81

7 Technique of Thyroidectomy

Daniel Oertli

Contents the anatomic situation is complicated by prior sur-

7.1 Introduction . . . 81
7.2 Extent of Surgery and Definitions . . . 82
7.3 Preoperative Measures . . . 82
7.4 Positioning and Draping . . . 82
7.5 Surgical Steps . . . 82
7.5.1 Skin Incision and Creation of Skin Flaps . . . 82
7.5.2 Strap Muscles . . . 83
7.5.3 Upper Pole . . . 83
7.5.4 Isthmus and Pyramidal Lobe . . . 84
7.5.5 Hilum of the Gland . . . 84
7.5.6 Handling of the Parathyroid Glands . . . 85
7.5.7 Lower Thyroid Pole . . . 86
7.5.8 Removal of the Lobe . . . 86
7.5.9 Wound Closure . . . 86
7.6 Reoperative Thyroid Surgery . . . 86
7.7 Minimally Invasive Thyroidectomy . . . 87
References . . . 87
7.1 Introduction
Thyroidectomy is the most frequent intervention in
endocrine surgery. When performed in specialized
centers, the operation is safe with low morbidity and
a virtually 0% mortality [1]. Complications of thyroid
surgery are directly correlated to the extent of resec-
tion and inversely proportional to the experience of
the operating surgeon [14]. Thus, the cornerstones
of safe and effective thyroid surgery are an adequate
training, the understanding of the anatomy and pa-
thology, as well as a meticulous dissection technique.
The dissection must be based on a sound knowledge
of three-dimensional topographic anatomy, typical
landmarks, and possible anatomic variations. The me-
ticulous dissection technique is achieved by a proper
exposure of all fine anatomic structures in a blood-
less dry surgical field. The use of magnifying glasses
(magnification 2.53.5 ), bipolar coagulation, and
fine titan clips or ligatures is highly recommended.
Neuromonitoring has proved useful for identifying
the recurrent laryngeal nerve (RLN), in particular if
gery [5]. However, neuromonitoring does not reliably
predict postoperative outcome [6,7]. A recent study
based on 288 patients undergoing thyroid surgery
with intraoperative identification and intraoperative
neuromonitoring showed that the incidence of recur-
rent nerve lesions in benign, malignant, and recur-
rent thyroid disease was not lowered by the use of in-
traoperative neuromonitoring [8]. Although an intact
nerve function can be verified by this method, we do
not recommend the routine use of RLN neuromoni-
toring.
The endocrine surgeons success depends com-
pletely on his or her devotion to a stepwise meticu-
lous and fine dissection technique. Several dissection
devices have recently been propagated for thyroid sur-
gery. The harmonic scalpel using ultrasonic frictional
heating to seal vessels is widely used in laparoscopic
and open abdominal surgery. It is documented to be
safe and fast for cutting and coagulating tissue. Its use
for dissection during thyroidectomy has been evalu-
ated in several studies and has been compared to the
conventional clamp-and-tie technique. Two random-
ized studies [9,10] and two case-controlled studies
[11,12] have shown that the harmonic scalpel signifi-
cantly shortens the operative time compared to the
conventional technique. This reduction of up to 20%
in operative time has proved to be cost-effective [13].
Thyroidectomy using the electrothermal seal-
ing technique has also been introduced and tested
[14,15]. However, this technique did not significantly
reduce operative time, blood loss, or the complica-
tion rate compared to conventional knot-tying but it
increased operative costs in one study [15]. All men-
tioned studies compared new ultrasonic or diathermy
dissection devices with the conventional clamp-and-
tie technique. However, no comparison with the uti-
lization of hemoclips to secure smaller vessels was
done. Personally, I make liberal use of hemoclips for
thyroid and parathyroid surgery and I am convinced
that this speeds up the operation similarly to the use
of the quite costly new devices.
82 Daniel Oertli

7.2 Extent of Surgery between the medial borders of the sternocleidomas-

and Definitions
Until 2000 there was no uniformly applied definition
in the literature regarding the extent of thyroidec-
tomy that should be performed for benign and malig-
nant pathologies. To fill this gap, Kebebew and Clark
formulated such a classification (Table 7.1) [16].
Lumpectomy or nodulectomy refer to removal of a
thyroid nodule alone with minimal surrounding thy-
roid tissue. Partial thyroidectomy involves removal of
a nodule with a larger margin of normal thyroid tis-
sue. The definition of subtotal thyroidectomy belongs
to the bilateral removal of more than 50% of each lobe
including the isthmus. Lobectomy or hemithyroidec-
tomy refers to the complete removal of one lobe with
the isthmus. Near total thyroidectomy is defined as
the total extracapsular removal of one lobe including
the isthmus with less than 10% of the contralateral
lobe left behind. During total thyroidectomy both
lobes and the isthmus are completely removed leaving
behind only viable parathyroid glands.
toid muscles. The appropriate position of the neck
incision is approximately two finger breadths above
the sternal notch or in the middle between the sternal
notch and the thyroid cartilage. If the incision is too
low, the tendency to keloid formation and resulting
unsatisfactory cosmesis is increased.
7.4 Positioning and Draping
The patient is positioned with the neck extended.
Rolled towels are placed under the shoulders which
allow sufficient neck extension. A sponge doughnut is
placed under the occiput for adequate head support.
In order to prevent venous congestion in the neck, the
head of the table is elevated to a 30 position during
surgery. Disinfection is performed using an alcoholic
agent without iodine which might interfere with post-
operative radionuclear scanning and ablative therapy.
The surgical field is draped from below the sternal
notch up to the chin and on the posterior margin of
the sternocleidomastoid muscles.

7.3 Preoperative Measures

All patients should be rendered euthyroid before sur-
gery. Preoperative preparation of patients with thyro-
toxicosis is particularly critical to avoid operative or
postoperative thyroid storm. The planned procedure
should be discussed with the patient and informed
consent must be obtained. Routine preoperative la-
ryngoscopy is not necessary if the patient does not re-
port voice changes [17]. However, if patients have pre-
viously undergone any type of neck surgery or if the
voice appears to be altered, laryngoscopy is indicated.
The tentative skin incision is marked preoperatively
using a permanent marker pen on the awake patient
with reclined neck. This is done in a symmetric fash-
ion along the Langers skin lines or in a skin crease in
7.5 Surgical Steps
Every surgeon should adopt a stepwise, standardized
strategy for thyroidectomy. One possible way (the
authors recommendation) for a successful thyroidec-
tomy is presented below. Modifications may be neces-
sary in the case of perithyroidal inflammation, large
goiters, or unexpected intraoperative findings.
7.5.1 Skin Incision and Creation
of Skin Flaps
A curvilinear collar-type incision is placed trans-
versally along the Langers line of the skin, i.e., the

Table 7.1 Definition of extent of resection

Thyroidectomy procedure Removal of: Indications
Partial (nodulectomy, lumpectomy) Nodule + margin of normal tissue Benign lesion
Subtotal More than one half of the thyroid gland Benign lesion
and isthmus
Lobectomy (= hemithyroidectomy) One entire lobe and isthmus Standard initial treatment for all indeter-
minate nodules
Near-total Lobectomy on one side, isthmectomy and Papillary carcinoma in a low-risk patient,
subtotal resection of contralateral lobe not requiring radioiodine ablation
Total Both lobes and isthmus Any other type of thyroid carcinoma

standard Kochers incision. The use of a natural skin
crease if present seems attractive. In order to optimize
cosmesis, the skin incision should be as long as nec-
essary but as short as possible. Personally, the author
believes that a 4- to 5-cm incision allows safe thyroid-
ectomy in most cases and results in excellent cosme-
sis. However, patients with larger tumors or goiters
or those with short necks will require a larger inci-
sion for optimal exposure. The incision is carried out
through the skin and the subcutaneous layer through
the platysma muscle to the lateral extent of the skin
incision. The two skin flaps are created by dissect-
ing them away from the strap muscles upward to the
thyroid cartilage and downward to the sternal border.
Elevation of the two flaps is almost bloodless if the
layer beneath the platysma is followed and dissected.
The cranial flap is transfixed using stay sutures that
are secured on two hooks placed on a horizontal rod
which is placed above the patients head (Fig. 7.1). The
caudal flap is pulled downward using a Roux retractor
enabling optimal exposure to the strap muscles.
7.5.2 Strap Muscles
The approach to the thyroid capsule is done by split-
ting the strap muscles in the midline. Small crossing
vessels are treated with bipolar coagulation. For a bi-
lateral approach, the left thyroid lobe is first dissected.
This is usually the more cumbersome preparation
7 Technique of Thyroidectomy 83
when the operating surgeon is positioned on the right
side of the patient. By predominantly blunt dissection,
the anterior aspect of the respective thyroid gland is
exposed. Caution should be applied while retracting
the strap muscles to avoid disrupting the medial thy-
roid veins. These veins are isolated and either ligated
or clipped and divided. Proper exposure to the lateral
aspects of the thyroid gland is achieved using right-
angled (de Quervain) retractors. Division of the strap
muscles may be necessary in the case of a very large
goiter, when a central neck dissection is indicated, or
in reoperative cases. The two muscles (sternohyoid
and sternothyroid) are separated using diathermia.
Their borders are secured with 2-0 threads that serve
as stay sutures.
7.5.3 Upper Pole
Using Kochers forceps, lateral retraction of the upper
pole of the thyroid lobe is applied in order to open up
the avascular space [18] between the lobe and the cri-
cothyroid muscle, thus exposing the external branch
of the superior laryngeal nerve [19,20]. This nerve
can sometimes be identified as it descends with the
vessels and anterior to the cricoid muscle but is often
not visible (Fig. 7.2). A recent study showed that the
identification and dissection of the superior laryngeal
nerve do not lower the risk of damage compared with
the simple transection of the superior vein and ar-
Fig. 7.1 Intraoperative situation after
creation of the superior skin-platysma flap
which is secured with threads. The inferior
flap is retracted using a Roux retractor
84 Daniel Oertli
tery close to the thyroid [21]. The superior vessels are
usually ligated with transfixing sutures. Large goiters
with prominent superior poles often require more
than one transection step.
7.5.4 Isthmus and Pyramidal Lobe
By blunt dissection, the isthmus is freed from the un-
derlying trachea and divided between transfixing liga-
tures. If subtotal or total thyroidectomy is performed,
the division of the isthmus is often not necessary. The
pyramidal lobe, which originates more often from the
left thyroid lobe, is traced upward and removed as
completely as possible.
7.5.5 Hilum of the Gland
Only the complete division of the superior vessels
enables the surgeon to medially rotate and anteriorly
mobilize the gland which results in optimal exposure
of the hilar structures. Capsular dissection, as de-
scribed by Thompson et al. [22], refers to the develop-
ment of a plane between the thyroid capsule and the
tertiary branches of the inferior thyroid artery. The
branches are ligated or clipped individually directly on
the surface of the thyroid gland. This method, which
is widely practiced today, minimizes surgical damage
to both the parathyroid glands and the RLN [23]. Me-
ticulous dissection steps will then enable identifica-
tion of the RLN where it crosses the inferior thyroid
artery, as well as the two parathyroid glands. It is wise
to preserve as much of the inferior thyroid artery and
its branches as possible, since it supplies the blood to
the two parathyroid glands. Truncal ligation of the in-
ferior thyroid artery should be omitted. However, it
is sometimes helpful to hold the trunk of the artery
Fig. 7.2 Lateral and caudal retraction of the upper pole of the
thyroid in order to open up the avascular space between the
lobe and the cricothyroid muscle, thus exposing the external
branch of the superior laryngeal nerve
using a vessel loop in order to facilitate further expo-
sure of the RLN. The nerve may easily be found at its
constant landmark, the so-called Zuckerkandl tuber-
culum [24,25], where it crosses beneath the thyroid
gland and enters below Berrys ligament of the thy-
roid cartilage (Fig. 7.3). The RLN can always be iden-
tified laterodorsally to the ligament of Berry; it never
penetrates the ligament [26]. The left RLN leaves the
vagus nerve as the vagus crosses over the arch of the
aorta. It hooks around the aorta and ascends again,
similarly to the right RLN, laterally to the trachea to
its terminal branches within the laryngeal muscles.
This explains why the left RLN runs closer to the tra-
cheoesophageal groove than the right RLN [27]. The
RLN may pass posteriorly or superficially to the in-
ferior thyroid artery or its branches intertwine with
many variations. Although several methods of local-
izing the RLN have been described, surgeons should
be aware of the variations and must have a thorough
knowledge of the normal anatomy to achieve a high
standard of care. This will ensure the integrity and
safety of the RLN during thyroid surgery. The iden-
tification of the RLN may be assisted by palpation; it
may be felt like a cord that can be rolled against the
trachea [28]. The nerve appears as a white cord com-
monly accompanied by a small artery. To clearly iden-
tify the RLN, dissection of its crossing point with the
inferior thyroid artery is critical. Gentle dissection,
best performed with a fine curved jaw hemostat, is
necessary at this point. Although there are many dif-
ferent anatomic relationships between the nerve and
the artery, the crossing point is one constant anatomic
landmark where the RLN can usually be identified.
One exception to this rule is the non-recurrent infe-
rior laryngeal nerve (Fig. 7.4). This anomaly is found
virtually only on the right side and is associated with
an anomalous right subclavian artery with a reported
frequency of 0.20.8% [2931].

7.5.6 Handling of the Parathyroid Glands
Regardless of whether a unilateral lobectomy or total
thyroidectomy is performed, all identified parathy-
roid tissue should be preserved on its native blood
supply. If a gland is devascularized during dissection,
it should be transplanted. Although there have been
sporadic reports of parathyroid autotransplantation,
it has only been in the last 30 years that the technique
has become used and only recently has it become ac-
cepted as part of routine clinical practice during total
thyroidectomy [32]. The best way to preserve the para-
thyroid glands in situ is the extracapsular dissection
of the thyroid gland. With the utilization of the extra-
capsular dissection, the parathyroid glands are swept
off the thyroid capsule and are left in situ with their
vascular pedicles. The superior parathyroid gland is
usually found after mobilization of the superior pole
of the thyroid. The lateral aspect of the thyroid gland
superior to the inferior thyroid artery usually reveals
a fat pad where the parathyroid can be found. This fat
pad including the parathyroid gland should be mobi-
lized off the lateral aspect of the thyroid starting at its
superior medial edge and sweeping the pad inferiorly
and laterally. It is important not to disrupt the fat pad
7 Technique of Thyroidectomy 85
Fig. 7.3 Topographic relationship between the inferior
thyroid artery and the tubercle of Zuckerkandl to the re-
current laryngeal nerve and the superior parathyroid gland
Fig. 7.4 Intraoperative finding of a non-recurrent inferior
laryngeal nerve
and not to dissect the gland further than just beyond
the edge of the thyroid to preserve its blood supply.
The inferior parathyroid gland is usually found at the
inferior pole of the thyroid or within the tongue of
the thymus. Once identified, it is taken off the infe-
rior pole in a similar fashion to the superior gland.
Disruption of the thyroid-thymic ligament should be
avoided as it provides most of the blood supply to the
inferior parathyroid gland.
All normal but devascularized parathyroid tissue
should be transplanted into the sternocleidomas-
toid muscle or other convenient muscle at the time
of thyroidectomy. Sometimes, the gland is partly de-
vascularized and should then be trimmed back to the
area of good arterial flow and viability. The remaining
portion is removed, minced, and autotransplanted.
Histologic confirmation of parathyroid tissue is cru-
cial in the setting of thyroid cancer. Nodal metasta-
ses from thyroid cancer can mimic parathyroid tissue
and should not be transplanted. There are principally
two ways to do a parathyroid autotransplantation.
First, the gland tissue is removed and minced into
tiny cubes that are smaller than 1 mm3. By separating
the muscle fibers of the sternocleidomastoid muscle, a
pocket containing about a 1-ml space is created using
86 Daniel Oertli
blunt dissection. The minced tissue is then trans-
planted into the pocket which is closed and marked
by hemostatic clips or a non-absorbable thread. It
is essential to leave a completely dry pocket behind
since hematoma formation within the pocket would
be prone to phagocytosis including the parathyroid
tissue. The second possibility to achieve the parathy-
roid transplantation is the creation of a parathyroid
suspension using saline which is then aspirated with
a 2-ml syringe and injected into the sternocleidomas-
toid muscle with an 18-gauge needle.
7.5.7 Lower Thyroid Pole
The transection of the vessels running to the lower
pole is usually done after proper exposition of the
RLN. Veins from the anterior superior mediastinum
are exposed and divided very close to the thyroid
gland. In up to 12% of cases an accessory ima artery
may spread into the lower pole. This vessel may origi-
nate either from the brachiocephalic trunk, the right
carotid artery, directly from the aortic arch, the inter-
nal thoracic artery, or from a mediastinal artery. This
vessel may cause intraoperative bleeding especially
when a large retrosternal goiter is bluntly mobilized.
7.5.8 Removal of the Lobe
During the final steps of the thyroidectomy, the lobe
is dissected away from the trachea under constant
exposure and preservation of the RLN. The dense
attachments at the level of the posterior suspensory
ligament (Berry) usually require sharp dissection. At-
tention must then be paid to the relatively constant
superior branch of the inferior thyroid artery (crimi-
nal branch) that often crosses underneath the RLN
and spreads medially from beneath the nerve into the
thyroid gland. This small artery should be isolated
and clipped before cutting (Fig. 7.5). The use of any
cautery or other thermal dissection device should be
avoided at this step due to the potential for thermal
injury of the RLN that is in close proximity to the in-
ferior thyroid artery. Inadvertent bleeding from this
artery and uncontrolled attempts of hemostasis at this
point of dissection may harm the RLN. Sudden bleed-
ing is best handled, with the aid of suction, by iden-
tifying the vessel stump, and clamping or clipping,
being constantly aware of the presence of the RLN. If
oozing occurs at this point, the placement of a hemo-
styptic gelatine sponge is advised.
7.5.9 Wound Closure
A postoperative drain can never replace accurate he-
mostasis and is of little or no use if severe postopera-
tive bleeding occurs. Two randomized trials did not
show any advantage of drainage after thyroidectomy
[33,34]. The strap muscles are sutured continuously
with a 3-0 absorbable thread, the platysma with a 4-0
thread, and the skin is closed by an intradermal run-
ning suture using 5-0 absorbable thread. A smooth
collar may be used for the first 24 hours postopera-
tively and the patient should be advised to keep a head
up position of about 30 in order to minimize venous
congestion and swelling of the soft tissues around the
wound.
7.6 Reoperative Thyroid Surgery
Avoidance of RLN injury is best achieved by iden-
tification of the nerve early during reoperation. The
best approach is the identification of the RLN in a
previously undissected area and to follow the nerve
into the dissected scarred region (from the known
Fig. 7.5 Last steps of dissection for thyroid lobec-
tomy: a small superior branch of the inferior thyroid
artery usually crosses underneath the RLN and
spreads medially from beneath the nerve into the
thyroid parenchyma

toward the unknown). Although the use of intra-
operative neuromonitoring for confirmation of the
RLN has some theoretical applications for a difficult
dissection, visual identification of the RLN is still es-
sential. Principally three distinct approaches exist for
reoperative thyroid and parathyroid surgery.
First, the lateral or back door approach enters
the thyroid bed between the anterior border of ster-
nocleidomastoid and the strap muscles (Fig. 7.6). Lat-
eral mobilizing of the sternocleidomastoid muscle ex-
poses the sternohyoid and underlying sternothyroid
muscles, whose fibers spread out inferiorly and later-
ally over the carotid artery and jugular vein. Gentle
retraction of the carotid artery exposes the paratra-
cheal soft tissue. This area, which is located inferolat-
erally to the inferior pole of the thyroid, is, if present,
usually unchanged from previous interventions. Here,
the RLN can usually be identified without difficulty.
Second, the low anterior approach enters the thy-
roid bed similarly to the primary operation. The strap
muscles are separated in the midline down to the ster-
nal notch and are reflected laterally. The dissection is
then carried out in the paratracheal regions inferior
to the area of previous dissection where the right or
left RLN is identified.
Fig. 7.6 With the back door approach, the surgeon enters the
thyroid bed between the anterior border of the sternocleido-
mastoid muscle and the lateral border of the strap muscles
7 Technique of Thyroidectomy 87
Third, the anterior superior approach exposes the
region between the superior pole of the thyroid, if
present, and the larynx. The RLN can be identified as
it enters the larynx with dissection in this avascular
space between the superior thyroid pole and the lar-
ynx. This can even be realized without taking down
the superior pole vessels. The RLN can be traced infe-
riorly and identified in the hilum of the thyroid which
is often extensively scarred.
7.7 Minimally Invasive
Thyroidectomy
Whereas minimally invasive parathyroidectomy has
become popular among endocrine surgeons, experi-
ence with minimally invasive thyroidectomy remains
limited. The feasibility and safety of fully endoscopic
thyroidectomy or video-endoscopically assisted thy-
roidectomy have been proved in a few studies that
reported a minor risk of complications and a low con-
version rate of 311% [3538]. The key to the success
of these approaches is a rigorous selection of the pa-
tients. Inclusion criteria are solitary nodules smaller
than or equal to 3 cm, thyroid volume less than 20 ml,
absence of thyroiditis, absence of previous neck irra-
diation, and absence of previous neck surgery. Thus,
minimally invasive thyroidectomies are valid alterna-
tives to conventional surgery for patients with small
solitary nodules [39]. However, only 10.6% of patients
requiring thyroid surgery eventually qualify for this
approach [40].
References
1. Bliss RD, Gauger PG, Delbridge LW (2000) Surgeons ap-
proach to the thyroid gland: surgical anatomy and the im-
portance of technique. World J Surg 24:891897
2. Runkel N, Riede E, Mann B, Buhr HJ (1998) Surgical
training and vocal-cord paralysis in benign thyroid dis-
ease. Langenbecks Arch Surg 383:240242
3. Lamade W, Renz K, Willeke F, Klar E, Herfarth C (1999)
Effect of training on the incidence of nerve damage in thy-
roid surgery. Br J Surg 86:388391
4. Udelsman R (2004) Experience counts. Ann Surg
240:2627
5. Ito Y, Iwase H, Tanaka H, Yuasa H, Kureyama Y, Yamashita
H, et al (2001) Metachronous primary hyperparathyroid-
ism due to a parathyroid adenoma and a subsequent carci-
noma: report of a case. Surg Today 31:895898
88 Daniel Oertli
6. Hermann M, Hellebart C, Freissmuth M (2004) Neuro-
monitoring in thyroid surgery: prospective evaluation
of intraoperative electrophysiological responses for the
prediction of recurrent laryngeal nerve injury. Ann Surg
240:917
7. Zambudio AR, Rodriguez J, Riquelme J, Soria T, Canteras
M, Parrilla P (2004) Prospective study of postoperative
complications after total thyroidectomy for multinodular
goiters by surgeons with experience in endocrine surgery.
Ann Surg 240:1825
8. Beldi G, Kinsbergen T, Schlumpf R (2004) Evaluation of
intraoperative recurrent nerve monitoring in thyroid sur-
gery. World J Surg 28:589591
9. Voutilainen PE, Haglund CH (2000) Ultrasonically acti-
vated shears in thyroidectomies: a randomized trial. Ann
Surg 231:322328
10. Defechereux T, Rinken F, Maweja S, Hamoir E, Meurisse
M (2003) Evaluation of the ultrasonic dissector in thyroid
surgery. A prospective randomised study. Acta Chir Belg
103:274277
11. Voutilainen PE, Haapiainen RK, Haglund CH (1998) Ul-
trasonically activated shears in thyroid surgery. Am J Surg
175:491493
12. Siperstein AE, Berber E, Morkoyun E (2002) The use of
the harmonic scalpel vs conventional knot tying for vessel
ligation in thyroid surgery. Arch Surg 137:137142
13. Ortega J, Sala C, Flor B, Lledo S (2004) Efficacy and cost-
effectiveness of the U1traCision harmonic scalpel in thy-
roid surgery: an analysis of 200 cases in a randomized
trial. J Laparoendosc Adv Surg Tech A 14:912
14. Dror A, Salim M, Yoseph R (2003) Sutureless thyroidec-
tomy using electrothermal system: a new technique. J Lar-
yngol Otol 117:198201
15. Kiriakopoulos A, Dimitrios T, Dimitrios L (2004) Use
of a diathermy system in thyroid surgery. Arch Surg
139:9971000
16. Kebebew E, Clark OH (2000) Differentiated thyroid
cancer: complete rational approach. World J Surg
24:942951
17. Jarhult J, Lindestad PA, Nordenstrom J, Perbeck L (1991)
Routine examination of the vocal cords before and after
thyroid and parathyroid surgery. Br J Surg 78:11161117
18. Aina EN, Hisham AN (2001) External laryngeal nerve in
thyroid surgery: recognition and surgical implications.
Aust N Z J Surg 71:212214
19. Monfared A, Gorti G, Kim D (2002) Microsurgical anat-
omy of the laryngeal nerves as related to thyroid surgery.
Laryngoscope 112:386392
20. Friedman M, LoSavio P, Ibrahim H (2002) Superior laryn-
geal nerve identification and preservation in thyroidec-
tomy. Arch Otolaryngol Head Neck Surg 128:296303
21. Bellantone R, Boscherini M, Lombardi CP, Bossola M,
Rubino F, De Crea C, et al (2001) Is the identification of
the external branch of the superior laryngeal nerve man-
datory in thyroid operation? Results of a prospective ran-
domized study. Surgery 130:10551059
22. Thompson NW, Olsen WR, Hoffman GL (1973) The con-
tinuing development of the technique of thyroidectomy.
Surgery 73:913927
23. Delbridge L, Reeve TS, Khadra M, Poole AG (1992) Total
thyroidectomy: the technique of capsular dissection. Aust
N Z J Surg 62:9699
24. Mirilas P, Skandalakis JE (2003) Zuckerkandls tubercle:
Hannibal ad Portas. J Am Coll Surg 196:796801
25. Pelizzo MR, Toniato A, Gemo G (1998) Zuckerkandls
tuberculum: an arrow pointing to the recurrent laryngeal
nerve (constant anatomical landmark). J Am Coll Surg
187:333336
26. Sasou S, Nakamura S, Kurihara H (1998) Suspensory
ligament of Berry: its relationship to recurrent laryngeal
nerve and anatomic examination of 24 autopsies. Head
Neck 20:695698
27. Liebermann-Meffert DM, Walbrun B, Hiebert CA, Siew-
ert JR (1999) Recurrent and superior laryngeal nerves:
a new look with implications for the esophageal surgeon.
Ann Thorac Surg 67:217223
28. Wheeler MH (1999) Thyroid surgery and the recurrent
laryngeal nerve. Br J Surg 86:291292
29. Proye CA, Carnaille BM, Goropoulos A (1991) Nonrecur-
rent and recurrent inferior laryngeal nerve: a surgical pit-
fall in cervical exploration. Am J Surg 162:495496
30. Chow SM, Law SC, Au SK, Mang O, Yau S, Yuen KT, et
al (2003) Changes in clinical presentation, management
and outcome in 1348 patients with differentiated thyroid
carcinoma: experience in a single institute in Hong Kong,
19602000. Clin Oncol (R Coll Radiol) 15:329336
31. Defechereux T, Albert V, Alexandre J, Bonnet P, Hamoir
E, Meurisse M (2000) The inferior non-recurrent laryn-
geal nerve: a major surgical risk during thyroidectomy.
Acta Chir Belg 100:6267
32. Wells SA Jr, Gunnells JC, Shelburne JD, Schneider AB,
Sherwood LM (1975) Transplantation of the parathyroid
glands in man: clinical indications and results. Surgery
78:3444
33. Schoretsanitis G, Melissas J, Sanidas E, Christodoulakis
M, Vlachonikolis JG, Tsiftsis DD (1998) Does draining the
neck affect morbidity following thyroid surgery? Am Surg
64:778780
34. Wihlborg O, Bergljung L, Martensson H (1988) To drain
or not to drain in thyroid surgery. A controlled clinical
study. Arch Surg 123:4041
35. Yeh TS, Jan YY, Hsu BR, Chen KW, Chen NIE (2000)
Video-assisted endoscopic thyroidectomy. Am J Surg
180:8285
36. Gagner M, Inabnet WB III (2001) Endoscopic thyroidec-
tomy for solitary thyroid nodules. Thyroid 11:161163
37. Miccoli P, Bellantone R, Mourad M, Walz M, Raffaelli
M, Berti P (2002) Minimally invasive video-assisted thy-
roidectomy: multi-institutional experience. World J Surg
26:972975

38. Mourad M, Saab N, Malaise J, Ngongang C, Fournier B,
Daumerie C, et al (2001) Minimally invasive video-as-
sisted approach for partial and total thyroidectomy: initial
experience. Surg Endosc 15:11081111
7 Technique of Thyroidectomy 89
39. Bellantone R, Lombardi CP, Bossola M, Boscherini M, De
Crea C, Alesina PF, et al (2002) Video-assisted vs conven-
tional thyroid lobectomy: a randomized trial. Arch Surg
137:301304
40. Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L
(2004) Minimally invasive video-assisted thyroidectomy:
five years of experience. J Am Coll Surg 199:243248