A Medial Approach to Thyroidectomy Benjamin F. Rush, Jr, MD, Newark, New Jersey A. P. Swaminathan, MD? Newark, New Jersey Rashmi Patel, MD, Newark, New Jersey
Thyroidectomy is a classic operation that evolved to its present form during the past century. The basic technic progressed from the original descriptions of Kocher, who in his lifetime developed a meticulous approach to the gland that incorporated most of the manipulations used today. Lahey [I] added to the operative routine the important admonition that the surgeon should always identify and expose the laryngeal nerve prior to ligation of the inferior thyroid artery branches. He also advocated the routine identification of at least one parathyroid gland on each side of the neck. Numerous minor alterations have been devised and described by various authors [2,3], including attention to the preservation of the superior laryngeal nerve and delivery of the superior lobe as the last step of the procedure [4]; however, in general, the thyroidectomy performed routinely throughout the United States is one devised by Kocher and introduced into this country by Halsted [5]. As such, it is basically a lateral approach to the gland with the dissection being carried from the lateral edge to the midline; the final maneuver is transection of the isthmus. We have recently observed that a dissection beginning medially and progressing laterally has some special advantages either for certain selected cases or as a routine procedure. Some, but not all, elements of such an approach have been noted by Lore [6]. From the Department of Surgery, New Jersey Medical School, Martland Hospital, Newark, New Jersey. Reprint requests should be addressed to Benjamin F. Rush, Jr, MD. Department of Surgery, New Jersey Medical School, 65 Bergen Street, Newark. New Jersev 07107. Presented at the Combined M&eting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orleans, Louisiana, March 25-29. 1975.
430
Technic The neck is entered through the usual collarshaped incision, 2 cm above the sternal notch. We directly down prefer to extend our incision through the platysma, transecting the sternothyroid and the medial portion of the sternohyoid muscle to gain direct access to the thyroid gland. The midline thyroid vessels are identified, ligated, and divided. The recurrent laryngeal nerve is identified on one or both sides, depending on whether unilateral or bilateral lobectomy is planned. The nerve is found through gentle dissection in the tracheoesophageal groove just below the lower pole of the thyroid gland. Branches of the inferior thyroid vein are identified during this dissection and also ligated and divided. The suspensory fascia of the thyroid along the upper border of the isthmus is then divided, and a clamp is passed beneath the isthmus at the midline. The isthmus is divided between multiple clamps, and bleeding is controlled by suture ligatures (Figure l), one or two of which may be left long to provide traction on the isthmus. When transection of the isthmus has been completed, the lobe of the thyroid is swung laterally by gradually releasing the many little fibrous adhesions between the thyroid and underlying trachea and cricoid cartilage. This dissection is relatively bloodless, although occasional small vessels perforating through the cartilage may be controlled by applying suture ligatures of fine silk. As the gland is swung more and more laterally, the “door is opened” to the tracheoesophageal and laryngopharyngeal groove and the nerve is exposed as it extends up to interdigitate with the trunk or the branches of the inferior thyroid artery. (Figure 2.)
The Am&can
Journal of Surgery
Thyroidectomy
Figure 2. Dissection of each lobe is carried into the tracheoesophageal groove over the surface of the cricoid and tracheal cartilagesas indicated by the arrow.
Figure 1. After exposure, through the m&Wne.
the isthmus is transected
The superior thyroid artery and vein that normally extend along the medial surface of the superior pole are also rotated into full view. If the dissection has been bilateral, it is possible to show the superior and inferior thyroid arteries and the right and left laryngeal nerves before any extirpation of the gland is carried out. (Figure 3.) At this point the subsequent maneuvers are dictated by the operation contemplated. If parathyroid exploration is planned, the surgeon traces out the fully exposed vessels bilaterally, along and adjacent to the inferior thyroid artery to expose the inferior parathyroid. To expose the superior parathyroid the surgeon traces the superior thyroid artery where it enters the gland at the junction of the middle and upper third. If extirpation is contemplated for hyperthyroidism, the surgeon may elect to ligate the vessels to the upper pole but to preserve the vessels to the tiny remnant of thyroid tissue in the vicinity of the inferior thyroid artery that will be left after removal bilaterally of the remainder of the gland. (Figure 3.) If lobectomy is intended, the inferior and superior thyroid arteries may be ligated at the point where they enter the thyroid, thus avoiding any risk that the ligatures may involve either the recurrent laryngeal nerve inferiorly or the external laryngeal nerve above. If no extirpation of the gland is performed, as in
vokma 130. octobw 1975
Figure 3. After both lobes are released, they can be rotated laterally exposing the parathyroid glands, the inferior thyroid arteries, and the continuation of the recurrent laryngeal nerves bilaterally. The dotted lines indicate the area of transection when subtotal thyroidectomy is performed.
parathyroid exploration, the isthmus is then sutured at the midline. (Figure 4.) We have used this procedure in a total of twelve patients thus far: six for parathyroid exploration, three for hyperthyroidism, and three for thyroid lobectomy for solitary thyroid nodules. All patients have done well, with benign postoperative courses, and were ready for discharge from the hospital three to five days after operation. Pa-
431
Rush, Swaminathan, and Pate1
tery. This area is immediately exposed by medial dissection but is often difficult to reach around the bulky edge of an enlarged gland from a lateral approach. There may well be some circumstances where a medial approach is contraindicated by a large isthmus in which very enlarged bilateral lobes are fused at the midline, but we have not yet encountered such a case. With the medial approach, a decision to ligate vessels can be made after adequate exposure of all the structures is achieved. If parathyroidectomy is planned, this approach offers a relatively avascular route to the parathyroid glands. If hyperthyroidism is the indication for operation, preservation of the recurrent laryngeal nerves, parathyroid glands, and blood supply to the remaining thyroid fragments is achieved more easily.
Summary
Figure 4. When parathyroid exploratlon alone has been carried out, the gland can be restored by suturing the isthmus at the mldline wlthout distwb~ng the major blood supply or the recurrent laryngeal nerves.
tients with hyperparathyroidism or hyperthyroidism remained a few days longer for additional laboratory study. A transient weakness of one cord in two of our earlier patients developed; we attribute this to overenthusiastic manipulation in demonstrating the nerves bilaterally during dissection. Comments We believe the medial approach to thyroidectomy has the intrinsic advantage of preserving all major vascular structures until the entire operative field is exposed and the surgeon has decided which particular approach to employ. We believe it has a special advantage in those bulky goiters that disturb the relationship between the recurrent laryngeal nerve and the inferior thyroid ar-
432
Thyroidectomy initiated by transecting the isthmus and peeling the lobes laterally away from the midline exposes the three vital elements of thyroid anatomy, namely the vessels, the recurrent laryngeal nerves and the parathyroid glands, by an almost bloodless dissection conducted at a distance from these vital structures. Part or all of the lobe or lobes can be removed while the parathyroid glands and recurrent laryngeal nerves remain clearly under view at all times.
References 1. Sedgewick CF: Surgery of the Thyroid Gland. Philadelphia, WB Saunders, 1974. 2. Hawe P, Lothian KR: Recurrent laryngeal nerve injury during thyroidectomy. Surg Gynecol Obstet 110: 488. 1960. 3. Moosman DA, DeWeese MS: The external laryngeal nerve as related to thyroidectomy. Surg Gyneccl Obstet 127: 1011, 1968. 4. Thompson NW, Olsen WR, Hoffman GL: The continuing development of the technique of thyroidectomy. Surgery 73: 913.1973. 5. Halsted WS: The operative story of goitre. Johns Hopkins Hospital Repott 19: 71, 1920. 6. Lore JM Jr: An Atlas of Head and Neck Surgery. Philadelphia, WB Saunders, 1962.
The Amerfcan Journal of 8urery
Thyroidectomy is a classic operation that evolved to its present form during the past century. The basic technic progressed from the original descriptions of Kocher, who in his lifetime developed a meticulous approach to the gland that incorporated most of the manipulations used today. Lahey [I] added to the operative routine the important admonition that the surgeon should always identify and expose the laryngeal nerve prior to ligation of the inferior thyroid artery branches. He also advocated the routine identification of at least one parathyroid gland on each side of the neck. Numerous minor alterations have been devised and described by various authors [2,3], including attention to the preservation of the superior laryngeal nerve and delivery of the superior lobe as the last step of the procedure [4]; however, in general, the thyroidectomy performed routinely throughout the United States is one devised by Kocher and introduced into this country by Halsted [5]. As such, it is basically a lateral approach to the gland with the dissection being carried from the lateral edge to the midline; the final maneuver is transection of the isthmus. We have recently observed that a dissection beginning medially and progressing laterally has some special advantages either for certain selected cases or as a routine procedure. Some, but not all, elements of such an approach have been noted by Lore [6]. From the Department of Surgery, New Jersey Medical School, Martland Hospital, Newark, New Jersey. Reprint requests should be addressed to Benjamin F. Rush, Jr, MD. Department of Surgery, New Jersey Medical School, 65 Bergen Street, Newark. New Jersev 07107. Presented at the Combined M&eting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orleans, Louisiana, March 25-29. 1975.
430
Technic The neck is entered through the usual collarshaped incision, 2 cm above the sternal notch. We directly down prefer to extend our incision through the platysma, transecting the sternothyroid and the medial portion of the sternohyoid muscle to gain direct access to the thyroid gland. The midline thyroid vessels are identified, ligated, and divided. The recurrent laryngeal nerve is identified on one or both sides, depending on whether unilateral or bilateral lobectomy is planned. The nerve is found through gentle dissection in the tracheoesophageal groove just below the lower pole of the thyroid gland. Branches of the inferior thyroid vein are identified during this dissection and also ligated and divided. The suspensory fascia of the thyroid along the upper border of the isthmus is then divided, and a clamp is passed beneath the isthmus at the midline. The isthmus is divided between multiple clamps, and bleeding is controlled by suture ligatures (Figure l), one or two of which may be left long to provide traction on the isthmus. When transection of the isthmus has been completed, the lobe of the thyroid is swung laterally by gradually releasing the many little fibrous adhesions between the thyroid and underlying trachea and cricoid cartilage. This dissection is relatively bloodless, although occasional small vessels perforating through the cartilage may be controlled by applying suture ligatures of fine silk. As the gland is swung more and more laterally, the “door is opened” to the tracheoesophageal and laryngopharyngeal groove and the nerve is exposed as it extends up to interdigitate with the trunk or the branches of the inferior thyroid artery. (Figure 2.)
The Am&can
Journal of Surgery
Thyroidectomy
Figure 2. Dissection of each lobe is carried into the tracheoesophageal groove over the surface of the cricoid and tracheal cartilagesas indicated by the arrow.
Figure 1. After exposure, through the m&Wne.
the isthmus is transected
The superior thyroid artery and vein that normally extend along the medial surface of the superior pole are also rotated into full view. If the dissection has been bilateral, it is possible to show the superior and inferior thyroid arteries and the right and left laryngeal nerves before any extirpation of the gland is carried out. (Figure 3.) At this point the subsequent maneuvers are dictated by the operation contemplated. If parathyroid exploration is planned, the surgeon traces out the fully exposed vessels bilaterally, along and adjacent to the inferior thyroid artery to expose the inferior parathyroid. To expose the superior parathyroid the surgeon traces the superior thyroid artery where it enters the gland at the junction of the middle and upper third. If extirpation is contemplated for hyperthyroidism, the surgeon may elect to ligate the vessels to the upper pole but to preserve the vessels to the tiny remnant of thyroid tissue in the vicinity of the inferior thyroid artery that will be left after removal bilaterally of the remainder of the gland. (Figure 3.) If lobectomy is intended, the inferior and superior thyroid arteries may be ligated at the point where they enter the thyroid, thus avoiding any risk that the ligatures may involve either the recurrent laryngeal nerve inferiorly or the external laryngeal nerve above. If no extirpation of the gland is performed, as in
vokma 130. octobw 1975
Figure 3. After both lobes are released, they can be rotated laterally exposing the parathyroid glands, the inferior thyroid arteries, and the continuation of the recurrent laryngeal nerves bilaterally. The dotted lines indicate the area of transection when subtotal thyroidectomy is performed.
parathyroid exploration, the isthmus is then sutured at the midline. (Figure 4.) We have used this procedure in a total of twelve patients thus far: six for parathyroid exploration, three for hyperthyroidism, and three for thyroid lobectomy for solitary thyroid nodules. All patients have done well, with benign postoperative courses, and were ready for discharge from the hospital three to five days after operation. Pa-
431
Rush, Swaminathan, and Pate1
tery. This area is immediately exposed by medial dissection but is often difficult to reach around the bulky edge of an enlarged gland from a lateral approach. There may well be some circumstances where a medial approach is contraindicated by a large isthmus in which very enlarged bilateral lobes are fused at the midline, but we have not yet encountered such a case. With the medial approach, a decision to ligate vessels can be made after adequate exposure of all the structures is achieved. If parathyroidectomy is planned, this approach offers a relatively avascular route to the parathyroid glands. If hyperthyroidism is the indication for operation, preservation of the recurrent laryngeal nerves, parathyroid glands, and blood supply to the remaining thyroid fragments is achieved more easily.
Summary
Figure 4. When parathyroid exploratlon alone has been carried out, the gland can be restored by suturing the isthmus at the mldline wlthout distwb~ng the major blood supply or the recurrent laryngeal nerves.
tients with hyperparathyroidism or hyperthyroidism remained a few days longer for additional laboratory study. A transient weakness of one cord in two of our earlier patients developed; we attribute this to overenthusiastic manipulation in demonstrating the nerves bilaterally during dissection. Comments We believe the medial approach to thyroidectomy has the intrinsic advantage of preserving all major vascular structures until the entire operative field is exposed and the surgeon has decided which particular approach to employ. We believe it has a special advantage in those bulky goiters that disturb the relationship between the recurrent laryngeal nerve and the inferior thyroid ar-
432
Thyroidectomy initiated by transecting the isthmus and peeling the lobes laterally away from the midline exposes the three vital elements of thyroid anatomy, namely the vessels, the recurrent laryngeal nerves and the parathyroid glands, by an almost bloodless dissection conducted at a distance from these vital structures. Part or all of the lobe or lobes can be removed while the parathyroid glands and recurrent laryngeal nerves remain clearly under view at all times.
References 1. Sedgewick CF: Surgery of the Thyroid Gland. Philadelphia, WB Saunders, 1974. 2. Hawe P, Lothian KR: Recurrent laryngeal nerve injury during thyroidectomy. Surg Gynecol Obstet 110: 488. 1960. 3. Moosman DA, DeWeese MS: The external laryngeal nerve as related to thyroidectomy. Surg Gyneccl Obstet 127: 1011, 1968. 4. Thompson NW, Olsen WR, Hoffman GL: The continuing development of the technique of thyroidectomy. Surgery 73: 913.1973. 5. Halsted WS: The operative story of goitre. Johns Hopkins Hospital Repott 19: 71, 1920. 6. Lore JM Jr: An Atlas of Head and Neck Surgery. Philadelphia, WB Saunders, 1962.
The Amerfcan Journal of 8urery
