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General Surgery
Thyroidectomy for Substernal Goiter
Built from Atlas of Thyroid Surgery
What’s inside
10 sections · 79 slides
Overview
- Scope of this chapter
Definition and classification
What a substernal goiter is, how it is grouped, and why position matters
- What a substernal goiter is
- Names used for the same condition
- General definition
- Primary versus secondary origin
- Vessels used for classification
- Type I versus type II position
- 1 in 5000
- Substernal goiter classification
- Why position predicts the nerve
- Substernal goiter according to different definitions
- Prevalence reports vary
Presentation and approach
How patients present, when to operate, and expected risks
- How patients present
- Common compressive symptoms
- Surgical approach
- Main postoperative complications
Case and imaging
A 53-year-old woman with a large type IIA goiter
- The patient
- CT findings
- Coronal CT of type IIA goiter
- Sagittal CT of type IIA goiter
- Axial CT of tracheal narrowing
Positioning
Supine with gentle neck extension and an EMG breathing tube
- Patient positioning
- Airway and nerve-monitoring tube
- Preparing the chest
- Patient preparation
Incision and exposure
Kocher incision, flaps, strap muscles, and vagal nerve monitoring
- Operative sequence at a glance
- Skin incision
- Kocher incision
- Subplatysmal flaps
- Superior subplatysmal flap
- Inferior subplatysmal flap
- Opening the strap muscles
- Strap muscle separation
- Dividing the strap muscles
- Transverse strap muscle section
- Which side to start on
- Finding the vagus nerve
- Vagus nerve isolation
- Continuous vagal monitoring
- Continuous EMG electrode on the vagus
- Optimizing the signal
- Neuromonitoring screenshot
Isthmus division and upper pole
Freeing the isthmus and ligating the superior pole vessels
- Dividing the isthmus
- Isthmus section with Harmonic
- Superior pole ligation
- Upper pole vessel ligation
Medial dissection: toboggan technique
Finding the RLN and freeing the lobe without traction
- The toboggan concept
- Searching for the RLN
- RLN search at the larynx
- Toboggan dissection, step by step
- Superior parathyroid and fluorescence
- Superior parathyroid with RLN
- Parathyroid autofluorescence
- Freeing and exteriorizing the lobe
- Berry ligament freed
- Inferior adhesions sectioned
- T-shape extension
- T-shape midline extension
- Reducing traction to protect the RLN
- Checking the inferior parathyroid
- Inferior parathyroid search
- Contralateral side and signal loss
Sternotomy
When the chest must be opened, and how it is done and closed
- When sternotomy is needed
- Preparing the sternotomy incision
- Preparing for sternotomy
- Dividing the sternum
- Sternotomy with oscillating saw
- Controlling bleeding and opening
- Bleeding control of the periosteum
- Finochietto retractor placement
- What sternotomy provides
- Closing the sternum
- Closure layers after sternotomy
Closure
Drain placement and layered neck closure
- Placing the drain
- Layered neck closure
- Key takeaways
- References
- References
- Atlas of Thyroid Surgery