Retrosternal Goitre: Anatomical Aspects and Technical Notes

Abstract

Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with “goitre plongeant“, and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1–3 days), while the average LOS was 5 days (4–7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.

Mediastinal Goiter from the View of Thoracic Surgery

“…Khairy et al (2) reported mean age of 54 years and the incidence of females was 3.3 times males. Battistella et al (5) coworkers published a study of 264 patients in more than 30 years with females 4 times males in RSG incidence and the mean age was 54years.…”

“…We did not adopt anterior thoracotomy in any of our cases. Battistella et al (5) agreed Machado that although anterior thoracotomy is an easy incision and done in supine position, but it is difficult to give a view of the right recurrent laryngeal nerve. He also denied thoracotomy as an access if the mediastinal portion is developed on the left side.…”

“…However, the most accepted definition of RSG nowadays describes when ≥ 50% of the mass portion of the goiter is in the mediastinum (1,3,4) . Other different definitions have been also assumed for the expression, e.g., goiter that extends beyond the thoracic inlet into the mediastinum for more than 2 cm is considered retrosternal (1) , or when the part of the goiter in the mediastinum is larger than the cervical one and it extends downwards beyond the thoracic inlet by two fingers, or by at least 4 cm (4)(5)(6) .…”

“…This happens with extension of goiter below the aortic arch, in redo surgeries, involvement of the posterior mediastinum, extension of the RSG towards carina, and primary ectopic RSG in the mediastinum (4,14) . Generally, sternotomy combined with a cervical approach is the standard favored approach for resection of anterior mediastinal goiters, while thoracotomy is advised for removal of posterior mediastinal goiters (1,5,7,12) .…”

“…Moreover, RSG can become life-threatening if there is a sudden increase in size of the goiter if hemorrhage and asphyxiation happened. In addition, a transformation to malignancy, reported in 3-21% of RSGs, could be missed, even with performing fine-needle aspiration cytology in the mediastinal portion of RSG (1,5) .…”