World Journal of Surgery

, Volume 42, Issue 5, pp 1415–1423 | Cite as

Medial Approach for the Resection of Goiters with Suprahyoid, Retropharyngeal, or Substernal Extension

  • Harry H. Ching
  • Jacob B. Kahane
  • Megan J. Foggia
  • Annabel E. Barber
  • Robert C. Wang
Original Scientific Report with Video
First Online:
  • 53 Downloads

Abstract

Background

Resection of massive goiters with suprahyoid, retropharyngeal, and substernal extension may not be amenable to standard approaches. This study evaluates a surgical approach allowing resection of massive goiters with minimal substernal and deep neck dissection.

Methods

Cases of thyroidectomy for goiters with substernal, retropharyngeal, or suprahyoid extension at a single institution from 2006 to 2017 were reviewed. The technique involves initial complete division of the medial thyroid tracheal attachments after identification of the RLN medial-inferiorly or superiorly. Deep components are then delivered into the superficial paratracheal region of the neck.

Results

Sixty patients were included, 46 of which had substernal and 14 had only suprahyoid or retropharyngeal extension. Mean substernal extension was 3.7 cm (range 1.5–7.5 cm). The medial approach was successful in identifying the RLN in 70 (83%) of 84 goiter sides (71% medial-inferiorly and 29% superiorly). Standard inferior/lateral approaches were used in 12 (14%) nerves or not found until after goiter removal in 2 (2.5%). No patients required sternotomy or tracheotomy. Complications included postoperative seroma/hematoma (n = 9, 15%) with one re-exploration, transient RLN injury (n = 4, 4% of all lobectomies), transient hypocalcemia (n = 6, 16% of total thyroidectomies), permanent hypocalcemia (n = 2, 5% of total thyroidectomies), and permanent RLN paralysis (n = 1, 1% of all lobectomies).

Conclusion

Large suprahyoid, retropharyngeal, and substernal goiters were resected transcervically with low morbidity. Early complete division of Berry’s ligament after medial-inferior RLN identification was achieved in a high proportion of patients, facilitating goiter delivery with minimal mediastinal and deep neck dissection.

This is a preview of subscription content, log in to check access

Notes

Acknowledgements

Illustrations in Figs. 1, 4, and 8 by Robert C. Wang.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2018_4576_MOESM1_ESM.mp4 (111.4 mb)
Supplementary material 1 (MP4 114027 kb)

References

  1. 1.
    Netterville JL, Coleman SC, Smith JC et al (1998) Management of substernal goiter. Laryngoscope 108:1611–1617CrossRefPubMedGoogle Scholar
  2. 2.
    Abboud B, Sleilaty G, Mallak N et al (2010) Morbidity and mortality of thyroidectomy for substernal goiter. Head Neck 32:744–749.  https://doi.org/10.1002/hed.21246 PubMedGoogle Scholar
  3. 3.
    Zambudio AR, Rodríguez J, Riquelme J et al (2004) Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg 240:18–25CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Proye C (1993) Substernal goitres—surgical technique. Curr Pract Surg 5:72–77Google Scholar
  5. 5.
    Chen AY, Bernet VJ, Carty SE et al (2014) American thyroid association statement on optimal surgical management of goiter. Thyroid 24:181–189.  https://doi.org/10.1089/thy.2013.0291 CrossRefPubMedGoogle Scholar
  6. 6.
    Hashmi SM, Premachandra DJ, Bennett AMD, Parry W (2006) Management of retrosternal goitres: results of early surgical intervention to prevent airway morbidity, and a review of the English literature. J Laryngol Otol 120:644–649.  https://doi.org/10.1017/S0022215106000995 CrossRefPubMedGoogle Scholar
  7. 7.
    Mack E (1995) Management of patients with substernal goiters. Surg Clin North Am 75:377–394CrossRefPubMedGoogle Scholar
  8. 8.
    Huins CT, Georgalas C, Mehrzad H, Tolley NS (2008) A new classification system for retrosternal goitre based on a systematic review of its complications and management. Int J Surg 6:71–76.  https://doi.org/10.1016/j.ijsu.2007.02.003 CrossRefPubMedGoogle Scholar
  9. 9.
    Henry BM, Sanna B, Graves MJ et al (2017) The reliability of the tracheoesophageal groove and the ligament of berry as landmarks for identifying the recurrent laryngeal nerve: a cadaveric study and meta-analysis. Biomed Res Int 2017:1–11.  https://doi.org/10.1155/2017/4357591 CrossRefGoogle Scholar
  10. 10.
    Pradeep PV, Jayashree B, Harshita SS (2012) A closer look at laryngeal nerves during thyroid surgery: a descriptive study of 584 nerves. Anat Res Int 2012:1–6.  https://doi.org/10.1155/2012/490390 CrossRefGoogle Scholar
  11. 11.
    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 20:695–698CrossRefPubMedGoogle Scholar
  12. 12.
    Cho HT, Cohen JP, Som ML (1986) Management of substernal and intrathoracic goiters. Otolaryngol Head Neck Surg 94:282–287CrossRefPubMedGoogle Scholar
  13. 13.
    Scarpa CR, Triponez F (2014) Retrosternal thyroid goiter: recurrent laryngeal nerve dissection according to the Charles Proye’s toboggan technique. VideoEndocrinology 1:ve.2014.0009.  https://doi.org/10.1089/ve.2014.0009 CrossRefGoogle Scholar
  14. 14.
    Padur AA, Kumar N, Guru A et al (2016) Safety and effectiveness of total thyroidectomy and its comparison with subtotal thyroidectomy and other thyroid surgeries: a systematic review. J Thyroid Res.  https://doi.org/10.1155/2016/7594615 PubMedPubMedCentralGoogle Scholar
  15. 15.
    Pandya S, Sanders LE (1998) Use of a Foley catheter in the removal of a substernal goiter. Am J Surg 175:155–157.  https://doi.org/10.1016/S0002-9610(97)00267-5 CrossRefPubMedGoogle Scholar
  16. 16.
    Shemen L, Ko W (2006) Current technique for resection of mediastinal goiter. Ear Nose Throat J 85:609–611PubMedGoogle Scholar
  17. 17.
    White ML, Doherty GM, Gauger PG (2008) Evidence-based surgical management of substernal goiter. World J Surg 32:1285–1300.  https://doi.org/10.1007/s00268-008-9466-3 CrossRefPubMedGoogle Scholar
  18. 18.
    Rugiu MG, Piemonte M (2009) Surgical approach to retrosternal goitre: do we still need sternotomy? Acta Otorhinolaryngol Ital organo Uff della Soc Ital di Otorinolaringol e Chir Cerv-facc 29:331–338Google Scholar
  19. 19.
    Cohen JP (2009) Substernal goiters and sternotomy. Laryngoscope 119:683–688.  https://doi.org/10.1002/lary.20102 CrossRefPubMedGoogle Scholar
  20. 20.
    Burns P, Doody J, Timon C (2008) Sternotomy for substernal goitre: an otolaryngologist’s perspective. J Laryngol Otol 122:495–499.  https://doi.org/10.1017/S0022215107000047 PubMedGoogle Scholar
  21. 21.
    Ahmed ME, Ahmed EO, Mahadi SI (2006) Retrosternal goiter: the need for median sternotomy. World J Surg 30:1945–1948.  https://doi.org/10.1007/s00268-006-0011-y (discussion 1949) CrossRefPubMedGoogle Scholar
  22. 22.
    Wheeler MH (1999) Clinical dilemma. Retrosternal goitre. Br J Surg 86:1235–1236.  https://doi.org/10.1046/j.1365-2168.1999.01290.x CrossRefPubMedGoogle Scholar
  23. 23.
    de Perrot M, Fadel E, Mercier O et al (2007) Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 55:39–43.  https://doi.org/10.1055/s-2006-924440 CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Harry H. Ching
    • 1
  • Jacob B. Kahane
    • 1
  • Megan J. Foggia
    • 1
    • 2
  • Annabel E. Barber
    • 1
    • 3
  • Robert C. Wang
    • 1
  1. 1.Department of Otolaryngology - Head and Neck SurgeryUniversity of Nevada Las Vegas School of MedicineLas VegasUSA
  2. 2.University of Nevada, Reno School of MedicineLas VegasUSA
  3. 3.Department of SurgeryUniversity of Nevada Las Vegas School of MedicineLas VegasUSA

Personalised recommendations