The thyroid operation is considered by many to be

at the pinnacle of endocrine surgery

Thyroid Surgery
Most endocrine surgeons agree that an accurately
performed thyroidectomy requires both experience
and technical ability

National endocrine surgical associations- strives for

the creation of centers of excellence for the future
training of endocrine surgeons
 Unacceptably high incidences of major
complications, like:
- recurrent laryngeal nerve palsies
- permanent hypoparathyroidism
are still reported in the surgical literature.
RLN function is tested by placing the surgeons finger in the prevertebral space
and palpating the aritenoid cartilage movements as the nerve is stimulated
using the nerve stimulator
Suspensory ligament of Berry : Its relationship
to recurrent laryngeal nerve and anatomic
examination of 24 autopsies
Authors
SASOU S. (1) ; NAKAMURA S.-I. (1) ; KURIHARA H. (2) ;

Authors Affiliations
(1) Division of Pathology, Central Clinical Laboratory, School of Medicine, Iwate

Medical University, 19-1 Uchimaru, Morioka 020-8505, Iwate, JAPON

(2) Kurihara Thyroid Clinic, Morioka 020-0015, JAPON
Background. It is important to clarify the relationship between the recurrent laryngeal
nerve (RLN) and the ligament of Berry to prevent damage to the RLN in thyroid
surgery.

The purpose - to identify this relationship to prevent surgical complications.

Methods.
Among the 486 thyroid surgery cases, 689 RLNs were identified and their course
detected. Topography of the laryngotracheoesophageal region and the histology of
the ligament of Berry were studied in detail in 25 autopsied cadavers.

Results. All nerves identified by surgery and autopsy were located laterodorsally to
the ligament of Berry. They were clearly separated, and no nerve penetrated the
ligament nor was medially located to it. The ligament of Berry strongly connected the
thyroid gland to the trachea and was identified as a whitish connective tissue band.

Conclusions. It was confirmed that the RLN never penetrates the ligament of Berry
but is located laterally to it. From these topographic findings, no injury to the RLN will
occur from a separation close to the goiter in thyroid surgery
1. Experience,
2. Sound judgment,
3. Meticulous technique
4. Adequate training
are the hallmarks required to eliminate
POSTOPERATIVE MORBIDITY
Thyroid Surgery
It would be prudent to design appropriate training
programs

Introduce uniform guidelines and standards for

performing these operations for the whole country
SUBTOTAL THYROIDECTOMY
INDICATIONS
Are decreasing
Thyrotoxicosis
Antithyroid drugs resistance
Recurrence after an apparently successful medication

Pressure symptoms
Cosmetic effect- large goitre

Inflammatory conditions
Riedels struma
Hashimotos disease
Preoperative preparation
Thyrotoxicosis
ATS drugs until an euthyroid state is reached
ATS drugs block the synthesis of thyroxine
but do not inhibit the release of the hormone from
existing colloid stores: 3w-3m~Q.colloid
When euthyroid than LUGOL-potassium iodide
solution, 10 days
Postop. tachycardia- beta blockers
Thyroid Surgery
The tubercle of Zuckerkandl
is a thickening of thyroid
tissue that is located at the
most postero-lateral edge
of the thyroid gland

Close proximity with PTs

and RLN
Laryngeal Nerves
OPERATIVE STEPS
Kocher incision
Dissection of the sup. and inf. skin flaps from thyroid
cartilage down to the suprasternal notch- - ! arch
connecting the 2 AJV
Retractor for skin flaps
Large goitre- division of SH/ST muscles in the sup. 1/3
(avoid injury to the motor nerve supply)
Free the ant. margin of SCM from the ST muscle
Midline vertical incision between the SH. muscles
from the thyroid notch to suprasternal notch
Crease line incision above the jugular notch
Raising the skin flaps
Stay anterior to the AJV- bloodless dissection
Strap muscles are separated by opening the linea alba
SH/ST divided in the sup.1/3rd- avoid injury to the nerve
supply (ansa cervicalis-inferiorly)
OPERATIVE STEPS
Pick up loose fascia over the thyroid and incise it-
cleavage plane between the thyroid gland and ST
muscle
Working in a proper cleavage plane, the delivery of the
gland may be facilitated by forefingers dissection
MTV ligated,
Branches of STA
Freeing the lobe using lateral approach
Ligate MTV.
OPERATIVE STEPS
Blunt dissection of the upper pole, pushing away from
the larynx
STA/STV exposed above their point of entry into the
gland
Lower pole- free from inf. veins
Exposing the ITA- identify RLN, PTs
Leave paratracheal thyroid tissue- clamping the
parenchyma
Divide the isthmus
Subtotal resection of the lobe
Excessive dissection of the RLN resulted in neuropraxia
due to interference with its neural blood supply
Line of resection for subtotal
thyroidectomy
Ligate the ITV
Myoraphy of the strap muscles
Types of thyroidectomies
Choice of surgical technique
Potential benefits and complications

Pts. with MNG- the main reason to perform bilateral

subtotal thyroidectomy is:
a presumed lower incidence of complications
an attempt to maintain the euthyroid status without
thyroxine replacement
Disadvantages
High recurrence rate and increased surgical morbidity
during reoperation
Some pts. still require thyroxine replacement
Unrecognized malignancy- SBT=inadequate surgery
TT- Advantages
Adequate removal of the disease

Prevention of the recurrence

Avoidance of the need for completion surgery

How to reduce the risk of
complications
Well trained endocrine surgeon
Technique of capsular dissection, staying close to the
thyroid gland
Preserving the blood supply to the PT
Identification of the RLN