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Heterotopic parathyroid autotransplantation in total parathyroidectomy - general and visceral surgery
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Kocher or collar incision
Standard skin incision 2 finger widths (2-3 cm) superior to the suprasternal notch between the bellies of the left and right sternocleidomastoid muscles.
With the Ligasure® divide subcutaneous tissue and platysma down to anterior fascia of the neck.
Expose the avascular plane between platysma and anterior cervical fascia of and free the skin-platysma flap cephalad and caudad.
Midline division of the strap muscles
Freeing the right superior pole of the thyroid
Exposing the vagus nerve
Resection of the superior right parathyroid
Exploring the inferior parathyroid at its usual location
After resection of the enlarged nodular right thyroid lobe (not illustrated), once more locate and neuromonitor the recurrent laryngeal nerve, visible in its entire course,
Then dissect at the usual location of the inferior parathyroid anterior to the nerve and inferior the inferior thyroid artery.
Since the parathyroid cannot be located here, continue the dissection along the thyrothymic ligament to the right lobe of the thymus.
Starting the right transcervical thymectomy
Precise anterior dissection between clips and Ligasure® seals avoids bleeding and spares the recurrent laryngeal nerve.
And finally, the left lobe of the thymic is also resected and extracted cephalad after deep ligature directly adjacent to the brachiocephalic trunk. The third parathyroid gland is now seen within the left lobe of the thymus.
Freeing the left thyroid lobe
Transect the right Kocher vein and free the left thyroid lobe laterally. Pull the lobe in an anteromedial direction with atraumatic Babcock forceps. Locate the vagus nerve within the carotid sheath and underrun it with a vessel loop. Verify correct functioning of the recurrent laryngeal nerve by neuromonitoring. After opening the space between the posterolateral aspect of the thyroid and the carotid sheath, filled with delicate alveolate connective tissue, expose the inferior thyroid artery. The recurrent laryngeal nerve crosses here and can be verified by neuromonitoring. After clip placement transect the left thyrothymic ligament and remove the entire thymus.
Resection of the superior left parathyroid
Layered wound closure
Preparing the graft