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Fig. 47.26 The external branch of the superior laryngeal nerve (circled), is identied, stimulated and preserved during dissection of the superior
pole
G. Garas et al.
Fig. 47.27 The superior pole is skeletonised, and each vessel is ligated individually with the Harmonic® shears away from the external branch of
the superior laryngeal nerve to prevent nerve injury from lateral thermal spread [19]
47 Video-Assisted andRobotic Thyroidectomy
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Fig. 47.28 Once it is totally freed, the thyroid lobe is delivered through the axillary incision by the assistant surgeon
503
Fig. 47.29 Following removal of the thyroid lobe, meticulous haemostasis is applied to address any remaining bleeding points in the thyroid bed.
Great care should be taken not to damage the recurrent and external laryngeal nerves and parathyroid glands at this stage
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Fig. 47.30 Two-layer closure is completed with 4–0 subcuticular
Vicryl Rapide™ sutures (Ethicon Products, Inc.; Johnson & Johnson,
Cincinnati, OH, USA) followed by application of Dermabond (Ethicon
Products, Inc) tissue glue on the wound
47.4 Post-Operative Care
andManagement ofComplications
47.4.1 Post-Operative Care
For thyroid lobectomy, patients can be discharged the following morning (<24h hospital stay). If completion or total
thyroidectomy has been undertaken, post-operative corrected
calcium and parathyroid hormone (PTH) level checks are
mandatory. The protocol for postoperative calcium and PTH
level checks and treatment of hypoparathyroidism (if present) does not differ from the protocol following open thyroidectomy. All patients undergo breoptic laryngoscopy
before discharge to assess post-operative RLN function.
To prevent hematoma and seroma, an anterior chest wall
compression dressing is applied overnight following wound
closure. The next morning, this is removed, and the patient is
advised to wear a sports bra or vest for 2weeks to provide
G. Garas et al.
light compression to the anterior chest wall. Oral antibiotics
(such as co-amoxiclav 625mg three times a day) are routinely given for 7days, as well as analgesia (acetaminophen
1g four times a day for 7days) as required. Regular follow up at 2weeks and at 3, 6, 12, 18 and 24months allows prospective long-term evaluation, including evaluation of scar
cosmesis, quality of life (QoL) and patient-reported outcome
measures (PROMs).
47.4.2 Complications andTheir Management
The risks of RT are the same as for conventional thyroidectomy with regard to injury to the RLN and/or EBSLN, infection, haematoma, seroma, hypoparathyroidism and the need
for revision surgery [5, 6]. Thus, preventing and managing
these complications involves the same measures as for open
thyroid surgery. The only exception relates to the prevention
of hematoma and seroma, which involves anterior chest wall
compression.
The complications that are specic to RT are dysesthesia on
the chest over where the subcutaneous ap has been raised and
brachial plexus neurapraxia. The chest wall dysesthesia should
have been explained to the patient as part of the informed consent process prior to surgery, so he or she will expect it.
Dysesthesia should not be regarded as a complication, but as a
natural sequel of raising the subcutaneous ap; all patients
experience it to some extent. It is important to explain to the
patient that it almost always resolves, though it can last for several months. Pain is not a particular problem with RT [5, 6].
The other risk relates to brachial plexus neurapraxia.
Before surgery, patients should be made aware of this important complication, which is a risk unique to the transaxillary
approach. It can be totally avoided by opting for conventional thyroidectomy. It should be explained, however, that
this complication is exquisitely rare when all appropriate
preventative measures are employed. The key to preventing
brachial plexus neurapraxia involves placing the arm in the
‘correct’ position (as illustrated in Figs.47.1 and 47.8) and
ensuring that this position is maintained for the entire duration of the operation, because the mechanism responsible for
this complication involves hyperextension (resulting in traction injury) of the brachial plexus over a prolonged period.
As part of the routine post-operative check in the recovery
room, it is vital to not only ask the patient about any abnormal sensation and/or weakness along their arm but to also
formally assess its neurovascular status. If any neurological
decit or shoulder stiffness is identied that has not resolved
by the next morning, the involvement of a physiotherapist at
an early stage (prior to discharge) is paramount. The patient
should be taught what daily exercises are required, and the
physiotherapist should follow up the patient in the outpatient
setting until full resolution has been achieved.
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47.5 Structured Training Program
andCredentialing
The most important determinants of outcomes in thyroid surgery relate to surgeon experience and volume [20, 21]. Thus,
mentoring and proctorship are key [22, 23]. To ensure patient
safety and optimise outcomes, especially when robotic surgeons are still in their learning curve, structured training programs for robotic surgery with formal training curricula have
been developed, with some variation across countries [24,
25]. The key components of a typical program are presented
in Table47.2 [26].
RT should be undertaken only by appropriately trained
and accredited surgeons, experienced in both open and
robotic thyroid surgery, with the procedure performed in
high-volume robotic institutions [8]. In addition to the surgeon, it is paramount for the entire OR team to receive formal training in robotic surgery.
Table 47.2
thyroidectomy
• Evidence of prociency in open thyroid surgery (minimum of
• Intuitive surgical online training program (successful
• da Vinci surgery training program
• Virtual reality (VR) training program (with da Vinci skills
• Observations of live robotic thyroidectomy cases performed by
• Structured dry-lab training followed by wet-lab training on live
• Advanced cadaveric robotic thyroidectomy course (as a
• Proctored cases (where proctor supervises and guides surgeon,
• Completion of accredited robotic head and neck and thyroid
a
Desirable (as opposed to essential) component
Structured training program and credentialing in robotic
50 cases perannum)
completion of all online training modules)
simulator) (minimum of 10h)
proctor in high-volume accredited robotic centre
animal models (minimum of 10h)
dissector)
at least for rst ve cases or until surgeon deemed competent)
surgery fellowship
a
References
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etal. Comparing transaxillary robotic thyroidectomy with conventional surgery in a UK population: a case control study. Int J Surg.
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6. Sun GH, Peress L, Pynnonen MA. Systematic review and metaanalysis of robotic vs conventional thyroidectomy approaches for
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7. Tolley N, Garas G, Palazzo F, Prichard A, Chaidas K, Cox J, etal.
Long-term prospective evaluation comparing robotic parathyroidectomy with minimally invasive open parathyroidectomy for primary hyperparathyroidism. Head Neck. 2016;38(Suppl 1):E300–6.
8. Kim MJ, Nam KH, Lee SG, Choi JB, Kim TH, Lee CR, et al.
Yonsei experience of 5000 gasless transaxillary robotic thyroidectomies. World J Surg. 2018;42:393–401.
9. Garas G, Arora A, Tolley N. Robotic surgery of the parathyroid
glands. In: Grillone GA, Jalisi S, editors. Robotic surgery of the
head and neck: a comprehensive guide. NewYork: Springer; 2015.
p.133–46.
10. Garas G, Darzi A, Arora A, Tolley N. Single-port tranasaxillary
robotic parathyroidectomy. In: Gil Z, Amit M, Kupferman ME, editors. Atlas of head and neck robotic surgery. NewYork: Springer;
2017. p.93–106.
11. Garas G, Markar SR, Malietzis G, Ashraan H, Hanna GB,
Zacharakis E, etal. Induced bias due to crossover within randomized controlled trials in surgical oncology: a meta-regression analysis of minimally invasive versus open surgery for the treatment of
gastrointestinal cancer. Ann Surg Oncol. 2018;25:221–30.
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12. Garas G, Holsinger FC, Grant DG, Athanasiou T, Arora A, Tolley
N. Is robotic parathyroidectomy a feasible and safe alternative
to targeted open parathyroidectomy for the treatment of primary
hyperparathyroidism? Int J Surg. 2015;15:55–60.
13. Tolley N, Arora A, Palazzo F, Garas G, Dhawan R, Cox J, Darzi
A. Robotic-assisted parathyroidectomy: a feasibility study.
Otolaryngol Head Neck Surg. 2011;144:859–66.
14. Chung WY.Pros of robotic transaxillary thyroid surgery: its impact
on cancer control and surgical quality. Thyroid. 2012;22:986–7.
15. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, etal. Robotassisted endoscopic surgery for thyroid cancer: experience with the
rst 100 patients. Surg Endosc. 2009;23:2399–406.
16. Foley CS, Agcaoglu O, Siperstein AE, Berber E.Robotic transaxillary endocrine surgery: a comparison with conventional open technique. Surg Endosc. 2012;26:2259–66.
17. Henry JF, Defechereux T, Gramatica L, de Boissezon C.Minimally
invasive videoscopic parathyroidectomy by lateral approach.
Langenbecks Arch Surg. 1999;384:298–301.
18. Pelizzo MR, Toniato A, Briguglio E.Lateral access in thyroidectomy. Technique and indications. Minerva Chir. 1993;48:189–91.
19. Garas G, Okabayashi K, Ashraan H, Shetty K, Palazzo F, Tolley
N, etal. Which hemostatic device in thyroid surgery? A network
meta-analysis of surgical technologies. Thyroid. 2013;23:1138–50.
20. Meltzer C, Klau M, Gurushanthaiah D, Tsai J, Meng D, Radler L,
Sundang A.Surgeon volume in thyroid surgery: surgical efciency,
outcomes, and utilization. Laryngoscope. 2016;126:2630–9.
21. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA,
Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg.
1998;228:320–30.
22. Athanasiou T, Patel V, Garas G, Ashraan H, Hull L, Sevdalis N,
et al. Mentoring perception, scientic collaboration and research
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An academic health science centre perspective. Postgrad Med J.
2016;92:581–6.
23. Athanasiou T, Patel V, Garas G, Ashraan H, Shetty K, Sevdalis N,
etal. Mentoring perception and academic performance: an academic
health science centre survey. Postgrad Med J. 2016;92:597–602.
24. Santok GD, Raheem AA, Kim LH, Chang K, Chung BH, Choi YD,
Rha KH.Proctorship and mentoring: its backbone and application
in robotic surgery. Investig Clin Urol. 2016;57(Suppl 2):S114–20.
25. Schreuder HW, Wolswijk R, Zweemer RP, Schijven MP, Verheijen
RH.Training and learning robotic surgery, time for a more structured approach: a systematic review. BJOG. 2012;119:137–49.
26. Requirements for credentialing of robotic surgeons. Epworth
Healthcare. Victoria, Australia. 2015. http://www.epworth.org.
au/Our- Services/Robotic- Surgery/Documents/Epworth%20
Robotic%20Credentialing%20revised%202015.pdf. Accessed 22
July 2019.
Surgery forIntrathoracic Goitres
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RicardSimó, IainJ.Nixon, andKarenHarrison-Phipps
48
48.1 Introduction
Intrathoracic goitre is (ITG) dened as an enlarged thyroid
gland extending into the mediastinum. This may present to
the surgeon for diagnostic and/or therapeutic purposes.
Challenges specic to this condition include patient evaluation, determination of the risk of malignancy within the multiple nodules of the gland, selecting patients who require
surgical management and planning a surgical approach to
deal with the disease process or processes without undue risk
of complications.
48.2 Current Indications forSurgery
Most patients with ITGs tend to present with compression
symptoms, mainly with increasing dyspnoea on exertion.
Intrathoracic goitres may also be diagnosed incidentally during chest radiography or other investigations such as USS,
CT, MRI or PET.Such an incidental presentation is reported
in up to 40% of cases [1]. Patients with ITG can therefore be
classied as symptomatic or asymptomatic. In the symptomatic group (dyspnoea, dysphagia or superior vena cava syndrome), surgery provides the only way of controlling local
aerodigestive symptoms and provides tissue for histological
R. Simó (*)
Head, Neck and Thyroid Oncology Unit, Department of
Otorhinolaryngology Head and Neck Surgery, Guy’s and St
Thomas’ Hospital NHS Foundation Trust, London, UK
e-mail: ricard.simo@gstt.nhs.uk
I. J. Nixon
Department of Otolaryngology-Head and Neck Surgery, NHS
Lothian, University of Edinburgh, Edinburgh, UK
e-mail: iain.nixon@nhslothian.scot.nhs.uk
K. Harrison-Phipps
Department of Otolaryngology and Head and Neck Surgery, Guy’s
and St Thomas’ NHS Foundation Trust, London, UK
e-mail: karen.harrison-phipps@gstt.nhs.uk
analysis [2]. For the few patients who present with malignancy, surgical resection provides the mainstay of therapy
and allows for adjuvant radioiodine treatment when indicated [3].
In the asymptomatic group, some authors consider the
mere presence of an ITG found incidentally as an indication
for surgery [2], whereas others have questioned the need for
surgery in all cases especially if malignancy is not suspected
[4]. Therefore, any decision-making regarding surgery in
this patient group should be individualised. An appropriate
management plan can be determined based upon goitre size,
degree of aero-digestive tract compression and the comorbidities of the patient. For example, a patient with an asymptomatic ITG detected on imaging to stage an incurable
aggressive malignancy clearly is not a candidate for surgery.
In contrast, an otherwise well patient with symptomatic tracheal compression and an excellent life expectancy will be a
good surgical candidate. Surgery in this clinical setting will
prevent increasing airway symptoms and avoid a situation
where an intubation attempt is unsuccessful. This can occur
in an emergency or elective situation and can place the
patient in danger.
The difcult patient is one with minor comorbidities and
asymptomatic disease, which causes early tracheal compression. Such patients should be made aware of the risks and
benets of both a conservative and a surgical approach.
Interval imaging often provides critical information about
the trajectory of disease, which aids in borderline cases.
48.3 Preoperative Checklist,
Considerations andAnaesthesia
Surgery for ITG may be associated with high rates of morbidity, and it is therefore essential to identify the most highrisk cases, which require a planned combined cervico-thoracic
approach either with sternotomy or lateral thoracotomy.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_48
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48.3.1 Essential Preoperative Checklist
An essential preoperative checklist should include the
following
• Clinical evaluation with breoptic laryngoscopy
• Thyroid function test and antibodies
• Calcitonin level if indicated
• Ultrasound-guided FNAC or core needle biopsy
• Multiplanar computerised tomography imaging
• Appropriate informed consent including tracheostomy
• Availability of intensive care facility
48.3.2 Preoperative Considerations
andAnaesthesia
Consideration should be given to the following:
1. Thyroid Function
All patients with preoperative hyperthyroidism must
be managed by an endocrinologist to achieve a euthyroid
state, in order to prevent life-threatening thyrotoxic crisis
during or after surgery. This usually involves thionamide
antithyroid drugs, or potassium iodide (40mg three times
daily for 10 days) +/− beta-blockade (e.g. propranolol
40–80mg three times per day).
2. Coagulation Status
Given the risk of bleeding, pre-existing clotting disor-
ders must be identied, and anticoagulation such as warfarin or clopidogrel should be stopped and substituted for
heparin if required depending on the underlying medical
or coagulation disorder.
3. Extent of Goitre and Relationship to Mediastinal Structures
Once the diagnosis of ITG is suspected, preoperative
cross-sectional imaging of the neck and chest with an
intravenous contrast agent is essential for surgical planning. CT or MRI may be used; however, most surgeons
may nd it easier to interpret CT scan images. The relationship of the ITG to the trachea, oesophagus and great
vessels should be easily appreciated on imaging, and this
will guide the surgical approach (cervical +/− sternotomy), which may require the input of other surgical
teams, as well as providing invaluable information to the
anaesthetist on the presence of laryngotracheal compression and likely problems with endotracheal intubation.
4. Comorbidities
Patients with signicant cardiorespiratory disease
requiring median sternotomy are at higher risk of postoperative complications, hence requiring close monitoring post-surgery in an intensive care setting.
5. Airway Management for Surgery and Other Anaesthetic
Issues
ITG can be associated with signicant laryngotracheal
compression resulting in difcult orotracheal intubation.
Prior to surgery, the surgeon and anaesthetist must discuss
the airway plan and review all imaging together. In most
cases, tracheal compression is ‘soft ‘in nature and can easily
be overcome on gentle insertion of the endotracheal tube,
which may need to be one size smaller than standard for the
patient. In order to avoid the dreaded emergency scenario of
‘can’t intubate, can’t ventilate’ at induction of anaesthesia
in a paralysed patient, the anaesthetic team may choose to
perform an awake breoptic oral or nasal tracheal intubation with the aid of topical local anaesthesia [2, 5].
Although the majority of cases are amenable to endotracheal intubation, as the tube splints the trachea open at
the area of maximal compression, airway management
may not always be straightforward. Many patients will
have variable symptoms related to head position. When
the neck is fully extended, the goitre is pulled up towards
the thoracic inlet, and the patient may nd this position
compromises the airway. In such cases, awake breoptic
intubation may be required in order to allow neck exion
during intubation. Truly difcult intubations are uncommon [2], but cooperation between the operating surgeon
and anaesthetist is crucial to avoiding problems at this
critical stage of the procedure [2].
In cases where extensive mediastinal dissection is
anticipated, a double lumen endotracheal tube may be
required to permit selective pulmonary ventilation. Such
cases require an experienced anaesthetic team with
appropriate head and neck and thoracic anaesthetic expertise, as these tubes can be challenging to place in patients
with a difcult airway [2, 5].
Recurrent laryngeal nerve intraoperative neuromonitoring has been reported to reduce nerve palsy rates following difcult thyroidectomy, such as ITG surgery [6].
Where nerve monitoring will be employed and muscle
relaxants are required at induction of anaesthesia, a short
acting agent should be used so as not to interfere with
neural monitoring during the operation.
Maintenance of anaesthesia is usually standard as per
other surgical procedures, with no special requirements.
At the end of surgery, tracheal compression resulting from
long-standing goitres may cause a degree of tracheomalacia; however, endotracheal extubation is almost always
possible. In the highly unlikely event that the patient suffers airway obstruction on extubation due to tracheomalacia, reintubation should be straightforward and an elective
tracheostomy performed at a later stage if necessary [7].
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6. Intraoperative Neuromonitoring
Intraoperative neuromonitoring is increasingly used in
thyroid surgery. In cases of ITG surgery, its use should be
encouraged due to the potential distortion of the RLN as
a consequence of the size of the goitre [8].
7. Antibiotic Prophylaxis
An antibiotic prophylaxis protocol should be in place
when doing surgery for ITG. As surgeries can be prolonged and the need for sternotomy is possible, the use of
appropriate antibiotic prophylaxis should be encouraged.
8. Peri-operative Hyperparathyroidism Protocol
An appropriate peri-operative calcium management
protocol should be in place [9].
48.4 Surgical Approaches
Surgery for ITG poses signicant intraoperative and postoperative challenges and therefore should be carried out by
experienced surgeons who are part of a dedicated multidisciplinary thyroid surgery team in specialised centres.
For patients with bilateral enlargement of the thyroid
gland, total thyroidectomy is the procedure of choice however in patients with unilateral enlargement, or in those
patients in which there is a signicant risk of injury to the
recurrent laryngeal nerve or the parathyroid function, thyroid
lobectomy is a perfectly accepted option as the majority of
these patients will have benign goitres [2].
In 95% of cases of ITG, excision can be achieved by a transcervical approach (TCA). The risk of sternotomy increases
substantially if a signicant proportion (more than 50%) of the
gland is in the mediastinum, the ITG is in a retro-tracheal or
retro-oesophagic position, and if the volume of the intrathoracic component is signicantly larger than that of the cervical
component. Most authors also advocate sternotomy if there is
evidence of malignancy [1, 10–14]. The main reported indications for an extracervical approach (ECA) are discussed below.
509
Fig. 48.1 Retroclavicular goitre
Fig. 48.2 Goitre reaching the upper border of the aortic arch
48.5 Extent ofSurgery
One very important point to be taken into account is whether
a lobectomy or a total thyroidectomy is undertaken and
when and how the thyroid isthmus should be addressed. If
the decision is being made to do a lobectomy, it is the opinion of the authors that dividing the isthmus earlier facilitates
cervical dissection. Therefore, this should be done early in
the procedure. In very large bilateral goitres, this can be
done earlier for the same reason, so the procedure becomes
essentially two lobectomies. In cases where a total thyroidectomy is preferred then, the dissection should start with the
smaller lobe and continue to the other side, which will facilitate the dissection of the larger lobe (Figs.48.1, 48.2 and
48.3) [2, 13, 15].
Fig. 48.3 Goitre extending beyond the aortic arch
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48.6 Indications forExtracervical
Approach
Indications for ECAs can be categorised as high risk, moderate risk and low risk. This categorisation is based on current available literature and the previous experience of the
surgical team. A member of the thoracic surgery team
should always be on stand-by for high- and moderate-risk
patients.
48.6.1 High-Risk Patients forECA
• ITG below the AA
• Recurrent goitres with intrathoracic extension to and
below the AA
• Giant extension (Fig48.4a)
• Goitres involving multiple mediastinal compartments
• Goitres with separate components
• Goitres with ‘iceberg’ or inverted cone shape
• Goitres with extension to the posterior pleura (Fig48.4b)
48.6.2 Moderate-Risk Patients forECA
• Goitres reaching the aortic arch
• Goitres reaching the aortic arch with oval or tubular
shape
• Goitres with minimal posterior mediastinal, retrotracheal
48.6.3 Low Risk forECA
• Goitres with retroclavicular extension
Fig. 48.4 (a) CT scan demonstrating a typical giant goitre extending to the diaphragm. (b) CT scan demonstrating a goitre with extension to the
posterior pleura
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48.7 Surgical Technique
48.7.1 Trans-Cervical Approach (TCA)
48.7.1.1 Incision
The incision for approaching ITG should be generous to
allow adequate exposure and excision of the goitre. An
extended Kocher incision is placed in the lower aspect of the
neck. This allows adequate exposure to the goitre at the thoracic inlet, and if a midline sternotomy is required, there is
minimal vertical element of the scar in the neck. If, however,
a lateral neck dissection is required, then a modied extended
Kocher incision is used [16].
48.7.1.2 Subplatysmal Flaps
Subplatysmal aps are elevated taking care to avoid injuring
the anterior jugular veins, which are often enlarged due to
venous congestion. The aps are elevated above the lower
border of the thyroid cartilage or higher if the cervical portion of the goitre extends beyond the thyroid cartilage or if
there is retropharyngeal extension. Inferiorly, the aps are
extended over the sternal notch and the sternoclavicular
joints. Laterally, the aps are extended over the sternocleidomastoid muscle.
When performing total thyroidectomy, the dissection
starts in the smaller of the lobes. In selected cases, a full total
lobectomy on the side of the smaller lobe, with division of
the isthmus is performed. This allows better mobilisation of
the dominant lobe, reducing cervical pressure and helping to
locate the RLNs and the parathyroid glands more easily
[8–13].
48.7.1.5 Superior Thyroid Pole
The thyroid lobe is dissected from the pre-thyroid strap muscles, and then the sternothyroid muscle is divided for access
to gain access to the upper pole. The superior thyroid pole is
identied and individual vessels ligated and divided closer to
the gland to avoid injury to the external branch of the superior laryngeal nerve. The upper pole is dissected from the
attachments to the crico-thyroid muscle, and the RLN is
identied (see below). Then the thyroid lobe is dissected
from its cervical attachments (oesophagus and trachea) into
the thoracic inlet as much as possible, so it is free from the
upper mediastinal attachments. The RLN can be identied
also laterally or inferiorly as demonstrated below.
48.7.1.6 Management oftheRecurrent
Laryngeal Nerve
The RLN was either identied at the crico-tracheal junction,
in its lateral position or inferiorly at the Baehr’s triangle
depending on the size and shape of the goitre.
Superior Approach Once the upper pole had been dis-
sected and mobilised, then the RLN was identied at the
crico-tracheal junction (CTJ) and dissected in a caudal direction tunnelling the tissue surrounding the nerve with a netip mosquito dissector. The RLN was dissected infero-laterally
as much as the approach allowed it under the common carotid
artery and brachio-chepalic artery and gently controlled with
a rubber vessel sling. Then the thyroid lobe was dissected
from its cervical attachments (oesophagus and trachea) into
the thoracic inlet as much as possible, so it is free from the
upper mediastinal attachments [17–19] (Fig.48.5).
48.7.1.3 Thyroid Isthmus
The thyroid isthmus is identied, skeletonised and divided
using Harmonic Scalpel® or other such device. The precrioid
lymph nodes and pretracheal fat is excised to help adequate
exposure to the trachea.
48.7.1.4 Strap Muscles
In large MNGs, the strap muscles (SM), in particular sternothyroid, is divided. The main advantages of this approach is:
better control of the regional veins, improved exposure to the
lateral aspect of the goitre and superior vascular pedicle and
better access to mobilise the goitre and visualise the anatomical structures that must be preserved.
Following division of the SM, the middle thyroid vein is
identied, dissected, ligated and divided. Rough manipulation of the gland should be avoided to prevent avulsion of the
internal jugular vein [17].
Lateral Approach The RLN can be also identied in its
lateral position above the axis of the ITA close to the tubercle
of Zuckerkandl and followed up superiorly and or inferiorly
depending on the size and shape of the goitre (Fig.48.6).
Inferior Approach In some cases, the RLN can identied
in its most inferior position in Beahr’s triangle and then followed cranially to the crico-tracheal joint and caudally to the
mediastinum, depending on the shape and size of the goitre.
48.7.1.7 Management oftheParathyroid
Glands
In surgery for large MNG, the parathyroid glands may be
displaced due to the aberrant growth of the thyroid gland. In
order to minimise the risk of hypocalcaemia, the following
surgical principles should be adopted; the superior pole of
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