The thyroid isthmus is usually divided early in the course of the operation. The thyroid lobe is bluntly dissected free from its investing fascia and rotated medially. The middle thyroid vein is ligated (Fig. 16C). The superior pole of the thyroid is dissected free, and care is taken to identify and preserve the external branch of the superior laryngeal nerve (Fig. 6). The superior pole vessels are ligated adjacent to the thyroid lobe, rather than cephalic to it, to prevent damage to this nerve (Fig. 16D). This nerve can be visualized over 90% of patients if it is carefully dissected in (51). The inferior thyroid artery and recurrent laryngeal nerve are identified (Fig. 16E). To preserve blood supply to the parathyroid glands, the inferior thyroid artery should not be ligated laterally as a single trunk; rather, its branches should be ligated individually on the capsule of the lobe after they have supplied the parathyroid glands (Fig. 16F). The parathyroid glands are identified, and an attempt is made to leave each with an adequate blood supply while moving the gland off the thyroid lobe. Any parathyroid gland that appears to be devascularized can be minced and implanted into the sternocleidomastoid muscle after a frozen section biopsy confirms that it is in fact a parathyroid gland. Care is taken to try to identify the recurrent laryngeal nerve along its course if a total lobectomy is to be done. The nerve is gently unroofed from surrounding tissue, with care taken to avoid trauma to it. The nerve is in greatest danger near the junction of the trachea with the larynx, where it is adjacent to the thyroid gland. Once the nerve and parathyroid glands have been identified and preserved, the thyroid lobe can be removed from its tracheal attachments by dividing the ligament of Berry (Fig. 16G). The contralateral thyroid lobe is removed in a similar manner when total thyroidectomy is performed. A near-total thyroidectomy means that a small amount of thyroid tissue is left on the contralateral side to protect the parathyroid glands and recurrent nerve. Careful hemostasis and visualization of all important anatomic structures are mandatory for success.

When closing, we do not tightly approximate the strap muscles in the midline; this allows drainage of blood superficially and thus prevents a hematoma in the closed deep space. Furthermore, we obtain better cosmesis by not approximating the platysmal muscle. Rather, the dermis is approximated by interrupted 4-0 sutures, and the epithelial edges are approximated with a running subcuticular 5-0 absorbable suture. Sterile paper tapes (Steri-strips) are then applied and left in place for about a week. When it is needed, a small suction catheter is inserted through a small stab wound; it is generally removed within 12 hours.

After thyroidectomy, even if a modified neck dissection is done for carcinoma, the patient can almost always be safely discharged on the first postoperative day. Others are kept longer if the need arises. We do not think that it is safe to discharge a patient on the day of surgery because of the risk of bleeding; however, same-day discharge is being practiced at some centers (52).

Bilateral subtotal lobectomy is the usual operation for Graves’ disease. An alternative operation, which is equally good, is lobectomy on one side and subtotal lobectomy on the other side. Once more, the parathyroid glands and recurrent nerves should be identified and preserved. Great care should be taken to not damage the recurrent laryngeal nerve when cutting across or suturing the thyroid lobe. At the end of the operation, several grams of thyroid tissue are usually left in place. The aim is to try to achieve a euthyroid state without a high recurrence of hyperthyroidism. However, a number of patients are hypothyroid with these small thyroid remnants and require thyroid hormone replacement. When the operation is done for severe ophthalmopathy, near-total or total thyroidectomy is performed.

An alternative technique of thyroidectomy is practiced by some excellent surgeons (6,53) and is used by the authors in some operations. In this technique, the dissection is begun on the thyroid lobe and the parathyroids are moved laterally as described previously. However, the recurrent laryngeal nerve is not dissected along its length, but rather small bites of tissue are carefully divided along the thyroid capsule until the nerve is encountered near the ligament of Berry. Proponents of this technique feel that visualization of the recurrent laryngeal nerve by its early dissection may lead to greater nerve damage; however, the authors feel that seeing the nerve and knowing its pathway is safer and facilitates the dissection in many instances.

MINIMALLY INVASIVE OPTIONS FOR THYROIDECTOMY

Over recent years, the development of ultrasonic shears for hemostasis and small size endoscopes has allowed surgeons to perform thyroidectomies through much smaller incisions than using traditional techniques. Two different approaches have been taken to minimally invasive thyroidectomies. One technique, largely popularized in areas of the Far East such as Japan, China, and Korea, involves making incisions away from the neck in hidden areas such as in the axillae, chest, or in the areola of the breast. The surgeon then creates a tunnel up to the neck where the thyroidectomy is performed with endoscopic instruments utilizing the endoscope for visualization. Approaches such as these are done in a gasless manner and can completely avoid any incisions on the neck itself (55-57). Although some authors utilizing such approaches have described removing large thyroid glands, most reports suggest significantly longer operative times. Perhaps most concerning to many American surgeons with these approaches is that if bleeding problems are encountered in the course of the thyroid dissection, a separate neck incision may need to be made to solve the problem.

The alternative technique, developed by Dr. Paolo Miccoli and more widely utilized in Europe and to a less extent in the United States, utilizes a smaller incision than usual, but it is placed in the conventional location in the neck (58,59). In general, a 1.5-2.0 cm incision is made in a conventional location in the neck and after the strap muscles are retracted from the thyroid gland, a 5 mm 30 degree endoscope is introduced into the incision. The scope is utilized to visualize the tissue along the lateral aspect of the thyroid gland and especially for the superior pole vessels. Usually after the superior and lateral aspects of the thyroid gland have been dissected free, the parathyroid glands and recurrent nerve are visualized and then the thyroid lobe is delivered through the neck incision and the remainder of the operation is performed in the conventional manner through the small cervical incision. Several authors in the United States have reported good results in small series with this video-assisted approach (60,61). A significant benefit of this approach is that the incision is in the usual location so that if any bleeding results in difficulty with visualization during the procedure, the incision can be enlarged and a conventional thyroidectomy can readily be completed. Most authors have found this approach to be similar to conventional thyroidectomy in operative time, although the small neck incision does limit the size of the thyroid gland that could be resected utilizing this technique. At this time in the United States, minimally invasive video-assisted thyroidectomy is offered in few specialized centers for selected patients with small thyroid nodules (usually less than 3 cm) and without evidence of thyroiditis. Except in the hands of surgeons very experienced in the technique, it should not be utilized for the treatment of most thyroid cancers.