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when there is high-volume or gross disease in the adjacent central neck. For patients
with Familial Medullary Thyroid Cancer (FMTC) or Multiple Endocrine Neoplasia
type 2A (MEN2A), the NCCN recommends considering prophylactic ipsilateral
MRND when the primary tumor is ≥1cm (>0.5cm if Multiple Endocrine Neoplasia
[MEN] 2B) or with adjacent central compartment metastases [9]. Other consensus
guidelines for the treatment of patients with MEN recommend MRND for patients
with MEN 2 only if there is clinical or radiographic evidence of involved lymph
nodes in the lateral neck [12]. The 2015 American Thyroid Association (ATA)
guidelines on the management of medullary thyroid cancer recommend dissection
of the lateral neck including levels IIA, III, IV, and V for patients with clinically
apparent lateral neck nodal metastases [13]. In patients with no abnormal lymph
nodes on pre-operative ultrasound, the guidelines state that prophylactic lateral neck
dissection may be considered based on serum calcitonin level, however, the Task
Force did not achieve consensus on this recommendation.
C. Sturgeon and D. M. Elaraj
2 Preoperative Preparation
All patients with a diagnosis of thyroid cancer should have a complete preoperative
ultrasound of the central and lateral compartments of the neck, with clear documentation of the description and location of suspicious lymph nodes using the standard
nomenclature described above. Fine needle aspiration biopsy of suspicious lymph
nodes should be performed to conrm the presence of disease and whenever it will
guide the extent of surgery [8]. The patency of both internal jugular veins should be
assessed and documented. A thorough neurologic examination should be done to
assess the baseline function of the nerves at risk during MRND.Preoperative laryngeal exam is recommended in cases of voice alteration or for revision surgery,
although many clinicians perform this routinely to evaluate baseline vocal cord
function in thyroid cancer patients. Patients should be counseled on the risks, benets, and alternatives to the proposed procedure(s), and the details of the discussion
and the patient’s understanding thereof should be documented. The surgical
approach and resultant scar should also be disclosed to the patient.
3 Description ofProcedure
The neck is extended and the head turned to expose the lateral aspect of the neck. A
beanbag or shoulder role is used to help extend the neck. A foam ring is helpful to
pad and immobilize the head. The patient is placed in semi-Fowler’s position to
decompress the neck veins. The entire neck extending from the chin, corner of the
mouth, and pinna of the ear, laterally to the shoulders, and down onto the upper
Modied Radical Neck Dissection
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chest is prepped and draped. In order to visually assess the function of the marginal
mandibular branch of the facial nerve, the corner of the mouth can be kept visible
with the use of clear sterile draping.
Many skin incisions have been described for the MRND [14]. An incision from
the mastoid process carried inferiorly along the posterior border of the SCM, then
curved medially in a Langer’s line towards the midline yields excellent exposure
with an acceptable cosmetic result. An alternative incision would be an extended
cervical incision along a natural skin crease past the posterior border of the SCM.For
simplicity, only the MRND through this hemi-apron or “hockey-stick” incision will
be described herein.
The skin is marked in the proposed line of the incision and inltrated with lidocaine with epinephrine to allow for sharp dissection in a relatively bloodless eld.
Total dose of lidocaine should be monitored to avoid systemic toxicity from overdose. The skin, subcutaneous tissues and platysma are incised sharply. Subplatysmal
aps are raised sharply towards the midline, taking care to preserve the great auricular nerve and external jugular vein as the dissection proceeds over the surface of the
SCM.The marginal mandibular branch of the facial nerve is preserved at the medial
aspect of the subplatysmal ap.
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3.1 Levels II andIII
Dissection is begun in Level II.The second layer of deep cervical fascia along the
anterior aspect of the SCM is incised along its entire length and the internal jugular
vein is exposed and traced cephalad to the posterior belly of the digastric muscle.
CN XI is usually identied as it crosses the internal jugular vein from medial to
lateral, or as it enters the posterior aspect of the SCM.There can be anatomic variation in the course of CN XI, with it coursing posterior to the internal jugular vein
rather than supercial to it in one-third of patients. Within the apex of the triangle
bordered by the internal jugular vein and CN XI lies the brofatty tissue containing
the level IIA nodes (Fig.2). This node-bearing tissue located anterior and inferior to
CN XI is opened sharply and swept inferiorly. Level IIB nodes (found superior and
posterior to CN XI) should also be included when there is evidence of their involvement. The dissection proceeds caudad and the brofatty tissue packet is sharply
dissected from the posterior aspect of the SCM and the anterior surface of the scalene muscles. The lateral border of the level II dissection is the posterior border of
the SCM.The dissection is continued caudad past the level of the hyoid bone into
Level III, and inferiorly to the omohyoid muscle, which is an alternative surgical
landmark for the inferior extent of Level III (Fig.3). The omohyoid muscle is mobi-
lized and preserved, although it can be divided without any consequence. The sensory branches of the cervical plexus are preserved when possible.
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Fig. 2 Right modied radical neck dissection. The dissection is started in Level IIA at the apex
bounded by the internal jugular vein, and the spinal accessory nerve (CN XI)
C. Sturgeon and D. M. Elaraj
3.2 Levels IV andVB
The dissection is continued caudad along the posterior border of the SCM until the
clavicle is reached. There is often additional node-bearing tissue inferior to the clavicle extending to the subclavian vein that should also be resected. Furthermore, the
node-bearing supraclavicular (Level VB) tissue can be resected en-bloc with Level
IV by extending the dissection eld lateral to the posterior border of the SCM to the
anterior border of the trapezius muscle.
3.3 Medial Dissection
The brofatty bundle is retracted medially and completely dissected off the deep
cervical fascia overlying the scalene muscles. This third layer of deep cervical fascia is usually preserved. The medial border of the dissection is the carotid sheath.
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Fig. 3 Right modied
radical neck dissection.
The brofatty lymph
node-bearing tissue of
Levels IIA and III has been
cleared. The omohyoid
muscle is being retracted
inferomedially. The
external jugular vein and
great auricular nerve are
visible on the anterior
surface of the
sternocleidomastoid
muscle
39
The phrenic nerve, vagus nerve (Fig.4), transverse cervical artery, and brachial
plexus are identied and preserved. Lymphatics joining the thoracic duct are individually ligated. The internal jugular vein is rolled medially to access the lymph
nodes deep to the carotid sheath. The internal jugular vein can be sacriced unilaterally for gross invasion when the contralateral vein is patent. Dissection of the brofatty tissue packet is then completed sharply over the surface of the carotid sheath.
Hemostasis is assured and closure is performed in the standard fashion. Selective
drainage of the operative eld is a common practice. Some surgeons routinely drain
the dissection bed and continue closed suction drainage until the output is less than
25–30mL in 24h and non-chylous.
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Fig. 4 Right modied
radical neck dissection.
The internal jugular vein is
being retracted medially
and the
sternocleidomastoid
muscle is being retracted
laterally. The vagus nerve
is visible posterior to the
internal jugular vein, and
the phrenic nerve is visible
on the surface of the
anterior scalene muscle
C. Sturgeon and D. M. Elaraj
4 Postoperative Care
When the patient has recovered sufciently from anesthesia, a neurological exam
should be performed and the results documented. A chest radiograph could be performed in the recovery room to rule out pneumothorax or elevated hemidiaphragm
if there is concern that the dissection violated the pleura or injured the phrenic
nerve. Vocal cord paresis is a rare complication of MRND, and is usually temporary.
There is general agreement that laryngeal exam should be performed for suspected
vocal cord paresis when early diagnosis and intervention would improve outcome
(i.e. in cases of dysphagia, impaired pulmonary toilet, aspiration or potential airway
compromise). Physical therapy is usually prescribed for patients with CN XI paresis.
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References
1. Shah JP, Strong E, Spiro RH, Vikram B.Neck dissection—current status and future possibilities. Clin Bull. 1981;11:25–33.
2. Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, etal. Neck dissection
classication update: revisions proposed by the American Head and Neck Society and the
American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck
Surg. 2002;128:751–8.
3. Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW.Standardizing neck
dissection terminology. Ofcial report of the Academy’s Committee for Head and Neck
Surgery and Oncology. Arch Otolaryngol Head Neck Surg. 1991;117:601–5.
4. Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito A, etal. Consensus statement on the classication and terminology of neck dissection. Arch Otolaryngol Head Neck
Surg. 2008;134:536–8.
5. Stack BC Jr, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S, etal. American Thyroid
Association consensus review and statement regarding the anatomy, terminology, and rationale
for lateral neck dissection in differentiated thyroid cancer. Thyroid. 2012;22:501–8.
6. Crile G.Excision of cancer of the head and neck with special reference to the plan of dissection
based on one hundred and thirty-two operations. JAMA. 1906;47:1780–8.
7. Bocca E, Pignataro O.A conservation technique in radical neck dissection. Ann Otol Rhinol
Laryngol. 1967;76:975–87.
8. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, 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;26:1–133.
9. Haddad RI, Bischoff L, Ball D, Bernet V, Blomain E, Busaidy NL, etal. Thyroid carcinoma,
version 2.2022, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw.
2022;20:925–51.
10. Evans DB, Shapiro SE, Cote GJ.Invited commentary: medullary thyroid cancer: the importance of RET testing. Surgery. 2007;141:96–9.
11. Moley JF, DeBenedetti MK.Patterns of nodal metastases in palpable medullary thyroid carcinoma: recommendations for extent of node dissection. Ann Surg. 1999;229:880–7, discussion 7–8.
12. Brandi ML, Gagel RF, Angeli A, Bilezikian JP, Beck-Peccoz P, Bordi C, etal. Guidelines for
diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab. 2001;86:5658–71.
13. Wells SA Jr, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, et al. Revised American
Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid.
2015;25:567–610.
14. Uchino S, Noguchi S, Yamashita H, Watanabe S.Modied radical neck dissection for differentiated thyroid cancer: operative technique. World J Surg. 2004;28:1199–203.
Parathyroidectomy
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JessicaLiuMcMullin andHerbertChen
1 Indications
Primary hyperparathyroidism (pHPT) is diagnosed biochemically by hypercalcemia in the presence of elevated or inappropriately normal parathyroid hormone
(PTH) levels. Eighty-ve percent of cases of sporadic pHPT are caused by a parathyroid adenoma—a single enlarged, hyperfunctioning gland. Four-gland hyperplasia represents about 10% of cases, while double adenomas constitute 4% and
parathyroid carcinoma <1%. The 2022 Fifth International Workshop consensus and
the American Association of Endocrine Surgeons (AAES) 2016 Primary
Hyperparathyroidism Guidelines both recommend surgical intervention for all
symptomatic patients unless medically contraindicated and describe other indications for asymptomatic patients [1, 2]. Both guidelines emphasize that parathyroidectomy should be performed by surgeons with adequate training and experience
with the management of pHPT.
Based on the previous edition chapter “Parathyroidectomy” by Lilah F Morris and Michael W Yeh.
J. L. McMullin (*)
Department of Surgery, University of Utah, Salt Lake City, UT, USA
e-mail: Jessica.McMullin@hci.utah.edu
H. Chen
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: hchen@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_6
43© The Author(s), under exclusive license to Springer Nature
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J. L. McMullin and H. Chen
2 Preoperative Preparation: Imaging Studies
Preoperative localizing studies may be performed after conrmation of the biochemical diagnosis and once the decision for surgery has been made. Preoperative
imaging should not be performed for diagnostic purposes and there is regional variability in imaging accuracy, with high-volume centers demonstrating higher sensitivity and an experienced clinician should be the one to determine which imaging
modality would be ideal to use based on regional differences. Additionally, smaller,
posterior located, or multiple adenomas are more difcult to detect when compared
to larger solitary adenomas. While preoperative imaging may allow for selective
parathyroidectomy, the rates of cure and postoperative complications are not
improved by preoperative imaging when in the hands of experienced surgeons [3].
A commonly used study is the
the site of abnormal parathyroid tissue with 78.9% accuracy and a 90.7% positive
predictive value (PPV) in a pooled meta-analysis (Fig.1a). Another method of
localization is a parathyroid ultrasound, with a pooled accuracy rate of 76.1% and
PPV 93.2% [4] (Fig.1b). Four-dimensional CT (4D CT) scan relies on the differential contrast enhancement between the thyroid and parathyroid glands (perfusion
over time is the fourth dimension) and pooled accuracy rates for localization of
parathyroid adenomas are 89.4% and PPV 93.5% [4]. Though several scanning protocols have been published, all include an early arterial phase followed by a delayed
venous phase. Parathyroid adenomas display avid early arterial contrast enhancement and rapid washout, and can thus be differentiated from the thyroid gland which
has less avid early contrast enhancement (Fig.1c). Given the increased anatomic
details provided with 4D CT, it has been demonstrated to have superior diagnostic
abilities and is particularly superior in identifying parathyroid adenomas that are not
localized by imaging modalities [5].
99m
Tc-sestamibi scan, which can correctly identify
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a
b
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Fig. 1 (a) This
99m
both the thyroid and parathyroid, and localizes the parathyroid adenoma to the left side of the
patient at 2h as a hyperfunctioning parathyroid gland will take up more of the
remain “bright” on imaging. (b) This parathyroid ultrasound demonstrates the presence of an
enlarged inferior parathyroid. This is a sagittal view of the lower lobe of the thyroid and the parathyroid gland is seen inferior to the thyroid lobe as a hypoechoic structure when compared to the
thyroid. (c) 4D CT images for parathyroid localization help distinguish parathyroid adenomas
from normal thyroid. These multiple imaging phases demonstrate the lower density parathyroid
gland (indicated by an arrow) compared to the thyroid on pre-contrast (a) and venous phase (c) but
is similar to the thyroid on arterial phase scan (b). (Images courtesy Dr. Ali Sepahdari, Department
of Radiology, UCLA David Geffen School of Medicine)
Tc-sestamibi scan demonstrates the uptake of the
99m
Tc-sestamibi at 15min in
99m
Tc-sestamibi and
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abc
Fig. 6.1 (continued)
3 Surgical Positioning andAnesthesia
J. L. McMullin and H. Chen
The patient should be positioned supine on the operating table with the neck hyperextended using a horizontal shoulder roll and both arms tucked. For bilateral neck
exploration, general anesthesia using an endotracheal tube or laryngeal mask airway
is commonly used. For limited exploration, some centers use general anesthesia
while others employ local/regional anesthesia with sedation (monitored anesthetic
care or MAC). Regardless of the planned procedure, the surgical area should be
prepped and draped to accommodate a bilateral neck exploration.
4 Description ofProcedure
4.1 Four-Gland Exploration
Bilateral neck exploration, with identication of all four parathyroid glands, has
long been the standard approach to parathyroid surgery. A 2.5–4cm central, transverse cervical (Kocher) incision is made along a skin crease 1cm below the cricoid
cartilage (Fig.2a). The strap muscles are separated in the midline (Fig.2b). The
plane between the sternothyroid muscles and the thyroid capsule is developed. The
middle thyroid veins are occasionally divided to allow rotation of the thyroid gland
anteriomedially, as the majority of the parathyroid glands lie posterior to the
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