The thyroid operation is considered by many to be at the pinnacle of endocrine

surgery

Thyroid SurgeryMost endocrine surgeons agree that an

accurately performed thyroidectomy requires both experience and technical ability

National endocrine surgical associations- strives for the creation of centers of excellence for the future training of endocrine surgeons

Unacceptably high incidences of major complications, like:

- recurrent laryngeal nerve palsies - permanent hypoparathyroidism

are still reported in the surgical literature.

RLN function is tested by placing the surgeon’s finger in the prevertebral space and palpating the aritenoid cartilage movements as the nerve is stimulated using the nerve stimulator

Suspensory ligament of Berry : Its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies AuthorsSASOU S. (1) ; NAKAMURA S.-I. (1) ; KURIHARA H. (2) ;

Authors Affiliations(1) Division of Pathology, Central Clinical Laboratory, School of Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Iwate, JAPON(2) Kurihara Thyroid Clinic, Morioka 020-0015, JAPON

Background. It is important to clarify the relationship between the recurrent laryngeal nerve (RLN) and the ligament of Berry to prevent damage to the RLN in thyroid surgery.

The purpose - to identify this relationship to prevent surgical complications.

Methods. Among the 486 thyroid surgery cases, 689 RLNs were identified and their course detected. Topography of the laryngotracheoesophageal region and the histology of the ligament of Berry were studied in detail in 25 autopsied cadavers.

Results. All nerves identified by surgery and autopsy were located laterodorsally to the ligament of Berry. They were clearly separated, and no nerve penetrated the ligament nor was medially located to it. The ligament of Berry strongly connected the thyroid gland to the trachea and was identified as a whitish connective tissue band.

Conclusions. It was confirmed that the RLN never penetrates the ligament of Berry but is located laterally to it. From these topographic findings, no injury to the RLN will occur from a separation close to the goiter in thyroid surgery

1. Experience, 2. Sound judgment, 3. Meticulous technique 4. Adequate training

are the hallmarks required to eliminate POSTOPERATIVE MORBIDITY

Thyroid Surgery

It would be prudent to design appropriate training programs

Introduce uniform guidelines and standards for performing these operations for the whole country

SUBTOTAL THYROIDECTOMYINDICATIONS Are decreasing• Thyrotoxicosis

– Antithyroid drugs resistance– Recurrence after an apparently successful medication

• Pressure symptoms• Cosmetic effect- large goitre

• Inflammatory conditions– Riedel’s struma– Hashimoto’s disease

Preoperative preparationThyrotoxicosisATS drugs until an euthyroid state is reachedATS drugs block the synthesis of thyroxine but do not inhibit the release of the hormone

from existing colloid stores: 3w-3m~Q.colloidWhen euthyroid than LUGOL-potassium

iodide solution, 10 daysPostop. tachycardia- beta blockers

Thyroid SurgeryThe tubercle of

Zuckerkandl is a thickening of thyroid tissue that is located at the most postero-lateral edge of the thyroid gland

Close proximity with PTs and RLN

Laryngeal Nerves

OPERATIVE STEPS• Kocher incision• Dissection of the sup. and inf. skin flaps from

thyroid cartilage down to the suprasternal notch- - ! arch connecting the 2 AJV

• Retractor for skin flaps• Large goitre- division of SH/ST muscles in the

sup. 1/3 (avoid injury to the motor nerve supply)• Free the ant. margin of SCM from the ST muscle• Midline vertical incision between the SH. muscles

from the thyroid notch to suprasternal notch

Crease line incision above the jugular notchRaising the skin flapsStay anterior to the AJV- bloodless dissection

Strap muscles are separated by opening the linea albaSH/ST divided in the sup.1/3rd- avoid injury to the nerve supply (ansa cervicalis-inferiorly)

OPERATIVE STEPSPick up loose fascia over the thyroid and

incise it- cleavage plane between the thyroid gland and ST muscle

Working in a proper cleavage plane, the delivery of the gland may be facilitated by forefingers dissection

MTV ligated, Branches of STA

Freeing the lobe using lateral approachLigate MTV.

OPERATIVE STEPS• Blunt dissection of the upper pole, pushing

away from the larynx• STA/STV exposed above their point of entry

into the gland• Lower pole- free from inf. veins• Exposing the ITA- identify RLN, PTs• Leave paratracheal thyroid tissue- clamping

the parenchyma• Divide the isthmus• Subtotal resection of the lobe

Excessive dissection of the RLN resulted in neuropraxia due to interference with its neural blood supply

Line of resection for subtotal thyroidectomy

Ligate the ITVMyoraphy of the strap muscles

Types of thyroidectomies

Choice of surgical techniquePotential benefits and complications

Pts. with MNG- the main reason to perform bilateral subtotal thyroidectomy is: a presumed lower incidence of complications an attempt to maintain the euthyroid status

without thyroxine replacement

DisadvantagesHigh recurrence rate and increased surgical

morbidity during reoperationSome pts. still require thyroxine replacementUnrecognized malignancy- SBT=inadequate

surgery

TT- AdvantagesAdequate removal of the disease

Prevention of the recurrence

Avoidance of the need for completion surgery

How to reduce the risk of complications

Well trained endocrine surgeonTechnique of capsular dissection, staying

close to the thyroid glandPreserving the blood supply to the PTIdentification of the RLN