Access to gland Exposure of the esln and the superior pole vessels Identifying the rln and the parathyroids



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Introduction

Surgical Anatomy

Surgical Strategy

Hemithyroidectomy

Total thyroidectomy

Partial thyroidectomy

  • Technique

Wound Closure

Postoperative Care and Complications

Summary

Recommendations

References

Introduction

The thyroid operation is considered by many to be at the pinnacle of endocrine surgery. The surgeon who can perform a good thyroidectomy can, with little additional training, handle most of the other operations in this field, because the technique required is much the same. Most endocrine surgeons agree that an accurately performed thyroidectomy requires both experience and technical ability. This has lead various national endocrine surgical associations to strive for the creation of centers of excellence for the future training of endocrine surgeons(1;2).

Unacceptably high incidences of major complications, like recurrent laryngeal nerve palsies and permanent hypoparathyroidism are still reported in the surgical literature. Experience, sound judgment, meticulous technique and adequate training are the hallmarks required to eliminate these (3). Notwithstanding the limited facilities, the shortage of trained staff and inefficient health planning programs in developing countries, it is possible to make up for the shortcomings with a little more enthusiasm and dedication to achieve better results. It would be prudent to design appropriate training programs and introduce uniform guidelines and standards for performing these operations for the whole East and Central African region.

Due to our unique disadvantaged position in the medical world, there has been a tendency to copy-cat everything without consideration to our unique cultures, customs and priorities. A typical example is: the indications of surgery for a benign asymptomatic goiter in an old African lady and her counterpart in the West should not be the same in my opinion. The concept of cosmetics is rather different in both women. Lack of a health insurance system worth talking about and rampant poverty should also encourage a bit of conservatism when it comes to indications for thyroidectomy.

Controversy on the best surgical procedure for various types of goiters still rages in the West, although the tendency is toward radical techniques, even for benign lesions. There are documented advantages of total thyroidectomy for some cases of benign goiter as pointed out by Bron and others(4;5). Delbridge is a proponent for total thyroidectomy in almost all benign goiters in which surgery is indicated(6).The more conservative surgeons are mainly concerned about increased debilitating complications associated with the radical techniques. When these operations are attempted by inexperienced novices in small poorly equipped hospitals, the complication rates and gravity are not any different from what Kocher, Billroth and Mickulicz and many others experienced in the 19th century(4). And yet these recently graduated rural surgeons, who might have assisted in several thyroid operations during training, feel motivated to attempt these techniques; just because the gurus of endocrine surgery recommend it in conferences and on the internet. The results are usually catastrophic.

Recent innovations in thyroid surgery include minimal access and laparoscopic techniques as popularized by Miccoli and others(7;8). Obviously these would not be applicable to the huge endemic goiters seen in developing countries, although they have their applications for small benign nodules and parathyroid adenomas. There is also quite a debate going on as to the usefulness of these techniques in comparison to open thyroidectomies, as they actually leave significant scarring, especially the so called video- assisted minimal access. Mammary and axillary approaches have been introduced to eliminate cervical scars(8;9). Outpatient thyroidectomy and short stay procedures are now well established(10), but should be used in selected patients because of the risk of bleeding(11).



Surgical Anatomy

The surgeon must be familiar with the normal anatomy of the neck and the anatomical course and position of the laryngeal nerve and the location and blood supply of the parathyroid glands in order to be able to perform successful thyroid surgery. The Tubercle of Zuckerkandl is a thickening of thyroid tissue that is located at the most posterolateral edge of the thyroid gland (Fig.1).



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