Atlas of Thyroid Surgery: Principles, Practice and Clinical Cases by Ernst Gemsenjaeger and Ernst Gemsenjäger

525b4695887939e-261x361.jpg Author Ernst Gemsenjaeger and Ernst Gemsenjäger
Isbn 9783131450319
File size 10MB
Year 2008
Pages 180
Language English
File format PDF
Category medicine


h This book is affectionately dedicated to my wife Hélène. Atlas of Thyroid Surgery Ernst Gemsenjaeger, MD Professor Emeritus Surgical Clinic Spital Zollikerberg Zollikerberg/Zurich Switzerland 341 illustrations Thieme Stuttgart · New York Library of Congress Cataloging-in-Publication Data. Gemsenjäger, Ernst. [Atlas der Schilddrüsenchirurgie. English] Atlas of thyroid surgery / Ernst Gemsenjäer. p.; cm. Includes bibliographical references. ISBN 978-3-13-145031-9 (alk. paper) 1. Thyroid gland—Surgery—Atlases. I. Title. [DNLM: 1. Thyroid Gland—surgery—Atlases. 2. Endocrine Surgical Procedures—methods–Atlases. WK 17 G323a 2008a] RD599.5.T47.G4613 2008 617.5’39—dc22 This book is an authorized and revised translation of the Swiss edition published and copyrighted 2005 by Verlag Hans Huber, Hogrefe AG, Bern. Title of the Swiss edition: Atlas der Schilddrüsenchirurgie. © 2009 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA Cover design: Thieme Publishing Group Typesetting by F3media, 71093 Weil im Schönbuch, Germany Printed in Germany by Appl Aprinta Druck, Wemding ISBN 978-3-13-145031-9 123456 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. Foreword Foreword During my first visit to Basel, Switzerland, in 1980, I had the pleasure of meeting Prof. Ernst Gemsenjäger. I was immediately impressed by the knowledge of this experienced and skillful surgeon. Other leaders, such as Professors Philipp Heitz and Hugo Studer, had most positive comments about Professor Gemsenjäger, who has special expertise in thyroid surgery. Safe thyroid surgery was established in Switzerland by Kocher (1841–1917), and Professor Gemsenjäger follows in his tradition. Kocher, as many already know, received the Nobel Prize in 1909 for his contributions to experimental physiology, pathology, and surgery. He not only helped make thyroid operations a safe procedure, but also by honestly reporting his complications, such as postoperative myxedema (cachexia strumipriva), documented that the thyroid gland was essential for life. Kocher was also a great surgical educator and certainly influenced William S. Halsted, MD (1852–1922), from Johns Hopkins Medical Center, and many other surgeons about the importance of meticulous surgical technique in a blood-free field, which decreases the risk of complications. Professor Gemsenjäger’s book is clearly written and provides useful information for physicians who care for patients with surgical disorders of the thyroid. The author uses his vast experience to illustrate proper clinical management. His description of surgical anatomy, the appropriate position of the surgical incision, and the technique of capsular dissection to avoid injuring the recurrent laryngeal nerves or devascularizing the parathyroid glands during thyroid operations is informative. He also outlines the mechanisms involved in the pathogenesis of nodular goiter and thyroid neoplasms. General, endocrine, and ENT surgeons will benefit from reading this superb book, as will endocrinologists, pathologists, residents, and medical students. Orlo H. Clark, MD Professor, Department of Surgery UCSF, Mt. Zion Medical Center San Francisco, USA Foreword For several decades, clinical thyroidologists throughout this country sent patients with unusually difficult surgical problems to the author of this Atlas of Thyroid Surgery for advice or intervention. Any reader leafing through this magnificent book will immediately understand why so much credit was lent to its author. All available techniques for surgically removing diseased thyroid tissue—be it nodular or diffuse, benign or malignant—are critically reviewed. A beautifully illustrated example is given for nearly every possible situation. Any thyroid surgeon faced with an uncommon or particularly difficult thyroid problem is most likely to find a detailed and well-founded description of the best procedure to be chosen in just the case they are confronted with. However, every surgeon who turns for advice to this book is expected to master the demanding technique of capsular dissection. This technique—first described by Theodore Kocher 100 years ago—is, in the author’s mind, underused or even ignored in some centers. It is, however, safer and far superior to any other technique (e. g., the often ill-defined “subtotal thyroidectomy”) for removing all pathologically growing thyrocytes—a prerequisite to avoid recurrence of benign or malignant nodules. The credentials of the author are exceptional. On the one hand, he has not only performed some 2500 thyroidectomies himself, but he has also personally followed all patients operated for thyroid malignancies over years and even decades, carefully monitoring every event related to the surgical intervention. This enormous clinical experience has been published in a number of widely cited papers. On the other hand, the author did participate in several fields of thyroid research not related to surgery. A particular hallmark of this book is Professor Gemsenjäger’s constant effort to explain the modern concepts of biological and molecular events that underlie the pathogenesis of thyroid lesions that may eventually appear in the hands of the surgeon. Particular consideration is given to the very early states of benign and malignant nodular growth, i. e., to those clusters of hydrolytes that are endowed with an intrinsic or acquired growth advantage. Radical surgical elimination of all such clusters is the ultimate goal of an optimal therapeutic approach. The author is highly qualified to critically review the techniques that allow this goal to be achieved. Professor Emeritus H. Studer Muri/Bern, Switzerland V VI Foreword Foreword As an internist, I had the privilege to work with Professor Ernst Gemsenjäger at the Zollikerberg District hospital, Zurich, Switzerland, from 1988 to 2002. During those 15 years, there were many opportunities for me to learn from his broad and precise knowledge of the field of thyroidology, which included modern cell biology, such as Professor Hugo Studer’s concept of follicle cell growth and function. It was typical of Professor Gemsenjäger that he not only focused on the local surgical problem but also always included endocrine pathophysiology in diagnostic and therapeutic considerations. As a result, every patient who came to his attention was a stimulating didactic lesson for the surgical and intern medical house staff as well as a source of knowledge for himself. His enthusiasm for clinical research combined with a deeply self-critical mind and his personal example as an excellent surgeon with huge experience in the field allowed several of his disciples to bring thyroid surgery to a high level of quality in other hospitals. Professor Gemsenjäger’s surgical procedures in endocrine surgery as well as in the whole spectrum of gastrointestinal surgery, which I was able to watch repeatedly in the operating theater, were meticulously nonbloody and complications were extraordinarily rare. Accordingly, even our many frail and polymorbid patients who needed thyroid or other surgical treatment were in very safe hands. Professor Max Stäubli, MD Zollikerberg, Zurich, Switzerland Preface Preface The thyroid surgeon enjoys two aspects of fascination and favor. First, thyroidology is challenging in the clinical and in the scientific domain. Highly interesting aspects of pathology and of cellular and molecular biology are a part of and the background of the thyroid surgeon’s daily work. Thus, he is an intellectual craftsman. Second, surgical craftsmanship in general includes a poorly definable aspect: the manner or style with which a surgical procedure is carried out, that is to say, with which a hemithyroidectomy, or the mobilization of a goiter, an esophagectomy, a peripancreatic necrosectomy, or a rectal excision is carried out with a defined strategy in mind. This “manner” reflects in some way the surgeon’s character. It also constitutes part of his skills and competence. It may be one of the determinants of surgical morbidity and oncological results, with the surgeon himself becoming a prognostic factor. In thyroid surgery, the importance of the “manner” has already been mentioned by Theodor Kocher (1841–1917), who practiced a delicate, bloodless, and precise preparatory style that enabled him to perform capsular dissections, i. e., anatomically and oncologically adequate excisions.140,141 Thyroid surgery has thus become an exquisite field for promoting a superior operating “manner” by the adoption of capsular dissection. The revolution of surgery for Graves disease promoted by Thomas P. Dunhill (1876–1957) represents another example of surgical progress based on fine dissection technique.270a The intention of this book is twofold: first, to present commitment to scholarship of the thyroid surgeon, together with presentations of results and personal experience; and second, to demonstrate in a detailed and “down-to-earth” description, including surgical videos, the surgical technique of capsular dissection, which, 100 years after its introduction by Kocher, has still not attained its deserved place (and potentially may even be threatened by some modern technologies and devices). This book on the thyroid is an invitation to experience clinical cases, problems, and decision-making, and to be exposed to surgical presentations, pathologies, and operative performance. Even extensive case records and detailed operative descriptions cannot, however, substitute for frequent visits to the operating theatre. It is our hope that surgeons, trainees, clinicians, pathologists, endocrinologists, ultrasonographers, etc. will frequently join the operating theater to gain insights into a fascinating reality-centered thyroidology, and to acquire a large amount of clinical experience. Assistance to surgical procedures is an important part of surgical training that may transmit skills and mastery from dedicated highvolume surgeons.246 In thyroid surgery, each operating situs and each case is noteworthy. VII VIII Acknowledgments Acknowledgments Ingrid Schweizer, MD, deserves thanks for her long-time assistance, for clinical discussions, for permission to use patients’ charts as well as pictures of her patients and of some of her operations. Her pictures (Figs. 5.7, 5.19, 6.5, 6.6, 6.7, 13.3, 17.1, 18.1, 19.10, 19.23, 21.4, 22.3 h, i, k, m, n) represent an important contribution to this work. Professor Dagmar Führer, MD, PhD, was kind enough to review the paragraphs on molecular pathogenesis. I thank her for her enthusiasm, for helpful remarks, for important additions, and for thyroidological discussions. I thank the following colleagues for their friendship, assistance, and helpful hints: Professor Hugo Studer, MD, who provided me with helpful reviews, hints, and comments. His eminent thyroidological research has had a substantial impact on my own activity during the past 40 years as well as on modern thyroid surgery in general. Professor Philipp U. Heitz, MD, with whom I was able to share an interest in thyroidology during 40 years of activity in Basel and Zürich. Professor Max Stäubli, MD, my colleague in internal medicine, with whom I had a wonderful collaboration that proved its value in day-to-day clinical work. Professor Alexander von Graevenitz, MD, and Rudolf Steiner, MD, who made important contributions to the translation of this book into English. I also want to acknowledge the many colleagues who provided me with data on course and outcome of their patients’ illness. Rudolf Steiner, MD, and Martin Zweifel, MD, PhD, were kind enough to contribute novel oncological treatment modalities. Finally, my heartfelt thanks go to Thieme Publishers Stuttgart and its staff who made possible the publication of this volume. Abbreviations Abbreviations AFN ATC bCT BRAF CCH cDNA CT CT DTC FMTC FNAB FNMTC fPTC FTC FVPTC GL MALT MEN MF MIP MIT MNG MRI mRNA MTC NIS ORL PCR PET pHPT autonomously functioning nodule anaplastic thyroid carcinoma basal (unstimulated) caclitonin B-type Raf kinase gene C-cell hyperplasia complementary DNA basal calcitonin computed tomography differentiated thyroid carcinoma familial MTC fine-needle aspiration biopsy familial nonmedullary thyroid cancer familial papillary thyroid carcinoma follicular thyroid carcinoma follicular variant of PTC Grenzlamelle (visceral fascia) mucosa-associated lymphoid tissue multiple endocrine neoplasia middle fascia minimally invasive parathyroid (surgery) minimally invasive thyroid (surgery) multinodular goiter magnetic resonance imaging messenger RNA medullary thyroid carcinoma sodium iodide symporter otorhinolaryngology polymerase chain reaction positron emission tomography primary hyperparathyroidism PPARγ PT PTC PTH RRA RAI rhTSH RLN SAGE SCM sCT SF T3 T4 TBAB TC Tg TgmRNA TPO TRAb TRH TSAB TSH TSHR TSHRm US VF peroxisome proliferator-activated receptor-gamma parathyroid gland papillary thyroid carcinoma parathyroid hormone RAI remnant ablation radioactive iodine (radioiodine, iodine-131, 131I) human recombinant TSH recurrent laryngeal nerve serial analysis of gene expression sternocleidomastoid muscle pentagastrin-stimulated calcitonin superficial fascia triiodothyronine thyroxine (tetraiodothyronine) thyroid-blocking antibody thyroid carcinoma thyroglobulin Tg gene-specific transcripts thyroid peroxidase thyroid receptor antibody thyrotropin-releasing hormone thyroid-stimulating antibody thyroid-stimulating hormone thyrotropin receptor TSH receptor mutations ultrasonography visceral fascia IX To access additional material or resources available with this e-book, please visit After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content. Table of Contents Table of Contents Part 1 Surgical Anatomy and Surgical Technique _ 1 8.2 Endocrine Function. Functional Autonomy. TSH Receptor Mutations _ 54 1 Notes on Positioning the Patient _ 2 9 Molecular Genetic Diagnosis. Gene Profiling _ 58 2 Basic Surgical Anatomy _ 3 10 10.1 3 3.1 3.2 Incisions; Thyroid Exposure _ 4 Skin and Platysma _ 4 Transverse Division of the Superficial Fascia and Middle Fascia _ 4 Longitudinal Median Division of the Superficial Fascia and Middle Fascia _ 6 Modifications _ 7 Follicular Neoplasia _ 60 Preoperative and Intraoperative Evaluation of Nodules _ 60 Differential Diagnosis of Follicular Neoplasia _ 62 3.3 3.4 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5 5.1 5.2 5.3 5.4 5.5 Capsular Dissection _ 9 Anatomy _ 9 Technique _ 12 Capsular Dissection at the Upper Pole _ 12 Lateral “Back Door” Approach _ 17 Historical Remarks on Capsular Dissection _ 22 Capsular Dissection and Modern Technologies _ 23 Minimal-Access Thyroid Surgery _ 23 Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl) _ 25 Anatomical Relationships between the Structures around the Thyroid Hilus _ 25 The Nerve at Risk _ 27 Investigation of Nerve Function _ 30 Parathyroid Glands _ 31 Tubercle of Zuckerkandl (Madelung–Zuckerkandl) _ 31 10.2 11 11.1 11.2 12 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 12.10 6 6.1 Further Case Records with Demonstrations of the Technique of Capsular Dissection _ 42 Graves Disease _ 46 12.11 12.12 Part 2 Thyroid Nodules—Modern Concepts _ 51 13 7 Basic Remarks _ 52 8 Proliferation, Clonality, and Autonomy of Thyroid Lesions _ 53 Growth. Nodules Are Genetically Determined Hyperplastic and Neoplastic Tumors _ 53 13.1 8.1 13.2 13.3 Thyroid Nodules in Surgical Practice. Strategy of Adequate Excision _ 63 Diagnoses in Thyroid Nodules (Personal Series) _ 63 Strategy of Adequate Excision _ 63 Case Records: Hyperplastic and Neoplastic Nodules; Functional Autonomy; Follicular Thyroid Carcinoma _ 67 Hyperplastic, Adenomatous Goiter _ 67 Follicular Neoplasia: Minimally Invasive Follicular Thyroid Carcinoma _ 69 Solitary Nodule. Diagnosis and Treatment _ 70 Risk-Group Assignment in Follicular Thyroid Carcinoma _ 70 Treatment of Patients with Follicular Thyroid Carcinoma _ 72 Plummer Disease and Minimally Invasive Follicular Thyroid Carcinoma _ 73 Very Low-Risk Follicular Thyroid Carcinoma _ 74 Widely Invasive Follicular Thyroid Carcinoma _ 75 Plummer Disease. Mediastinal Goiter. Acute Respiratory Distress _ 77 Long-Standing Huge Goiter with Acute Hemorrhage and Necrosis _ 79 Plummer Disease in an Older High-Risk Patient with Large Compressing Goiter; Transsternal Approach _ 80 Long-Standing Huge Goiter with Widely Invasive Follicular Thyroid Carcinoma _ 81 Embryological Thyroid Development and Developmental Anomalies: Clinical Aspects _ 83 Aberrant, Ectopic or Heterotopic Thyroid Tissues _ 83 Further Clinical Aspects. Thymus _ 83 Case Records _ 85 XI XII Table of Contents 14 14.1 14.2 14.3 14.4 15 15.1 15.2 15.3 Total Thyroidectomy for Benign Nodular Goiter _ 87 Case Records. Huge Goiters _ 87 Total Thyroidectomy for Toxic Multinodular Goiter _ 88 Surgical Morbidity _ 89 Conclusion _ 89 Long-Standing Solitary Nodule _ 90 Solitary Toxic Nodule (Goetsch Disease) _ 90 Solitary Nodule with Normal Thyroid Stimulating Hormone (Cold Nodule) _ 91 Solitary Thyroid Nodule in a Personal Series (Prospective Clinical Study) _ 92 16 16.1 16.2 Further Clinical Considerations _ 94 The Small Subclinical and Clinical Nodule _ 94 Ultrasonographic Findings Relevant for the Thyroid Surgeon _ 95 17 17.1 17.2 17.3 17.4 Nodules in Graves Disease _ 96 Functioning and Nonfunctioning Nodules _ 96 Nuclear Scan for Differential Diagnosis _ 96 Diagnostic and Therapeutic Regimen _ 96 Case Records: Papillary Thyroid Carcinoma in Graves Disease _ 97 18 Nodules in Chronic Autoimmune Thyroiditis (Hashimoto Thyroiditis, Hashimoto Disease, Lymphocytic Thyroiditis) _ 99 Hashimoto Thyroiditis _ 99 Nodules in Hashimoto Disease _ 99 Primary Thyroid Lymphoma _ 100 Conclusion _ 100 Case Records _ 101 Acute Events. The Firm Thyroid Gland. The Rapidly Growing Thyroid Mass _ 105 18.1 18.2 18.3 18.4 18.5 18.6 Part 3 Malignant Tumors _ 107 19 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 Papillary Thyroid Carcinoma _ 108 Clinical and Biological Features Relevant for Rational Treatment _ 108 Low Risk and High Risk, Recurrence, Survival _ 108 Treatment Principles: Selective Treatment Policy _ 109 Case Records (I). Selective Treatment Options _ 109 Age-Related Prognostic TNM Classification _ 113 Lymph Node Metastasis _ 115 Case Records (II) _ 117 Morphological Subclassification of Papillary Thyroid Carcinoma _ 131 19.9 Familial Papillary Carcinoma (Familial Nonmedullary Thyroid Carcinoma) _ 132 19.10 Conclusion. Risk-Dependent Amount of Therapy in Papillary Thyroid Carcinoma _ 135 20 Anaplastic (Undifferentiated) Thyroid Carcinoma _ 136 20.1 General Remarks _ 136 20.2 Thyroidectomy for Excision of Anaplastic Carcinoma. Cases _ 137 20.3 Novel Treatment Strategies _ 138 21 21.1 21.2 21.3 21.4 21.5 21.6 21.7 Medullary Thyroid Carcinoma (C-Cell Carcinoma) _ 141 Introduction (General Remarks) _ 141 Diagnosis _ 141 C-Cell Hyperplasia _ 143 Conclusions (Sporadic Medullary Thyroid Carcinoma) _ 143 Hereditary Medullary Thyroid Carcinoma _ 144 Case Records _ 144 Casuistic Experience _ 151 Part 4 Concluding Remarks 22 Basic Tools _ 154 22.1 Clinical Examination _ 154 22.2 Recapitulation of the Technique of Capsular Dissection _ 154 22.3 The Surgeon as a Prognostic Factor _ 154 22.4 Evidence-Based Medicine _ 159 Reference List _ 160 Index _ 174 D Media Center Information Overview and Comments_179 PART 1 Surgical Anatomy and Surgical Technique 1. Notes on Positioning the Patient _ 2 2. Basic Surgical Anatomy _ 3 5. Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl) _ 25 3. Incisions; Thyroid Exposure _ 4 4. Capsular Dissection _ 9 6. Further Case Records with Demonstrations of the Technique of Capsular Dissection _ 42 2 Part 1 Surgical Anatomy and Surgical Technique 1 Notes on Positioning the Patient Comfortable access to the operative field may be compromised by too wide an operating table. The upper back of the patient should be elevated with a pillow, allowing the shoulders to fall posteriorly with both arms placed to the side. The patient is positioned with the neck hyperextended, and the head has to be supported since hyperextension may cause postoperative pain and is limited in older patients. The neck should not fall posteriorly so as to avoid an inconvenient position (“en bayonet”). Draping as well as placement of the anesthesiologist’s equipment must permit three surgeons to be comfortably positioned around the surgical field, i. e., on both sides and cephalad. Usually the surgeon is assisted by two assistants: For proper exposure we prefer manual traction with movable hand-hold hooks to rigid and cumbersome self-retractors. The operating table is brought into a slight reverse Trendelenburg position, which serves to improve presentation of the operative field to the surgeon and to decrease venous congestion. Despite this positioning, thromboembolic events are found to be extremely rare in thyroid and parathyroid surgery if routine prophylactic anticoagulation and antithrombotic stockings are used. Basic Surgical Anatomy 2 Basic Surgical Anatomy The thyroid gland is exposed on its anterior aspect after incision and retraction of U The skin with the platysma muscle and subcutaneous fat U The superficial cervical fascia (SF) containing the superficial veins U The middle cervical fascia (MF) containing the sternohyoid, the sternothyroid, and the omohyoid muscles The SF and the MF are opened either by transverse or by longitudinal division. The dorsal and peritracheal aspects of the thyroid gland lie contiguous to the visceral compartment of the neck, which is covered by the so-called Grenzlamelle (GL), or visceral fascia, a fine demarcating fascial layer. For dorsal exposure and excision, the thyroid must be separated from the visceral compartment and its covering fascia. This is achieved by capsular dissection. Dorsal dissection represents the most critical and delicate part of thyroid surgery, an issue of much discussion and controversy throughout its history and development. Hence, special emphasis will be placed on capsular dissection as the method of choice for dorsal dissection, and on the role of total lobectomy and total thyroidectomy as opposed to subtotal resections. 3 4 Part 1 Surgical Anatomy and Surgical Technique 3 Incisions; Thyroid Exposure 3.1 Skin and Platysma † Fig. 3.1 The Kocher incision (1 in Fig. 3.1) is centered over the isthmus of the thyroid, which lies just caudad to the cricoid cartilage. This placement is preferred to a more caudal one.215 If the neck is hyperextended the incision will lie more caudally once the patient is in the erect position. The level of the suprasternal notch should be avoided because of the risk of unfavorable scar formation since the platysma is lacking in the midline at that level. Symmetry of length and height of the slightly curved incision, placed in a normal neck line or skin fold, is important. The length depends on neck configuration, goiter size, and planned surgical procedure. The planned incision line is marked preoperatively with the patient in the erect position, and on the operating table with the neck hyperextended. The laryngotracheal axis, the anterior border of the sternocleidomastoid muscles (SCM), and the sternal notch are also outlined with a marking pen. In selected patients an additional vertical midline (T-)incision of the skin (and of the SF and MF) extending down to the manubrium (2 in Fig. 3.1) may be essential for mobilization of large mediastinal and thoracic inlet goiters. There is a risk of scar enlargement or contraction, which may later necessitate a Z-plastic correction. a Fig. 3.1 a,b Incisions of skin and platysma. 1, Kocher incision; 2, midline incision extending to the manubrium; 3, Kocher incision extended laterally to the posterior The Kocher incision may be extended laterally to the posterior margin of the SCM (McFee incision) or to the trapezius muscle (3 in Fig. 3.1) if excisions of large goiters or lateral nodal dissection are planned. For these indications a longitudinal incision along the anterior border of the SCM may also be used (4 in Fig. 3.1), with or without a simultaneous Kocher incision. Hemostasis of these incisions is effected for the most part by pressure on a gauze for a short time. 3.2 Transverse Division of the Superficial Fascia and Middle Fascia † Fig. 3.2 Superficial fascia (SF). No mobilization of skin platysma flaps is carried out. After transection of the platysma a very shallow scalpel incision will denude the superficial veins, which may turn out to be rather large. They are not dissected free, but simply cut between perpendicularly placed clamps and ligated or secured with suture ligatures (a later sudden flooding bleeding may originate from a reopened superficial vein). The SF encompasses the SCM and may be incised on its medial border, freeing the muscle for lateral retraction (Fig. 3.2 a, b). Middle fascia (MF, strap muscles). The underlying sternohyoid muscles, incorporated in a thin fascia, are cut transversely with a scalpel or with blunt scissors from the midline laterally; the fine fascia encompassing the b margin of the SCM; 4, longitudinal incision along the anterior border of the SCM. Incisions; Thyroid Exposure a b c d e f Fig. 3.2 a–g Transverse division of the superficial fascia (SF) and middle fascia (MF). a, b Superficial fascia divided, MF exposed. The sheath of the sternocleidomastoid muscle (SCM) is opened on the left side. c Sternohyoid muscle divided. The thin fascia of the more laterally situated sternothyroid muscles is exposed. d Strap muscles (MF) divided. e, f MF transected. Exposure of the capsula propria with enlarged vessels beneath. g Incision of the MF at the lateral edge. g 5 6 Part 1 Surgical Anatomy and Surgical Technique more laterally situated sternothyroid muscles is then lifted off the thyroid surface in the midline and carefully transected transversely with the scissors together with Case 5). No muscle crushing clamps the muscle († are placed across the strap muscles; minor bleeding ceases spontaneously or with diathermy. Laterally the fascial incision may be extended toward the jugular–carotid bundle; care is taken not to injure the ansa cervicalis (which innervates the strap muscles) and the internal jugular vein. At the lateral edge the MF may be incised in a longitudinal direction over a short distance (a few centimeters), thus opening a “back door approach” (see Fig. 4.9 a, b). The MF is gently lifted or pushed away and dissected free as one layer from the thyroid capsule in a cephalad, caudad, and lateral direction, with traction exerted to the cut muscles and the SCM on one side and to the thyroid gland on the other side. As middle and inferior (pretracheal) veins are encountered, they are individually dissected free, ligated, and divided near the thyroid capsule. The more lateral and posterior mobilization of the thyroid will then be achieved by capsular dissection (see Figs. 4.1–4.3). a 3.3 Longitudinal Median Division of the Superficial Fascia and Middle Fascia † Fig. 3.3 For this approach, a skin–platysma flap must be mobilized from the Kocher incision, cephalad to the level of the thyroid notch, and caudad down to the level of the sternal notch. The flap dissection is carried out with curved blunt scissors in the avascular plane between the platysma and the SF. The flap is held tautly vertically by fine hooks or between the surgeon’s left thumb and fingers away from the SF, which is pulled downward, permitting proper blunt and sharp dissection. For mobilization of the inferior flap, the surgeon changes his place, moving to the top of the operating table. The exposed SF, a rather strong fascial layer, is then incised in the midline and divided longitudinally in its entire length; care must be taken not to harm the superficial veins that are running parallel. With slight retraction of the cut SF, the midline of the MF is defined, picked up with two toothed pincers, and opened longitudinally. Successively, the layer of the sternohyoid and the underlying thin fascia of b Fig. 3.3 a–c Median longitudinal division of the superficial and middle fascia. a Mobilization of skin platysma flaps. Exposure of the superficial fascia (SF) with superficial veins. b Incision of the superficial fascia. c Incision and retraction of the fascia of the sternohyoid and sternothyroid muscles. c Incisions; Thyroid Exposure the sternothyroid muscles are incised in their full length. The SF and the MF are retracted from the thyroid capsule laterally in one layer. At that stage the capsular dissection (laterodorsal skeletization of the thyroid gland) will be started. A longitudinal fascial division (Fig. 3.3) (with or without transection of the sternothyroid muscle) is very satisfactory for small goiters. A liberal fascial division throughout the entire length is important. Postoperative transient edema formation is less frequently seen than after transverse division; there is a risk (albeit very low) of hematoma or abscess formation in the large subcutaneous space. This access is insufficient for large goiters and for goiters with high extension of the upper poles. For wound closure, all layers are sutured separately, using atraumatic absorbable suture material, by a running suture for transverse incisions, and by single stitches for longitudinal incisions. Larger spaces are drained with a fine suction drain for 12–24 hours. The platysma is sutured by a 5–0 thread. The skin is reapproximated with intracutaneous single stitches, and then compressed with gauze for a short time. Adhesive skin closures (e. g., Steri Strips) are then applied in a vertical direction on the incision line. The operative field is compressed with both hands during extubation, if there is coughing, and in a state of excitation of the patient. A skin stitch is placed and left for 12 hours if there is bleeding from the skin margins. a 3.4 Modifications Separation of the strap muscles (blunt dissection between the sternohyoid and the sternothyroid muscles) (Fig. 3.4) has been recommended for better exposure,35 for posterior digital exploration without interfering with dorsal vessels,215 and to avoid postexploratory scar formation in the surgical space in case of an eventual reoperation. Intraoperative contralateral exploration has now widely been replaced by preoperative ultrasound. With a longitudinal midline incision of the SF and MF the access may be improved by transverse transection of the sternothyroid muscle. We reapproximate transected strap muscles by a running suture when the wound is closed. b Fig. 3.4 a, b Modifications of fascial incision I. a Separation of the strap muscles (according to reference 35). b Digital exploration in the avascular space (according to reference 215). 7

Author Ernst Gemsenjaeger and Ernst Gemsenjäger Isbn 9783131450319 File size 10MB Year 2008 Pages 180 Language English File format PDF Category Medicine Book Description: FacebookTwitterGoogle+TumblrDiggMySpaceShare An outstanding reference for performing successful thyroid operations   Atlas of Thyroid Surgery: Principles, Practice, and Clinical Cases is a concise guide for the surgical management of thyroid disease.   Highlights:   Descriptions of endocrine pathophysiology and the pathogenesis of nodular goiter and thyroid neoplasms Thorough discussion of the capsular dissection technique and its essential advantages as a minimally invasive approach with low morbidity Numerous clinical cases with step-by-step demonstrations of surgical procedures and concise comments on management, helping clinicians prepare for range of scenarios encountered in everyday practice More than 100 clear line drawings and full-color photographs that illustrate key concepts Surgical videos on an accompanying DVD present detailed surgical technique in five clinical cases with cross references to the text   Atlas of Thyroid Surgery: Principles, Practice, and Clinical Cases is a superb guide for general surgeons and endocrine and ENT surgeons operating on the thyroid. Endocrinologists, oncologists, pathologists, and residents in these specialties will also greatly benefit from the wealth of information provided in the text.