Thyroid and Parathyroid

thyroid tissue on one side has the advantage of obviating the need to reoperate on one
side in cases in which reoperation may be necessary, and the possibility of damage to
the recurrent laryngeal nerve and parathyroid on that side during future procedures is
. reduced
Subtotal lobectomy is achieved in a similar fashion to lobectomy, but after division of
the superior thyroid pole, arterial clamps are placed along the length of the lobe,
anterior to the insertion of the inferior thyroid artery, usually leaving approximately 1
to 2 cm3 (4 to 8 g) of thyroid tissue. The thyroid is oversewn and secured to the
lateral tracheal fascia to encourage hemostasis. Suction drains rarely are necessary.
They can be used when there is a large space, e.g., after removing a large substernal
goiter. Strap muscles are reapproximated with absorbable sutures, as is the platysma,
. and the skin is closed with subcuticular sutures or clips
Surgical Removal of Intrathoracic Goiter
In 99 percent of the patients, intrathoracic goiter can be removed via a collar incision
in the neck rather than resorting to a sternotomy. Patients with substernal goiters who
have had previous thyroid operations, some with invasive malignant tumors, and
. patients with no thyroid tissue in the neck may require a median sternotomy
Vascular connections in the neck are identified, ligated, and divided. The superior
pole vessels and the middle thyroid veins are identified and ligated first. Dividing the
isthmus may help with subsequent mobilization of the substernal goiter from beneath
. the sternum
Several large 1-0 or 00 sutures are placed deeply into the goiter, and through a
combination of traction and blunt dissection the thyroid usually can be delivered into
the neck from its substernal location. In patients with a very large colloid goiter, the
colloid occasionally may be evacuated to permit delivery, but this maneuver usually is
unnecessary, and it is contraindicated if cancer is present. Although 1 percent of
goiters contain cancer, the frequency of cancer in substernal goiter is as high as 10
. percent in some series
In approximately 1 percent of patients, part or all of the thyroid gland is intrathoracic.
This usually is a consequence of extension or migration of the thyroid into the
mediastinum rather than aberrant glandular tissue. The blood supply usually
originates in the neck rather than the mediastinum. These goiters are more difficult to
. remove because it is difficult to apply traction
Substernal goiters occasionally are too large to deliver via a neck incision, and a
sternotomy is required. In patients in whom thyroid cancer is suspected or
demonstrated in an intrathoracic gland, attempts should be made to avoid rupture of
. the thyroid capsule
Because the blood supply to the thyroid gland, thymus gland, and lower parathyroids
primarily is derived from the inferior thyroid arteries in the neck, median sternotomy
usually is unnecessary. Sternotomy is indicated in patients in whom the intrathoracic
gland is cancerous and mediastinal node involvement or metastatic cancer deep in the
mediastinum has been demonstrated by scanning. When sternotomy is indicated, the
sternum usually should be divided to the level of the third intercostal space and then