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performing a right lobectomy, any suspicious nodules on the left thyroid lobe should
undergo ne-needle aspiration biopsy) [10]. Further imaging modalities such as CT,
MRI, PET may be selectively used in a minority of patients. Patients should ideally
be euthyroid at the time of operation, with either antithyroid medication or Lugol’s
solution for hyperthyroidism or exogenous thyroid hormone supplementation for
hypothyroidism.
Preoperative vocal cord assessment, most commonly with indirect laryngoscopy
but also with laryngeal ultrasound in centers with appropriate expertise, should be
performed in any patient with hoarseness or a prior history of neck operation. Preanesthetic evaluation should be a routine step prior to any procedure requiring general anesthesia.
W. Sh en
3 Positioning andAnesthesia
Most thyroidectomies are performed under general anesthesia with endotracheal
intubation. The patient is placed supine in a 20° reverse Trendelenburg position,
with both arms tucked. The neck is hyperextended by placing a beanbag, inated
arterial line bag, or soft roll behind the scapulae and a foam ring under the head.
This places the thyroid in a more anterior position. The head must be well supported
to prevent postoperative posterior neck pain. The surgical area is prepared with 1%
iodine or chlorhexidine and sterilely draped. Intraoperative nerve monitoring is
increasingly used as an additional tool to monitor nerve integrity during thyroidectomy, particularly in high-risk operations [11]. Set up requires intubation with electrode positioning at the level of the vocal folds for both continuous and intermittent
monitoring. We routinely perform our own ultrasound prior to surgical prep in order
to assess the anatomy and facilitate operative planning.
Identication and preservation of the parathyroid glands during thyroidectomy is
crucial. Visual assessment remains the primary method of identication, though
some centers use near-infrared (NIR) uorescence spectroscopy as an emerging
intraoperative adjunct with high sensitivity and specicity in identifying parathyroid glands in situ.
4 Postoperative Care (Keep All Images FromLast Version)
In general, thyroid operations should be performed in a bloodless eld so that vital
structures can be identied. Bleeding obscures the normal color of the parathyroids
and recurrent laryngeal nerve (RLN), placing these important structures at greater
risk for injury. If bleeding does occur, pressure should be applied; vessels should be
clamped only if they are precisely identied or shown to not be in close proximity
to the RLN.
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Fig. 1 Skin incision. The
pen marks, from top to
bottom, denote the thyroid
cartilage, cricoid cartilage,
and suprasternal notch,
respectively. A centrally
placed, 4–6cm Kocher
transverse incision is made
1cm caudad to the cricoid
cartilage, paralleling the
normal skin lines of the
neck (white dotted line)
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A centrally placed, 4–6cm Kocher transverse incision is made 1cm caudad to
the cricoid cartilage, paralleling the normal skin lines of the neck (Fig.1). The incision is extended through the platysma, at which point subplatysmal aps are raised,
rst cephalad to the level of the thyroid cartilage and then caudad to the suprasternal
notch. Kelly or Kocher clamps can be placed on the dermis of each ap to aid in
retraction for this dissection.
In a cancer operation, dissection of the thyroid gland is generally begun on the
side of the suspected tumor, since a problem with the dissection on this side could
lead the surgeon to perform a less-than-total thyroidectomy on the contralateral side
in order to avoid complications. One exception is the large bulky tumor, in which
case the surgeon sometimes dissects the contralateral side rst in order to more easily mobilize the thyroid gland.
The strap muscles are separated in the midline via an incision through the supercial layer of the deep cervical fascia starting at the suprasternal notch and extending cephalad to the thyroid cartilage. On the side of the suspected tumor, the more
supercial sternohyoid is separated from the deeper sternothyroid muscle by blunt
dissection, proceeding laterally until the ansa cervicalis is visible at the lateral border of the sternothyroid muscle. The sternothyroid muscle is then dissected from the
underlying thyroid capsule until the middle thyroid vein is encountered laterally.
The thyroid is retracted anteromedially and the carotid sheath and strap muscles are
retracted laterally. A peanut sponge can be used to facilitate retraction and exposure of the area posterolateral to the thyroid. The middle thyroid vein is optimally
exposed for division at this time (Fig.2).
In the case of thyroid lobectomy, the isthmus can be divided early in the dissection to facilitate mobilization. The isthmus is clamped and divided lateral to the
midline, taking care to not leave residual tissue anterior to the trachea to minimize
the chances of hypertrophy of the thyroid remnant. The LigaSure or harmonic
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Fig. 2 Identication of the
middle thyroid vein
(MTV). On this side, the
right thyroid lobe (RTL) is
retracted anteromedially to
expose the MTV, which is
isolated in preparation for
division and ligation
W. Sh en
scalpel coagulation devices are useful for dividing the thyroid parenchyma in a
hemostatic manner; alternatively, the isthmus can be divided with a scalpel between
clamps and the thyroid remnant oversewn at the cut edge.
The superior pole is dissected mostly in a blunt fashion with a small peanut
sponge on a clamp or using a small tip ligasure. The dissection is carried out superolaterally and posteriorly, with counter-traction of the thyroid inferomedially. This
exposes the superior thyroid vessels as well as some connective tissue lateral to the
superior pole. These tissues are carefully mobilized below the level of the cricothyroid muscle, since the RLN passes through Berry’s ligament and enters the cricothyroid muscle at the level of the cricoid cartilage. The superior pole vessels are
individually skeletonized, double- or triple-clamped, and ligated (Fig.3). They are
then divided close to the surface of the thyroid in order to prevent injury to the external branch of the superior laryngeal nerve as it traverses the anterior surface of the
cricothyroid muscle. Division of these vessels allows for easy sweeping of the
remaining lmy tissues away from the posterior aspect of the superior pole via blunt
dissection. The superior parathyroid gland is often identied behind the superior
pole during this dissection, at the level of the cricoid cartilage. It is usually located
close to a small posterolateral protuberance of the thyroid lobe known as the tubercle of Zuckerkandl, and as a general rule is located posterolateral to the RLN
(Fig.4).
The mobilization of the lateral and inferior aspects of the thyroid lobe includes
the denitive identication of the inferior parathyroid gland and RLN.With the
thyroid lobe retracted anteromedially and the carotid sheath laterally, dissection
should proceed cephalad along the lateral edge of the thyroid. Fatty and lymphatic
tissues immediately adjacent to the thyroid are swept laterally with a peanut sponge
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Fig. 3 Dissection of the
superior pole (SP). In the
image, counter-traction of
the right thyroid lobe
(RTL) inferomedially
exposes the SP vessels,
which are individually
skeletonized, clamped, and
ligated
Fig. 4 Identication of the
superior parathyroid gland
(SPT) and recurrent
laryngeal nerve (RLN).
The SPT is usually
posterolateral to the RLN
(shown here with the nerve
monitoring probe), at the
level of the cricoid
cartilage. The right thyroid
lobe, including the tubercle
of Zuckerkandl (TOZ), is
retracted medially for
optimal exposure of
the RLN
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and small vessels are ligated with clips. The inferior parathyroid and RLN are usually encountered during this lateral mobilization, and care must be taken not to
transect any tissues in this area until these vital structures are identied. The location of the inferior parathyroid gland is less consistent than that of the superior
gland, but it is usually located anterior to the RLN and inferior to the inferior thyroid artery as it crosses the RLN (Fig.5). All normal parathyroid glands should be
carefully swept away from the thyroid on as broad a vascular pedicle as possible to
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Fig. 5 Identication of the
inferior parathyroid (IPT).
After the superior pole
(SP) has been dissected
and mobilized, the right
thyroid lobe (RTL) is
retracted superomedially to
begin the inferior pole
dissection. The IPT is often
variable in position, but is
usually anterior to the
recurrent laryngeal nerve.
Note also the pyramidal
lobe (PyL), which in this
case was mobilized prior to
the RTL dissection
W. Sh en
prevent devascularization, since this would necessitate autotransplantation of the
gland. The course of the right and left RLN can vary considerably. The left RLN is
usually situated more medially, running in the tracheoesophageal groove, while the
right RLN takes a more oblique course and may pass either anterior or posterior to
the inferior thyroid artery.
The pyramidal lobe, present in 80% of patients, is mobilized prior to resection
(Fig.5). The pyramidal lobe extends in a cephalad direction and can reach the level
of the hyoid bone. It is mobilized by retracting it caudally and dissecting away adjacent tissues on either side, proceeding cephalad until it becomes a thin brous band.
Once the parathyroids and RLN are identied and preserved, the remainder of the
thyroid lobe is easily dissected off the trachea and resected. The same steps apply
for the other side in the case of a total thyroidectomy. After meticulous hemostasis,
the sternothyroid and sternohyoid muscles are re-approximated with 4-0 absorbable
sutures, with a small opening left in the midline at the suprasternal notch to allow
any blood to exit. The platysma layer is approximated with similar sutures and the
skin is closed with either deep dermal or a subcuticular suture.
5 Postoperative Care
Though relatively uncommon in experienced centers, signicant complications can
occur after thyroidectomy, including RLN injury, hypoparathyroidism, hematoma
leading to life-threatening airway compromise, injury to the external branch of the
superior laryngeal nerve, infection, seroma, and keloid formation. Because of the
small but serious risk of neck hematoma, postoperative patients are observed for up
to 6 h after operation before consideration for discharge. For patients who have
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undergone total or completion thyroidectomy, serum calcium and/or parathyroid
hormone should be measured postoperatively. Prophylactic oral calcium supplementation may be administered for the rst several days. Patients who have undergone rst-time thyroid lobectomy alone do not require calcium check or
supplementation.
The vast majority of patients are discharged on the same day or rst postoperative day following thyroid lobectomy or total thyroidectomy; patients undergoing
total or completion thyroidectomy are given a prescription for thyroid hormone
replacement. Most patients can return to work or full activity within 1week. They
are seen in the outpatient clinic within 2weeks after discharge, at which time further
management is discussed in light of pathology ndings as well as the results of any
relevant follow-up laboratory evaluation.
References
1. Patel KN, Yip L, Lubitz CC, et al. The American Association of Endocrine Surgeons
guidelines for the denitive surgical management of thyroid disease in adults. Ann Surg.
2020;271(3):e21–93. https://doi.org/10.1097/SLA.0000000000003580.
2. Stang MT, Armstrong MJ, Ogilvie JB, et al. Positional dyspnea and tracheal compression
as indications for goiter resection. Arch Surg. 2012;147(7):621–6. https://doi.org/10.1001/
archsurg.2012.96.
3. Shen WT, Kebebew E, Duh QY, Clark OH.Predictors of airway complications after thyroidectomy for substernal goiter. Arch Surg. 2004;139(6):656–9.; ; discussion 659–60. https://doi.
org/10.1001/archsurg.139.6.656.
4. Portereld JR Jr, Thompson GB, Farley DR, Grant CS, Richards ML.Evidence-based management of toxic multinodular goiter (Plummer’s disease). World J Surg. 2008;32(7):1278–84.
https://doi.org/10.1007/s00268- 008- 9566- 0.
5. Palit TK, Miller CC 3rd, Miltenburg DM.The efcacy of thyroidectomy for Graves’ disease: a
meta-analysis. J Surg Res. 2000;90(2):161–5. https://doi.org/10.1006/jsre.2000.5875.
6. Farwell AP, Braverman LE. Inammatory thyroid disorders. Otolaryngol Clin N Am.
1996;29(4):541–56.
7. Haugen BR, Alexander EK, Bible KC, etal. 2015 American Thyroid Association Management
guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the
American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1–133. https://doi.org/10.1089/thy.2015.0020.
8. Matsuzu K, Sugino K, Masudo K, etal. Thyroid lobectomy for papillary thyroid cancer: longterm follow-up study of 1,088 cases. World J Surg. 2014;38(1):68–79. https://doi.org/10.1007/
s00268- 013- 2224- 1.
9. Hirshoren N, Kaganov K, Weinberger JM, etal. Thyroidectomy practice after implementation
of the 2015 American Thyroid Association guidelines on surgical options for patients with welldifferentiated thyroid carcinoma. JAMA Otolaryngol Head Neck Surg. 2018;144(5):427–32.
https://doi.org/10.1001/jamaoto.2018.0042.
10. Yeh MW, Bauer AJ, Bernet VA, etal. American Thyroid Association statement on preoperative imaging for thyroid cancer surgery. Thyroid. 2015;25(1):3–14. https://doi.org/10.1089/
thy.2014.0096.
11. Wong KP, Mak KL, Wong CK, Lang BH. Systematic review and meta-analysis on intraoperative neuro-monitoring in high-risk thyroidectomy. Int J Surg. 2017;38:21–30. https://doi.
org/10.1016/j.ijsu.2016.12.039.
Remote Access Thyroidectomy
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LikolaniArthurs andInsooSuh
1 Indications
The indications for remote access thyroidectomy have evolved and expanded alongside the pace with which the various techniques have been invented, improved, and
rened. For example, a 2016 ATA consensus statement concluded that remoteaccess thyroidectomy should only be performed in high-volume centers by surgeons with expertise in both thyroid and endoscopic or robotic surgery, but should
also only be considered in selected patients with unilateral small thyroid nodules
who wish to avoid a neck incision [1, 2]. In contrast, current generally accepted
indications for the more recent transoral approach are much broader, and include the
following:
• Thyroid nodules
– Benign (Bethesda category 2 cytology): ≤6cm in maximal dimension
– Cytologically indeterminate (Bethesda 3 or 4): ≤4 cm (may increase or
decrease depending on additional molecular proling results)
– Suspicious for malignancy or malignant (Bethesda 5 or 6): ≤2cm
• Goiters (includes Graves disease, toxic and nontoxic multinodular goiter)
– ≤8cm in maximal dimension
– Preference for euthyroid patients without signicant evidence of thyroiditis
L. Arthurs · I. Suh (*)
Division of Endocrine Surgery, New York University Grossman School of Medicine,
New York, NY, USA
e-mail: Likolani.Arthurs@nyulangone.org
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_2
11© The Author(s), under exclusive license to Springer Nature
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Contraindications include the following [3]:
• Poorly differentiated or anaplastic carcinoma
• Central or lateral neck lymphadenopathy (relative contraindication)
• Extrathyroidal involvement
• Known recurrent laryngeal nerve injury
• Prior transcervical neck surgery
• Prior trauma or surgery in any area along the remote access route
• Active oral infection or other inammatory process
• Inability to tolerate surgery and/or anesthesia
• Extreme obesity (BMI>45)
L. Arthurs and I. Suh
2 Preoperative Preparation
Patients undergoing remote access thyroidectomy should undergo the same preoperative workup as in traditional thyroidectomy, including preoperative biochemical
thyroid function assessment, neck ultrasound with ne-needle aspiration biopsies as
needed and selected use of additional cross-sectional imaging, and voice evaluation
and vocal cord assessment as appropriate. Additional preoperative preparation steps
may be needed that are specic for the remote access technique; for example, some
transoral surgeons prescribe preoperative dental evaluation and cleaning.
3 Positioning andAnesthesia
Remote access thyroidectomies are performed under general anesthesia with endotracheal intubation, usually with a specially congured endotracheal tube with an
integrated electromyographic electrode for intraoperative neuromonitoring of the
recurrent laryngeal nerve. Patient position is based on the specic procedure being
performed (see below). As in traditional thyroidectomies, the surgical area can be
prepared with 1% iodine or chlorhexidine and sterilely draped. An ultrasound prior
to surgical prep can be performed in order to assess the anatomy and facilitate operative planning.
4 Description ofProcedure [4]
In general, all thyroid operations regardless of technical approach should be performed in a bloodless eld so that vital structures can be identied. Bleeding
obscures the normal color of the parathyroids and recurrent laryngeal nerve (RLN),
Remote Access Thyroidectomy
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placing these important structures at greater risk for injury. If bleeding does occur,
pressure should be applied; vessels should be clamped only if they are precisely
identied or shown to not be in close proximity to the RLN.
4.1 Transaxillary Approach
The transaxillary approach avoids a cervical scar as incisions are placed in the
axilla, where they are naturally hidden by the arm. There are multiple variations of
both robotic and endoscopic transaxillary techniques, with and without the use of
CO2 insufation [5]. In the gasless robotic technique, patients are placed supine
with the neck slightly extended, and the ipsilateral arm raised to expose the axilla
and shorten the distance between the axilla and the neck. A 6–9cm incision is made
in the anterior axilla along the lateral edge of the pectoralis major muscle, and a
subcutaneous tunnel is made under direct visualization over the pectoralis major
muscle and clavicle to the sternocleidomastoid (SCM) muscle (Fig.1). The two
heads of the SCM are separated, and the strap muscles are retracted to expose the
thyroid. Four robotic arms are then placed through the incision, as well as an external retractor to maintain working space. Dissection of the lobe can proceed either in
a superior- to-inferior, or inferior-to-superior direction, depending on the surgeon’s
preference for timing and exposure of the recurrent laryngeal nerve. Total thyroidectomy is also technically possible using the same incision by greater medial retraction of the thyroid; however, dissection of the contralateral lobe in the manner is
technically challenging and requires specialized expertise [6].
Fig. 1 Incision and
dissection area of
transaxillary approach.
(From: Graves and
Suh [4])
6–9 cm incision
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L. Arthurs and I. Suh
The advantages of this approach include its easy access to the upper and lower
poles of the ipsilateral thyroid lobe, as well as its enablement of central neck dissection. Disadvantages include its need for a relatively longer incision in the axilla and
its distance from the target anatomy necessitating greater dissection and changes in
patient positioning including signicant arm extension. These disadvantages have
manifested in rare but unique complications such as axillary skin ap perforation
and brachial plexus injury [7–9].
4.2 Bilateral Axillo-Breast Approach (BABA)
Though rst described in 2007 as an endoscopic procedure, visualization and dissection were limited by the 2-dimensional camera and rigid instruments within a
small working space. Therefore, in 2009, BABA was adapted for the robotic platform. Patients are positioned supine and bilateral incisions are made in the circumareolar areas. A subcutaneous ap is created through blunt dissection in the breast
and chest, subplatysmal space up to the thyroid cartilage superiorly and medial
edges of the SCM laterally (Fig.2). With the camera placed in the ipsilateral breast
incision, dissection of the thyroid then proceeds, typically in an inferior-to-superior
approach.
Among the main advantages of BABA include its exibility in directionality due
the multiple ports and angles of dissection afforded by them. In addition, its relative
midline approach enables total thyroidectomy with relative ease, and also can
enable central and lateral neck dissection in selected cases. Similar to the transaxillary approach, however, the distance of the incisions from the target anatomy is relatively lengthy, requiring more extensive dissection, longer operative times, and
potentially increased tissue trauma. In addition, although central neck dissection is
Fig. 2 Incisions and
dissection area of
BABA. (From: Graves and
Suh [4])
Ant. border SCM
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