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Part 1 Surgical Anatomy and Surgical Technique

3
Incisions; Thyroid Exposure
3.1
Skin and Platysma Fig. 3.1
The Kocher incision (1 in Fig. 3.1) is centered over the
isthmus of the thyroid, which lies just caudad to the cricoid cartilage. This placement is preferred to a more caudal one.215
If the neck is hyperextended the incision will lie more
caudally once the patient is in the erect position.
The level of the suprasternal notch should be avoided
because of the risk of unfavorable scar formation since
the platysma is lacking in the midline at that level. Symmetry of length and height of the slightly curved incision, placed in a normal neck line or skin fold, is important. The length depends on neck configuration, goiter
size, and planned surgical procedure. The planned incision line is marked preoperatively with the patient in
the erect position, and on the operating table with the
neck hyperextended. The laryngotracheal axis, the anterior border of the sternocleidomastoid muscles (SCM),
and the sternal notch are also outlined with a marking
pen.
In selected patients an additional vertical midline
(T-)incision of the skin (and of the SF and MF) extending
down to the manubrium (2 in Fig. 3.1) may be essential
for mobilization of large mediastinal and thoracic inlet
goiters. There is a risk of scar enlargement or contraction, which may later necessitate a Z-plastic correction.

The Kocher incision may be extended laterally to the


posterior margin of the SCM (McFee incision) or to the
trapezius muscle (3 in Fig. 3.1) if excisions of large goiters or lateral nodal dissection are planned. For these indications a longitudinal incision along the anterior border of the SCM may also be used (4 in Fig. 3.1), with or
without a simultaneous Kocher incision.
Hemostasis of these incisions is effected for the most
part by pressure on a gauze for a short time.

3.2
Transverse Division of the Superficial Fascia and
Middle Fascia Fig. 3.2
Superficial fascia (SF). No mobilization of skin platysma
flaps is carried out. After transection of the platysma a
very shallow scalpel incision will denude the superficial
veins, which may turn out to be rather large. They are
not dissected free, but simply cut between perpendicularly placed clamps and ligated or secured with suture
ligatures (a later sudden flooding bleeding may originate
from a reopened superficial vein). The SF encompasses
the SCM and may be incised on its medial border, freeing
the muscle for lateral retraction (Fig. 3.2 a, b).
Middle fascia (MF, strap muscles). The underlying sternohyoid muscles, incorporated in a thin fascia, are cut
transversely with a scalpel or with blunt scissors from
the midline laterally; the fine fascia encompassing the

4
3
1
2
a

Fig. 3.1 a,b Incisions of skin and platysma.


1, Kocher incision; 2, midline incision extending to the manubrium; 3, Kocher incision extended laterally to the posterior

margin of the SCM; 4, longitudinal incision along the anterior


border of the SCM.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Incisions; Thyroid Exposure

SCM

SF
a

Platysma
Skin

Sternothyroid
muscle (MF)

Subcutaneous
tissue
SF, veins

Sternohyoid
muscle (MF)

MF

Capsula propia

SF
SF, SCM

Internal
jugular vein
g

f
Fig. 3.2 ag Transverse division of the superficial fascia (SF)
and middle fascia (MF).
a, b Superficial fascia divided, MF exposed. The sheath of
the sternocleidomastoid muscle (SCM) is opened on
the left side.
c
Sternohyoid muscle divided. The thin fascia of the more
laterally situated sternothyroid muscles is exposed.
d
Strap muscles (MF) divided.
e, f MF transected. Exposure of the capsula propria with
enlarged vessels beneath.
g
Incision of the MF at the lateral edge.

MF

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

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Part 1 Surgical Anatomy and Surgical Technique

b
Fig. 4.6 a, b Capsular dissection (multinodular colloid goiter).
The fascia of the visceral compartment (VF) is put under tension and exposed by traction and countertraction (
Cases 1, 2). Its separation from the thyroid capsule is achieved
by dissection and division of the numerous branches of the

inferior thyroid artery on the capsula propria (arrows).


In both patients total lobectomy is indispensable for complete excision of all nodules. The capsular dissection is yet incomplete posteriorly for a total extracapsular removal of the
lobe.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Capsular Dissection

a1

a2

b1

b2

Fig. 4.7 a, b Capsular dissection (left side), pursued posteriorly toward the trachea.
a The thin fascia of the visceral compartment (Grenzlamelle) remains intact and will be dissected away from
the nodules (arrows). X: a more lateral dissection through
the fascia is avoided. The visceral compartment is not entered. % = Upper parathyroid lying on the visceral fascia.
%% = Recurrent nerve visualized par transparence running in the visceral compartment.
b Two of the rare illustrations of the visceral fascia in the literature: b1 Represents a part (just the cranial part) of
the cervical visceral fascia as shown in the Textbook of Operative Surgery by Theodor Kocher.141b He was the first sur-

geon to describe the technique of capsular dissection.141


b2 According to the German surgeon E. Enderlen (1863
1940),57 the thin visceral fascial layer becomes visible
when the goiter is retracted medially. The inferior thyroid
artery pierces the fascia; note, however, that the recurrent
nerve is incorrectly depicted as running on top of the fascia instead of dorsally underneath the fascia.
The resemblance to fascial structure shown in Fig. 4.6 a, b
is obvious.
(Published with permission. Figure b2 was published in
Der Chirurg, Vol. 4, Enderlen E., Zur Technik der Operation
des Kropfes, pp. 293300. Copyright Springer [1932].)

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

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Part 1 Surgical Anatomy and Surgical Technique

Fig. 4.11 aj Total completion lobectomy for a retrovisceral


and upper mediastinal recurrent goiter; lateral approach and
capsular dissection (see also Fig. 4.9 c, d).
a
Cervicomediastinal goiter with deviation of trachea and
venous stasis. Kocher incision along with an extensive
longitudinal incision.
b
Incision of the transverse anterior scar and of the SF
(arrows) along the SCM (sheath of the SCM).
c, d Transection of the strap muscles down to the goiter
capsule; longitudinal lateral transection of the MF (Z).
ej Meticulous capsular dissection of numerous colloid
nodules. They are successively freed and mobilized anteriorly as they emerge from their retrovisceral and upper mediastinal location. No postoperative adhesions
or scar formation are encountered in this area.
Following total lobectomy the layers (MF, SF, platysma)
are closed longitudinally and transversely. The skin is
reapproximated with intracutaneous stitches and SteriStrips.
a

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Capsular Dissection

ular tissue behind.76,217 On the basis of its inherent,


persistent growth advantage45,254 it may grow to a
clinical recurrent goiter.
The rational procedure consists of a complete extracapsular excision of the goitrous thyroid remnant.
This can usually be done safely by capsular dissection,
with the same low morbidity as in primary surgery,
because scar formation is encountered in the anterior
but not in the delicate posterior area. The difficulty of
the operation is determined rather by the extent of
the goiter. Recurrent goiters selected for surgery are
larger, grow more rapidly and lead to retrovisceral extension and compressive and functional (autonomy)
symptoms. With posterior thorax inlet goiters the recurrent laryngeal nerve may be displaced anteriorly
(see section 5.2). Meticulous dissection close to the
capsula propria will protect the nerve (running be-

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

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26

Part 1 Surgical Anatomy and Surgical Technique

Thyroid hilus

Thyroid hilus,
suspensory
ligament

Inferior PT
Recurrent
laryngeal
nerve

Superior PT

Tubercle
Superior PT

Recurrent
laryngeal nerve

Tubercle

Visceral fascia

Traction suture
on tubercle

Tubercle

Superior PT

Suspensory
ligament
Recurrent laryngeal
nerve
e

Suspensory ligament
f

Fig. 5.2 af Capsular dissection at the level of the posterior


tubercle of Zuckerkandl (lateral view in a, c, d, e; transection
in b, f).
a, b The branches of the inferior thyroid artery for the tuberculum. Ultraligation of the upper PT and individual
ligation and division of the lateral, inferior, medial

cf

Recurrent laryngeal nerve

Visceral fascia

branches of the inferior artery are performed on the


capsula propria of the tubercle. The tubercle lies anterior to the visceral fascia that covers the inferior laryngeal
nerve.
Capsular dissection of the tubercle in progress.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl)

The suspensory ligament of Berry (named also the


ligament of Gruber) contains terminal branches of the
inferior thyroid artery (see Fig. 4.3), which are divided
Cases 2, 3). With the thyduring total lobectomy (
roid retracted anteriorly, these short peritracheal vessels
are successively clamped with curved mosquito clamps
on the tracheal surface from posterior to anterior and
sharply divided (Fig. 5.2 e, f). The minute arterial branches must be ligated or suture-ligated; they may be the
source of a severe, rapidly developing bleeding with compression (see postoperative hemorrhage, p. 50). When a
short bleeding stump retracts beneath the recurrent
nerve, bleeding must be controlled with fine stick tieligatures, with the nerve being carefully protected.
For the posterior capsular dissection, the use of magnifying glasses or of a surgical loupe is recommended
(see Fig. 22.2). For minute bleeders, bipolar electrocoagulation is briefly applied. Note: Modern technologies and
devices that produce heat should not be used for dissection of the tubercle and suspensory ligament or for sealing the vessels encountered.
The suspensory ligament may contain minute
amounts of residual thyroid tissue surrounding the vessel stumps and fixed on the tracheal wall (see Figs. 6.4 c,
6.5 c). Though appearing on scans with postthyroidectomy nuclear imaging in some patients, this kind of
remnant clearly differs from that of near total excision
(see section 11.2.1; Fig. 5.15). Excision of the tuberculum of
Zuckerkandl and transection of the suspensory ligament of
Cases
Berry represent steps of capsular dissection (
2, 3).79 Berry visited Kocher in Berne142; Kocher called
James Berry an intelligent learner (ein so intelligenter
Schler) who adopted Kochers technique [see ref. 142:
p. 1644].
In his description of total lobectomy from 1919, Dunhill mentions the attachment of the thyroid gland to the
trachea not as the ligament of Berry but as the three
penny patch of Professor Watson.53a He notes that the
dissection may be extraordinarily difficult when dealing
with the very short, fragile, newly-formed vessels in exophthalmic goiter (see also 6.1).

veins ought to be divided, keeping close to the capsula propria.


The nerve may split in two (or several) branches at
some distance from the larynx (Figs. 4.2 b, 5.3).33,133,149a
A ventral branch with motor function for the vocalis
muscle or a posterior branch innervating the posticus
muscle may both lead to vocal cord paresis when inadvertently injured.
In a few patients with a posterior tubercle, the nerve
(or a branch of it) courses on the lateral aspect of the
tubercle instead of its medial side,33,69 though still behind the visceral fascia (Figs. 5.3, 5.4). Such a deviating nerve is at high risk when the tubercle is involved
in goitrous enlargement and when a goiter of the tubercle is lifted from the thoracic inlet and posterior
mediastinum (see also Fig. 5.19).
A nonrecurrent inferior laryngeal nerve runs either
together with the peduncle of the superior thyroid
vessels, or transversely at any level through the visceral compartment.264 The nerve runs always behind
the visceral fascia and is thus anatomically protected
on strict capsular dissection.

Capsular dissection
Visceral fascia

5.2
The Nerve at Risk
The surgeon must be aware of the inferior laryngeal
nerve being at high risk of injury in the following situations and anatomical variations:
U
During reoperative surgery when the visceral compartment and its fascia have been severed (in most
patients with recurrent benign goiter this is not the
case) (see Fig. 4.11).217
U
The nerve may be drawn or may run anteriorly in relation to the tracheoesophageal groove at the level of
the inferior thyroid pole, where the inferior thyroid

Inferior thyroid
artery
b

Recurrent inferior laryngeal nerves

Fig. 5.3 a,b Extralaryngeal division of the recurrent inferior


laryngeal nerve into two branches (lateral view; cross-section
at the level of the thyroid hilus). In this case the branches
course under and over the tubercle, respectively. Arrows indicate capsular dissection.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

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Part 1 Surgical Anatomy and Surgical Technique

6
Further Case Records with Demonstrations of the Technique of
Capsular Dissection
Figs. 6.16.5

In Fig. 6.1, a left-sided lobectomy in the course of a total


thyroidectomy for PTC is demonstrated. The 64-year-old
woman patient noticed a solitary, rather firm nodule in

the upper pole of her left thyroid. TSH and calcitonin


were normal. FNAB cytology revealed a PTC.

Fig. 6.1 aj Total thyroidectomy for PTC; capsular dissection, left side. Macroscopic appearance of PTC (nonencapsulated mass; intrathyroidal PTC upper pole). The patient was a
64-year-old woman. View from cephalad; firm nodule in the
upper pole (x). Traction sutures avoiding the nodule.

a, b Mobilization, capsular dissection of the lateroposterior


aspect of the left lobe; dissection with the visceral fascia placed under tension and countertension.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Further Case Records with Demonstrations of the Technique of Capsular Dissection

No suspicious lymph nodes were found on clinical,


preoperative sonographic, and intraoperative macroscopic examinations (stage clinical (c) N0).

(for various patterns of macroscopic appearance of


PTC, see section 19.4.2).
Staging and risk-group assignment (see section
19.5): this is a pT2 cN0, TNM low-risk stage II tumor269 (former stage pT2a, unifocal).268
Prophylactic central node dissection is judged facultative, and use of prophylactic RAI (remnant ablation) is
not recommended in this patient83,110,111a,111b (see section 19.4.1). Thyroid hormone substitution should induce subsuppression of TSH (sections 19.4.3, 19.10).
The prognosis after total thyroidectomy is excellent.
There is a small risk (~3 %) of subsequent (metachronous) lymph node involvement during the early post-

Comment
PTC can often be diagnosed with confidence by FNAB.
Clinically, a MTC must also be considered when a suspicious nodule is located in the upper pole (see
Fig. 21.3).
The surgeon can recognize a characteristic macroscopic appearance of a PTC on section of the specimen; the tumor appears hypercellular, has no capsule
Case 3)
and infiltrates the thyroid parenchyma (

ce Dissection continued posteriorly; a Zuckerkandl tubercle (arrow) becomes apparent and is mobilized, with
preservation of the adjoining superior PT (e) (arrowhead).

fh Division of the suspensory ligament (arrow) anterior to


the recurrent nerve at the tip of the Overholt (g).

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Fig. 6.1 i,j

43

ANZ J. Surg. 2002; 72: 1517

ORIGINAL ARTICLE

OPTIMAL POSITION FOR A CERVICAL COLLAR INCISION:


A PROSPECTIVE STUDY
STEPHEN JANCEWICZ,* STAN SIDHU,* BIN JALALUDIN, AND PETER CAMPBELL*
*Endocrine Surgical Unit, Liverpool Hospital, and Epidemiology Unit, South Western Sydney Area Health Service,
Sydney, New South Wales, Australia.
Background: The descriptions of the optimal method for placing a cervical collar incision for thyroidectomy or parathyroidectomy
are varied. It has been our impression that a collar incision marked in the neutral upright neck, migrates superiorly relative to the sternal
notch when the patient is placed in the supine position. The aim of this study was to investigate the validity of this impression and to
assess whether this is influenced by patient factors and/or pathology.
Methods: Fifty patients undergoing either thyroid or parathyroid surgery had a planned incision marked 1 finger-breadth
(17 mm) above the sternal notch when sitting in the upright position. When placed in the supine position, with neck extended, the distance from the sternal notch to the marked incision was remeasured. Patient variables such as body mass index, height, weight and neck
circumference were documented prospectively and data were recorded on operative details and tumour pathology.
Results: The collar incision marked in the neutral upright neck, migrated on average 21 mm superiorly once the patient was placed
supine with the neck extended (P = 0. 0001 ).The extent of migration was independent of all patient factors, type of operation and thyroid
or parathyroid pathology.
Conclusions: Migration of a proposed cervical collar incision does occur. An inappropriately placed incision may lead to excessive
scarring if it is too low, or unusual prominence if it is too high. We believe a good position for marking such an incision is 1 fingerbreadth above the sternal notch with the patient in a neutral, upright position.

Key words: cicatrix, scars, thyroid surgery, wounds.


Abbreviations: ANOVA, analysis of variance; WHO, World Health Organisation.

INTRODUCTION
During the 1850s operations on the thyroid gland were undertaken via longitudinal, oblique or vertical neck incisions.1 Jules
Boeckel of Strasbourg introduced the collar incision to thyroid
surgery in 1880 and this approach was popularized by Theodore
Kocher.1 Modern texts of operative surgery commonly describe
a collar incision as the appropriate neck incision for thyroidectomy or parathyroidectomy.26 These descriptions differ as to the
correct position of the incision. Descriptions include:
(1) 1.52.0 cm superior to the sternoclavicular joints, preferably
in a pre-existing skin crease.2
(2) 1 cm caudal to the cricoid cartilage.3
(3) 2 finger-breadths above the sternal notch.4
(4) Midway between the sternal notch and the notch of the
thyroid cartilage.5
(5) At the root of the neck just above the clavicles.6
The above incisions are all made with the patient supine and the
neck hyperextended. In this position, we believe it is difficult to
predict the position of the scar in the neutral upright neck the
position of the scar seen by the patient.
S. Jancewicz FRACS; S. Sidhu FRACS; B. Jalaludin PhD; Peter Campbell
FRACS.
Correspondence: Dr P. Campbell, Suite 12, 41 43 Goulburn Street, Liverpool, NSW 2170, Australia.
Email: endocrin@bigpond.net.au

Accepted for publication 25 August 2001.

We believe the optimal position of the scar in the neutral


upright neck is 1 finger-breadth above the sternal notch, just
above the clavicles. This position reduces the possibility of a
hypertrophic scar which is said to be more frequent when the
scar lies over the manubrium.3,7 Furthermore, this position
allows the scar to be hidden by clothing.3 Unsightly scars can
initiate complaints and such wounds can provide grounds for
litigation.8
It has been our impression that there is a difference in the
position of a collar incision relative to the sternal notch when it is
made with the neck extended, compared to when it is made
along a line marked in the neutral upright neck. The aim of this
study, therefore, was to prospectively compare the position of
our optimal collar incision in the neutral, upright neck, with its position in the supine, hyperextended neck, and to evaluate if this
position is influenced by the degree of thyroid or parathyroid
pathology.

METHODS
Approval was granted for this study by the Ethics Committee of
South Western Sydney Area Health Service. All patients were
documented (measured) prospectively. Preoperatively, with the
patient sitting upright and looking straight ahead, the measurement
of 1 index finger-breadth was marked in the midline superior to the
sternal notch. This then provided the lowermost point of a skin
crease curvilinear incision (concave up). At the same time the
patient's neck circumference was measured. The goitre was
assigned a World Health Organisation (WHO) classification.9

16

JANCEWICZ ET AL.

That is, a goitre grade 0 describes no visible or palpable goitre. A


goitre grade l describes a palpable yet non-visible goitre and a
goitre grade 2 is given to those with an obviously visible and
palpable goitre. Once the patients were anaesthetized, a 1 L
flask of intravenous fluid was placed transversely in line with
the spines of the scapulae beneath the patient, and the neck was
comfortably extended with the head resting in a gelatinous
head-ring. The distance was then remeasured from the midpoint of
the proposed incision to the sternal notch and documented.
The incision was performed with a scalpel through platysma.
After the operation was completed, the skin was closed with
interrupted subcuticular vicryl, and steristrips were applied. Any
redness of the wound was diagnosed as early wound infection
and was treated empirically with a 5 day course of an oral
cephalosporin.
Continuous variables were compared using Students t-test
and one way analysis of variance (ANOVA), and categorical
variables were tested for associations using the 2 test. Paired t-test
and repeated measures of ANOVA were used where appropriate. Finally, a multivariate regression analysis was conducted
to determine predictive factors for the difference in the two
measurements. All statistical analyses were conducted using
SAS (SAS Institute Inc. Cary, North Carolina, USA). P < 0.05
denotes statistical significance.

Fifty patients undergoing a primary thyroid or parathyroid operation were evaluated. There were 14 men and 36 women with a
mean age of 51.3 years (Table 1).
The distance between the sternal notch and the midpoint
of the collar incision marked in the neutral, upright neck was
1 finger-breadth (SJ) or 17 mm. The mean distance between the
sternal notch and the midpoint of the collar incision in the
supine, hyperextended neck was 37.7 mm. The average change in
the distance from the sternal notch to the midpoint of the collar
incision in the extended neck compared to the upright neck for all
cases was 20.7 mm (P = 0.0001).
The change in distance for the cohort was then analysed with
respect to patient characteristics and the type of neck pathology

This study demonstrates that a proposed collar incision marked


in the neutral upright neck, moves on average 21 mm when a
patient is subsequently positioned for surgery with the neck in the
supine, extended position. The amount of movement is independent
of neck pathology. This finding has implications for surgeons
undertaking thyroid or parathyroid surgery.
There are many articles in the literature that report the complications of thyroid and/or parathyroid surgery, however, these
reports concentrate on nerve injury and hypoparathyroidism.1011
Cosmesis is an important issue in thyroid and parathyroid surgery
Demographic and clinical characteristics of study sample

Characteristic
Men
Mean age (SD, range)
Mean BMI (SD, range)
Mean neck circumference (SD, range)
Type of surgery
Thyroid parathyroid surgery
Parathyroid surgery only
Mean distance sitting (SD, range)
Mean distance lying (SD, range)
Mean change in distance (SD, range)
Missing

n = 14 (28%)
51.3 (13.9, 2777)
20.7 (6.8, 16.948.3)
392.9 (43.1, 329.0487.0)
n = 36 (72%)
n = 14 (28%)
17.0 mm (1.8, 10.020.0)
37.7 mm (7.9, 12.052.0)
20.7 mm (7.7, 2.037.0)

= 8. BMI, body mass index; SD, standard deviation.

Change in the distance of the cervical incision between sitting and lying positions by patient and clinical characteristics (n = 50)

Age (years)
BMI
Neck circumference (mm)
Goitre
Weight of thyroid (g)
Type of surgery
Data

CONCLUSIONS

Table 1.
(n = 50)

RESULTS

Table 2.

(Table 2). Factors such as age, body mass index (BMI), neck
circumference, presence of a goitre, weight of the gland and the
type of surgery did not significantly affect the measured distance in the sitting and lying positions. Furthermore, there was no
statistically significant change in distance for those patients with a
WHO classification for goitre of 0 compared with those with a
WHO classification of 2 (21.1 mm and 21.2 mm respectively).
Finally, in a multivariate regression model, none of the variables
in Table 2 were significant predictors of the difference in the
distance between the sitting and the recumbent positions.

60
> 60
27.2
> 27.2
392.8
> 392.8
Grade 0
Grade 1
Grade 2
< 20
2039
40+
Thyroidectomy
Parathroidectomy

missing for 8 patients. BMI, body mass index.

Mean (SD)
change in distance
(mm)

P value

36
14
23
19
27
23
11
5
14
5
9
16
36
14

19.9 7.6
22.6 8.1
21.1 7.7
20.7 6.5
22.0 7.1
19.1 8.3
21.2 7.2
20.4 9.2
21.1 7.8
22.6 6.8
18.3 7.9
20.8 6.6
19.8 7.9
22.9 7.1

0.85
0.89
0.33
0.91
0.86
0.27

OPTIMAL POSITION FOR A CERVICAL COLLAR INCISION

that is not explored very often. The few publications that refer to
it, note that it is a cause for concern for patients, with an
improperly placed incision attracting significant morbidity.8,12,13 An
incision placed too superiorly may be prominent, while one
placed too inferiorly may lead to hypertrophic and possibly
keloid scarring.
The planned incision, which we measured with the patient
upright, migrated an average of 21 mm superiorly with the
patient supine. By deduction, an incision marked in the supine
position will migrate an equal distance inferiorly regardless of
pathology or patient factors. Therefore, an incision marked with the
patient supine, placed approximately 2 finger-breadths above
the sternal notch would provide a similar outcome to our proposed
incision.
We therefore recommend that the optimal position for marking the
midpoint of a collar incision is 1 finger-breadth above the sternal
notch in the neutral upright neck, or 2 finger-breadths above the
sternal notch in the supine, extended neck. This allows for excellent
cosmesis and minimizes the risk of hypertrophic scarring.

ACKNOWLEDGEMENT
We thank Val Poxon, Director of the Clinical Review Unit in
Surgery, Division of Surgery, South Western Area Health
Service (SWAHS), Liverpool Hospital, for all her assistance
with data management and scientific methodology.

REFERENCES
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York: Praeger Publishers, 1990.

17

2. Broughan TA, Esselystyn CB. Lobectomy and subtotal thyroidectomy. In: Nyhus LM, Baker RJ (eds). Mastery of Surgery,
2nd edn. Boston: Little, Brown and Company, 1992; Ch. 23.
3. Clark OH. Total thyroidectomy and lymph node dissection for
cancer of the thyroid. In: Nyhus LM, Baker RJ (eds) Mastery of
Surgery, 2nd edn. Boston: Little, Brown and Company, 1992;
Ch. 24.
4. Scott-Conner CE, Dawson DL. Operative Anatomy, 1st edn.
Philadelphia: J.B. Lippincott Company, 1993.
5. Milroy E. Parathyroid gland exploration. In: Dudley H, Carter DC,
Russell RC (eds) Atlas of General Surgery, 2nd edn. London:
Butterworths, 1985; 9229.
6. Dudley H. Thyroidectomy. In: Dudley H, Carter DC,
Russell RC (eds) Atlas of General Surgery, 2nd edn. London:
Butterworths, 1985; 914922.
7. Songun I, Kievik J, van de Velde CJ. Complications of thyroid
surgery. In: Clark OH, Quan-Yang D (eds) Textbook of Endocrine
Surgery, 1st edn. Philadelphia: W.B. Saunders Company, 1997;
Ch. 22.
8. Ready AR, Barnes AD. Complications of thyroidectomy. Br. J.
Surg. 1994; 81: 15556.
9. WHO, UNICEF, ICCIDD. Indicators for assessing iodine
deficiency disorders and their control through salt iodization
(document). Geneva: World Health Organisation, 1994.
10. Netterville JL, Aly A, Ossoff RH. Evaluation and treatment
of complications of thyroid and parathyroid surgery. Otol. Clin.
North Am. 1990; 23: 52952.
11. Farrer WB. Complications of thyroidectomy. Surg. Clin. North
Am. 1993; 63: 135361.
12. Bartel AR, Rupprecht H, Schubert H. Mediastinoscopy and
scar keloids in Boecks sarcoid (Abstract). Z. Erkrankungen der
Atmungsorgane. 1976; 145: 38894.
13. Eldridge PR, Wheeler MH. Stitch granulomata after thyroid
surgery. Br. J. Surg. 1987; 72: 62.

26

Part 1 Surgical Anatomy and Surgical Technique

Thyroid hilus

Thyroid hilus,
suspensory
ligament

Inferior PT
Recurrent
laryngeal
nerve

Superior PT
Tubercle

Superior PT

Recurrent
laryngeal nerve

Tubercle

Visceral fascia

Traction suture
on tubercle

Tubercle

Superior PT

Suspensory
ligament
Recurrent laryngeal
nerve
e

Suspensory ligament
f

Fig. 5.2 af Capsular dissection at the level of the posterior


tubercle of Zuckerkandl (lateral view in a, c, d, e; transection
in b, f).
a, b The branches of the inferior thyroid artery for the tuberculum. Ultraligation of the upper PT and individual
ligation and division of the lateral, inferior, medial

cf

Recurrent laryngeal nerve

Visceral fascia

branches of the inferior artery are performed on the


capsula propria of the tubercle. The tubercle lies anterior to the visceral fascia that covers the inferior laryngeal
nerve.
Capsular dissection of the tubercle in progress.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl)

The suspensory ligament of Berry (named also the


ligament of Gruber) contains terminal branches of the
inferior thyroid artery (see Fig. 4.3), which are divided
Cases 2, 3). With the thyduring total lobectomy (
roid retracted anteriorly, these short peritracheal vessels
are successively clamped with curved mosquito clamps
on the tracheal surface from posterior to anterior and
sharply divided (Fig. 5.2 e, f). The minute arterial branches must be ligated or suture-ligated; they may be the
source of a severe, rapidly developing bleeding with compression (see postoperative hemorrhage, p. 50). When a
short bleeding stump retracts beneath the recurrent
nerve, bleeding must be controlled with fine stick tieligatures, with the nerve being carefully protected.
For the posterior capsular dissection, the use of magnifying glasses or of a surgical loupe is recommended
(see Fig. 22.2). For minute bleeders, bipolar electrocoagulation is briefly applied. Note: Modern technologies and
devices that produce heat should not be used for dissection of the tubercle and suspensory ligament or for sealing the vessels encountered.
The suspensory ligament may contain minute
amounts of residual thyroid tissue surrounding the vessel stumps and fixed on the tracheal wall (see Figs. 6.4 c,
6.5 c). Though appearing on scans with postthyroidectomy nuclear imaging in some patients, this kind of
remnant clearly differs from that of near total excision
(see section 11.2.1; Fig. 5.15). Excision of the tuberculum of
Zuckerkandl and transection of the suspensory ligament of
Cases
Berry represent steps of capsular dissection (
2, 3).79 Berry visited Kocher in Berne142; Kocher called
James Berry an intelligent learner (ein so intelligenter
Schler) who adopted Kochers technique [see ref. 142:
p. 1644].
In his description of total lobectomy from 1919, Dunhill mentions the attachment of the thyroid gland to the
trachea not as the ligament of Berry but as the three
penny patch of Professor Watson.53a He notes that the
dissection may be extraordinarily difficult when dealing
with the very short, fragile, newly-formed vessels in exophthalmic goiter (see also 6.1).

veins ought to be divided, keeping close to the capsula propria.


The nerve may split in two (or several) branches at
some distance from the larynx (Figs. 4.2 b, 5.3).33,133,149a
A ventral branch with motor function for the vocalis
muscle or a posterior branch innervating the posticus
muscle may both lead to vocal cord paresis when inadvertently injured.
In a few patients with a posterior tubercle, the nerve
(or a branch of it) courses on the lateral aspect of the
tubercle instead of its medial side,33,69 though still behind the visceral fascia (Figs. 5.3, 5.4). Such a deviating nerve is at high risk when the tubercle is involved
in goitrous enlargement and when a goiter of the tubercle is lifted from the thoracic inlet and posterior
mediastinum (see also Fig. 5.19).
A nonrecurrent inferior laryngeal nerve runs either
together with the peduncle of the superior thyroid
vessels, or transversely at any level through the visceral compartment.264 The nerve runs always behind
the visceral fascia and is thus anatomically protected
on strict capsular dissection.

Capsular dissection
Visceral fascia

5.2
The Nerve at Risk
The surgeon must be aware of the inferior laryngeal
nerve being at high risk of injury in the following situations and anatomical variations:
U
During reoperative surgery when the visceral compartment and its fascia have been severed (in most
patients with recurrent benign goiter this is not the
case) (see Fig. 4.11).217
U
The nerve may be drawn or may run anteriorly in relation to the tracheoesophageal groove at the level of
the inferior thyroid pole, where the inferior thyroid

Inferior thyroid
artery
b

Recurrent inferior laryngeal nerves

Fig. 5.3 a,b Extralaryngeal division of the recurrent inferior


laryngeal nerve into two branches (lateral view; cross-section
at the level of the thyroid hilus). In this case the branches
course under and over the tubercle, respectively. Arrows indicate capsular dissection.

aus: Gemsenjaeger, Atlas of Thyroid Surgery (ISBN 9783131450319) 2009 Georg Thieme Verlag KG

27

Clinical Anatomy of the


Thyroid and Adrenal Glands
Handout download:
http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

28 October 2003

Lawrence M. Witmer, PhD


Department of Biomedical Sciences
College of Osteopathic Medicine
Ohio University
Athens, Ohio 45701
witmer@exchange.oucom.ohiou.edu

Anatomical Overview

thyroid
cartilage

isthmus

common
carotid a.

Right & left lobes connected


by an isthmus
Occasional pyramidal lobe
Levator glandulae thyroideae
Slightly larger in women; may
enlarge during menstruation &
pregnancy
Extends from oblique line on
thyroid cartilage down to 4th
or 5th tracheal ring
Attaches to cricoid cartilage
via suspensory ligament

cricoid
cartilage

variation
(from
Hollinshead 1968)

pleural
cupola

From Netters Atlas

thyroid lobes

Case Presentation
A 32-year-old woman presents with a swelling on the anterior part of
her neck. She also reports that her breathing is sometimes affected by
the swelling. On examination, a single, firm, rounded mass can be felt
on the left side of the laryngotracheal region. It moves up and down
with swallowing. Ultrasound reveals a solid nodule in the left lobe of
her thyroid gland. A needle biopsy subsequently indicates that
malignant changes have taken place in the cells.
Preliminary Diagnosis:
Tumor of the left lobe of the thyroid

Questions
1. Why does the mass move up and down on swallowing?
2. What can explain the difficulty breathing?
3. What structures would be endangered by subtotal or total thyroidectomy?
4. Why is the nature of the patients voice of interest postoperatively?

pretracheal
fascia

investing
fascia

platysma
sternohyoid

sternothyroid

thyroid

buccopharyngeal
fascia
trachea
alar
fascia
carotid
sheath

prevertebral
fascia

From Netters Atlas

Cervical Fascia

sternocleidomastoid

recurrent
laryngeal n.

parathyroid

Strap Muscles
thyroid
cartilage
hyoid bone
sternocleidomastoid
(cut)
thyrohyoid
omohyoid
sternothyroid
sternohyoid
internal jugular v.

cricothyroid

thyroid

From Netters Atlas

Attachment of sternothyroid to
oblique line on thyroid cartilage
prevents superior expansion of thyroid

normal

strap muscles
trachea

C7

Thyroid CT

esophagus

Compression and displacement


of trachea by thyroid tumor
displaced trachea

Thyroid (

thyroid
tumor

internal
jugular v.

common
carotid a.

C7
sternocleidomastoid

normal

From Ellis et al. 1991

From web reference 1

Anterior View
superior thyroid a.

Vascular Supply
& Relations

superior thyroid v.
pyramidal lobe
external laryngeal n.

thyroid
cricothyroid m.
middle thyroid v.
internal jugular v.
pretracheal lymph node
inferior thyroid a.

common carotid a.

inferior thyroid v.
recurrent laryngeal n.

From Netters Atlas

Posterior View
superior thyroid a.

Vascular Supply
& Relations

external laryngeal n.

inferior
constrictor m.

inferior thyroid a.

recurrent laryngeal n.

thyroid

parathyroids

common carotid a.

esophagus
recurrent laryngeal n.

From Netters Atlas

common carotid a.

inferior thyroid
a. & branches

thyroid

Recurrent Laryngeal N.
& Suspensory Lig. of Berry
Variation in relationship of recurrent
laryngeal n. to inferior thyroid a.

recurrent
laryngeal n.

recurrent
laryngeal n.

From Netters Atlas

(from Hollinshead 1968)

inferior thyroid
a. & branches

superior thyroid
a. & v. (cut)

thyroid

Recurrent Laryngeal N.
& Suspensory Lig. of Berry
Variation in relationship of recurrent
laryngeal n. to suspensory lig.
susp. lig.

superficial to
ligament

deep to
ligament

passes thru
gland

splits around
ligament

parathyroids
inferior thyroid
a. & branches

From Netters Atlas

recurrent
laryngeal n.

(from Hollinshead 1968)

suspensory ligament of Berry

thyroid

Recurrent Laryngeal N.
& Suspensory Lig. of Berry
Variation in relationship of recurrent
laryngeal n. to suspensory lig.
susp. lig.

recurrent
laryngeal n.

trachea

inferior thyroid a.

From Sasou et al. 1998

superficial to
ligament

deep to
ligament

passes thru
gland

splits around
ligament

(from Hollinshead 1968)

Case Presentation
A 43-year-old male presents with a swelling in the front of his neck. He
first noticed it 9 months ago and it has steadily grown. The lump lays near
the midline and moves on swallowing. On palpation, it is firm and lays
anterior to the thyroid cartilage. The mass is smooth, non-pulsatile, and
non-fluctuant. The dorsum of the tongue was inspected but no thyroid
tissue was observed. Ultrasound showed the mass to be cystic and
separate from the thyroid gland.
cyst

Preliminary Diagnosis:
Thyroglossal Cyst

From Moore & Persaud 2003

thyroid
cartilage

Questions

1. What is the embryonic derivation of a thyroglossal cyst?


2. Why did the mass move upwards on swallowing?
3. Why did the surgeon look for thyroid tissue on the tongue?

Thyroid Development

From Moore & Persaud 2003

Ectopic Thyroid Tissue

From Moore & Persaud 2003

Possible Locations of Thyroglossal Duct Cysts

From Moore & Persaud 2003

Adrenal Overview
sympathetic
trunk

spinal
cord

T13 T12 T11 T10

splanchnic
nerves

preganglionic
fibers to
chromaffin cells
in medulla

From Grays Atlas

preaortic
ganglia
(celiac,
aorticorenal)

adrenal
corticosteroids, androgens
cortex
adrenal
catecholamines (esp. epinephrine)
medulla
From Netters Atlas

inferior phrenic a.

superior adrenal aa.


(from inferior phrenic a.)

middle adrenal aa.


(from aorta)

inferior adrenal aa.


(from renal a.)

inferior phrenic v.

Vascular Supply
& Relations
adrenal
gland

adrenal v.

IVC (cut)

left renal v.

From Netters Atlas

adrenal
gland

pararenal
fat

Perirenal fascia of Gerota


transversalis
fascia

Toldts fascia
(ant. layer of Gerotas f.)

peritoneum

liver

L2

kidney

colon
Gerotas
fascia

From Netters Atlas

perirenal
fat
Zuckerkandls fascia
(post. layer of Gerotas f.)

psoas
fascia

Imaging
Adrenal tumor

liver

IVC
aorta

right
adrenal

pancreas
left
adrenal

T11

From Ellis et al. 1991

crus of diaphragm

From web reference 3

References
Print
Ellis, H., B. Logan, and A. Dixon. 1993. Human Cross-Sectional Anatomy: Atlas of Body Sections and
CT Images. Butterworth-Heinemann, London.
Hollinshead, W. H. 1968. Anatomy for Surgeons: Volume 1. The Head and Neck, Second Edition. Harper
& Row, New York.
Moore, K. L. and A. F. Dalley. 1999. Clinically Oriented Anatomy. Lippincott, Williams, & Wilkins,
Baltimore.
Moore, K. L. and T. V. N. Persaud. 2003. The Developing Human: Clinically Oriented Embryology.
Saunders, Philadelphia.
Netter, F. H. 1987. The CIBA Collection of Medical Illustrations, Volume 8: Musculoskeletal System.
CIBA-Geigy, Summit.
. 1997. Atlas of Human Anatomy, 2nd. Ed. Novartis, East Hanover.
Sasou, S., S. Nakamurak, and H. Kurihara. 1998. Suspensory ligament of Berry: its relationship to
recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head & Neck 20:695698.
Younes, N. A., and D. H. Badran. 2002. The cricothyroid space: a guide for successful thyroidectomy.
Asian Journal of Surgery 25(3):226231.
Web
1. Thyroid tumor: http://www.auntminnie.com/ScottWilliamsMD2/nucmed/Tumor/Thallium/Thallium.htm
2. Adrenal surgery: http://www.emedicine.com/med/topic3018.htm
3. Adrenal surgery: http://www.surgery.wisc.edu/general/patients/endocrine.shtml
4. Grays Anatomy of the Human Body: http://www.bartleby.com/107/