and downward to the sternal border. Their borders are secured with 2-0 threads that serve
Elevation of the two flaps is almost bloodless if the as stay sutures.
layer beneath the platysma is followed and dissected.
The cranial flap is transfixed using stay sutures that
are secured on two hooks placed on a horizontal rod 7.5.3 Upper Pole
which is placed above the patients head (Fig. 7.1). The
caudal flap is pulled downward using a Roux retractor Using Kochers forceps, lateral retraction of the upper
enabling optimal exposure to the strap muscles. pole of the thyroid lobe is applied in order to open up
the avascular space [18] between the lobe and the cri-
cothyroid muscle, thus exposing the external branch
7.5.2 Strap Muscles of the superior laryngeal nerve [19,20]. This nerve
can sometimes be identified as it descends with the
The approach to the thyroid capsule is done by split- vessels and anterior to the cricoid muscle but is often
ting the strap muscles in the midline. Small crossing not visible (Fig. 7.2). A recent study showed that the
vessels are treated with bipolar coagulation. For a bi- identification and dissection of the superior laryngeal
lateral approach, the left thyroid lobe is first dissected. nerve do not lower the risk of damage compared with
This is usually the more cumbersome preparation the simple transection of the superior vein and ar-

Fig. 7.1 Intraoperative situation after


creation of the superior skin-platysma flap
which is secured with threads. The inferior
flap is retracted using a Roux retractor
84 Daniel Oertli

Fig. 7.2 Lateral and caudal retraction of the upper pole of the
thyroid in order to open up the avascular space between the
lobe and the cricothyroid muscle, thus exposing the external
branch of the superior laryngeal nerve

tery close to the thyroid [21]. The superior vessels are using a vessel loop in order to facilitate further expo-
usually ligated with transfixing sutures. Large goiters sure of the RLN. The nerve may easily be found at its
with prominent superior poles often require more constant landmark, the so-called Zuckerkandl tuber-
than one transection step. culum [24,25], where it crosses beneath the thyroid
gland and enters below Berrys ligament of the thy-
roid cartilage (Fig. 7.3). The RLN can always be iden-
7.5.4 Isthmus and Pyramidal Lobe tified laterodorsally to the ligament of Berry; it never
penetrates the ligament [26]. The left RLN leaves the
By blunt dissection, the isthmus is freed from the un- vagus nerve as the vagus crosses over the arch of the
derlying trachea and divided between transfixing liga- aorta. It hooks around the aorta and ascends again,
tures. If subtotal or total thyroidectomy is performed, similarly to the right RLN, laterally to the trachea to
the division of the isthmus is often not necessary. The its terminal branches within the laryngeal muscles.
pyramidal lobe, which originates more often from the This explains why the left RLN runs closer to the tra-
left thyroid lobe, is traced upward and removed as cheoesophageal groove than the right RLN [27]. The
completely as possible. RLN may pass posteriorly or superficially to the in-
ferior thyroid artery or its branches intertwine with
many variations. Although several methods of local-
7.5.5 Hilum of the Gland izing the RLN have been described, surgeons should
be aware of the variations and must have a thorough
Only the complete division of the superior vessels knowledge of the normal anatomy to achieve a high
enables the surgeon to medially rotate and anteriorly standard of care. This will ensure the integrity and
mobilize the gland which results in optimal exposure safety of the RLN during thyroid surgery. The iden-
of the hilar structures. Capsular dissection, as de- tification of the RLN may be assisted by palpation; it
scribed by Thompson et al. [22], refers to the develop- may be felt like a cord that can be rolled against the
ment of a plane between the thyroid capsule and the trachea [28]. The nerve appears as a white cord com-
tertiary branches of the inferior thyroid artery. The monly accompanied by a small artery. To clearly iden-
branches are ligated or clipped individually directly on tify the RLN, dissection of its crossing point with the
the surface of the thyroid gland. This method, which inferior thyroid artery is critical. Gentle dissection,
is widely practiced today, minimizes surgical damage best performed with a fine curved jaw hemostat, is
to both the parathyroid glands and the RLN [23]. Me- necessary at this point. Although there are many dif-
ticulous dissection steps will then enable identifica- ferent anatomic relationships between the nerve and
tion of the RLN where it crosses the inferior thyroid the artery, the crossing point is one constant anatomic
artery, as well as the two parathyroid glands. It is wise landmark where the RLN can usually be identified.
to preserve as much of the inferior thyroid artery and One exception to this rule is the non-recurrent infe-
its branches as possible, since it supplies the blood to rior laryngeal nerve (Fig. 7.4). This anomaly is found
the two parathyroid glands. Truncal ligation of the in- virtually only on the right side and is associated with
ferior thyroid artery should be omitted. However, it an anomalous right subclavian artery with a reported
is sometimes helpful to hold the trunk of the artery frequency of 0.20.8% [2931].
7 Technique of Thyroidectomy 85

Fig. 7.3 Topographic relationship between the inferior


thyroid artery and the tubercle of Zuckerkandl to the re-
current laryngeal nerve and the superior parathyroid gland

Fig. 7.4 Intraoperative finding of a non-recurrent inferior


laryngeal nerve

7.5.6 Handling of the Parathyroid Glands and not to dissect the gland further than just beyond
the edge of the thyroid to preserve its blood supply.
Regardless of whether a unilateral lobectomy or total The inferior parathyroid gland is usually found at the
thyroidectomy is performed, all identified parathy- inferior pole of the thyroid or within the tongue of
roid tissue should be preserved on its native blood the thymus. Once identified, it is taken off the infe-
supply. If a gland is devascularized during dissection, rior pole in a similar fashion to the superior gland.
it should be transplanted. Although there have been Disruption of the thyroid-thymic ligament should be
sporadic reports of parathyroid autotransplantation, avoided as it provides most of the blood supply to the
it has only been in the last 30 years that the technique inferior parathyroid gland.
has become used and only recently has it become ac- All normal but devascularized parathyroid tissue
cepted as part of routine clinical practice during total should be transplanted into the sternocleidomas-
thyroidectomy [32]. The best way to preserve the para- toid muscle or other convenient muscle at the time
thyroid glands in situ is the extracapsular dissection of thyroidectomy. Sometimes, the gland is partly de-
of the thyroid gland. With the utilization of the extra- vascularized and should then be trimmed back to the
capsular dissection, the parathyroid glands are swept area of good arterial flow and viability. The remaining
off the thyroid capsule and are left in situ with their portion is removed, minced, and autotransplanted.
vascular pedicles. The superior parathyroid gland is Histologic confirmation of parathyroid tissue is cru-
usually found after mobilization of the superior pole cial in the setting of thyroid cancer. Nodal metasta-
of the thyroid. The lateral aspect of the thyroid gland ses from thyroid cancer can mimic parathyroid tissue
superior to the inferior thyroid artery usually reveals and should not be transplanted. There are principally
a fat pad where the parathyroid can be found. This fat two ways to do a parathyroid autotransplantation.
pad including the parathyroid gland should be mobi- First, the gland tissue is removed and minced into
lized off the lateral aspect of the thyroid starting at its tiny cubes that are smaller than 1 mm3. By separating
superior medial edge and sweeping the pad inferiorly the muscle fibers of the sternocleidomastoid muscle, a
and laterally. It is important not to disrupt the fat pad pocket containing about a 1-ml space is created using
86 Daniel Oertli

blunt dissection. The minced tissue is then trans- thyroid gland. This small artery should be isolated
planted into the pocket which is closed and marked and clipped before cutting (Fig. 7.5). The use of any
by hemostatic clips or a non-absorbable thread. It cautery or other thermal dissection device should be
is essential to leave a completely dry pocket behind avoided at this step due to the potential for thermal
since hematoma formation within the pocket would injury of the RLN that is in close proximity to the in-
be prone to phagocytosis including the parathyroid ferior thyroid artery. Inadvertent bleeding from this
tissue. The second possibility to achieve the parathy- artery and uncontrolled attempts of hemostasis at this
roid transplantation is the creation of a parathyroid point of dissection may harm the RLN. Sudden bleed-
suspension using saline which is then aspirated with ing is best handled, with the aid of suction, by iden-
a 2-ml syringe and injected into the sternocleidomas- tifying the vessel stump, and clamping or clipping,
toid muscle with an 18-gauge needle. being constantly aware of the presence of the RLN. If
oozing occurs at this point, the placement of a hemo-
styptic gelatine sponge is advised.
7.5.7 Lower Thyroid Pole

The transection of the vessels running to the lower 7.5.9 Wound Closure
pole is usually done after proper exposition of the
RLN. Veins from the anterior superior mediastinum A postoperative drain can never replace accurate he-
are exposed and divided very close to the thyroid mostasis and is of little or no use if severe postopera-
gland. In up to 12% of cases an accessory ima artery tive bleeding occurs. Two randomized trials did not
may spread into the lower pole. This vessel may origi- show any advantage of drainage after thyroidectomy
nate either from the brachiocephalic trunk, the right [33,34]. The strap muscles are sutured continuously
carotid artery, directly from the aortic arch, the inter- with a 3-0 absorbable thread, the platysma with a 4-0
nal thoracic artery, or from a mediastinal artery. This thread, and the skin is closed by an intradermal run-
vessel may cause intraoperative bleeding especially ning suture using 5-0 absorbable thread. A smooth
when a large retrosternal goiter is bluntly mobilized. collar may be used for the first 24 hours postopera-
tively and the patient should be advised to keep a head
up position of about 30 in order to minimize venous
7.5.8 Removal of the Lobe congestion and swelling of the soft tissues around the
wound.
During the final steps of the thyroidectomy, the lobe
is dissected away from the trachea under constant
exposure and preservation of the RLN. The dense 7.6 Reoperative Thyroid Surgery
attachments at the level of the posterior suspensory
ligament (Berry) usually require sharp dissection. At- Avoidance of RLN injury is best achieved by iden-
tention must then be paid to the relatively constant tification of the nerve early during reoperation. The
superior branch of the inferior thyroid artery (crimi- best approach is the identification of the RLN in a
nal branch) that often crosses underneath the RLN previously undissected area and to follow the nerve
and spreads medially from beneath the nerve into the into the dissected scarred region (from the known

Fig. 7.5 Last steps of dissection for thyroid lobec-


tomy: a small superior branch of the inferior thyroid
artery usually crosses underneath the RLN and
spreads medially from beneath the nerve into the
thyroid parenchyma
7 Technique of Thyroidectomy 87

toward the unknown). Although the use of intra- Third, the anterior superior approach exposes the
operative neuromonitoring for confirmation of the region between the superior pole of the thyroid, if
RLN has some theoretical applications for a difficult present, and the larynx. The RLN can be identified as
dissection, visual identification of the RLN is still es- it enters the larynx with dissection in this avascular
sential. Principally three distinct approaches exist for space between the superior thyroid pole and the lar-
reoperative thyroid and parathyroid surgery. ynx. This can even be realized without taking down
First, the lateral or back door approach enters the superior pole vessels. The RLN can be traced infe-
the thyroid bed between the anterior border of ster- riorly and identified in the hilum of the thyroid which
nocleidomastoid and the strap muscles (Fig. 7.6). Lat- is often extensively scarred.
eral mobilizing of the sternocleidomastoid muscle ex-
poses the sternohyoid and underlying sternothyroid
muscles, whose fibers spread out inferiorly and later- 7.7 Minimally Invasive
ally over the carotid artery and jugular vein. Gentle Thyroidectomy
retraction of the carotid artery exposes the paratra-
cheal soft tissue. This area, which is located inferolat- Whereas minimally invasive parathyroidectomy has
erally to the inferior pole of the thyroid, is, if present, become popular among endocrine surgeons, experi-
usually unchanged from previous interventions. Here, ence with minimally invasive thyroidectomy remains
the RLN can usually be identified without difficulty. limited. The feasibility and safety of fully endoscopic
Second, the low anterior approach enters the thy- thyroidectomy or video-endoscopically assisted thy-
roid bed similarly to the primary operation. The strap roidectomy have been proved in a few studies that
muscles are separated in the midline down to the ster- reported a minor risk of complications and a low con-
nal notch and are reflected laterally. The dissection is version rate of 311% [3538]. The key to the success
then carried out in the paratracheal regions inferior of these approaches is a rigorous selection of the pa-
to the area of previous dissection where the right or tients. Inclusion criteria are solitary nodules smaller
left RLN is identified. than or equal to 3 cm, thyroid volume less than 20 ml,
absence of thyroiditis, absence of previous neck irra-
diation, and absence of previous neck surgery. Thus,
minimally invasive thyroidectomies are valid alterna-
tives to conventional surgery for patients with small
solitary nodules [39]. However, only 10.6% of patients
requiring thyroid surgery eventually qualify for this
approach [40].

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88 Daniel Oertli

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