Diagnostic Lobectomy for Unilateral Follicular Nodules of the Thyroid Gland

We describe our technique of diagnostic lobectomy (DL) and the rationale it is based on. We define DL as a minimally invasive procedure consisting of total lobectomy and isthmusectomy, with preservation of the omolateral recurrent laryngeal nerve and parathyroid glands, but without digital exploration of the contralateral lobe. The fact that re-entry into the previously explored field to complete thyroidectomy increases the risk of complications must be taken into consideration. The subjects were 63 consecutive patients who underwent surgery for unilobar follicular neoplasms of the thyroid gland between January 1997 and December 2002. There were 49 follicular adenomas and 14 carcinomas. In the 14 patients with thyroid cancer, total thyroidectomy was performed within 2 weeks after the first operation in a sterile environment with normal anatomical cleavage plains, avoiding any risk of injury to the laryngeal nerves and parathyroid glands. It is concluded that DL is a safe and suitable surgical procedure for patients with follicular-structured lesions of the thyroid gland.     

Total thyroidectomy: the technique of capsular dissection.

This paper describes the technique of total thyroidectomy using capsular dissection. Total thyroidectomy is a safe straightforward anatomical procedure in which meticulous dissection can provide protection to the parathyroid glands and to the recurrent laryngeal nerve. This protection is achieved by using capsular dissection, hugging the gland and dividing the tertiary branches (i.e. the third order of division) of the vessels while dissecting the parathyroid glands with their vascular pedicles free from the thyroid surface, with minimal exposure of the recurrent laryngeal nerve and disturbance of its blood supply. Total thyroidectomy removes all visible thyroid tissue although it is permissible to leave a very small remnant of tissue (less than a fraction of a gram) in the region of the ligament of Berry in order to protect the recurrent laryngeal nerve and the blood supply to the parathyroid glands. This technique ensures that the incidence of complications, including permanent hypoparathyroidism and recurrent laryngeal nerve palsy, is reduced to a minimum.     

TOTAL THYROIDECTOMY: THE TECHNIQUE OF CAPSULAR DISSECTION

Book reviews in this article: This paper describes the technique of total thyroidectomy using capsular dissection. Total thyroidectomy is a safe straightforward anatomical procedure in which meticulous dissection can provide protection to the parathyroid glands and to the recurrent laryngeal nerve. This protection is achieved by using capsular dissection, hugging the gland and dividing the tertiary branches (i.e. the third order of division) of the vessels while dissecting the parathyroid glands with their vascular pedicles free from the thyroid surface, with minimal exposure of the recurrent laryngeal nerve and disturbance of its blood supply. Total thyroidectomy removes all visible thyroid tissue although it is permissible to leave a very small remnant of tissue (less than a fraction of a gram) in the region of the ligament of Berry in order to protect the recurrent laryngeal nerve and the blood supply to the parathyroid glands. This technique ensures that the incidence of complications, including permanent hypoparathyroidism and recurrent laryngeal nerve palsy, is reduced to a minimum.     

腔镜甲状腺切除术中喉返神经的显露

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法2011年4月～2012年4月,行胸乳晕人路腔镜下甲状腺切除术17例。于乳腺前皮下置入troear,注入CO2（压力6mmHg）建立操作空间,用超声刀显露喉返神经。结果17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术（6例双侧叶结节和1例甲状腺癌）,5例行一侧甲状腺叶切除术（一侧腺叶多发结节）,5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17．6％（3／17）、47．1％（8／17）和35．3％（6／17）,术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。     

HEMITHYROIDECTOMY: A HEURISTICS PERSPECTIVE

Heuristics describe the multiple small steps required for successful surgery, which are often taken for granted, enabling key manoeuvres, their correct order and their timely performance. Successful hemithyroidectomy is dependent on correct siting of the incision; tension to allow elevation of sub‐platysmal flaps without damaging anterior jugular veins; strap muscle division with preservation of the ansa cervicalis; recognition of the importance of the sub‐sternothyroid plane; superior mobility of the thyroid lobe, involving freeing the superior strap muscle layer and dissection of the pyramidal lobe; division of the isthmus to assist anteromedial mobility; dissection of the lateral thyroid space to free the posterior ‘v’ lip of the superior pole; medial to lateral dissection of the avascular cricothyroid space with preservation of the external laryngeal nerve, prior to ligation of the superior thyroid vessels; anteromedial rotation of the thyroid lobe with elevation of any retrosternal component; capsular dissection of the inferior pole with preservation of vascularity of the inferior parathyroid gland; dissection of the thyroid lobe off the recurrent laryngeal nerve, especially above the inferior thyroid artery in the region of greatest risk to the nerve, the region of the ligament of Berry; preservation of a vascularized superior parathyroid gland; capsular dissection, creating windows between vessels enabling their precise control, thereby minimizing haemorrhage. This paper aims to emphasize these heuristic components of thyroidectomy.     

Endoscopic transaxillary near total thyroidectomy.

BACKGROUND: Since first reported in 1996, endoscopic minimally invasive surgery of the cervical region has been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. The endoscopic transaxillary technique uses a remote lateral approach to the thyroid gland. Because of the perceived difficulty in accessing the contralateral anatomy of the thyroid gland, this technique has typically been reserved for patients with unilateral disease. OBJECTIVES: The present study examines the safety and feasibility of the transaxillary technique in dissecting and assessment of both thyroid lobes in performing near total thyroidectomy. METHODS: Prior to this study we successfully performed endoscopic transaxillary thyroid lobectomy in 32 patients between August 2003 and August 2005. Technical feasibility in performing total thyroidectomy using this approach was accomplished first utilizing a porcine model followed by three human cadaver models prior to proceeding to human surgery. After IRB approval three female patients with histories of enlarging multinodular goiter were selected to undergo endoscopic near total thyroidectomy. RESULTS: The average operative time for all models was 142 minutes (range 57-327 min). The three patients in this study had clinically enlarging multinodular goiters with an average size of 4 cm. The contralateral recurrent laryngeal nerve and parathyroid glands were identified in all cases. There was no post-operative bleeding, hoarseness or subcutaneous emphysema. CONCLUSION: Endoscopic transaxillary near total thyroidectomy is feasible and can be performed safely in human patients with bilateral thyroid disease.     

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??Modified thyroid lobectomy??360 cases report LIU Quan-fang ,YAO Yuan , HUANG Chi-ming ,et al. Department of General Surgery,Guangdong Provincial People’s Hospital, Guangzhou 510080,China
Corresponding author :LIU Quan-fang , E-mail: doc.liuquanfang @163.com
Abstract Objective To explore the feasibility of thyroid surgery mainly composed of modified thyroid lobectomy with the purpose of averting superior laryngeal nerve,exposing recurrent laryngeal nerve and preserving parathyroid gland. Methods This retrospective review analyzed the clinical data of 360 cases of thyroid surgery mainly composed of modified thyroid lobectomy in Guangdong Provincial People’s Hospital from Dec 2004 to June 2009. Results 360 cases of thyroid surgery including 411 sides of modified thyroid lobectomy was performed on the basis of eradicating lesion,thyroid function was preserved to the greatest extent, exposing rate of recurrent laryngeal nerve was 100%, a total of 543 parathyroid glands was preserved (average 1.32 parathyroid gland per lobe),no relative complications such as injuries of superior laryngeal nerve,recurrent laryngeal nerve and parathyroid gland were followed. Conclusion Thyroid surgery mainly composed of modified thyroid lobectomy might preserve thyroid function to the greatest extent,decrease all kinds of complications relating to thyroid surgery,and reduce postoperative recurrence.     

The cricothyroid space: a guide for successful thyroidectomy

OBJECTIVE: The frequent complications of thyroid surgery are mostly related to the anatomy of the region. This stimulated us to look for a starting point that makes exploration of the region easier and consequently reduces complications. We aimed to explore and define the anatomy of the cricothyroid [CT] region from cadaveric dissection and to present the outcome of 73 consecutive thyroidectomies starting from a space in the CT region. METHODS: Dissection in the thyroid gland region and creating a space in the CT region was performed on five cadavers [10 spaces], followed by 73 consecutive thyroidectomies through a standard approach beginning from the CT space. RESULTS: In all cadavers, a space was easily created in the CT region. Vessels, nerves and the parathyroid glands were identified. Standard thyroidectomy starting from the CT space was performed on 73 patients. The external laryngeal nerve was seen in 40% of the cases. The recurrent laryngeal nerve was identified and preserved in all patients. Six patients had temporary hypocalcaemia and eight had a temporary voice change. None of the patients had permanent hypoparathyroidism or recurrent laryngeal nerve palsy. CONCLUSION: The CT space is an avascular space medial to the thyroid lobe and is a good starting point for thyroidectomy that allows easy and safe exploration of the region.     

Zuckerkandl's tuberculum: could it be useful in thyroid surgery?

A thorough knowledge of thyroid anatomy could reduce the incidence of lesions to the inferior laryngeal nerve. In view of its relationship with the recurrent laryngeal nerve and the parathyroid gland, Zuckerkandl's tuberculum should be considered an anatomical landmark for the recurrent laryngeal nerve in thyroid surgery. The aim of the study was to verify whether the identification of Zuckerkandl's tuberculum could be useful to reduce the incidence of recurrent laryngeal nerve lesions. Four hundred and thirty-two patients underwent thyroid surgery over the period from January 2001 to December 2003 for benign (377 patients) or malignant disease (55 patients). Three-hundred and forty-eight (81%) underwent total thyroidectomy. Zuckerkandl's tuberculum was found in 74.5% of patients, with a high prevalence in the right lobe: in 5% of patients it was grade I, in 50% grade II and in 45% grade III. Its presence was associated with the recurrent laryngeal nerve in almost all cases. Eight of the patients undergoing total thyroidectomy suffered recurrent nerve paralysis, only 4 of which proved definitive. Identification of Zuckerkandl's tuberculum allows safer isolation of the recurrent laryngeal nerve and superior parathyroid gland dissection.     

改进法甲状腺叶切除术（附360例报告）

【摘要】 目的 探讨以避开喉上神经、显露喉返神经和保留甲状旁腺的改进法甲状腺叶切除术为主体的甲状腺手术的可行性。方法 对2004年12月至2009年6月广东省人民医院普通外科完成的360例改进法甲状腺叶切除术为主体的甲状腺手术的全部临床资料进行回顾性分析。结果 在根治病变的基础上,共完成360例411侧改进法甲状腺叶切除术为主体的甲状腺手术,最大限度地保留了甲状腺功能,喉返神经显露率达100％,共保留甲状旁腺543个（平均每侧腺叶1.32个）,术后无一例出现喉上神经、喉返神经和甲状旁腺损伤相关并发症。结论 改进法甲状腺腺叶切除术为主体的甲状腺手术能最大限度保留甲状腺功能、降低手术相关并发症发生率、减少术后复发。     

精细化被膜解剖法在甲状腺全切手术中的应用

目的探讨精细化被膜解剖法在甲状腺全切手术中的应用。方法回顾性分析四川省肿瘤医院头颈外科2012年1月至12月118例应用精细化被膜解剖法行甲状腺全切术患者的临床资料。结果所有病例术中均发现并保留l～4枚甲状旁腺。其中16例未发现明确的下旁腺;术中发现上甲状旁腺197枚,其中42枚由甲状腺上动脉分支供血,131枚由甲状腺下动脉上行支供血;下甲状旁腺163枚,明确的下动脉分支血管供血的136枚。术后有62例（52.5%）甲状腺激素（PTH）值低于正常值（一过性甲状旁腺功能低下）,其中56例于术后第7天恢复正常,其余6例于术后2～4周恢复正常;23例有暂时性低钙血症症状的患者,术后4 d～1月都恢复正常,无永久性低钙血症。所有病例术中均解剖并显露双侧喉返神经,除术前喉返神经受侵或损伤的患者,其余患者均未发生永久性喉返神经损伤。结论采用精细化被膜解剖法行甲状腺全切除术,能较好地原位保留甲状旁腺及其血供、避免喉返神经损伤的发生,减少甲状腺全切除术的并发症。     

Importance of identifying the course of the recurrent laryngeal nerve in total and near-total thyroid lobectomies

In our clinic, near-total thyroidectomy is the principal surgical procedure performed for benign thyroid diseases. We conducted a single-institution study on 176 consecutive patients who underwent near-total thyroidectomy due to various thyroid diseases. We compared the incidence of recurrent laryngeal nerve injury between total and near-total thyroid lobectomy sides in each patient. Our hypothesis was that the incidence of recurrent laryngeal nerve injury after total thyroid lobectomy would be similar to that of near-total thyroid lobectomy when the course of the recurrent laryngeal nerve was identified during surgery. The temporary recurrent laryngeal nerve palsy rates on the total and near-total thyroid lobectomy sides were 3.9 per cent (7 of 176 nerves) and 2.2 per cent (4 of 176 nerves), respectively. The difference was not statistically significant. Permanent recurrent laryngeal nerve palsy did not occur in any of our patients. In conclusion, the incidence of recurrent laryngeal nerve injury in total versus near-total thyroid lobectomy is not different when the course of the recurrent laryngeal nerve is identified during surgery.     

The external laryngeal nerve]

An investigation on the external laryngeal nerve is carried out from cadeverous material (24 thyroid glands). Various origins of the nerve are reported. The relationships are investigated. They are particularly important on the superior pole of the thyroid gland. The nerve may pass at a variable distance of the superior pole of the thyroid gland. The size of the gland and particularly the more the more or less early intramuscular course of the nerve through the fibers of the inferior pharyngeal constrictor muscle determine the relationships. Those relationships will be made closer if the nerve is adherent to the thyroid sheath, passes forward of the superior thyroid artery or between the supra polar branches. The collateral nervous branches for the thyroid gland or for the thyroid vessels, the arterial branches which passed into the pharyngeal constrictor muscle with the nerve may also change the relationships. Practical applications in thyroid surgery are made through this investigation.     

A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation

A series of 1,000 consecutive thyroid operations is presented, without a case of permanent recurrent laryngeal nerve injury. Emphasis is placed on the identification of variations and complete dissection of the recurrent laryngeal nerve, including peripheral branches and technical aspects of the dissection. Sixty-five percent of the cases had multiple terminal branches of the recurrent laryngeal nerve and five cases on the right side had a nonrecurrent course. A low incidence of hypoparathyroidism is presented, due in part to the avoidance of ligating the inferior thyroid artery in continuity and the technique of extracapsular dissection of the thyroid gland. The external branch of the superior laryngeal nerve was protected by the early mobilization of the superior thyroid vessels and ligatures placed flush on the capsule of the superior pole.     

Endoscopic Lateral Approach Thyroid Lobectomy: Safe Evolution from Endoscopic Parathyroidectomy

Introduction Endoscopic thyroid surgery has been shown to be feasible. Most minimal access procedures have been performed via a midline approach. Based on our experience of more than 500 endoscopic parathyroidectomies via a lateral approach we have used the same method for thyroid lobectomy. Methods We present our experience of endoscopic thyroid lobectomy via a lateral approach (ETLA) and review of the results over a 1-year period (2004). Inclusion criteria for ETLA were (1) solitary nodule with atypical/suspicious fine–needle biopsy (FNB) or solitary toxic nodule; (2) lesions with a diameter of <3 cm. Patients with a history of previous neck surgery or radiation exposure were excluded. All patients underwent postoperative vocal cord checks and plasma calcium evaluation. Results A total of 742 thyroid procedures were performed during 2004. Among them, 38 patients (5.1%) underwent ETLA. Indications for surgery were suspicious FNB results (36 patients) and a toxic nodule (2 patients). Mean nodule size was 19.2 mm. Mean ± SD operating time was 102 ± 27 minutes. All recurrent laryngeal nerves were identified (including one that was nonrecurrent). Of the 38 patients, the superior parathyroid gland was identified in 36 and the inferior parathyroid gland in 33. There were two conversions due to difficulty with the dissection. Two operations were converted because malignancy was diagnosed on frozen section examination. Two patients underwent a delayed completion thyroidectomy when definitive histology necessitated it. There were no permanent operative complications, and all patients were discharged on the first postoperative day. Conclusions ETLA offers excellent intraoperative visualization of the vital structures and is a safe alternative to conventional thyroid lobectomy in selected cases.     

甲状旁腺的术中观察及术后甲状旁腺功能减退的探讨

目的在甲状腺手术中认识甲状旁腺的局部解剖及甲状腺手术切除范围和甲状旁腺功能减退的关系,探讨术后甲状旁腺功能减退的原因及预防治疗措施。方法回顾2582例甲状腺手术患者的临床资料并术后随访。结果其中对721例双侧甲状腺侧叶全切者行术中探察,发现甲状腺病理状态下甲状旁腺的局部解剖位置及数量变异大,探察到的每种情况术后暂时性甲状旁腺功能减退发生率各不相同,其中上下甲状旁腺双侧均不明显组永久性甲状旁腺功能减退发生1例。2453例手术中行甲状腺部分切除、单侧叶次全切除、单侧叶全切除、双侧叶全切除、双侧叶全切及颈淋巴结清扫者（即甲状腺癌根治）暂时性甲状旁腺功能减退发生率依次增高,其中以双侧叶次全切除暂时性甲状旁腺功能减退发生率最高。且又因甲状腺疾病病种各不相同,甲状旁腺功能减退发生率亦各不相同。结论术后甲状旁腺功能减退的发生与手术操作、甲状旁腺的局部解剖及其变异、甲状腺手术切除范围、巨大甲状腺及其内巨大包块对双侧甲状腺后被膜深面组织的压迫,甲状腺疾病病种不同而手术难度各异等皆有关系。     

A medial approach to thyroidectomy.

Thyroidectomy initiated by transecting the isthmus and peeling the lobes laterally away from the midline exposes the three vital elements of thyroid anatomy, namely the vessels, the recurrent laryngeal nerves and the parathyroid glands, by an almost bloodless dissection conducted at a distance from these vital structures. Part or all of the lobe or lobes can be removed while the parathyroid glands and recurrent laryngeal nerves remain clearly under view at all times.     

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??Precise anatomy near ligament of Berry in the view of endoscopic thyroidectomy WANG Bo, ZHAO Wen-xin, YAN Shou-yi, et al, Department of Vascular and Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
Corresponding author: ZHAO Wen-xin, E-mail: fzhzwx6688@163.com
Abstract Objective To study the anatomy near ligament of Berry in the View of Endoscopic Thyroidectomy, discuss the programmed endoscopic thyroid surgery. Methods From 346 side’s endoscopic Thyroid lobectomies were analyzed retrospectively, important structural which restriction Thyroid lobectomy and its relationship with recurrent laryngeal nerve were analyzed. Results From the view of endoscopic thyroid lobectomy, ITA and PGA two artery layers were identified??these anatomic landmarks appears rates were 75.2%,52.6% in the left and 82.8%,74.2% in the right, Respectively. Conclusion ITA layer and PGA layer often leads to U-shaped stretch to the Recurrent laryngeal nerve, these anatomical landmarks are helpful to the protection of the recurrent laryngeal nerve and the artery of superior parathyroid gland.     

The Identification,Preservation and Classification of the External Branch of the Superior Laryngeal Nerve in Thyroidectomy

Background

Avoiding injury to the external branch of the superior laryngeal nerve is one of the major challenges during thyroid operation. The aim of this study was to propose a practical classification of the external branch of the superior laryngeal nerve.

Methods

A retrospective study of total thyroidectomy was performed. Totally 240 patients were included, with 480 external branches of the superior laryngeal nerves explored by intraoperative neuromonitoring. The classification of the external branch of the superior laryngeal nerve was determined by the distance between the upper edge of the superior thyroid pole and the lowest point of the nerve when the thyroid lobe was retracted in the lateral and inferior direction. Multinomial logistic regression analysis was run to predict the type of the nerve from several variables.

Results

The identification rate of the external branch of the superior laryngeal nerve was 98.54% (473 of 480 nerves). Higher ratio of longitudinal size of the thyroid lobe to ipsilateral neck length increased the likelihood of that both the type 2 and 3 nerve with respect to type 1 nerve, with OR 2.72, 95% CI = 1.21–6.12 and OR 5.30, 95% CI = 2.09–13.44, respectively. (1a) The nerve whose lowest point (entry into the muscle) was located more than 1 cm above the horizontal plane passing the upper border of superior thyroid pole. (1b) The nerve whose lowest point (the point right above the superior thyroid pole) was located more than 1 cm above the plane. (2a) The nerve whose lowest point (entry into the muscle) was located within 1 cm above the plane. (2b) The nerve whose lowest point (the point right above the superior thyroid pole) was located within 1 cm above the plane. (3a) The nerve whose lowest point (entry into the muscle) was located below the plane. (3b) The nerve whose lowest point (the point right below the superior thyroid pole) was located anterior to the gland. (3c) The nerve whose lowest point (the point right below the superior thyroid pole) was located posterior to the gland.

Conclusions

Identification rate of the external branch of the superior laryngeal nerve by intraoperative neuromonitoring was significantly high. Understanding the new practical classification of the nerve allows for better identification and function preservation of this nerve during thyroidectomy.

     

经口甲状腺切除术

经口甲状腺切除术是近年发展起来的新术式。通过口腔前庭向颈部建立手术腔隙施行微创手术。适用于甲状腺良性病变以及没有侧颈淋巴结转移的甲状腺癌。优点是颈部无疤痕;手术入路相对临近;暴露良好并可以一次处理双侧甲状腺病变和中央区淋巴结。本例患者诊断为甲状腺癌,经口施行了甲状腺全切除和中央区淋巴结清扫。术中清晰暴露上位甲状旁腺并全程解剖喉返神经。利用超声刀安全稳固处理甲状腺上动脉和下动脉,失血少,术野清晰,而且术后无需置放引流管。术后并发症主要是术野区疼痛以及下唇周围麻木,通过术后镇痛和休息可以得到完全恢复。经口甲状腺切除术需要严格选择病例并由经验丰富的外科医生施行才能安全,有效。