Surgeon's Approach to the Thyroid Gland: Surgical Anatomy and the Importance of Technique

Abstract

Abstract. The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of thyroid anatomy and pathology. With appropriate techniques, total thyroid lobectomy and total thyroidectomy (which should be considered simply as a bilateral total thyroid lobectomy performed during the same operation) can be undertaken with minimal risk of damage to the recurrent laryngeal nerves, the external branches of the superior laryngeal nerves, and the parathyroid glands. Safe surgery requires a specific operative plan, progressing in a series of logical, orderly, anatomically based steps. Exposure of the thyroid gland is followed by careful dissection of the superior pole, utilizing the avascular plane between the superior pole and the cricothyroid muscle to identify and preserve the external branch of the superior laryngeal nerve. Medial retraction of the gland then allows dissection of the lateral aspect of the thyroid lobe. Protection of the recurrent laryngeal nerves and preservation of the blood supply to the parathyroid glands is best achieved by "capsular dissection," ligating the tertiary branches of the inferior thyroid artery on the gland surface. If a parathyroid gland cannot be preserved or becomes ischemic after dissection of its vascular pedicle, it should be immediately minced and autotransplanted into the ipsilateral sternocleidomastoid muscle. The current evolution of outpatient or shortstay thyroidectomy emphasizes the need to avoid complications by utilizing meticulous surgical technique. Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery.During the latter half of the nineteenth century a revolution in surgery and surgical technique occurred. Before that time, thyroid surgery was limited to treating only life-threatening conditions. With a reported mortality rate of more than 20%, the reputation of thyroid surgery was so poor that the French Academy of Medicine banned its practice in 1850. Indeed, when Greene reported his successful thyroidectomies in America, he warned that the operations should be used "never, for the relief of deformity or discomfort merely; only, to save life" [1]. However, by the time the Nobel Prize was awarded to Kocher in 1909, the mortality rate in his hands had been reduced to 0.18% [2].The key to increasing safety of thyroid surgery was then, as now, a thorough understanding of thyroid anatomy and pathology. The general developments in surgical techniques and instrumentation, and the improvements in antisepsis and anesthetic techniques, were also crucial. When thyroidectomy became safe to perform, the specific complications of the procedure could be addressed, including prevention of injury to the recurrent laryngeal nerves and avoidance of accidental injury to, or removal of, the parathyroid glands. The surgical techniques developed at that time were, i...

The Factors Related with Postoperative Complications in Benign Nodular Thyroid Surgery

“…Better knowledge with the surgical anatomy of the neck, thyroid pathology and required surgical treatment is essential to keep complications within reasonable limits [13]. There is no consensus concerning the appropriate management of benign thyroid nodules [8].…”

Malignant Thyroid Disease; Hypocalcaemia Following Thyroid Surgery

“…Despite it, postoperative hypocalcemia is still regarded as frequently encountered complication presenting as Tetany in the postoperative period. 7 Literature also mention the experience of surgeon, retrosternal extension of thyroid, type of thyroidectomy, neck dissection and paratracheal lymph node dissection as key factors for postoperative hypocalcemia as mentioned by Mirkine ND et al 14 in their study.…”

“…Noticeable risk factors of hypocalcemia following thyroid surgery include; large goiters, recurrent goiter, retrosternal goiter extension, hyperthyroidism, total thyroidectomy and experience of the surgeons. 7,8 The present study was intended to find out the frequency of Hypocalcemia in patients operated for malignant thyroid surgery. It includes risk associated with the extent of surgery & severity of Hypocalcemia.…”

Salient Anatomical Landmarks of Thyroid and Their Practical Significance in Thyroid Surgery: a Pictorial Review of Thyroid Surgical Anatomy (Revisited)

“…Even the monumental efforts in the field of thyroid surgery have yielded Nobel Prize in Medicine to Theodor Kocher in the year 1909. In spite of volumes of literature on embryology, anatomy, and pathology of the thyroid gland, comprehensive description of practical aspects of surgical anatomy is limited to fewer papers [2][3][4]. Surgeons contemplating thyroid surgery need to be aware of embryology, anatomy, and pathological alterations for optimal results and minimal morbidity.…”