CHAPTER
Subtotal and Total Thyroidectomy
47  Author Gary L. Clayman
Commentary by Maisie Shindo, Gregory W. Randolph, and Gianlorenzo Dionigi
Preoperative Considerations
Ultrasound with fine-needle aspiration cytology is a
requisite in all thyroid surgery. Subtotal thyroidectomy
is largely for historical reference. Subtotal thyroidecto-
mies were primarily performed for cytologically benign
neoplasms, small (less than 1.5 cm) differentiated papil-
lary thyroid carcinomas in young patients, or follicular
lesions that cannot otherwise be further classified. These
surgeries are performed for definitive pathologic diag-
nosis as well as treatment. The surgical management of
thyroid malignancies remains total thyroidectomy, and
among low-risk patients possessing less than 1.5-cm
malignancies, hemithyroidectomy can be considered.
Generally we prefer to perform either lobectomy or
total thyroidectomy. Revision surgery, when it is
necessary, in a thyroid bed with thyroid tissue left in
place can be difficult.  GWRandolph and GDionigi
In my opinion, there are only few indications for
“subtotal” thyroidectomy. It can be performed in the
rare situation of a benign compressive goiter with
bilateral nodules where the compressive side already
has vocal cord paralysis. In this setting, one would
really want to minimize the risk of paralyzing the
functioning contralateral vocal cord, and therefore it
would be justified to leave a significant volume of
thyroid tissue to protect that nerve. Subtotal
thyroidectomies should not be performed for any
thyroid cancer or follicular neoplasm because if there
is any chance that one may have to subsequently
administer radioactive iodine treatment, the amount of
thyroid tissue left behind will reduce the effectiveness
of the radioactive iodine. In other words, most of the
iodine administered will go to the residual thyroid
tissue rather than to metastatic site(s). With too much
thyroid volume left, one may need to return for
completion thyroidectomy, which may significantly
increase complications because of scar tissue that
would have resulted in the surgical field on that side
from prior partial dissection. Therefore, in general, the
consensus for treatment of thyroid cancer is near-total
or total thyroidectomy. In the low-risk patient (i.e.,
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tumor smaller than 1.5 cm, patient younger than 45
years of age), one could consider hemithyroidectomy,
not subtotal. If a hemithyroidectomy is performed and
the contralateral side has not been dissected, having
to go back and do a completion thyroidectomy, should
it be necessary, does not increase surgical risks
because the surgical field has not been violated.
Also, if one is performing thyroidectomy for an
indeterminate follicular lesion, the procedure should be
hemithyroidectomy rather than subtotal thyroidectomy,
again for the previously stated reason. My statements
are also supported by the most recent American
Thyroid Association (ATA) Management Guidelines for
patients with thyroid nodules and cancer (see Cooper
et al, 2009). I think it would be better to perhaps
separate out the indications for total thyroidectomy
and subtotal thyroidectomy.  MShindo
Ultrasound of the lateral necks should be performed
with all thyroid ultrasounds in the analysis of the lateral
neck. Suspicious lymph nodes should be cytologically
analyzed independent of the thyroid mass size or cyto-
logic diagnosis.
In patients with fine-needle aspiration–proven papillary
carcinoma, we prefer ultrasound and computed
tomography (CT) scan with contrast given the
improved sensitivity of this preoperative radiographic
algorithm in the detection of central neck nodal
disease.  GWRandolph and GDionigi
Although I have rarely performed subtotal thyroi­
dectomies in the management of multinodular goiters,
in areas of the globe of underserved populations with
limited medical and pharmaceutical access, the benefit
of a small amount of retained functioning thyroid tissue
and easily maintained parathyroid functioning tissue
should not be underestimated.
Preoperative thyroid functions including analysis of
thyroid-stimulating hormone (TSH) levels are needed
in all patients. Biochemically hyperthyroid (suppressed
TSH) patients should be diagnosed prior to thyroid
surgery and should be controlled and presented treat-
ment options of surgery as well as radioactive iodine
therapy.
465
466 UNIT VI  Thyroid and Parathyroid
TSH assessment is of course necessary prior to CT
scan and with contrast.  GWRandolph and GDionigi
Preoperative evaluation of vocal cord function
and laryngeal positioning (rotation) should be per-
formed in all patients by either indirect or fiberoptic
examination.
Subtle laryngeal dysfunction may require videostro-
boscopic examination to clarify functional laryngeal
issues. Normal functioning recurrent laryngeal nerves
rarely require sacrifice due to the presence of local
malignancy; however, knowledge of their function or
lack thereof may affect the approach to areas of invasive
thyroid malignancy.
Despite the paralysis of a unilateral recurrent laryn-
geal nerve preoperatively, transection of this paralyzed
nerve should be preoperatively discussed because the
patient will frequently experience a further diminution
in the quality of voice due to acute lack of vocal fold
tone as well as the potential of loss of function of ini-
tially unaffected arborized branches.
We absolutely agree with this statement. Often a nerve
associated with preoperative glottic paralysis may still
retain some intraoperative electrical stimulability with
neural monitoring assessment. The resection of such a
nerve often results in further decrease in voice and
swallowing function.  GWRandolph and GDionigi
Although technically thyroid surgery can be per-
formed without the assistance of magnification, magni-
fied surgery of at least 2.5× facilitates safe surgery. This
provides early identification and protects the superior
and recurrent laryngeal nerves and their arborized
branches from injury and allows both identification and
meticulous surgery of the adjacent parathyroid glands.
We agree that magnification at surgery is
tremendously helpful.  GWRandolph and GDionigi
Operative Technique
STEP 1. With a marking pen, mark the incision’s cepha-
locaudal location with the patient awake and in a seated
position (Figure 47-1).
Despite the beautiful nature of thyroid surgery, the
surgeon must be cognizant that patients primarily focus
on incision length, location, design, and healing in their
assessment of the overall quality of their surgery (barring
complications). Optimally, the incision should be ade-
quate to provide access and visualization for the surgery
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Thyroid cartilage
Trachea
Incision
Manubrium of
sternum
FIGURE 47-1.  Location of incision.
and delivery of the thyroid and masses within it or
around it. With time, the healed the incision should rest
somewhere in the sulcus of the suprasternal notch area.
Incisions that eventually fall below the clavicle are less
cosmetically acceptable than the well-placed cervical
incision.
In general, the thyroid isthmus is located over the
cricoid cartilage. A more cephalad incision facilitates the
dissection of the upper pole of the thyroid but may
hinder more inferior dissection of the inferior paratra-
cheal area and superior mediastinum.
If the patient has a cervical crease(s), the incision
should be strongly considered for this location. Marking
the incision location with the patient sitting upright
prior to general anesthesia can facilitate the incision
design.
An incision placed in a cervical crease looks much
better than one in the sulcus of the suprasternal
notch, even if it is placed higher. My approach to
incision placement is to determine if there is a
substernal component. If there is, the incision should
be placed in that sulcus of the suprasternal notch to
allow adequate access to the mediastinum. If there is
no substernal component, then determine where the
patient’s isthmus is and look for a prominent crease at
that level. If there is no visible prominent crease, go
through the maneuvers that the author describes (i.e.,
flex neck) and place the incision as close to the
isthmus as possible.  MShindo
Often some compromise between the cricoid loca-
tion, existing cervical creases, and the planned supra-
sternal notch location of the well-healed incision site is
 CHAPTER 47  Subtotal and Total Thyroidectomy
required. In younger patients, the absence of cervical
creases is usual, and flexion of the neck may facilitate
more optimal incision location in a neck fold with this
maneuver. In younger patients, an incision location
approximately 2 to 3 cm superior to the sternal notch
should be planned.
This is because the incision may migrate inferiorly
below the suprasternal notch as the patient ages. 
MShindo
A 4-0 silk suture strung with tension along this area
nicely produces an indentation to mark the area for
incision. The incision length is generally 3.5 to 4 cm in
overall length for open procedures when the thyroid
mass is 3 cm or less in size. For larger masses, the inci-
sion length must be able to accommodate the delivery
of the mass and have adequate superior and inferior
gland visualization.
In general we like to avoid placing the scar in an
indented, scaphoid suprasternal notch, fearing
widening of the scar in this area. An overarching issue
of importance in incision placement is that the scar
be placed in or parallel to a normal skin crease
line.  GWRandolph and GDionigi
Incision length must be based on several factors.
First, it is imperative that the surgeon have adequate
visualization. In general, the incision must extend
enough to adequately deliver the thyroid itself. For
example, a 4-cm thyroid mass would require at least a
4-cm incision in order to deliver the mass without spill-
age. Clearly, smaller thyroid masses can be removed
though shorter incision lengths to ultimately about 2 cm
(that of the video-assisted thyroidectomy).
STEP 2. The patient is positioned with the back section
of the table elevated to reduce venous congestion and
the table placed in Trendelenburg to facilitate superior
pedicle visualization (a lounge chair position).
The legs are lowered and compression stockings placed
on all patients. The patient is slightly hyperextended in
the neck. I leave the patient with the head toward the
anesthesiologist and simply request space around the
head by moving the table about 2 feet away from
the typical bed or anesthesia room configuration.
We agree with all of these important points regarding
patient positioning. It is essential that both the
surgeon and anesthesiologist jointly assess that
the patient’s head is adequately supported after
the positioning.  GWRandolph and GDionigi
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467
STEP 3. The chin is pointing upward toward the ceiling.
STEP 4. Field anesthetic is used with 0.5% mepivacaine
1:200,000 epinephrine.
This provides both postoperative pain management and
incision hemostasis without cautery.
Anesthetic also allows postoperative pain manage-
ment with antiinflammatory medication only and out-
patient surgery facilitation.
STEP 5. The incision is made with a scalpel through to
the subcutaneous tissues.
Attention to detail in incising and handling skin reduces
cicatrix hypertrophy.
STEP 6. Electrocautery is used to incise the subcutane-
ous tissues deep to the platysma to the fascia envelop-
ing the strap musculature and the communicating
anterior jugular veins.
Although skin flap elevation is generally immediate sub-
platysmal in neck dissections, in thyroid surgery, espe-
cially in obese individuals, (in the midline) elevating at
the level of the investing fascia eliminates the potential
for lipectomy or searching for the linea alba.
STEP 7. The flaps are elevated to the level immediately
above the thyroid notch superiorly, and the sternal notch
inferiorly.
Skin rake tension on the flaps elevated primarily per-
pendicular allows the plane above the anterior jugular
veins and strap musculature to be readily visualized and
opened with the electrocautery.
STEP 8. The flaps are suspended with the use of 2-0 silk
sutures placed at the very base of the elevated flap with
a moistened sponge to keep from drying.
Although some individuals prefer self-retaining retrac-
tors, I have not used them and prefer suture suspension
to anchored drapes on the patient.
STEP 9. The linea alba is identified inferiorly and incised
with the use of electrocautery.
In most patients, the linea alba or median raphe of the
strap musculature is self-evident. The linea alba is
unquestionably much easier to define first lower in the
468 UNIT VI  Thyroid and Parathyroid
Median raphe of
strap musculature
after
Cooley
FIGURE 47-2.  Gentle lifting and retraction of the
sternothyroid muscle facilitates the rapid avascular separation
of the midline raphe (linea alba) of the strap musculature.
neck. Gentle lateral tension of the sternothyroid muscle
with application of the electrocautery on the raphe from
the immediate suprasternal area to the thyroid notch is
performed to separate these muscles (Figure 47-2).
Communicating branches of the anterior jugular
veins may be encountered and controlled with suture
ligatures or a Harmonic or similar type of ultrasonic
device.
STEP 10. The sternohyoid and sternothyroid strap
muscles are elevated off of the lateral surface of the
thyroid gland bilaterally with the use of electrocautery.
As the muscles are laterally retracted with army-navy or
small Richardson’s retractors, the muscles are separated
from the anterior and lateral surfaces of the thyroid
gland.
In any circumstance when there is even a question
of strap musculature invasion or effacement by the neo-
plasm, a “margin” of muscle should be obtained by
resecting the muscle in continuity with the thyroid mass
(still attached). Depending on the mass location, usually
a portion of the sternothyroid muscle can be easily left
in continuity with the thyroid mass.
The strap muscles are much easier to elevate off of
the gland toward the opposite side that the surgeon is
standing. To facilitate the ipsilateral elevation of these
muscles, the bed can be temporarily rotated toward the
primary surgeon.
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STEP 11. The superior vascular pedicle is visualized by
retraction of the sternothyroid and sternohyoid muscles
both superiorly and laterally.
Although I leave each patient and his or her neoplasm
to dictate the ultimate progression (order of events) in
their procedure, in general, I prefer to address the take-
down of the superior thyroid pedicle first.
Takedown of a small portion of the sternothyroid
muscle can be performed if there is incomplete visualiza-
tion of the pedicle with retraction only. The experienced
surgeon will rapidly recognize the anatomic variations
of thyroid location and strap musculature insertions
that suggest that this release is indicated.
We generally prefer to leave the superior pole as a last
resort in thyroid surgery. We think the more fully
mobilized thyroid lobe can be downwardly displaced,
more effectively allowing the dissection of the superior
pole vessels away from the external branch of the
superior laryngeal nerve. This maneuver is performed
after the superior parathyroid gland is reflected off of
the thyroid’s superior pole.  GWRandolph and GDionigi
STEP 12. Gently lifting the superior-most portion of the
gland allows for identification of a fascial plane envelop-
ing the superior vascular pedicle.
STEP 13. A mosquito hemostat is used to dissect the
plane beneath the superior thyroid artery and vein, and
the superior laryngeal nerve is identified deep to these
structures.
Branches of the superior laryngeal nerve are frequently
quite arborized.
If the superior laryngeal nerve is difficult to visualize,
I prefer to take down the individual vessels of the supe-
rior aspect of the lobe in a stepwise fashion to spare
variants of superior laryngeal nerve anatomy in contrast
to Step 14.
Neural stimulation is very helpful in identifying the
external branch of the superior laryngeal nerve. The
nerve stimulator can be run across the inferior
constrictor at the level of the superior pole to identify
electrically the external branch of the superior
laryngeal nerve. When stimulated, this nerve results in
a discrete contraction of the cricothyroid muscle and
typically gives a laryngeal electromyographic waveform
of small amplitude and short latency.  GWRandolph
and GDionigi
 CHAPTER 47  Subtotal and Total Thyroidectomy
Superior
thyroid a./v.
after
Cooley
FIGURE 47-3.  The superior vascular pedicle is clamped and
sectioned once the superior laryngeal nerve is identified deep
to those structures.
STEP 14. A small right-angle clamp allows both vessels
to be isolated, clamped, and then sectioned with elec-
trocautery (Figure 47-3).
Suture ligature or Harmonic control of these vessels is
equivalent. Harmonic instrumentation allows rapid and
efficient control of these vessels but must be carefully
oriented to place the insulated portion toward the supe-
rior laryngeal nerve.
I have always avoided the use of surgical clips in
thyroidectomy and neck dissections due to their effect
on surveillance with both computerized axial tomogra-
phy as well as ultrasound.
STEP 15. With the superior vascular pedicle transected,
the superior lobe is mobilized in the capsular plane of
the thyroid along its medial, lateral, and ventral surfaces
such that the superior pole should be totally mobile.
The superior parathyroid gland may be located along
the thyroid gland fascia and care should be used in
preserving these glands if they are in this location.
Regarding mobilization of superior pole, when
dissecting inferiorly along the medial aspect of the
superior pole, dissection should stop as one
approaches the inferior border of the cricothyroid
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469
Inferior
thyroid v.
after
Cooley
FIGURE 47-4.  As the dissection of the thyroid transitions to a
more inferior and then posterior lateral approach, the inferior
thyroid vein is sectioned along the gland capsule.
muscle. The distal course of the recurrently laryngeal
is in proximity to this area. Therefore, at this point, go
laterally as described in the next step and identify the
recurrent nerve.  MShindo
STEP 16. The lateral capsular surface of the gland con-
tinues the dissection.
Small capillaries and neovascularization are frequently
encountered and are controlled with bipolar electrocau-
tery or similar means.
STEP 17. The middle and inferior thyroid veins are usually
dominant and are transected along the gland’s capsule
(Figure 47-4).
We do not rely on the Harmonic scissors to control
the middle thyroid vein if it is of significant caliber. 
GWRandolph and GDionigi
STEP 18. As the thyroid gland is dissected, it is mobilized
more medially, with the middle thyroid vein transected
along the posterior lateral surface of the gland.
Carmalt retractors or moistened sponges help medialize
the gland and allow for adequate visualization of the
posterolateral component of the dissection.
470 UNIT VI  Thyroid and Parathyroid
Meticulous dissection and capsular excision tech-
nique facilitates maintaining vascularity of the parathy-
roid glands.
The hand retracting the thyroid lobe, providing cranial
retraction to some degree as well as rotation over the
trachea medially, grasps the thyroid with a unfolded
sponge to improve traction. This medial retraction of
the gland opposes the lateral strap muscle retraction
and serves to open up the lateral thyroid region. 
GWRandolph and GDionigi
STEP 19. With the gland medialized, the inferior thyroid
artery and the inferior parathyroid gland can usually be
visualized.
I tend to medialize the gland with a moistened sponge
and countertraction. Vascular Carmalt clamps are
another alternative as well as Kocher clamps.
STEP 20. Bipolar electrocautery and sharp dissection
are used to mobilize the parathyroid gland(s) on their
vascular pedicle(s).
I like to use bipolar electrocautery on very small, fine
vessels at very low settings to minimize parathyroid
gland vascular compromise.
STEP 21. The recurrent laryngeal nerve is identified gen-
erally within the area of the inferior parathyroid gland
(Figure 47-5).
Its location, whether deep to or superficial to the infe-
rior thyroid artery, is not constant or totally predictable.
For practical purposes, the nerve may be identified
caudal to the inferior parathyroid gland, but this may
lead to a higher risk of compromise to the parathyroid
gland’s vascular supply. I generally identify the nerve
and its arborized branches immediately beneath the
gland once the inferior parathyroid gland has been
lateralized.
We agree with this approach. The inferior gland being
more ventral than the nerve is best reflected prior to
identification of the nerve.  GWRandolph and GDionigi
The recurrent laryngeal nerves arise from the vagus
nerve, on both sides, and pass beneath the vessels that
are derived from the primitive fourth aortic embryologic
arch. Therefore the right recurrent laryngeal nerve
passes beneath the right subclavian artery, whereas the
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Recurrent Thyroid
laryngeal n. gland
Inf. parathyroid
gland
FIGURE 47-5.  The right recurrent laryngeal has been
identified and a stepwise dissection of the nerve along its
most medial branches is ensued. The right superior and
inferior parathyroid glands are laterally dissected and
displaced from the thyroid gland.
left recurs beneath the ligamentum arteriosum of the
aortic arch. Both nerves then ascend toward the larynx
in the approximate area of the tracheoesophageal
groove. This understanding is critical in safe dissection
in that the recurrent laryngeal nerves are never at risk
in the superior mediastinum in the dissection of struc-
tures lateral to the carotids, aortic arch, innominate, or
subclavian arteries.
Due to their sites of recurrence (redirection), the left
recurrent laryngeal nerve assumes a course ascending
relatively longitudinally parallel lateral to the border of
the trachea, whereas the right recurrent laryngeal nerve
tends to be directed more angularly as it ascends medi-
ally to the larynx. Depending on the lobe size and loca-
tion, the nerves may pass laterally or primarily beneath
the lobes as they approach the cricothyroid membrane.
In meticulous microdissection, the recurrent laryngeal
nerves, proximally, possess a wide range of arborized
branches that may originate centimeters from the laryn-
geal insertion. One or more of the medialized proximal
branches usually pass immediately posterior to the
lateral suspensory ligament of the thyroid (Berry’s).
Variability is the rule here and instances of anterior
branches penetrating thyroid tissue in the ligament can
be present. In these circumstances, total thyroidectomy
still results in a tiny remnant of thyroid tissue that can
be ablated if so indicated.
 CHAPTER 47  Subtotal and Total Thyroidectomy 471

We agree that the relationship of the recurrent

laryngeal nerve branches to the ligament of Berry
varies. Branches of the nerve containing motor fibers
at this level may therefore be tethered or banded by
the ligament of Berry as the thyroid gland is retracted.
Under these circumstances, the mobilized lobe’s
retraction is conveyed to the nerve through the
posterior ligament of Berry attachments. One must
Berry’s ligament
therefore always keep the nerve in view as one
Sup.
retracts the thyroid and dissects the ligament of parathyroid
Berry.  GWRandolph and GDionigi gland
Thyroid
Recurrent
gland
Although great attention has been placed on the laryngeal n.
relationship of the inferior thyroid artery to the recur- Inf. parathyroid
rent laryngeal nerve, basically the artery may present gland
superficial, posterior, or branch in both locations sur-
rounding the recurrent laryngeal nerve. Independent
of the anatomic configuration, the recurrent laryngeal
nerve should be anatomically identified prior to transec-
tion of these vascular structures.
The nonrecurrent laryngeal nerve can only be found
on the right side and is present in about 1% of the
population. This occurs due to an anomalous right sub-
clavian artery that is retroesophageal. In such circum-
stances, the right subclavian artery arises as the final
branch of the aortic arch, originating behind the esoph-
FIGURE 47-6.  The most anterior branch of the recurrent
agus and terminating into the supraclavicular and axil-
laryngeal nerve has been preserved and a mosquito hemostat
lary regions. The right common carotid artery arises
placed on the vascularized suspensory ligament prior to
directly from the aortic arch in these circumstances and sectioning.
therefore the nerve follows a direct course from the
vagus, traversing posterior to the common carotid artery
and assuming a variable horizontally angulated course Thyroid tissue frequently invests into the area of the
beneath the thyroid lobe into the laryngeal inlet. cricothyroid membrane laterally in the area of Berry’s
The philosophy of protecting the nerve by solely dis- ligament, thus making complete removal of all thyroid
secting on the thyroid capsule does not necessarily tissue unreasonable in some patients due to the inter-
ensure protection of the nerve from injury. In some digitated nature of their recurrent laryngeal nerve
circumstances, small anterior branches of the recurrent branches. In other instances, the ligament and small
laryngeal nerves may penetrate the capsule especially in vasculature may be bipolar cauterized or suture liga-
the vicinity of the suspensory ligament. tured with minimal to no thyroid tissue recognized in
The parathyroid glands frequently are situated along this area (Figure 47-6).
the course of the recurrent laryngeal nerves and preser- If paratracheal pathology is identified and pathologi-
vation of their function is requisite by maintaining their cally confirmed, a standard level VI and VII dissection
adequate lateral blood supply. The clear identification should be performed during this procedure.
of the recurrent laryngeal nerves and distal dissection of
these nerves allow safe division of the longitudinally and
medially directed vascular supply to these glands, which STEP 23. The pretracheal fascia is entered and elec­
is mandated for their normal function. trocautery (on a pure cutting setting) can be used to
mobilize the thyroid to the contralateral side of the
isthmus.
STEP 22. From a lateral to medial approach, the branches
of the recurrent nerve are identified and small vessels Once the medial-most branch of the recurrent (or non-
are controlled with bipolar electrocautery and larger recurrent nerve) is identified, the pretracheal fascia can
vessels are managed by ligatures. be safely used as a dissection plane.
The recurrent laryngeal nerve, if monitored, can be
Gentle cottonoid tracing of the nerve allows for atrau- stimulated with a minimal setting of 0.5 to 0.9 mA. I
matic dissection along the nervous sheath. have not adopted practice of stimulating the dissected

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472 UNIT VI  Thyroid and Parathyroid
nerve and do not alter surgical procedure based on such
findings.
Although I have not routinely used nerve monitor-
ing, I currently use monitoring for resident and fellow
education. It has not, however, altered my surgical tech-
nique or discontinued completion of thyroid surgery
based on nerve stimulation criteria.
Neural monitoring has many applications, particularly
in education. Neural monitoring allows for rapid
identification of the nerve (i.e., neural mapping prior to
actual nerve visualization), allows for intermittent
confirmation of neural integrity and neural identification
during nerve dissection, and, possibly most important,
allows for postdissection testing of the nerve to ensure
postoperative function prior to contralateral dissection.
One may reduce the risk of bilateral cord paralysis by
acknowledging the accuracy of this information. 
GWRandolph and GDionigi
STEP 24. The pyramidal lobe and delphian lymph node
are mobilized with the thyroid isthmus.
The fascia and the thyroglossal remnant area are freed
with the use of electrocautery starting superiorly at the
inferior level of the hyoid bone and connecting inferi-
orly to the isthmus dissection. In some instances the
tract and pyramidal remnants may be very prominent
and in other instances they may be vestigial
Delphian nodes and tissue in the area of the
cricothyroid muscle and membrane should be skele­
tonized to their fascia in surgical management of
malignancies.
Care must be taken during pyramidal lobe and
delphian lymph node dissection not to injure the
delicate, thin, wafer-like cricothyroid muscles on the
anterior surface of the lower larynx.  GWRandolph and
GDionigi
STEP 25. The clean plane between the thyroid gland and
tracheal fascia continues to be elevated with the use of
electrocautery toward the contralateral lobe.
As the surgeon becomes increasingly comfortable with
thyroidectomy, the elevation of the isthmus and contra-
lateral thyroid lobe from the pretracheal fascia greatly
facilitates the rapidity of the procedure.
The pretracheal elevation toward the already dis-
sected lateral aspect of the gland can safely proceed
toward the area of the lateral dissection inferiorly and
more superiorly approaching the suspensory ligament
area (but not to the suspensory ligament).
Larger thyroid glands can be delivered outside of the
incision at this time to reduce ultimate incision length;
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however, the gland remains tethered contralaterally on
the undissected side.
Completing a Total Thyroidectomy
STEP 26. Completion of the total thyroidectomy is
performed essentially identically as described on the
primary side of the surgery in the preceding steps.
I prefer to ligate the middle and inferior thyroid veins
prior to the more superior dissection of the superior
thyroid pedicle, at this time.
The surgeon should focus on meticulously preserving
every parathyroid gland unless clinically involved with
suspected malignancy.
Any devascularized parathyroid tissue should be
removed immediately, a small portion sent for frozen
section pathologic confirmation of parathyroid tissue,
and then autotransplanted.
Devascularized glands should be finely minced imme-
diately to provide oxygen and nutrients to the cellular
suspension in a timely fashion.
If left devascularized for a prolonged period without
creating a cellular suspension, irreversible anoxic
damage occurs to the majority of the gland except
the surface levels, which will be maintained due to
diffusion.
I perform autotransplantation using an injection
technique except in circumstances of multiple endocrine
neoplasia type I or II. In the latter, I transplant into a
defined pocket that is marked for localization if required
in the future.
In cases unlikely to subsequently develop parathyroid
adenomatous change, we prefer to mince the resected
normal parathyroid into small individual pieces and
place them into three separate muscle pockets in the
ipsilateral sternocleidomastoid muscle.  GWRandolph
and GDionigi
STEP 27. The paratracheal areas—both homolateral and
contralateral—are inspected for metastatic disease.
For patients with differentiated thyroid cancers, the
common carotid artery is dissected along its anterior
and medial surfaces from the superior thyroid artery
takeoff to the subclavian artery on the right and the
innominate artery on the left.
For patients with T4- and T3-differentiated thyroid
malignancies, the homolateral paratracheal lymphatics
have already been significantly dissected and exposed
during the course of the thyroidectomy.
The recurrent laryngeal nerve is identified inferiorly
within each paratracheal basin.
 CHAPTER 47  Subtotal and Total Thyroidectomy 473

A cottonoid pledget is used to displace the paratra-

cheal lymphatics medial and lateral to the recurrent
laryngeal nerves.
Visual and digital examination is used. Small, but
rounded nodules or lymph nodes are removed and sent
for frozen section analysis. Lymph nodes that are clearly
enlarged, indurated, or possess a blue or purple hue are
removed and sent for frozen section analysis.
For patients with positive frozen section analysis for
thyroid malignancy, a paratracheal and superior medi- Sup.
parathyroid
astinal dissection (levels VI and VII) is performed (see gland
paratracheal and superior mediastinal dissection in
Recurrent
Chapter 50). laryngeal n.
Inferior parathyroid glands, clearly distinct from
malignancy, should be pathologically confirmed and Thyroid gland
Inf. parathyroid remnant
autotransplanted. For patients younger than 45 years of gland
age with minimal homolateral disease, I thoroughly
inspect the contralateral paratracheal lymphatics and
perform a more limited paratracheal dissection of the
contents medial to the recurrent laryngeal nerve. The
lateral to nerve paratracheal contents are not removed
in these select patients unless disease is suggested during after
Cooley
the dissection.

FIGURE 47-7.  Artist’s representation of a subtotal

We titrate paratracheal dissection lymph node surgery
to objective data obtained on preoperative radiographic
mapping including ultrasound and CT scan. If there is
clearly identifiable disease on these preoperative
studies, the paratracheal region affected is dissected at
surgery. If these modalities are negative, we visualize
and palpate the paratracheal region, and if that
assessment is negative, we do not perform
paratracheal dissection. If preoperative imaging and
intraoperative assessment are negative, such
dissection would at most yield microscopic disease.
We think that the patient’s risk factor for nodal disease
is less important in the determination of nodal surgery
than the objective individual preoperative radiographic
data for that patient.  GWRandolph and GDionigi
thyroidectomy surgical bed. The right recurrent and superior
laryngeal nerves and both superior and inferior parathyroid
glands have been visualized and spared on the right. On the
left, a remnant of normal thyroid tissue remains from the level
of the middle thyroid vein to anterior of the suspensory
ligament area.
STEP 28. The superior pole is left intact and the inferior
and middle thyroid veins are ligated.
STEP 29. The gland is sectioned with the use of electro-
cautery in the location of the already separated plane
between the thyroid gland and the trachea (pretracheal
fascia) (Figure 47-7).

In pediatric and adolescent patients, enthusiasm to Bipolar electrocautery can be used to control vessels
remove all disease must be tempered with preserving that bleed within the retained thyroid tissue.
parathyroid function.
Closure of Subtotal and
Completing a Subtotal Thyroidectomy Total Thyroidectomies
The amount of gland to be retained varies based on the
surgeon’s experience, location of nodules or irregulari- STEP 30. The removed specimen is thoroughly inspected.
ties within the remnant area, and patient anatomic
variations. Any suspected parathyroid tissue is separated and a
small specimen sent for frozen section analysis and the
Should one perform a subtotal thyroidectomy, one remainder finely minced and placed in autologous serum
must be cautious that the recurrent laryngeal nerve’s or tissue solvent for transplantation.
course relative to the posterior thyroid lobe remnant is Any suspicious lymph nodes are separated and ana-
completely understood before dividing the lobe.  lyzed utilizing frozen section to determine whether para-
GWRandolph and GDionigi tracheal dissection (and completion of thyroidectomy)
is indicated.
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474 UNIT VI  Thyroid and Parathyroid
STEP 31. Bipolar electrocautery is used as required
during the very meticulous inspection and control of very
small vessels that may ooze in the wound. The wounds
do not require drainage tubes except in instances of
large goitrous glands for evacuation of dead space.
We like to reexamine the operative space in all its
interstices with anesthesia providing intermittent
Valsalva maneuver during ventilation to facilitate
venous oozing during this examination.  GWRandolph
and GDionigi
STEP 32. The strap muscles are reapproximated in the
midline with one or two interrupted absorbable sutures.
STEP 33. Meticulous closure of subcutaneous tissues
and skin is performed with fine attention to detail.
I tend to use absorbable suture in a subcuticular fashion
and further apply adhesive and Steri-strips as well.
Postoperative Care
Subtotal and total thyroidectomies are generally per-
formed as 23-hour observation procedures.
The patients are discharged on antiinflammatory
pain medication with narcotics only for breakthrough
discomfort. Patients are discharged on liothyronine
(Cytomel), 25 mcg twice daily until final pathologic
review.
An intact parathyroid hormone level is obtained
immediately on arrival to the recovery room.
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For a parathyroid hormone level (PTH) greater than
14 pg/mL, calcium supplementation only is given. For
a PTH 10 to 14 pg/mL, patients are supplemented with
calcitriol 0.25 mcg daily and 1 g of elemental calcium
twice daily for the first week only. Patients with PTH
less than 10 pg/mL are replaced with 0.25 mcg of cal-
citriol twice daily and 2 g of elemental calcium three
times daily (patients greater than 70 kg or with PTH
less than 1 pg/mL are replaced with 0.5 mcg calcitriol
twice daily). For patients with PTH less than 10 pg/mL,
a repeat PTH and serum calcium, magnesium, and phos-
phorus is obtained prior to discharge, and if normalized,
no further testing is required.
The patient’s first outpatient follow-up is at 1 week
for pathology review, wound inspection, and further
instruction on wound care and follow-up. Laboratory
analysis of parathyroid hormone level and serum
calcium is obtained at the first follow-up for patients
with PTH less than 10 pg/mL.
Suggested Readings
Berlin D: Recurrent laryngeal nerves in total ablation of the
normal thyroid gland. Surg Gynecol Obstet 60:19, 1935.
American Thyroid Association (ATA) Guidelines Taskforce
on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL,
Mandel SJ, et al. Revised American Thyroid Association
management guidelines for patients with thyroid nodules
and differentiated thyroid cancer. Thyroid 19:1167-1214,
2009.
Lennquist S, Cahlin C, Smeds S: The superior laryngeal nerve
in thyroid surgery. J Surg 102:999, 1987.
Wang CA: Anatomic basis of parathyroid surgery. Ann Surg
183:271, 1976.