Thyroidectomy: Technique

A nerve monitor sensor is placed around the endotracheal tube at the level of the vocal cords to aid in identification of the recurrent laryngeal nerve during dissection.

The thyroidectomy incision is marked 2 to 3 centimeters above the sternal notch along a skin crease; in smaller children, an equivalent incision is chosen between the thyroid cartilage and the suprasternal notch.

The incision should extend the same distance on each side of the midline and usually continues beyond the anterior border of the sternocleidomastoid.

Shorter incisions not only provide inadequate exposure, but due to excessive retraction may be cosmetically unappealing.

Maintaining the dissection close to the platysma ensures that the cervical fascia is not included in the flap.

The superior subplatysmal flap extends upward to the thyroid notch, and the lower flap extends downward to the sternal notch.

Subplatysmal flap creation should be blood-free as the superficial veins lie in the cervical fascia.

If there is local invasion by a thyroid neoplasm, the thyroid lobe is resected en bloc with its overlying strap muscles.

Dissection close to the strap muscles minimizes bleeding.

The correct plane of dissection is entered when the vessels overlying the thyroid gland become prominent.

During superior pole dissection, care is taken to stay directly on the gland in order to minimize the risk to the external laryngeal nerve.

The recurrent laryngeal nerve is identified in the tracheoesophageal groove.

Identification of the recurrent laryngeal nerve is necessary to prevent injury.

The parathyroid glands are identified as small yellowish brown tissue with a single small artery entering the gland.

It is important to maintain blood supply to the parathyroid during dissection.

The upper parathyroid gland is usually found behind the upper third of the thyroid adjacent to the cricothyroid junction.

The inferior parathyroid gland is found near the inferior thyroid artery on the posterior surface of the thyroid, though the location may vary.

If in doubt about parathyroid identification, a frozen section or rapid PTH may be used.

Dissection must proceed directly on the thyroid itself in order to avoid injury to surrounding structures.

The recurrent laryngeal nerve lies in the tracheoesophageal groove as it passes posterior to the inferior pole of the thyroid, travels obliquely closer to the gland, crosses the inferior thyroid artery, and ascends into the larynx.

If a parathyroid gland is taken during the dissection or blood supply to it is compromised, it may be auto-transplanted into the sternocleidomastoid or the non-dominant forearm.

For parathyroid autotransplantation, the gland should be placed in saline in an ice bath until autotransplantation is performed.

For autotransplantation, the parathyroid is minced with tenotomy scissors in a small amount of saline, drawn into a syringe, and injected into the sternocleidomastoid muscle, taking care not to create a hematoma.

For a good cosmetic result, the platysma is carefully approximated with 3-0 absorbable suture.

The skin is closed with a running 4-0 non-absorbable monofilament that is then removed the next day, or an absorbable monofilament may also be used.