Abstract
Background: Thyroidectomy is one of the most commonly performed procedure for both benign and malignant diseases of the thyroid. By developing a thorough understanding of anatomical landmarks and by making use of them, the surgeon can minimise the risk associated with the procedure. Experience of the surgeon is a significant factor in minimising or dealing with the complications. During each thyroidectomy, recurrent laryngeal, external branch of superior laryngeal nerves, and parathyroids should be routinely preserved. For this, various approaches like inferior, superior or lateral, tubercle of Zuckercandl, or landmarks like inferior thyroid artery, space of reeves may be used. The unidentified nerves are most likely to be damaged leading to high morbidity and rarely mortality. Transient or permanent hypoparathyroidism is due to inadvertent gland removal or injury to its vascular pedicle.
Aim: To analyse the cardinal anatomical structures to be preserved during each thyroidectomy and the tips for safeguarding them. Material and methods: This is an observational study of 75 thyroidectomies performed for various indications from 2016 December to 2018 December. Surgical details from case sheets and surgical register were perused for it. Patients on medical treatment for thyroid diseases were excluded.
Conclusions: The recurrent laryngeal nerve, external branch of superior laryngeal nerve and parathyroids are the cardinal structures to be preserved during each thyroidectomy. Inferior, superior or lateral approaches, tubercle of Zuckercandl, superior or inferior thyroid arteries, space of reeves may be used.
Keywords: External branch of superior laryngeal nerve, Parathyroids, Recurrent laryngeal nerve, Thyroidectomy, Tubercle of Zuckercandl.
References
- Hegner CF, A history of thyroid surgery. Annals of surgery. 1932 Apr;95(4):48
- A E Giddings, The history of thyroidectomy J R Soc Med. 1998; 91(Suppl 33): 3–6.
- Sakorafas, G.H. Historical Evolution of Thyroid Surgery: From the Ancient Times to the Dawn of the 21st Century World J Surg (2010) 34: 1793.
- Hannan SA, The magnificent seven: a history of modern thyroid surgery. Int J Surg 2006;4(3):187-91. Epub 2006 May 4.
- Max MH, Scherm M, Bland KI. Early and late complications after thyroid operations. South Med J 1983 Aug;76(8):977-80.
- Huang CF et al, The preoperative evaluation prevent the postoperative complications of thyroidectomy, Ann Med Surg (Lond). 2014 Dec 18;4(1):5-10. doi: 10.1016
- William Halsted, The Operative Story of Goitre: The Author's Operation
Volume 19, Part 2 of Johns Hopkins Hospital Reports
- Lifante JC, Payet C, Ménégaux F, Sebag F, Kraimps JL, Peix JL, Pattou F, Colin C, Duclos A, Arnalsteen L, Caizzo R. Can we consider immediate complications after thyroidectomy as a quality metric of operation?. Surgery. 2017 Jan 1;161(1):156-65.
- Wittekamp BH, van Mook WN, Tjan DH, Zwaveling JH, Bergmans DC. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Critical Care. 2009 Dec 1;13(6):1.
- Karlan MS, Catz B, Dunkelman D, Uyeda RY, Gleischman S. A safe technique for thyroidectomy with complete nerve dissection and parathyroid Head & neck surgery. 1984 Jul 1;6(6):1014-9.
- Ravikumar K, Sadacharan D, Muthukumar S, Mohanpriya G, Hussain Z, Suresh RV. EBSLN and factors influencing its identification and its safety in patients undergoing total thyroidectomy: a study of 456 cases. World journal of surgery. 2016 Mar 1;40(3):545-50.
- Sung ES, Chang JH, Kim J, Cha W. Is cricothyroid muscle twitch predictive of the integrity of the EBSLN in thyroid surgery?. The Laryngoscope. 2018 Nov;128(11):2654-61.
- Menon RR, Murali S, Nair CG, Babu MJ, Jacob P. Correlation between the Cernea classification of external branch of superior laryngeal nerve in relation to the ultrasound-based volume of thyroid gland. Indian journal of endocrinology and metabolism. 2017 Nov;21(6):845
- Sakorafas GH, Kokoropoulos P, Lappas C, Sampanis D, Smyrniotis V. External branch of the superior laryngeal nerve: applied surgical anatomy and implications in thyroid surgery. The American Surgeon. 2012 Sep 1;78(9):986-91.
- Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands. Surgery. 1984 Jan;95(1):14-21.
- Hojaij F, Vanderlei F, Plopper C, Rodrigues CJ, Jácomo A, Cernea C, Oliveira L, Marchi L, Brandão L. Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study. Anatomical science international. 2011 Dec 1;86(4):204-12.
- Park I, Rhu J, Woo JW, Choi JH, Kim JS, Kim JH. Preserving parathyroid gland vasculature to reduce post-thyroidectomy hypocalcemia. World journal of surgery. 2016 Jun 1;40(6):1382-9.
- Elsheikh E. Superior parathyroid gland approach to the recurrent laryngeal nerve. Head & neck. 2017 Jul;39(7):1287-90.
- Xie L, Wang J, Zhou L. Inferior Parathyroid Gland Preservation In Situ during Central Neck Dissection for Thyroid Papillary Carcinoma. InThyroid Disorders 2018 Nov 5. IntechOpen.
- Cavallaro G, Iorio O, Centanni M, Porta N, Iossa A, Gargano L, Del Duca S, Gurrado A, Testini M, Petrozza V, Silecchia G. Parathyroid reimplantation in forearm subcutaneous tissue during thyroidectomy: a simple and effective way to avoid hypoparathyroidism. World journal of surgery. 2015 Aug 1;39(8):1936-42.
Corresponding Author
Arun.S
Assistant Professor Dept of General Surgery, Government Medical College Manjeri, Kerala, India, 676121
DOI: https://dx.doi.org/10.18535/jmscr/v7i7.102
