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Thyroidectomy Vula Atlas
Thyroidectomy Vula Atlas
Thyroidectomy Vula Atlas
Inf constrictor
Cricothyroid
Parathyroids
Thyrocervical
trunk
2
Blood supply pole of the thyroid (Figure 5). It provides
blood supply to the thyroid, upper
The arterial supply is based on the oesophagus and trachea, and is the sole
superior thyroid (STA) and inferior thyroid arterial supply to all the parathyroid
(ITA) arteries. Occasionally the thyroidea glands, both superior and inferior. The
ima artery is encountered inferiorly but is relationship of the ITA and RLN is
seldom of surgical relevance. It arises from reviewed later.
the innominate artery or aortic arch and
ascends along the front of the trachea. Venous drainage is quite variable and
occurs via a capsular network of thin-
The superior thyroid artery (STA) is the walled, freely intercommunicating veins
first branch of the external carotid artery which drain through the superior thyroid
(Figures 2, 5, 7). It courses over the veins (adjacent to the STA), the inferior
external surface of the inferior constrictor thyroid veins (exit the inferior pole), and
muscle of the pharynx, entering the gland the middle thyroid vein(s), which course
posteromedially just below the highest laterally to drain directly into the internal
point of the upper pole where it usually is jugular vein (Figure 1). The middle
located superficial to the external branch of thyroid vein is surgically most relevant; it
the SLN (Figure 2). Its branches com- is encountered early during thyroid
municate with the ITA and cross to the mobilisation, and failure to secure it causes
contralateral thyroid lobe via the thyroid bothersome bleeding.
isthmus.
Lymphatic drainage parallels the venous
drainage and occurs to the lateral deep
cervical and pre- and paratracheal lymph
nodes (Figure 8). Understanding the
pattern of nodal drainage is particularly
important in managing patients with
STA
thyroid cancer since the cervicocentral
compartment is most commonly involved
in metastatic thyroid cancer.
ITA
Thyrocervical
Subclavian a
3
Recurrent Laryngeal Nerve (RLN) The RLN may be non-recurrent in
approximately 0.6% of patients i.e. does
During thyroid surgery, identification and not pass around the subclavian artery, but
preservation of the RLN and all of its branches from the Xn higher in the neck,
divisions is essential to minimise passing directly to the larynx close to the
morbidity. The RLN innervates all the superior thyroid vessels (Figure 9). This
intrinsic muscles of the larynx except the aberration almost always occurs on the
cricothyroid muscle (SLN) and provides right side and is associated with a
sensory innervation to the larynx. Even retroesophageal subclavian artery.
minor neuropraxia may cause dysphonia;
irreversible injury confers permanent Knowledge of the anatomical relationships
hoarseness. The reported incidence of RLN of the RLN to the tracheoesophageal
injury during thyroidectomy is 0 - 28% and groove, ligament of Berry, and ITA is
is the most common reason for medico- essential. The course of the RLN with
legal claims following thyroidectomy. respect to the ITA is quite variable. Most
commonly it crosses behind the branches
The RLNs originate from the Xn. After of the artery, more predictably so on the
circling around the subclavian artery left. However, the nerve may pass deep to,
(right) and aortic arch (left) the RLNs superficial to, or between the terminal
ascend superiorly and medially toward the branches of the ITA. Up to twenty
tracheoesophageal groove (Figures 8, 9). anatomical variations have been described.
The right RLN enters the root of the neck In Figure 10 the RLN is seen to pass
from a more lateral direction. Its course is anterior to the artery.
less predictable than that of the left RLN.
The RLNs enter the larynx deep to the
inferior constrictor muscles and posterior
to the cricothyroid joint.
Xns
Figure 10: RLN passing over the inferior
thyroid artery (right neck, thyroid reflected
RLNs medially)
Subclavian arteries
The majority of RLNs are located within
Aortic arch
3mm of Berrys ligament; rarely the nerve
is embedded in it, and more commonly lies
laterally to it.
4
laterally, the oesophagus medially, and the XIIn
ITA superiorly (Figure 11).
SLN (internal)
SLN (external)
Oesophagus STA
RLN
Sup pole thyroid
ITA
Carotid
Figure 12: Anatomical relations of
internal and external branches of right
Figure 11: RLN crossing Simons triangle
SLN to superior thyroid artery and to
formed by oesophagus, inferior thyroid
superior pole of thyroid
artery (ITA) and common carotid artery
(right neck, thyroid reflected medially)
The usual configuration is that the nerve is
located behind the STA, proximal to its
The Tubercle of Zukerkandl may also be
entry into the superior pole of the thyroid.
used as an anatomical landmark to identify
The relationships of the nerve to the
the nerve (Figure 6). The RLN generally
superior pole and STA are however
courses between this structure and the
extremely variable. Variations include the
trachea. However, this relationship can
nerve passing between the branches of the
vary with enlargement of the tuberculum
STA as it enters the superior pole of the
thereby placing the nerve at risk during
thyroid gland; in such cases it is
exploration.
particularly vulnerable to injury.
Superior Laryngeal Nerve (SLN)
SLN Ext branch
6
Types of thyroidectomy calcaemia. Total thyroidectomy is however
associated with both increased short- and
Thyroid lobectomy: Either lobe is long-term morbidity relating to RLN
removed, usually with a small segment of paralysis and hypocalcaemia, particularly
the thyroid isthmus; the contralateral lobe in an occasional thyroid surgeons hands.
is left undisturbed. It is most commonly Short-term complication rates for total
performed as a diagnostic procedure for a thyroidectomy occur in 10-40% of
thyroid nodule of uncertain nature. It may patients; long-term complications (mainly
be a sufficient for cure in some cases of hypoparathyroidism) occur in 5-20%. Most
thyroid carcinoma with favourable prog- thyroidectomies are done in general
nostic criteria. hospitals by surgeons not specialising in
endocrine surgery; complication rates have
Subtotal thyroidectomy: 90-95% of been reported to correlate with the number
thyroid tissue is removed bilaterally, leav- of thyroidectomies done. In the absence of
ing a small (1x2cm) thyroid remnant in convincing evidence that total thyroidec-
situ overlying the RLN. This operation has tomy confers survival benefit in favourable
slowly lost favour as it is by its very nature differentiated thyroid cancers (especially
inexact, is prone to recurrence of the thy- when I131 therapy is not available), coupled
roid pathology, and in expert hands does with the morbidity and mortality of total
not result in lower rates of RLN injury thyroidectomy, the occasional thyroid
when compared to total thyroidectomy. surgeon or the surgeon practising in a
setting where calcium monitoring and re-
Total thyroidectomy: Both right and left placement are suboptimal may therefore
lobes, isthmus and pyramidal lobe (when elect rather to perform thyroid lobectomy
present) are removed; no macroscopic thy- or subtotal thyroidectomy for differentiated
roid tissue is left in situ. This is the proce- thyroid cancer.
dure of choice for the treatment of thyroid
carcinoma and is commonly performed for
a MNG with compressive symptoms, or Pre-operative evaluation
for thyrotoxicosis.
Ultrasonography (US) permits accurate
Subtotal vs. total thyroidectomy for distinction between the common thyroid
differentiated thyroid carcinoma pathologies and is the imaging technique
of choice for a thyroid mass. Neoplasms
Bilateral RLN injury causing airway com- typically cause focal enlargement within a
promise and hypoparathyroidism causing normal gland (solitary nodule). Features
hypocalcaemia in situations where moni- strongly suggestive of thyroid carcinoma
toring serum calcium and treating hypo- are hypoechogenicity, increased and
calcaemia with calcium and Vitamin D are haphazard vascularity patterns within the
not possible may have fatal consequences. lesion, microcalcifications, irregular mar-
Regardless of surgical expertise, the com- gins, elevated height-to-width ratio, and
plication rates rise with the extent of regional lymphadenopathy. A multinodular
resection. Unilateral thyroid lobectomy goitre (MNG) typically shows multiple
rarely causes RLN injury and almost never hyper- or isoechoic nodules, some cystic
causes significant hypoparathyroidism. changes and coarse macrocalcifications
Subtotal thyroidectomy preserves the involving both thyroid lobes.
blood supply to the ipsilateral parathyroid
glands and reduces the risk of hypo-
7
Focal thyroid masses or suspicious lymph- Thyroid uptake scans may be requested in
adenopathy should be investigated by fine cases of thyroid enlargement with thyro-
needle aspiration cytology. toxicosis, but are not routinely done as
they seldom add more information to that
All patients with thyroid complaints must available from the US.
undergo thyroid function tests as clinical
manifestations of thyrotoxicosis or hypo- Laryngoscopy: It is medico-legally prudent
thyroidism are notoriously unreliable. Thy- to document vocal cord function prior to
rotoxicosis must first be controlled medi- thyroid surgery; it is essential in patients
cally before surgical intervention. Failure with symptoms of dysphonia.
to do so may precipitate a thyroid storm.
8
generally becomes evident 3-4 weeks Placing the incision too low causes an
following surgery. Thyroxine replacement unsightly low scar over the heads of the
therapy is routinely instituted immediately clavicles when the extended neck is
postoperatively to prevent hypothyroidism. returned to its normal position. The width
The exception is if total thyroidectomy has of the incision may need to be extended for
been performed for a well-differentiated large goitres or for a lateral lymph node
carcinoma and I131 therapy is envisaged; a dissection.
hypothyroid state is deliberately induced in
such patients until the I131 therapy has been Subplatysmal flaps: Subcutaneous fat and
administered. platysma are divided, and a subplatysmal
dissection plane is developed superiorly
(platysma is often absent in the midline)
Anaesthesia, positioning and draping remaining superficial to the anterior
jugular veins, up to the level of the thyroid
General anaesthesia with endotracheal cartilage above, and the sternal notch
intubation below (Figure 18).
Prophylactic antibiotics are not
indicated
Neck slightly hyperextended by
placing a bolster between the scapulae
Head stabilised on a head ring
Table tilted to 30 anti-Trendelenberg
position to reduce venous engorgement
Head is free-draped to allow turning of
the head
Surgical technique
Skin incision (Figure 17): A curvilinear Figure 18: Subplatysmal flaps elevated
incision is placed in a skin crease two
fingerbreadths above the sternal notch
between the medial borders of the sterno-
cleidomastoid muscles.
AJV
s
It is usual at this stage for the surgeon to Dividing the STA (Figure 23): The retrac-
move to the side of the table opposite to the tors are repositioned to allow full visua-
thyroid lobe to be resected. lisation of the superior pole of the thyroid.
This brings the STA into view. The author
Medially rotating the thyroid: Using does not routinely identify the external
gentle digital retraction the surgeon rotates branch of the SLN, but simply takes great
the thyroid gland medially (Figure 21). care to divide the artery as close to the
thyroid parenchyma as possible so as to
Dividing the middle thyroid vein(s) avoid injury to nerve. The superior arterial
(Figure 21): The first important vascular pedicle is double ligated with 2/0 or 3/0
structure to come into view is the middle tie.
thyroid vein(s), which is tightly stretched
10
ensure meticulous haemostasis. The gland
must remain in situ with blood supply
intact. This is best achieved by carefully
dissecting it off the posterior aspect of the
thyroid gland, and using short bursts of
bipolar cautery to control bleeding.
TZ
Sup parathyroid
Crossing point
of RLN & STA
11
If the RLNs course is viewed in a coronal
plane then the inferior parathyroid is
superficial (ventral) to the plane of the
nerve (Figures 14a, b). The inferior gland
may now become visible on the inferior
aspect of the lower pole of the thyroid or
within the thyrothymic ligament (Figure
25). Care must be taken to preserve it in
situ and to avoid damaging its ITA blood
supply.
Figure 27: Ligament of Berry still needs to
Identifying the RLN: The thyroid is be divided
rotated medially; lateral retraction is
applied to the carotid artery and jugular Dividing the thyroid isthmus: When doing
vein. The RLN is located by carefully a thyroid lobectomy the isthmus is cross-
dissecting/teasing apart the tissues in clamped with a haemostat and divided.
Simons triangle which is formed by the The residual remnant is oversewn using a
common carotid artery laterally, the continuous, interlocking technique (Figure
oesophagus medially, and the inferior 28).
thyroid artery superiorly (Figure 11).
Others favour finding the nerve at its point
of entry into the larynx approx. 0.5cm
caudad to the inferior cornu of the thyroid
cartilage. The nerve must remain undis-
turbed and in situ i.e. is not skeletonised or
handled.
12
thyroid bed and brought out through a uncommon. A CT scan is indicated as US
laterally placed skin puncture is not ideal for the evaluation of media-
The strap muscles are approximated for stinal pathology. It is essential to exclude
70% of their length, and the platysma other causes of a mediastinal mass such as
is closed with interrupted absorbable lymphoma, thymoma or teratoma. Addi-
3/0 sutures tional steps required for removal of a large
A subcuticular skin closure is achieved retrosternal goiter include:
with an absorbable monofilament su- Full neck extension
ture Skin incisions are unchanged
A light dressing is applied Transection of the strap muscles (ster-
nohyoid & sternothyroid) greatly
facilitates exposure of the middle
Postoperative care thyroid vein and STA
Digitally dissecting the gland in the
The patient is monitored overnight for mediastinum with concomitant traction
bleeding and airway obstruction of the already-mobilized superior pole
The intravenous line is removed and a will always result in delivery of the
normal diet is taken as tolerated gland into the neck wound
If a drain has been placed it is removed A delivery instrument such as a sterile
when drainage is <50ml/24hrs spoon or Kiellands obstetric forceps
Following total thyroidectomy, serum has been reported to facilitate this step,
PTH must be recorded at 24hrs post- although this has never proven neces-
operatively. If the PTH reading is low, sary in the authors experience
then calcium and Vitamin D1 are It is MOST UNCOMMON for a
commenced even in the absence of thoracotomy to be required
symptoms of hypocalcaemia. If PTH
assays are unavailable the calcium Postoperative stridor: Early stridor may be
levels are monitored postoperatively. encountered due to a haematoma and/or
airway oedema; more uncommonly it
occurs due to bilateral RLN injury or
Additional points tracheomalacia. Delayed onset may be due
to hypocalcaemia (tetany).
Devascularised parathyroid: Should a
parathyroid gland accidentally have been Haematoma: Avoid large, bulky dressings
devascularized or come free during dis- so as not to conceal a haematoma. A large
section it should be reimplanted. This is haematoma is a surgical emergency as it
particularly important when performing may cause airway obstruction.
total thyroidectomy. It is stored in saline
until the conclusion of the thyroidectomy, Seroma: Small seromas are very common
then cut into 1 mm cubes and placed in and are simply followed clinically and
small pockets within the sternocleido- allowed to resorb. Larger, symptomatic
mastoid muscle. seromas may be (repeatedly) aspirated
under sterile conditions.
Retrosternal goiter: Presentation, workup
and technique: Retrosternal goiters may RLN injury: Unilateral RLN paralysis
present with airway compression, stridor, presents as a breathy voice and hoarseness,
and effort intolerance; venous congestion and less commonly as dysphagia and
of the head and neck region is not aspiration. It may not be immediately
13
apparent depending on the resting position Scalpel and Ligasure Device), which
of the vocal fold. Bilateral RLN paralysis achieve safe haemostasis and avoid the
usually manifests immediately following need for multiple ligatures (Figure 29).
extubation with stridor or airway obstruct-
tion. Should the patient be unable to main-
tain an adequate airway then emergency
tracheostomy or cricothyroidotomy is
indicated. Subsequent management de-
pends on the surgeons knowledge of
whether the RLNs were seen to be intact
and hence the likelihood of vocal fold
function to recover. Options might include
a watchful waiting approach for up to a
year or CO2 laser cordotomy/arytenoid-
ectomy.
Figure 29: Harmonic Scalpel
Continuous electrophysiologic monitoring
of the RLN during thyroid surgery:
Recent studies have shown that intra- A number of randomised trials have shown
operative monitoring can assist with equivalence between the commercially
finding the RLN, but some pitfalls limit its available products, and a significant reduc-
usefulness: there is no consensus about tion in operating time without an increase
which types of electrodes should be used in complications when compared to stan-
for EMG registration which is the best dard thyroidectomy technique. The author
method for recording nerve action, or uses the Harmonic Scalpel as a means of
which EMG parameters should be selected sealing and transecting vessels and to
as predictive of postoperative vocal cord reduce surgical operating time.
dysfunction. The technology is not widely
available, and most endocrine surgeons
achieve equivalent RLN morbidity rates Minimally Invasive Thyroid Surgery: A
without it. number of techniques have evolved in an
attempt to reduce the extent of skin
Tracheomalacia: This is characterized by incisions and bring the putative benefits of
flaccidity of the tracheal cartilages which minimally invasive techniques to thyroid
in turn causes tracheal wall collapse. It is surgery. Minimally invasive thyroidectomy
thought that a longstanding goiter can act can be performed via a limited 2-3cm neck
as an external support structure for the incision with the visual assistance of an
trachea and predispose to secondary trach- endoscope, specially designed retractors
eomalacia. Thyroidectomy unmasks trach- and a harmonic scalpel. An alternative
eomalacia causing respiratory obstruction. approach is to place incisions for 3-4 ports
In clinical practice this is an uncommon in the axilla and periareolar regions to
cause of airway obstruction after thyroid- avoid a neck scar altogether. The clinical
ectomy. benefits are marginal at best, but they will
continue to be driven by patient demand
Thyroid specific haemostatic devices and the industry. Only patients with small
(Figure 29): The last decade has seen the thyroid nodules are suitable for such a
introduction of thyroid specific haemosta- surgical approach.
tic devices (Ultrasonic scissors/ Harmonic
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Useful References THE OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY, HEAD &
1. Mohebati A, Shaha AR. Anatomy of
thyroid and parathyroid glands and NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
neurovascular relations. Clin Anat.
2012;25(1):19-31
2. Bliss RD, Gauger PG, Delbridge LW.
Surgeon's Approach to the Thyroid
Gland: Surgical Anatomy and the The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
Importance of Technique. World J johannes.fagan@uct.ac.za is licensed under a Creative
Surg. 2000;24(8):891-7 Commons Attribution - Non-Commercial 3.0 Unported
License
3. Wang C. The anatomic basis of
parathyroid surgery. Ann Surg. 1976;
183:2715
Parathyroidectomy
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