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The thyroid gland
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
At this stage the nerve should be traced towards the cricothyroid joint as it enters the larynx. This point is the area where the nerve is most commonly damaged. The pretracheal fascia condenses into Berry’s ligament at this stage. Small vessels within the ligament retract if not controlled with bipolar diathermy or ties, and the resulting bleeding can disorientate the surgeon placing the nerve at risk (Figure50.19).
Thyroidectomy
Published in John Dudley Langdon, Mohan Francis Patel, Robert Andrew Ord, Peter Brennan, Operative Oral and Maxillofacial Surgery, 2017
At this point, the only attachment remaining in order to free the gland is Berry’s ligament. This structure must be divided to free the thyroid from the trachea. Gentle medial traction of the gland is provided. The key is to avoid pulling too enthusiastically. This can cause two problems. First, the nerve can be pulled up within the fascia and become very difficult to differentiate from fascia as it arborizes distally. Second, aggressive traction makes it more likely for the smaller vessels in the area to tear and bleed, which compounds the problem of visually tracking the nerve. Thus, we dissect the tenuous Berry’s ligament using bipolar cautery and right angle dissector where necessary to maintain a plane above the RLN. The dissection here is brought towards the trachea and completed by joining the plane inferiorly where the tracheal fascia has been exposed previously. Dissection is finished by freeing the thyroid isthmus towards the contralateral paramedian trachea.
Thyroidectomy
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
Ricard Simo, Iain J. Nixon, Ralph P. Tufano
The position of the RLN varies depending on the side, as previously described in the anatomy section. Although most RLNs are single, up to 30% of nerves can branch before entering the larynx and this may lead to higher risk of injury (Figure 67.9).31, 32Lateral approach: The nerve is usually identified in the Beahrs triangle in the lower lateral part the neck. This triangle is defined by the inferior thyroid artery superiorly, the trachea medially and the common carotid artery laterally. This is safest way of identifying the recurrent laryngeal nerve (Figure 67.10).33Superior approach: The nerve can be identified at the level of the cricothyroid junction at its entry into the larynx. This approach can be very useful in cancer patients with extensive nodal disease, reoperative surgery, when other approaches have failed and when considering a non-recurrent laryngeal nerve. Once the nerve is identified, it should be dissected in a caudal direction, tunnelling the tissue surrounding the nerve with a mosquito fine-tip dissector (toboggan technique). The tissue above the tunnel is then diathermized with bipolar diathermy and divided (Figure 67.11).33Inferior approach: In large goitres or in revision surgery, an inferior approach can be used. This allows identification of the nerve in a virgin site (Figure 67.12).33 In every thyroidectomy, an attempt should be made to identify the nerve. Without this attention to detail, injury rates can be unacceptably high. Having identified the nerve, there is no need for it to be traced for any great distance. With experience, the surgeon will come to recognize the importance of the relationship between Berry’s ligament and the nerve. In patients with a low Berry’s ligament, which sits posterior on the trachea, the nerve will be in close proximity to the gland at this crucial point. In these cases the nerve must be carefully traced and the gland mobilized off the nerve. When Berry’s ligament is high, the nerve is often quite laterally placed in comparison, and minimal dissection will be required. This minimizes the chance of inadvertent injury.
Intraoperative Posterior Cricoarytenoid Muscle Electromyography May Predict Vocal Cord Function Prognosis after Loss of Signal during Thyroidectomy
Published in Journal of Investigative Surgery, 2021
Nurcihan Aygun, Adnan Isgor, Mehmet Uludag
In this study, 95% of patients with Type I LOS were female, and 64% of Type 2 LOS patients were male. Similarly, in a multicenter study with 115 patients with LOS, Schneider et al. [8] reported that 95% of patients with Type I LOS were female and 51% of patients with Type 2 LOS were male. In accordance with other studies, traction trauma was the most common cause of LOS in the current study [7–9, 18]. The traction trauma causing LOS was detected in men with a higher rate than female patients (7.2% vs 2%, p = 0.005, respectively). RLN passes through the anterolateral side of the Berry ligament before entering the larynx. At this level, it is attached to the Berry ligament by loose areolar fascia [19]. The higher prevalence of traction trauma in men may be due to the stronger and more dense areolar facial structure that attaches the nerve to the Berry ligament.
Evaluation Criteria and Surgical Technique for Transoral Access to the Thyroid Gland: Experimental Study
Published in Journal of Investigative Surgery, 2019
Alexander M. Shulutko, Vasiliy I. Semikov, Elkhan G. Osmanov, Sergey E. Gryaznov, Anna V. Gorbacheva, Alla R. Patalova, Gaukhar T. Mansurova, Airazat M. Kazaryan
The sternohyoid and sternothyroid muscles, that cover the operated lobe of the thyroid gland, were dislocated anterolaterally with further fixation to the wall of the operating cavity using a ligature that pierced through the skin. After dissection from the trachea the thyroid isthmus was dissected with further mobilization of the lobe. By conducting the anterior-caudal traction of the lobe (held in the forceps and introduced through the trocar in the neck), the upper lobe of the gland was separated by crosscutting the upper thyroid vessels. We separated the lateral surface by conducting the medial traction of the lobe and cross-cutting the medial plexus vein. Further procedures included cross-cutting the Berry ligament and mobilizing the lobe's lower pole.