Thyroidectomy technique: Defusing the recurrent laryngeal nerve – The superior approach

• Published in: The American journal of surgery Vol. 222; no. 4; pp. 712 - 714
• Main Authors: Papachristos, Alexander J., Sidhu, Stan B.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2021; Elsevier Limited
• Subjects: Cartilage; Dissection; Larynx; Surgical techniques; Tethering; Thyroid; Thyroid gland; Thyroidectomy; Endocrine surgery; Superior approach; Surgical technique; Thyroidectomy; Recurrent laryngeal nerve
• ISSN: 0002-9610; 1879-1883; 1879-1883
• DOI: 10.1016/j.amjsurg.2021.03.039

The critical advantage of this approach is that it allows early dissection of the most vulnerable portion of the nerve; the distal segment that passes through the fascial tunnel created by the vascular and fibrous leaflets of the ligament of Berry (LB).3 This point of tethering cannot be released during the lateral approach until complete anteromedial mobilisation has occurred. The inferior cornu of the thyroid cartilage can be palpated at this stage to assist with estimation of the position of the RLN entry point to the larynx, which is reliably identifiable and not subject to the anatomical variation that makes the lateral approach challenging. Furthermore, the superior approach negates the risks associated with variations in RLN course, such as passage lateral to the TZ (7% of cases), on the anterior surface of the thyroid gland (6% of cases) or non-recurrence on the right side (0.5% of cases).8 Once retrograde exposure of the RLN has been completed, the plane lateral to the nerve is developed and thyroidectomy using capsular dissection is completed in a standard fashion.Conclusion By identifying the RLN at its insertion to the larynx and performing a retrograde dissection, the multiple points of RLN fixation caused by fascial bands and SILABs can be defused prior to manipulating the thyroid lobe, thereby minimising the forces exerted on the RLN.Declaration of competing InterestCOI There is no conflict of interest to declare.Funding No funding or other support was received to carry out this work.