Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult
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Incision
FIGURE 1 –3
FIGURE 1 –4
FIGURE 1–5
FIGURE 1 –6
FIGURE 1 –7
Sternohyoid
muscle
FIGURE 1 –8
CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 5
6 Section I • Head and Neck and Endocrine Procedures
◆ The thyroid lobe is further exposed by mobilizing the strap muscles away from the lobe
using a combination of sharp and blunt dissection (Figure 1-9).
◆ A small Richardson retractor is then placed under the strap muscles, retracting them
laterally (Figure 1-10).
◆ Occasionally, for large bulky thyroid lesions, better exposure of the thyroid lobe can be
obtained by dividing the strap muscles, which are then approximated at the end of the
procedure. If transection of the strap muscles is necessary, this should be performed superi-
orly to minimize denervation, because both of these muscle groups are innervated from a
caudal direction through the ansa hypoglossi nerves (Figure 1-11).
◆ The thyroid lobe is grasped with Babcock forceps (shown) and retracted gently toward the
midline to expose the middle thyroid vein, which is ligated using either 3-0 or 4-0 silk
suture and divided. This allows further mobilization of the lobe and identifi cation of the
parathyroid glands, as well as the recurrent laryngeal nerve (Figure 1-12).
CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 7
Anterior jugular vein
Sternohyoid muscle
Sternocleidomastoid
muscle
FIGURE 1 –9
Superior thyroid
artery and vein
Inferior thyroid vein
FIGURE 1 –10
Sternohyoid
muscle
FIGURE 1 –11
Middle thyroid
vein
FIGURE 1 –12
8 Section I • Head and Neck and Endocrine Procedures
◆ The thyroid gland is regrasped with the Babcock clamp and retracted downward to
expose the superior pole vessels, including the branches of the superior thyroid artery. The
external branch of the superior laryngeal nerve courses along the cricothyroid
muscle just medial to the superior pole vessels. Therefore, to avoid injuring this
nerve, which controls tension of the vocal cords, the superior pole vessels are divided indi-
vidually as close as possible to the thyroid gland (Figure 1-13).
◆ Next, the Babcock clamp is repositioned to grasp the thyroid lobe so that the inferior
thyroid veins can be exposed and ligated as they enter the thyroid gland. Occasionally, a
venous plexus (i.e., thyroid ima) is noted in the midline position over the trachea and
entering the isthmus. These vessels are likewise carefully ligated and divided, avoiding
injury to the trachea (Figure 1-14).
CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 9
Superior thyroid
artery and vein
A
B
Superior thyroid artery and vein
External branch
of superior
laryngeal nerve
FIGURE 1 –13
Inferior thyroid vein
FIGURE 1 –14
10 Section I • Head and Neck and Endocrine Procedures
◆ As the thyroid lobe is retracted medially, gentle dissection is performed to expose the para-
thyroid 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 thy-
roid 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
Right recurrent laryngeal nerve
FIGURE 1 –16
CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 11
◆ 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 inferior thyroid
artery
Right recurrent laryngeal nerve
Right recurrent laryngeal
nerve
FIGURE 1 –17
FIGURE 1 –18
12 Section I • Head and Neck and Endocrine Procedures
◆ 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).
B
Left thyroid remnant
FIGURE 1 –19
A
Thyroid gland
CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 13
◆ 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).
B
Thyroid cartilage
Inferior thyroid
artery
Trachea
Cricothyroid cartilage
Parathyroid gland
Cricothyroid muscle
Esophagus
Left recurrent laryngeal
nerve
FIGURE 1 –20
A
14 Section I • Head and Neck and Endocrine Procedures
◆ 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.