Surgeon's approach to the thyroid gland: Surgical anatomy and the importance of technique

The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of thyroid anatomy and pathology, With appropriate tec hniques, total thyroid lobectomy and total thyroidectomy (which should be c onsidered simply as a bilateral total thyroid lobectomy performed during th e same operation) can be undertaken with minimal risk of damage to the recu rrent laryngeal nerves, the external branches of the superior laryngeal ner ves, and the parathyroid glands. Safe surgery requires a specific operative plan, progressing in a series of logical, orderly, anatomically based step s, Exposure of the thyroid gland is followed by careful dissection of the s uperior pole, utilizing the avascular plane between the superior pole and t he cricothyroid muscle to identify and preserve the external branch of the superior laryngeal nerve. Medial retraction of the gland then allows dissec tion of the lateral aspect of the thyroid lobe, Protection of the recurrent laryngeal nerves and preservation of the blood supply to the parathyroid g lands is best achieved by "capsular dissection," ligating the tertiary bran ches of the inferior thyroid artery on the gland surface. If a parathyroid gland cannot be preserved or becomes ischemic after dissection of its vascu lar pedicle, it should be immediately minced and autotransplanted into the ipsilateral sternocleidomastoid muscle. The current evolution of outpatient or short-stay thyroidectomy emphasizes the need to avoid complications by utilizing meticulous surgical technique. Minimally invasive thyroidectomy u tilizing endoscopic techniques may also affect the practice of thyroid surg ery. Even so, understanding the surgical anatomy of the thyroid gland and i ts possible variations is paramount to safe and effective surgery.