How is thyroidectomy performed for thyroid cancer?

Updated: May 09, 2018
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

Positioning of the patient is important. Place the patient in a supine position with his or her neck extended by using a shoulder roll. Plan a horizontal incision in a natural skin crease to contour the curvature of the neck. The location should overlie the thyroid gland, evenly extending between the anterior aspect of the sternocleidomastoid muscles on both sides.

Elevate skin flaps superiorly and inferiorly in a subplatysmal plane. (Platysma is often absent in the midline.) Ligate the anterior jugular veins only if they directly limit exposure. Separate the sternohyoid and sternothyroid muscles in the median raphe, and retract them laterally to expose the cricoid cartilage and thyroid isthmus.

In the anterior region, dissect the strap muscles off the face of the thyroid lobe (bilaterally for total thyroidectomy). Supracapsular dissection is continued until the superior pole and its vascular pedicle are isolated. The superior pole vessels are divided and ligated. The dissection continues laterally with division of the middle thyroid vein. The thyroid lobe is gradually medialized. Careful blunt dissection is performed to identify the recurrent laryngeal nerve in the tracheoesophageal groove.

After the recurrent nerve is identified, carefully follow the nerve superiorly toward the larynx. The nerve passes closely to the Berry ligament, but its position varies. After the nerve is thoroughly identified in this region, divide the ligament to release the thyroid gland.

Keep the location of the parathyroid glands in mind during lateral dissection. Avoid disturbing the gland and vasculature as much as possible. Dissection close to the thyroid capsule minimizes this risk. If possible, ligate the inferior thyroid artery only after the vessels to the inferior parathyroid gland branch.

If a parathyroid gland is inadvertently removed, reimplant it in the sternocleidomastoid muscle or on the volar surface of the forearm after slicing it into small pieces and marking it with a surgical clip.

During superior dissection, remember the nearby location of the external branch of the superior laryngeal nerve, which innervates the cricothyroid muscle. Ligation of the superior-pole vessels tight to the thyroid in this area avoids inadvertent injury to this nerve.

If only lobectomy is planned, divide the thyroid isthmus in the midline. Ligate the final soft-tissue attachments, and remove and label the lobe. Send it to the pathology laboratory. When total thyroidectomy is performed, the surgeon may elect not to divide the thyroid isthmus in the midline, but rather, to perform lateral dissection bilaterally. Identify the recurrent laryngeal nerves, and manage the inferior and superior vascular pedicles similarly. Remove the gland in 1 piece, label it, and send it for pathologic analysis.

Irrigate the wound, and achieve meticulous hemostasis. The decision to place a passive or closed suction drain often depends on the surgeon's judgment. If a drain is used, place it into the wound and bring it out laterally through the incision or through a separate stab incision. The present authors have found the routine use of drains unnecessary. Reapproximate the sternothyroid and sternohyoid, and carefully close the skin in layers.

A study by Salari et al of 35 patients with advanced thyroid malignancy and extensive nodal disease suggested that in such cases, a neural-monitored, staged surgical approach can safely and effectively be used in place of a simultaneous bilateral operation. [30]


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