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Total thyroidectomy in bilateral nodular goiter - general and visceral surgery
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The surgical technique will be demonstrated in stage II multinodular goiter. The procedure is started on the right side.
Kocher collar incision about 2 fingers wide superior to the suprasternal notch.
If the incision is placed too far inferior this may result in keloid formation.
In large goiters the incision should be placed somewhat more superior since it will descend once the goiter has been removed.
Mobilizing the wound edges
Mobilizing the strap muscles
Incise along the white line (linea alba colli) and mobilize the strap muscles.
It is important to identify the correct plane of connective tissue between the thyroid and the muscles because this will avoid venous bleeding. This maneuver may be rather difficult in a status post previous inflammation.
In large goiters it is recommended to transversely transect the infrahyoid muscles.
Exposing and neuromonitoring the vagus nerve
Exposing and transecting the vessels of the superior pole
Mobilize the superior pole of the thyroid and with the LigaSure® system transect the vessels there close to the gland.
When pulling too hard on the thyroid, this will tear off the veins at their next branching, in other words craniad. In this case identification and ligation of the stumps may prove to be rather challenging!
Whenever the superior pole extends far craniad and the ligatures are not placed close to the gland, this runs the risk of injury to the external branch of the superior laryngeal nerve.
Tips on how to avoid secondary bleeding from the pole vessels is found here:Polgefäße [Pole vessels]
Mobilizing the inferior parathyroids and exposing the recurrent laryngeal nerve
Transecting the Kocher vein (medial thyroid vein) will expose the inferior parathyroid which needs to be dissected off the thyroid without compromising its blood supply. Expose the recurrent laryngeal nerve and institute continuous neuromonitoring.
Mobilizing the inferior pole
Exposing the superior parathyroid and following the recurrent laryngeal nerve to the larynx
Mobilizing the thyroid lobe mediad
After mobilizing both its superior and inferior pole the thyroid lobe may now be mobilized mediad; in the video tutorial this is mostly performed with the LigaSure® system. Place any ligatures as close to the capsule as possible because this will avoid accidental injury to the RLN; this can be verified by tying the sutures under continuous neuromonitoring.
Removing the entire thyroid