Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) |
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Superior thyroid artery and vein
External branch of superior laryngeal nerve
Superior thyroid artery and vein
B
A
FIGURE 1–13
Inferior thyroid vein
FIGURE 1–14
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As the thyroid lobe is retracted medially, gentle dissection is performed to expose the parathyroid glands, inferior thyroid artery, and recurrent laryngeal nerve. The recurrent nerve usually passes behind the inferior thyroid artery in the tracheoesophageal groove but can occasionally lie anterior to the artery. The nerve is best found by careful dissection just inferior to the inferior thyroid artery (Figure 1-15).
At this point, the nerve can then be traced upward and its position in relation to the thyroid can be determined. Parathyroid glands that lie on the thyroid surface can be mobilized with their vascular supply and thus preserved (Figure 1-16).
Inferior thyroid artery
FIGURE 1–15
Parathyroid gland
Right recurrent laryngeal 
nerve
FIGURE 1–16 Right recurrent laryngeal nerve
C H A P T E R 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) |
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The branches of the inferior thyroid artery are divided at the surface of the thyroid gland and individually ligated using 3-0 or 4-0 sutures. The connective tissue (ligament of Berry), which tethers the thyroid gland to the tracheal rings, is then carefully divided by sharp dissection. There are usually several small accompanying vessels, which must be individually ligated after careful dissection, because the recurrent nerve is closest to the thyroid at this point and most vulnerable. Division of the ligament allows the thyroid to be mobilized medially (Figure 1-17).
Dissection of the thyroid from the trachea can then be performed with the electrocautery by division of the loose connective tissue between the structures (Figure 1-18).
Parathyroid gland
Right recurrent laryngeal nerve
Right inferior thyroid 
artery
Right recurrent laryngeal nerve
FIGURE 1–17
FIGURE 1–18
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If lobectomy is indicated, then the isthmus is clamped using a Kocher or tonsil clamp (Figure 1-19, A), divided, and oversewn with an interlocking continuous 3-0 Vicryl suture
(Figure 1-19, B).
Thyroid gland
A
Left thyroid remnant
B
FIGURE 1–19
C H A P T E R 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) |
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If total thyroidectomy is indicated, the operation is continued in a similar fashion on the other side to remove the thyroid gland in toto (Figure 1-20, A) and to preserve both the parathyroid glands and the recurrent laryngeal nerves (Figure 1-20, B).
A
Cricothyroid cartilage |
Thyroid cartilage |
Cricothyroid muscle
Parathyroid gland
Esophagus
Inferior thyroid |
|
artery |
Left recurrent laryngeal |
Trachea |
nerve |
|
B
FIGURE 1–20
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Some surgeons prefer to perform a subtotal resection if operating for benign disease, thus preserving the parathyroid glands and not dissecting in the area of the recurrent laryngeal nerves. The line of resection on the thyroid lobe to preserve this rim of thyroid tissue overlying the parathyroid glands is shown in Figure 1-21, A. The remnant thyroid tissue is illustrated in Figure 1-21, B.
C H A P T E R 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) |
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Parathyroid gland
Thyroid gland
Inferior thyroid artery
A
Right thyroid remnant |
Left thyroid remnant |
B
FIGURE 1–21
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3. CLOSING
Once resection is completed and hemostasis is ensured, closure is performed by first reapproximating the strap muscles at the midline using interrupted 3-0 Vicryl sutures
(Figure 1-22).
The platysma muscle is likewise reapproximated using interrupted 3-0 Vicryl sutures
(Figure 1-23).
Finally, the skin is reapproximated with a subcuticular stitch of 4-0 Monocryl suture
(Figure 1-24).
STEP 4: POSTOPERATIVE CARE
Although once routinely placed after thyroid resection, drains are seldom indicated.
One of the most immediate postoperative complications can be wound hematoma, which occurs in a small percentage of patients. It is more common in those patients who are taking anticoagulant medications or nonsteroidal anti-inflammatory drugs (NSAIDs) or who have had total thyroidectomy.
A small hematoma in this location can severely compromise respirations and should be immediately evacuated either in the operating room or, if this is not possible, at the bedside.
Injury of a recurrent laryngeal nerve can lead to hoarseness; bilateral injury of the recurrent laryngeal nerves may result in paralysis of both vocal cords, which would require reintubation and possibly tracheostomy.
Postoperative hypoparathyroidism is usually a transient phenomenon that is relatively rare but occurs more often after total thyroidectomy. Calcium replacement and possibly vitamin D may be required to maintain adequate serum calcium levels.
In an uncomplicated thyroid lobectomy, patients may be discharged on the same day as surgery.
C H A P T E R 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) |
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Sternohyoid muscle |
Thyroid cartilage |
Sternocleidomastoid muscle
Anterior jugular vein
FIGURE 1–22
Platysma muscle
FIGURE 1–23
FIGURE 1–24
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STEP 5: PEARLS AND PITFALLS
The most dreaded complication of thyroid resection is damage to the recurrent laryngeal nerve. It is imperative to identify the nerve throughout its course in the neck to avoid injury.
During thyroidectomy, the recurrent laryngeal nerve is at greatest risk of injury at the ligament of Berry, during ligation of branches of the inferior thyroid artery, or at the thoracic inlet.
In most patients, the dissection can be carried out entirely through the cervical incision. In the rare patient, a partial median sternotomy may be required for anterior mediastinal lesions that cannot be safely mobilized through the cervical incision. This possibility should be anticipated by preoperative physical examination.
SELECTED REFERENCES
1. Hanks JB: Thyroid. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 17th ed. Philadelphia, Saunders, 2004, pp 947-983.
2. Wong CKM, Wheeler MH: Thyroid nodules: Rational management. World J Surg 2000;24:934-941. 3. Schlumberger MJ: Papillary and follicular thyroid carcinoma. N Engl J Med 1998;338:297-306.
4. Clark OH: Surgical anatomy. In Braverman LE, Utiger RE (eds): Werner and Ingbar’s The Thyroid, 7th ed. Philadelphia, Lippincott-Raven, 1996, pp 462-468.