General Principles

The following principles apply to all thyroid operations:

1. Good exposure of the thyroid gland is essential for good results.

2. No operation should be performed on the thyroid gland without proper identification of the anatomic structures.

3. Bleeding can and should be kept to a minimum.

4. Diathermy (even bipolar) should be avoided in the area around the laryngeal nerves.

Optimal Access

As in all operations, optimal access to the entire operative field is one of the keys to success. It is a misconception, however, that good exposure means a long incision. Good exposure can be achieved by a number of simple procedures, which are described later. Time and effort spent learning these techniques are repaid many times during the operation.

Identification of the Anatomic Structures

Another misconception is that operations in this area could or even should be done without proper identification of the anatomic structures. It is hoped that this way of operating has been abandoned today. As late as 1976, however, published recommendations could be found that advocated that "the dissection at no time should be directed at identification and uncovering of the recurrent laryngeal nerve,"1 and identification of the parathyroid glands was described as "an erroneous guesswork implying a risk of inducing hypoparathyroidism."1 It is still possible to find surgeons who continue to follow these principles; this is difficult to understand because the general principle in surgery is that it is "always better to see what you are doing." It is generally considered to be impossible to perform a safe, complete lobectomy without identification of the anatomic structures.

The argument that time is saved by not identifying the anatomic structures is also based on a false premise: a surgeon who can see what he or she is doing operates not only more safely but also faster than a surgeon who does not know precisely where the parathyroid glands or recurrent nerves are positioned.9

Minimal Bleeding

My recommendation is that suction should not be used routinely during thyroid surgery. First, the surgeon who does not use suction dissects gently and precisely, with meticulous ligation of vessels. Second, frequent suctioning may injure the parathyroid glands and the nerves.

Restricted Use of Diathermy

The true state of the art of thyroid surgery can best be judged by the way in which the recurrent laryngeal nerves are handled. This is where the truly skilled thyroid surgeon can be separated from the others. The process of meticulous dissection and ligation of the vessels in Berry's ligament requires absolute precision. It is a good technical exercise for the whole field of endocrine surgery and should be done properly. This is the only safe way to avoid injuries to the recurrent laryngeal nerve.

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