1/29/13

//Surgical Technique

Search Here

Surgical Technique
The surgical approach of the superior thyroid pole is necessary in most operations involving the thyroid gland. Some authors prefer to start the thyroidectomy with the superior pole dissection;[14,][21] for others, this is the final step.[17] Regardless of the sequence, the dissection of the superior thyroid pole usually starts with initial mobilization of the whole thyroid lobe. Ligation of the middle thyroid vein is advisable, to facilitate this initial mobilization. It is highly recommended that the sternothyroid-laryngeal triangle be completely exposed before any superior pole suture is placed (see Figure 32-2). In most instances, when the thyroid lobe is of normal size or only slightly enlarged, there is no need for complete section of the strap muscles. However, in many situations, a partial incision of the sternothyroid muscle with cautery may improve the access to the superior thyroid pedicle (Figure 32-5) (see Chapter 30, Principles in Thyroid Surgery).

Figure 32-5 Incision is made in the sternothyroid muscle w ith cautery, increasing superior pole exposure.

The superior thyroid vessels usually divide into three branches that embrace the superior thyroid pole; two are located anteriorly, and one runs dorsally to the thyroid superior pole. It is imperative that the surgeon dissect and ligate these branches individually, placing sutures as caudally as possible (Figure 32-6). Lor et al. emphasized that gentle traction of the thyroid lobe caudally may help to preserve the integrity of the EBSLN.[17]

Figure 32-6 Superior thyroid pole dissection w ith individual superior thyroid artery branch ligation. Sutures should be placed as
far caudally as possible.

Generally, the EBSLN will be situated cranially to the superior border of the thyroid lobe, and strict adherence to the aforementioned principles will offer reasonable protection. However, in 15% to 20% of cases, the nerve may be type 2b. Thus, in all cases, superior pole vessel ligature and dissection in the sternothyroid-laryngeal triangle and along the medial surface of the thyroid's superior pole must be performed meticulously, with wide exposure. The surgeon should have a low threshold for use of a nerve stimulator when dissecting in this area. This is especially useful in those circumstances (approximately 20% of cases) in which the EBSLN is deep to the inferior constrictor muscle fascia.[8] When the nerve is electrically stimulated, a quick but powerful contraction of the CTM is immediately obtained (see this chapter's SLN video). Once the EBSLN is visualized, it must be kept constantly under direct vision during the entire dissection of the superior thyroid pole (Figure 32-7). After completion of superior thyroid pole dissection, the integrity of the nerve may also be documented through electrical stimulation (see Chapter 33, Surgical Anatomy and Monitoring of the Recurrent Laryngeal Nerve).

www.expertconsultbook.com/expertconsult/b/book.do?method=getContent&refreshType=AJAX&print=true&decorator=printpreview&eid=4-u1.0-B978-1-4377

1/3

1/29/13

//Surgical Technique

Figure 32-7 Gentle caudal traction of the thyroid lobe is recommended to preserve EBSLN.

Some authors have based their identification and preservation of the EBSLN only on surgical anatomic findings.[8,][10] One clear advantage in the use of nerve stimulation in EBSLN management is the ability to stimulate the nerve superiorly and get a positive signal even if the nerve is subfasical within the fibers of the inferior contrictor. The positive response results in CTM twitch as well as a typical small response on endotracheal monitoring systems (through the human communicating nerve). The bands of tissue taken as part of superior pole management can then be stimulated as negative before they are divided (see Chapter 33, Surgical Anatomy and Monitoring of the Recurrent Laryngeal Nerve, section on SLN monitoring). Nevertheless, as do many others in the international literature,[18-20,][22] we prefer a positive electrical identification.[21,][23] Recently Barczynski has studied 210 patients in a randomized controlled study of RLN and EBSLN visualization vs visualization and neural monitoring and found significant improvement in ability to identify the EBSLN with monitoring (83% with monitoring vs 34% without monitoring) as well as significant improvement in multiple early voice postoperative parameters with monitoring (see Chapter 33, Surgical Anatomy and Monitoring of the Recurrent Laryngeal Nerve, section on SLN monitoring).[48] Dissection of the superior thyroid pole is much more difficult when the surgeon is dealing with a large goiter. In this instance, the upper border of the pole is elevated markedly, putting it in close contact with the EBSLN (Figure 32-8). An additional problem is the enlargement of the superior thyroid vessels, which usually parallels the dimensions of the goiter, demanding an even more careful dissection. The sectioning of the strap muscles offers a better and safer exposure of this area. We have demonstrated that the probability of a high-risk 2b nerve in patients with goiter may rise to 54%.[23] Hence, attempts to obtain a positive identification of the EBSLN in such goiters are especially important.

Figure 32-8 Dissection of the superior thyroid pole is more difficult w hen the surgeon is faced w ith a large goiter.

Recently, some authors have employed minimally invasive techniques to approach the thyroid gland, including video-assisted thyroidectomy. It is important to emphasize that the anatomic classification that we proposed in 1992 was developed using nonpreserved cadavers after rigor mortis, in order to enable the neck to be hyperextended, exactly in the same position as in a conventional thyroidectomy. However, no neck hyperextension is applied during a video-assisted thyroidectomy, thus approximating the EBSLN to the superior
www.expertconsultbook.com/expertconsult/b/book.do?method=getContent&refreshType=AJAX&print=true&decorator=printpreview&eid=4-u1.0-B978-1-4377 2/3

1/29/13

//Surgical Technique

thyroid pole. In a limited series of 12 cases, Dedivitis and Guimares were able to clearly identify the nerve in 83.3% of the cases, mentioning that they ran medially to the branches of the superior thyroid vessels in 80% and laterally in 20%.[42] On the other hand, the magnification and illumination offered by the scope probably facilitate the visualization and preservation of the EBSLN. In 2009, Inabnet et al. published a prospective study of 10 patients submitted to minimally invasive thyroidectomy under local anesthesia, with nerve monitoring of the EBSLN.[43] Among the 15 nerves at risk, 8 were identified and successfully preserved, with their normal function assessed during the operation by the nerve monitoring and postoperative by video laryngoscopy.

Copyright 2013 Elsevier Inc. All rights reserved. Read our Terms and Conditions of Use and our Privacy Policy. For problems or suggestions concerning this service, please contact: online.help@elsevier.com

www.expertconsultbook.com/expertconsult/b/book.do?method=getContent&refreshType=AJAX&print=true&decorator=printpreview&eid=4-u1.0-B978-1-4377

3/3